Professional Psychology: Research and Practice Copyright 2001 by the American Psychological Association, Inc.

2001, Vol. 32, No. 6, 618-625 0735-7028/01/S5.00 DOI: 10.1037//0735-7028.32.6.618

Anger as a Vehicle in the Treatment of Women Who Are Sexual Abuse

Survivors: Reattributing Responsibility and Accessing Personal Power
Patricia Van Velsor and Deborah L. Cox
Southwest Missouri State University

Some clinicians view client anger as a problematic symptom to be reduced, whereas others view it as an
opportunity for therapeutic development. The present authors describe how client anger, a fitting
emotional response to abuse, can work as a vehicle to help sexual abuse survivors reattribute responsi-
bility and develop personal efficacy. The role of anger in the healing process of the sexual abuse survivor
is explored through 2 case studies. It is suggested that by reframing anger as a vehicle for recovery rather
than a symptom, therapists can learn to effectively incorporate anger work (which involves successfully
negotiating any dynamics that cause therapist discomfort) into the treatment of survivors.

Can anger, typically described as a negative emotion, be used as
a therapeutic tool for treating sexual trauma survivors? Experts
have suggested that women who have survived childhood sexual
abuse benefit from making sense of abuse events by placing
appropriate responsibility on their perpetrators (e.g., Hoagwood,
1990; Morgan & Cummings, 1999). Experts have also proposed
that survivors need to develop a feeling of personal efficacy in the
recovery process (e.g., Apolinsky & Wilcoxon, 1991; Backos &
Pagon, 1999). Although some writers have emphasized the signif-
icance of anger in facilitating these changes (e.g., Blume, 1990;
Morgan & Cummings, 1999), the vital role of anger as instrumen-
tal in the healing process for female survivors has been largely
overlooked.
The intent of this article is to explore women's anger in the
process of recovery from childhood sexual abuse, reframing anger
as constructive, rather than symptomatic. We broadly refer to
survivors as those who self-identify as such, and we define child-
hood sexual abuse as "a sexual act imposed on a child who lacks
[the] emotional, maturational, and cognitive development" (Sgroi,
Blick, & Porter, 1982, p. 9) to give informed consent. We view
anger simply as an emotion and focus on the role of anger as it
relates to reattribution of responsibility and the development of
personal efficacy. We provide two case examples to elucidate our
ideas as well as treatment suggestions for therapists working with
sexual abuse survivors. Our suggestions to therapists, however, are
less about technique and more about attitudes toward anger and
anger work. Although we agree with Courtois (2000) that the
sexual abuse of males "must be recognized and not minimized" (p.
551), we focus solely on female survivors because males may
PATRICIA VAN VELSOR received her PhD in counseling from the University
of Toledo in 1995. She is an associate professor in the Department of
Counseling at Southwest Missouri State University.
DEBORAH L. Cox received her PhD in counseling psychology from Texas
Woman's University in 1996. She is an assistant professor in the Depart-
ment of Counseling at Southwest Missouri State University.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Patricia
Van Velsor, Department of Counseling, Southwest Missouri State Univer-
sity, 901 South National Avenue, Springfield, Missouri 65804-0095. Elec-
tronic mail may be sent to pvv034f@smsu.edu.
618
respond differently from females to childhood sexual abuse
(Heath, Bean, & Feinauer, 1996).
We can expect survivors to reclaim outrage in a number of ways
as therapists encourage women's expression of anger at individual
perpetrators and social establishments and traditions that tacitly
support them. Anger at the therapist emerges as a possible channel
through which women begin to experience and express anger, and
the likelihood for such dynamics raises the potential for in-session
interactions that are uncomfortable for both parties. Although this
kind of open anger expression may be unfamiliar territory for the
therapist, we suggest that the potential benefits of such make it
useful for the clinician to become prepared to receive survivors'
anger in therapy. When the client experiences the healthy unleash-
ing of repressed anger toward her perpetrator(s), or others in her
social surround, she claims a boundary, or a piece of personal
entitlement to certain rights involving safety and protection, per-
sonal integrity, emotional reality, and the outward expression
thereof, and reinstitutes feelings of personal efficacy and power.
