It has been our clinical impression that the experience and expression of intense anger during imaginal exposure may interfere with the emotional processing of fear and thereby limit reductions in PTSD symptoms. In support of this impression, Foa, Riggs, Massie, and Yarczower (1995) found that high levels of anger prior to treatment are associated with less fear arousal during imaginal exposure, which in turn is associated with poorer outcome. Therefore, to optimize the gains from PE it is important for the client to focus his or her attention and narrative on the fear- rather than the anger-eliciting aspects of the event. However, it is also important to validate the survivor's anger. When a client focuses primarily on anger, we first validate these feeling as an appropriate response to trauma and as a symptom of PTSD. We then explain that the focus on anger may prevent him or her from fully engaging the fear associated with the traumatic memory, although it may be less distressing to feel angry than to feel frightened. Indeed, some therapists have suggested that anger serves as a way of avoiding the fear associated with the memory. In most cases, clients agree readily with this observation and are able to refocus on the fear-related aspects of the memory. This shift can be further reinforced by reviewing the treatment rationale and explaining the importance of focusing on fear and anxiety. Support for the value of shifting away from anger and maintaining the focus of treatment on anxiety is provided by Cahill, Rauch, Hembree, and Foa (2003a), who found that treatments that targeted PTSD also resulted in a significant reduction in anger. The effect of PTSD treatment on anger was particularly notable among patients with extremely high anger scores prior to treatment. Anger scores at posttreatment did not differ between patients who started treatment with extremely high levels of anger and those who did not. Moreover, average posttreatment anger scores in both groups of patients were within the "normal" range, based on the normative sample.
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