Cognitive therapy for violence: reaching the parts that anger management doesn't reach

In forensic clinical settings, the most popular model for working with violence has been anger management, which uses a cognitive behavioural approach to explain how stimuli may cause anger via a series of information processing biases. There seem to be a variety of cognitions and thinking processes that are either more common or more extreme in individuals who behave violently. Despite concerns about meta-analytic reviews of treatment effectiveness, and reservations about the relevance of anger management for reducing violence and reoffending, its use is widely advocated in prison and secure settings. We have suggested that low self-esteem is central to violence rather than high self-esteem, but that self-esteem may appear high. Combining cognitive behavioural and psychodynamic approaches produces a formulation that can be used for treatment incorporating not only emotional and behavioural work but also reconstruction of core beliefs and dysfunctional assumptions (rules). It is proposed that because important cognitions relating to violence also relate to self-esteem and the protection of (false inflated) low self-esteem in the face of humiliation, any intervention for violence must also account for a fragile inner sense of self-esteem which, it is proposed, has a causal relationship (along with other factors) with violence. The approach presented here includes a number of core therapeutic tasks. A case study is described to demonstrate its application. It offers a structured but flexible and individually tailored approach to working clinically with violence.