Attributional Analyses of Sexual Abuse Events
Studies suggest that sexual abuse survivors often take personal
responsibility for the abuse (e.g., Courtois, 1999; Mannarino &
Cohen, 1996; Morrow, 1991) and that this self-blame relates to
poorer adjustment (Hoagwood, 1990); interpersonal problems
(Hazzard, 1993); and psychological symptomatology (Feinauer &
Stuart, 1996; Hazzard, 1993; Mannarino & Cohen, 1996), includ-
ing depression and self-destructive behaviors (Morrow, 1991; Pe-
ters & Range, 1996).
Calof (1995) described the process by which a child in an
abusive family learns to distort reality and attributions of respon-
sibility as parents create a climate and a rule-meaning system in
which the child must meet the needs of adults. If the child ac-
knowledges that she is being mistreated in such a profound way,
the emotional (and often physical) costs are greater than the child
can handle because they implicate adults. Therefore, the child
begins to adapt by developing a tendency to numb herself and
dissociate in order to shut down emotional and sensory experi-
ences in the immediate environment. This dissociation process sets
the stage for adaptive (at the time) distortions of reality and
misappropriations of responsibility.
 ANGER AND SEXUAL ABUSE
Internalized societal attitudes also contribute to the misdirection
of responsibility for sexual abuse. The propensity to blame moth-
ers and mother figures for abuse by male perpetrators has been
observed in sexual abuse survivors (Croghan & Miell, 1995) as
well as professionals, including clinicians (Kalichman, Craig, &
Follingstad, 1988, 1990), child protection workers, police officers,
nurses^ and others (Kelley, 1990). Herman (1981) maintained that
some survivors direct feelings of anger and betrayal toward their
nonoffending mothers and, in turn, regard all women, including
themselves, with disdain.
According to Dalenberg (2000), therapists often confront cli-
ents' self-blame by encouraging other blame, with potential dele-
terious effects. We suggest that empowerment for survivors is less
an issue of blame and more an issue of direct access to genuine
response, that is, anger; hence, it is important that survivors and
their therapists attend to the process of uncovering and expressing
anger as an integral part of the recovery experience.
Anger as a Mediating Factor in Sexual Abuse Recovery
According to emotional dysregulation theory (Friedrich, 1996),
the child raised in the incestuous family atmosphere, where her
feelings are systematically distorted, fails to learn how to differ-
entiate and respond to these feelings. Because rage is the most
appropriate emotional response to being sexually traumatized
(Courtois, 1988; Faller, 1995), the child is continually bombarded
with feelings of complete fury with no understanding of or safe
receptacle for processing them. As adults, survivors often fail to
use their anger as an information channel identifying "danger" and
often prolong situations that are unhealthy for them. According to
Simonds (1994), survivors attempt to cope with their anger
through the extremes of suppression and numbing to uncontrolla-
ble outbursts, leaving them more disempowered as they struggle to
contain and manage these feelings. According to clinical observa-
tions, the consequences of repressed anger include " 'acting out'
(lashing out at or abusing others, destroying), 'acting in' (abusing
the self), depression, eating disorders, chemical dependency, ul-
cers, sleep disturbances, anxiety, physical problems such as the
jaw joint disease called temporo-mandibular joint syndrome
(TMJ), and suicide" (Blume, 1990, p. 141). Empirical evidence
also exists for negative consequences of suppressed or repressed
emotion, as well as repressed thoughts about emotionally laden
experiences (Berry & Pennebaker, 1993; Petrie, Booth, & Penne-
baker, 1998; Richards & Gross, 1999; Richards & Gross, 2000).
These consequences include not only cognitive (memory) reduc-
tions (Richards & Gross, 1999, 2000) but also immunological
compromise (Petrie et al., 1998).
Although most literature on survivor anger patterns uses this
traditional "anger-in" and "anger-out" model to conceptualize op-
tions for expression of oppositional feeling, both in relation to
perpetrators and to significant others in survivors' lives, writers in
the area of women's emotional development have suggested that
using an "in" or "out" conceptualization may oversimplify wom-
en's anger (e.g., Cox, Stabb, & Bruckner, 1999; Jack, 2000).
