Chapter 7

Using ACT to Manage Aggressive Behavior

Physical aggression most often manifests as grabbing, pushing, and slapping, but more serious aggression is less common (including forcible restraint and punching). Although males commit more severely aggressive acts, particularly to dominate women, research shows that both men and women engage in the more common forms of aggressive behavior.

Extensive research has led to better understanding of aggression and its causes, but treatment for it is lacking. Most treatments tend to be outdated and not well supported by empirical evidence. The information on risk factors was taken and employed in contextual behavioral science to construct a model. In that model, psychological and physical aggression are seen as ways to escape from or avoid undesirable personal experiences. The unique model comprises connected techniques and components of treatment, examining the processes that affect treatment.

Physical aggression is often closely connected to depression, anxiety, substance use, and physical health issues, as well as relationship distress, separation, and divorce. Overall, aggression exacerbates problem conditions such as depression and relationship management. It drags down occupational and cognitive functioning.

A thesis by Zarling compartmentalizes the risk factors for aggression in this way (2013, 6-9):

1. Family – Partner aggression in family situations featuring severe discipline, low cohesion and acute conflict in relation to relationships among non-aggressive adults are reviewed.
2. Relationship – Aggression precedes relationship dissolution and distress, complicated by interpersonal skill deficits that increase the potential for conflict within the couple.
3. Personality and psychopathy – Personality and psychopathy are the most predominant predictors, and are likely rooted in childhood or adolescent antisocial behavior, childhood trauma or abuse, depression, and comportment issues. Axis II pathologies (e.g., Antisocial Personality Disorder and Borderline Personality Disorder) are correlated with partner aggression, sometimes complicated by depression and maladaptive attachment patterns linked with anxiety, and an unstable sense of self and impulsivity.
4. Cognitive and affective factors – Anger being the most researched factor, the problem may lie in how individuals respond to anger. Fear, shame, and jealousy may also be associated, as are symptoms reported by patients with panic attacks. There is weak research based on self-reporting by aggressive people that cognitive biases and irrational beliefs may be in play, as may be blame toward the victims.
5. Other factors – Substance abuse, stress, and the characteristics of relationships are reviewed, though how these factors bear on aggression is hazy. Arguments and verbal aggression often accompany psychological and physical aggression, suggesting that such verbal exchanges may set the stage for other aggression.

Arising out of social learning theory, CBT treatments have resulted in modest improvements compared to other forms of treatment. They prefer motivational techniques over confrontational techniques (Zarling, 2013, 18). They aim to change problem behavior, ideas, beliefs, and emotions to prevent violence. Motivation to end the violence is encouraged, crisis and anger-management strategies are learned, and communication skills are instilled.

Zarling cites some shortcomings of social learning theory and CBT as well as feminist approaches in treating partner aggression. Techniques are adjusted for partner aggression, but CBT cannot account for perpetrators of aggression who have no history of learned aggression. Also, social learning theory, feminist theory, and CBT can explain the onset of aggression but not the maintenance of aggressive behavior. Additionally, research has not proven that substantive modifications to aggression cognitions and personality traits result from treatment. Consequences to emotional functioning through this treatment are unknown. Finally, the frequency of anger may not be reduced.

So far, claims Zarling, no one treatment set has been shown to be superior in the treatment of aggression (2013, 20). She discusses the limitations of CBT and other kinds of treatments and a paucity of research that would identify the best techniques.

A better form of treatment would single out the change processes underlying treatment, asserts Zarling (2013, 25). An understanding of them is necessary for more successful therapy. Therapeutic techniques ought to be finely linked to change processes. The assumptions behind social learning, feminist and other theories in therapy should be critically examined, including the assumptions underlying partner aggression. Models are too “mechanistic.” Information on how internal events and overt behaviors work together is required.

Therefore, ACT is (probably) well suited for the treatment of partner aggression, Zarling concludes (ibid.), as it is from the stance of functional contextualism. Functions of emotions and cognitions should be discovered to proceed with improved treatment. Personal historical events are contacted with the present situational context. ACT can lead to “the prediction and influence of behavior,” known as “workability truth criterion” (Zarling, 2013, 27). It can lead to specific criteria for change. Causes are only explored for their impact on changing behavior. This is a practical approach.

ACT looks for variables that the patient can manipulate in order to bring about change. One set is values, and another a range of consciously altered meanings and language that can overtake the problem cognitive system. For example, the person becomes aware of the personal experience of anger and its relationship to outbursts of aggression. ACT can, thus, work with clients to “enhance the development and selection of more effective and efficient behavior modification techniques.” (Zarling, 2013, 28)

Zarling recommends a model of therapy that aims to change the contexts that are causally attached to the content of thoughts or feelings (ibid.). A principle of a more successful model would be avoidance. The role of fear is discussed. ACT sees experiential avoidance as commonly connected to a range of anxiety and other negative states. A person strives to avoid internal experiences they do not want in an effort to control or modify those internal experiences. They fight their feelings and thoughts. This is fine for short-term coping but not as a longer-term strategy for getting through the challenges of daily life and relationships, for problems are bound to arise. Prolonged thought suppression and thought control are examples (Zarling, 2013, 30).

Substance use is another problematic pattern of behavior that interferes with normal functioning. Problematic behavior blocks more effective adaptive behavior from developing. Acceptance and redirected values can be implemented to face the troublesome inner experiences and set behavior on value-based action. These two processes have been clinically tested and shown to be effective.

Zarling came up with a functional perspective of partner aggression to provide a framework so that processes in partner aggression can be pinpointed and joined with therapeutic change processes (2013, 36). This offers practical outcomes.

Her model contrasts with feminist perspectives that understand aggression as an effort to overpower women, and it contrasts with CBT approaches that understand aggression as a direct result of anger (Zarling, 2013, 37). Instead, ACT perceives aggression as an especially efficient strategy for avoiding unwanted emotions. Zarling’s model sees aggression being triggered by an emotional response and ideas due to an “evocative interpersonal conflict” and a learning history (ibid.).

The aggressor retains fear or sensitivity to the inner experience urging him or her to avoid the inner experience. This arousal may be more intense on the part of individuals who commit partner aggression, and such individuals may have less tolerance and skill with social interactions (Zarling 2013, 41 and 42). This is the context for engaging in aggression, which can momentarily distract him or her or reduce the psychological process. Success, albeit brief, in averting the unwanted inner experience reinforces the desire to be aggressive.

Zarling depicts this process that produces partner aggression in this fashion (2013, 38):

STIMULUS (interpersonal conflict) >> INTERNAL EXPERIENCE >> AGGRESSION >> RELIEF

ACT’s objective is to undermine the emotional response (Zarling 2013, 46). By decreasing the need to control the innermost experiences, aggressive behavior can be reduced (ibid.). The subject comes to see and verbalize the effects of the strategy of aggression, recognizing his or her own avoidance and control tactics. The therapist teaches more adaptive responses, so that the person unlearns the rigid rules of avoidance of that former strategy. The therapist redirects his or her behavior towards value-oriented goals. The person discusses and explores his or her priority values to construct a new direction. Work on values is paramount in the population of perpetrators of partner aggression.

Regarding mindfulness, several CBT approaches employ it as a therapeutic intervention. Hershfield defines it as a range of “specific techniques for challenging distorted thought processes” which lead to compulsions (The OCD Stories, 2016). It is used as an enhancement tool to cognitively reframe their experiences in a healthy way. It can also help one to be in the presence of an uncomfortable thought. In Exposure and Response Prevention (ERP), mindfulness is coupled with exposure for response prevention.