Rather than focus on anger as either unexpressed or expelled, we
borrow the framework of Cox et al., which draws distinctions
between four types of anger diversions, or means of escaping full
conscious awareness of anger. This conceptualization acknowl-
edges the individual's potential for both internalizing and exter-
619
nalizing anger as well as the physical, social, and psychic tolls of
either extreme, as anger is absorbed and/or expelled inappropri-
ately. Extreme guilt or self-deprecating behavior may arise from
chronic internalization of anger, whereas abuse of others with less
perceived power may result from externalization. Further, survi-
vors may divert anger through suppression, in which their bodies
undergo the prolonged effects of heightened arousal, or segmen-
tation, in which they disavow anger overtly, while allowing it to be
expressed unconsciously in their relationships. Any of these anger
diversions, used singly or in combination, presents problems for
the client, as her opportunities for reattribution, empowerment, and
relationship mutuality are derailed (Cox et al., 1999; Sperberg &
Stabb, 1998).
Although some experts have highlighted the importance of
anger expression in facilitating survivor recovery (e.g., Apolinsky
& Wilcoxon, 1991; Backos & Pagon, 1999; Faller, 1995; Morgan
& Cummings, 1999; Simonds, 1994), empirical researchers have
left room for uncertainty regarding their assumptions about anger
(e.g., Carey, Kempton, & Gemmill, 1996) or have categorized
anger either with psychological symptomatology (Neumann,
Houskamp, Pollock, & Briere, 1996) or low self-esteem (Sapping -
ton, Pharr, Tunstall, & Rickert, 1997). One exception is a study
conducted by Scott and Day (1996), who contended that "the
healing process for [survivors of childhood incest trauma] must
include learning to recognize and validate their right to possess and
express anger, as well as mastering the skills to direct anger toward
the appropriate individuals" (p. 209). These researchers examined
anger experience and symptom formation in adult victims of
childhood sexual abuse. The researchers found support for their
hypothesis that survivors of childhood incest who appropriately
express their anger report significantly fewer symptoms than those
who suppress their angry feelings. Specifically, inwardly directed
anger was significantly and positively correlated with a host of
survivor symptoms including fear and anxiety, vulnerability and
isolation, detachment, powerlessness, and intrusive thoughts.
Anger From a Sociopolitical Perspective
Reattribution for sexual abuse survivors seems to take place by
means of the process of acknowledging the automatic boundary
that is present between self and other when one becomes fully
conscious of one's anger at that other (L. M. Brown, 1998; Cox et
al., 1999; Jack, 1999). This kind of cognitive-emotional shift
appears to foster empowerment on an individual level. Nonethe-
less, focusing solely on women's intrapsychic change in response
to felt anger at individual abusers leaves unspoken the sociopoliti-
cal changes that could be experienced by them.
For example, wornen who become involved in social activism
organized against toxic waste in their communities come to trust
the validity of their instincts through the process of reclaiming
personal outrage at big business and government authorities (P.
Brown & Ferguson, 1995). Activists' knowledge develops from
naive original trust in larger institutions to discoveries that evoke
their anger and continues to evolve into the empowered ability to
act on these discoveries. In this way, emotion is central in the
formation of social movements, and women derive powerful
knowledge in their connection to intense affect, often taking place
inside important relationships with others.
620 VAN VELSOR AND COX
Important relationships with others often include relationships
with therapists, and it is inside these unique bonds that survivors
often come to develop a sense of personal and separate identity for
the first time. Women in therapy with professionals who under-
stand gender and power often discover their "subjective knowing"
(P. Brown & Ferguson, 1995, p. 155) or inner voice-wisdom. This
can happen as survivors reclaim the-instrumentally angry aspects
of their personhoods.
The following case examples illustrate two female survivors'
emerging anger in the therapy process and depict the varied styles
with which women who are survivors of sexual trauma may
express anger. It is important to note that the identities of these
clients have been carefully disguised to protect anonymity.
The Case of Allison
"Allison," a 32-year-old Caucasian sales representative, came to
therapy to begin working through issues related to childhood
sexual abuse experienced at the hands of her maternal uncle,
"Jerry." She reported symptoms of posttraumatic stress disorder
(PTSD), including suicidal ideation and periods of sudden, intense
anxiety brought on by exposure to situations in which she or other
women were being sexually objectified. She disclosed an intense
fear of being alone as well as a history of relationship problems. It
was decided that Allison would attend sessions every other week
to accommodate her financial concerns and to respect her stated
desire to manage the emotional intensity of the therapeutic process,
which led to an 18-month course of treatment.
Allison's presenting distress also involved her own relationship
with "Brad," her partner of 1 year. Brad actively participated in a
pornography addiction, as had her Uncle Jerry, the perpetrator of
her childhood abuse, often pressuring Allison into watching por-
nographic movies with him and acting out the scenes from the
movies in their own relationship. The most distressing aspect about
Brad's sexuality, for Allison, was his constant comparison of her
physical attributes to those of other women with whom the couple
came into contact. For the first 6 to 9 months of therapy, Allison
found herself experiencing extreme visceral sensations (e.g., short-
ness of breath, dizziness), feelings of panic, and tearfulness in
response to Brad's allusions to pornography and other women. In
terms of Cox et al.'s (1999) model of anger diversion, Allison
seemed to be both suppressing and internalizing her anger at Brad.
As she diverted her anger, she tended to experience insecurity,
panic, dissatisfaction with her body, and physiological symptoms
instead of clear anger with an urge to act in her own behalf or voice
grievances with her partner. During this time, the therapist re-
flected Allison's feelings and encouraged her to recognize her own
dignity and worth as she noticed her outrage at Brad.
During the initial months of therapy, Allison spent a great deal
of time grieving about her potential for losing Brad, either to
another woman or in response to her own expressed anger. She
appeared more sensitized to her fear of loss and her physical
imperfections than her rights and dignities as Brad's partner. This
first excerpt from her therapy journal sheds light on her attempts to
disavow her anger in an effort to spare her relationship:
I feel so afraid. He (Brad) says he's been having a lot of fun at
his ... [parties] and he's not sure if he wants to be lovers.... I thought
maybe if we started having fun again, things might work out. I don't
understand why he broke up with me now.
Over time, her dialogue and journaling began a qualitative shift.
As a marker of this shift, Allison, who had given up her cherished
vocation of acting in local theaters so that Brad could develop his
acting without her being present to "distract" him with her jeal-
ousy, decided to rejoin her friends at the theater and reclaim this
part of her life. This excerpt in her journal illustrates an emerging
sense of anger in her relationship with Brad:
I was wrong because I did trust you and you weren't honest. You
didn't want me at the ... [parties] because you were checking out the
. .. [women]. The night we broke up, as painful as that was, you still
had to tell me about the ... [women] at the bar and then got mad at
me when I didn't want to talk about other women.
At this point, Allison experienced both uncompromising rage
for herself and all women and the sadness that accompanies the
knowledge of her separateness from Brad and others. The follow-
ing excerpt in Allison's journal shows her gradual development of
anger at the larger social context that supports and maintains
sexual oppression of women:
In America, we have our own version of genital cutting, breast
implants. We slice them open, insert an empty rubber bag, and then
fill it with saline solution. So, we have millions of women going
through life with water balloons shoved into their breasts. We live in
a patriarchal world and it's not spiritually healthy for women. God
bless us all. I hope we can learn to love our bodies just the way they
are without augmentation. I certainly hope I can learn to love mine.
Allison also fluctuated between clear, direct expressions of
anger toward its target and more indirect, passive expressions.
After approximately 12 months in therapy, she missed three con-
secutive therapy appointments without calling to cancel or explain
until the day after the missed appointments. When queried about
this, she struggled to explain her behavior, offering reassurance
that she was "not mad about anything." Weeks later, she alluded to
some vague feelings with regard to her therapist in the following
journal excerpt:
See, I know that you [therapist] will not like Tim [her new live-in
boyfriend]. You will probably be thinking that this is way too soon
and I haven't had time to get over Brad and I'm just going to repeat
the same old thing with another guy. .. . But I love him and he treats
me so much better than Brad ever did.
Allison and her therapist discussed this excerpt, and she tentatively
explored both her fear that her therapist wouldn't approve of the
new relationship and her anger that the therapist avoided giving
open endorsement of Allison's choices. This exchange seemed to
open the door to continued and more direct dialogue about Alli-
son's anger at her therapist. For example, Allison expressed anger
that her therapist tried to "get her off the phone" when she paged.
She accurately sensed her therapist's desire to make these
between-sessions conversations short, helping Allison focus on
ways to bring her current feelings and concerns to the next meet-
ing.
For Allison, anger awareness unfolded through in-session verbal
exploration and therapist encouragement, coupled with out-of-
session journaling and letter writing. Gradually, her anger became
more clearly articulated and directed not only at her perpetrator but
also at social systems that may tacitly foster the abuse of women.
Demonstrable therapeutic outcomes included Allison's return to
 ANGER AND SEXUAL ABUSE
the theater, a reduction in her suicidal thoughts, and a marked
decrease in her PTSD symptoms.
The Case of Keisha
"Keisha," a 22-year-old biracial (African American and Cauca-
sian) mother of two was referred for therapy through a state
contract with Children's Protective Services (CPS). Keisha had
been referred because of "an attitude problem" by the facilitator of
a parenting group that Keisha had been attending because of a
mandate by CPS. On further inquiry, Keisha was described as
"loud and boisterous" in the group and "verbally aggressive"
toward other group members. The facilitator reported that she had
received complaints from other group members (all White) about
Keisha's behavior. In addition, Keisha had "stormed off when the
facilitator had attempted to discuss this behavior with her after a
recent group session.
During the first session with the psychologist, a White woman,
Keisha appeared reluctant to talk about herself and told the ther-
apist that she did not want to be there. This prompted a discussion
between the two about Keisha's anger at CPS and the parenting
group facilitator for referring her for counseling. At some point
during this conversation, Keisha picked up a box of tissues and
hurled it forcefully against the cinder-block wall of the psycholo-
gist's office, making a sharp "whack." The psychologist remained
calm and reflected the apparent anger that provoked this move, to
which Keisha began to respond verbally. When invited to throw
the tissue box again, Keisha declined and sat in silence for most of
the remaining minutes of the session. She agreed to meet again the
following week.
Over the course of Keisha's 6 weeks of therapy, she disclosed
abuse experiences as a young teenager at the hands of an 18-year-
old male cousin and also by a neighbor in his thirties. When Keisha
communicated interest in the play therapy sessions of her children,
the therapist suggested that she explore her own feelings about
being abused through various art and craft activities. In this way,
Keisha was able to combine her tendency to verbalize about
factual material with her tendency toward more nonverbal emo-
tional expression. The therapist asked Keisha to describe her works
and try to name the feelings she had in response to them. Keisha
also wrote poetry about her feelings that included direct ("I'm so
mad at my mom for letting that happen") and indirect ("I would
like to take a knife and chop [Derek] into little pieces. I would start
by chopping off his you-know-what.") expressions of anger.
Where Keisha voiced a desire to physically punish her abusers, she
was queried as to her separation of fantasy and appropriate overt
behavior. In each case, Keisha reported understanding the distinc-
tion between the two and assured the therapist that she had no
intention of harming her perpetrators, even though the aggressive
fantasies persisted. All of these developments took place during
the 6-week intervention.
In terms of Cox et al.'s (1999) model of anger diversion, Keisha
entered therapy diverting her anger through externalization, pri-
marily in the form of physical punishment of her children. She also
had learned to externalize with people who otherwise might have
been her friends, as manifested in her behavior in the parenting
group. In other words, rather than talking directly about her anger
with group members or others, she disrupted the group process,
sometimes insulting those whose support would have helped her in
621
her efforts to grow and change. Most of the time, group members
recoiled from Keisha when she appeared angriest. Their with-
drawal from her fueled further isolation, resentment, and external-
ized anger on Keisha's part.
In therapy, the psychologist's reaction to the thrown tissue box
served as a turning point; her acknowledgement and acceptance of
Keisha's open and forceful expression of anger helped to ease
Keisha's fears about that anger and also helped her subsequently to
take responsibility for her emotional expressions. This precipitated
a form of anger work in which art activities and poetry served to
facilitate her anger awareness related to family and the abuse.
Markers of change in Keisha's case included her gradually
increased ability to listen to her peers in the therapy group. Keisha
seemed to relax and become more attentive as evidenced by the
reports of her group facilitator. She even reported a growing
friendship with two of her peers in group.
Implications for Practice
The cases of Allison and Keisha illustrate how anger may serve
as a vehicle for assigning appropriate responsibility to the perpe-
trator while accessing personal power. In the brief therapy of
Keisha, the psychologist demonstrated how therapist attitudes can
facilitate discussion of client anger; the therapist's nonverbal com-
munication to Keisha that she was comfortable with Keisha's
anger facilitated further client disclosure about family and anger.
In the longer term treatment of Allison, this client further exhibited
a growing awareness of the sociopolitical ramifications of her own
personal story. Allison had to grieve the loss of a socialized belief
in the myth that women should try to please men physically and
that such behavior connects women and men emotionally and
sexually. In doing this, Allison discovered that she felt angry about
women's socialized pressure to have bodies that resemble those of
plastic dolls and connected this broader injustice to her individual
perpetrators' behaviors.
In the cases presented here, the clients were symptomatic, but
neither one met full diagnostic criteria for PTSD, which appears to
be associated with childhood sexual abuse (Andrews, Brewin,
Rose, & Kirk, 2000). However, clients with PTSD often have
regulatory deficits, and uncontrolled anger in these clients can
activate destructive aggression (Novaco & Chemtob, 1998). Ac-
cording to Yehuda (1999), research is currently emerging that
supports the prevalence of aggression in PTSD, and, in such cases,
the use of psychopharmacology may be indicated, particularly if
the client is aggressive and explosive.
Although examinations of aggression and PTSD have tended to
focus on combat veterans (e.g., Beckham & Moore, 2000; Chem-
tob, Hamada, Roitblat, & Muraoka, 1994; Chemtob, Novaco,
Hamada, Gross, & Smith, 1997) and, to a somewhat lesser degree,
victims of violent crime (e.g., Brewin, Andrews, & Rose, 2000;
Feeny, Zoellner, & Foa, 2000), it is prudent for therapists to
recognize the connection between childhood sexual abuse and
PTSD in the diagnosis of survivors. Beckham and Moore (2000)
suggested the inclusion of anger and violence measures in assess-
ment of veterans with PTSD; the therapist treating the childhood
sexual abuse survivor must decide if such evaluation is warranted
for individual clients. In cases in which interpersonal violence is a
salient feature associated with a PTSD diagnosis, the therapist will
622 VAN VELSOR AND COX
want to fortify the client with anger control strategies such as those
outlined by Yehuda (1999).
The case of Allison demonstrated the use of anger as a vehicle
in the treatment of a White woman from a middle-class back-
ground. In treating women of color, it may be helpful to consider
a few pertinent issues. People whose cultural backgrounds are
more collective, or tend to emphasize group harmony over indi-
vidual goal seeking, may experience more distress if asked to focus
on anger, as it tends to be an emotion that highlights them as
unique or separate (Gabrielidis, Stephan, Ybarra, Pearson, & Vil-
lareal, 1997; Stephan, Stephan, & de Vargas, 1996; Triandis,
1994). Although within-group differences abound, Native Ameri-
cans, Asian Americans, and Latin Americans are all considered to
be more oriented toward the collective, or the goals of the group or
family, than are European Americans (Whites). Individuals from
these groups often prefer conflict resolution styles that highlight
accommodation to others. Thus, in working with Asian American
women, for example, caution should be exercised in encouraging
the overt expression of oppositional feeling. These women may be
more likely to benefit from techniques that indirectly empower
them and accentuate concern for others' well-being, without draw-
ing overt attention to their more self-focused emotion.
Therapists working with African American women, on the other
hand, should not assume that their clients will have difficulty
claiming and expressing anger or outrage, because Black women
may have more social sanction to express anger openly than White
women, particularly White women of higher socioeconomic status
(Coll, Cook-Nobles, & Surrey, 1997). The case of Keisha shows
the effects of anger acceptance by the therapist on the development
of a client's trust and self-exploration. Further, although Keisha's
peers were the ones demonstrating'distaste for her volatility, White
therapists working with Black women are very likely to experience
discomfort in receiving the anger of Black women (Cannon &
Heyward, 1992), that is, listening empathically and sharing the
anger experience versus deflecting or encouraging suppression.
Overall, it is important that therapists endeavor, through consul-
tation or further training, to develop cultural sensitivities as they
relate to anger work.
Because therapists report that graduate training regarding anger
is inadequate (Pope & Tabachnick, 1993), it is critical that the
psychologist explore his or her own upbringing and assumptions
about anger and its expression, especially as they relate to women,
before initiating anger work with survivors. We suggest that ther-
apists do genogram work aimed at uncovering family of origin
rules related to anger expression and role-playing episodes in
which they must work with an angry client. Especially relevant in
role-playing are those scenarios in which the "client's" anger is
directed at the therapist, because this creates the opportunity to
prepare for future countertransference by "practicing" with an
"angry client" in a supportive environment. These exercises can be
conducted with colleagues or in workshops designed for such
work. Psychologists working as supervisors to therapist trainees
can be helpful to their supervisees by promoting an atmosphere of
nonjudgmental acceptance and by modeling self-disclosure of sit-
uations that elicit supervisors' own angry responses (Abernethy,
1995).
Because a therapist's discomfort with anger expression may
reinforce a survivor's conditioning to suppress anger at parents and
other perpetrators, it is crucial that therapists possess basic atti-
tudes related to anger and its expression. The informed therapist
views anger as a positive force that helps women to reattribute
responsibility for past abuse as well as to define parameters of
acceptable treatment in current relationships. In the therapeutic
process with survivors, the psychologist needs to (a) reframe anger
as an adaptive emotion useful in defining one's own rights and
needs, (b) discuss the covert norms for anger expression by
women, and (c) help survivors harness anger for constructive
action, rather than diverting it (Cox et al., 1999). This serves to
counteract a widespread fundamental misunderstanding of anger
as destructive and a larger cultural imperative that disallows the
expression of anger, particularly for women (Miller & Surrey,
1997).
As the survivor in the recovery process becomes increasingly
sensitive to previously unacknowledged anger and knowledgeable
of family of origin variables relating to anger expression, she also
learns to identify her angry feelings as a signal that something
needs to be amended in her relational world and to act on her anger
instrumentally. Moreover, survivors may come to attach different
meanings to their anger as they learn to reclaim personal and
emotional space (Jack, 1999). These different meanings depend on
a variety of factors including culture, socioeconomic and relation-
ship status, and a host of other contextual and interpersonal vari-
ables. For instance, a single woman may readily see her anger in
terms of its survival value, whereas a married woman may need to
navigate her new-found emotional awareness around her partner's
suggestions that she revert to status quo behaviors. At this point in
the therapeutic process, psychologists can suggest ways for clients
to practice assertive expression in contexts such as trusted friend-
ships and work relationships. These should involve "I" statements
and some form of postencounter self-evaluation, such as
journaling.
Other therapeutic techniques involve releasing anger through
experiential exercises (Simonds, 1994), art (Backos & Pagon,
1999), or journaling; symbolically confronting the perpetrator
(Apolinsky & Wilcoxon, 1991); and learning to recognize other
instances that are abusive (Blume, 1990). Although none of these
techniques have been formally tested, clinical wisdom continues to
support their use.
Just as suppression or internalization of anger may have detri-
mental consequences for the survivor, some researchers suggest
that the direct experience of anger in the absence of self-regulatory
mechanisms can prove harmful (Novaco & Chemtob, 1998). Sur-
vivors may cope with overwhelming affect through self-injury
(Connors, 1996); destructive aggression, as in the case of PTSD
clients (Novaco & Chemtob, 1998); dissociation; sexual acting
out; or other self-destructive behaviors, such as suicide or exces-
sive substance abuse (Briere, 1996). In encouraging anger expres-
sion, it is the therapist's responsibility to monitor client affect to
keep the client from becoming overwhelmed and initiating these
inwardly or outwardly destructive avoidance responses. Therapists
treating clients whose presenting symptomatology includes such
responses should approach anger work with heightened caution. If
the client has problems with aggression, she will need to
strengthen self-regulation, which involves being helped by the
therapist to identify emotion, differentiate types and degrees of
emotion, and record self-observations (Novaco & Chemtob, 1998).
The processing of abuse memories requires a safe therapeutic
surround to help the survivor experiment with various levels of
 ANGER AND SEXUAL ABUSE
anger and to feel comfortable with such affects (Briere, 1992).
When the therapist determines that the client is so flooded with
affect that her internal protective systems are overwhelmed (Bri-
ere, 1996), he or she will need to help the survivor develop skills
to limit the intensity of affective states (Enns et al., 1998). This can
be done through the use of anger containment exercises, including
deep breathing and visualization (Simonds, 1994). One useful
image in this kind of visualization is that of a balloon filled with
air, the neck of which may be opened and closed deliberately to
allow air to escape or prevent it from doing so (M. Watson,
personal communication, September, 9, 1992).
Perhaps the most difficult task in facilitating the anger work of
the sexual abuse survivor surfaces when a woman begins to
experience and express her anger at her therapist. The client may
do so by criticism or rejection of the therapist, by missed appoint-
ments, or sometimes by even leaving therapy. The survivor's
repeated projections of angry feelings onto the clinician in the
therapy sessions, without fear of reprisal or rejection from the
therapist, can play a critical role in recovery (Briere, 1992). How-
ever, the relationship dynamics may threaten the psychologist, and
he or she may be tempted to suggest anger control techniques,
instead of facilitating direct client anger expression within the
safety of the therapeutic relationship. Case consultation with col-
leagues about ways to be receptive to client anger can help the
therapist to avoid unwittingly interfering with or even discourag-
ing the survivor's discovery of feelings. At this juncture, it is
important that the psychologist be aware of issues of
countertransference.
According to Dalenberg (2000), the literature on countertrans-
ference suggests that therapists' most typical reaction to client
anger is "counterhostility" manifested in responses such as "subtle
withdrawal or mistimed disclosures" (p. 198). In working with
trauma survivors, she contended, therapists develop countertrans-
ference anger in relation to issues such as perceived client manip-
ulation or frustration with the slow pace of therapy. In addition,
there may be countertransferential issues related to the gender of
the therapist (Pearlman & Saakvitne, 1995). The female therapist
may identify with the female survivor as grieving victim and, in
doing so, deny or condemn other client identifications and feel-
ings, including anger. On the other hand, the male therapist work-
ing with female survivors abused by men may feel guilt by
association with men. This guilt may precipitate feelings of defen-
sive anger in the therapist and interfere with his ability to hear
client anger at perpetrators. It is critical that therapists develop
strategies to address their own anger with survivors, and we
suggest that this requires the same instrumental expression of
anger prescribed for clients. The psychologist must strive to avoid
diverting countertransferential anger through withdrawal or coun-
terhostility and instead model instrumental anger expression by
appropriate interpretation, confrontation, and/or disclosure.
In sum, we suggest that anger be reframed as a developmental
medium through which sexual trauma survivors can experience
cognitive restructuring and self-empowerment in a supportive ther-
apeutic relationship. Although certain caveats argue for watchful-
ness on the part of the clinician, the carefully timed use of
techniques for promoting a woman's conscious awareness of her
anger may actually help her avoid some of the problematic behav-
iors typically associated with "dysfunctional anger" (Eckhardt &
Deffenbacher, 1995, p. 40) or with PTSD (Novaco & Chemtob,
623
1998). In other words, women may be able to develop empathy for
themselves (Arauzo, Watson, & Hulgus, 1994) and others through
deliberate attention to their own anger, its history, and its current
phenomenology.
Finally, because much practical clinical wisdom continues to
regard anger as a tool for survivors' self-healing, it follows that
more clinicians should begin to examine anger as central, not
peripheral, to the treatment process and to consider even its man-
ifestation as directed at the therapist to be a marker of growth and
change. This approach may require less in the way of technique
and more in the way of a shift—from thinking about anger as a
symptom to considering it as a vehicle for recovery.
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Psychological Association.

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