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Cognitive and Behavioral Practice 18 (2011) 235–240

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A Comprehensive Treatment Program for a Case of Disturbed Anger

Raymond DiGiuseppe, St. John’s University and The Albert Ellis Institute

Santanello (2011) presented the case of a man with long-term anger problems who does not meet the criteria for any DSM-IV-TR
diagnosis for treatment recommendations by several authors. This paper presents a comprehensive treatment package applied to this
case. Of crucial importance is the building of a therapeutic alliance. In addition to refusing to agree to the goals and tasks of
therapy, this client has intimidated several previous therapists. Strategies to build the alliance are discussed. Cognitive restructuring
techniques aimed at the client's narcissistic needs for recognition by others and resentment about past abuses are all detailed. The use
of imaginal exposure to anger triggers and strategies to learn new adaptive behaviors are also explored.

with social roles, learning history, and environmental

THE case
with of
anger
Mr. problems.
P is similarInterestingly,
to many clients
when
who
he present
pre-
sented for treatment, Mr. P's problems failed to fit into
any DSM-IV-TR (American Psychiatric Association, 2004)
diagnostic categories. The lack of anger and aggressive
disorders in the DSM taxonomy has contributed to
misunderstandings and the lack of clear treatment
guidelines in such problems. Even when angry clients
present with a comorbid diagnosis, these conditions fail to
account for their disturbed anger and aggression.
Taxonomic categories help psychologists form initial
organizing schema to begin their case conceptualizations.
An understanding of the characteristics of disturbed
anger will guide psychologists in doing assessments that
can lead to successful treatment plans (Lachmund,
DiGiuseppe, & Fuller, 2005). Anger differs from other
emotional disturbance in that it is associated with
attributional, informational, and evaluative cognitions
that emphasize the misdeeds of others. Anger motivates a
response of antagonism to thwart, drive off, retaliate,
attack, seek retribution with, or control the source of the
perceived threat (DiGiuseppe & Tafrate, 2007). People
communicate anger through facial or postural gestures,
vocal inflections, aversive verbalizations, and aggressive
behavior. These forms of communication achieve the
goals of driving off the transgressor or reestablishing
the angry person's dominance in a social hierarchy
(Deffenbacher, Oetting, Lynch, & Morris, 1996). A
person's choice of strategies to communicate anger varies
1077-7229/10/235–240$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
contingencies (DiGiuseppe & Tafrate, 2007).
Anger is an empowering emotion (Frijda, 1986), which
people feel little desire to change (Scherer & Wallbott,
1994). Expressed anger often coerces others to comply
with the client's demands, to withdrawal from encroach-
ing on the client's resources, or to submit to the angry
client's display of social dominance (Stevens & Price,
1996). Anger destroys relationships (Scherer & Wallbott).
Despite this fact, even self-referred clients appear
ambivalent about controlling their anger. Once angry
clients recognize that their anger may be maladaptive,
they are still enticed by the allure of control and the fear
in others that anger inspires. Angry clients often focus on
the immediate control and dominance consequences of
anger and forget its impact on social relationships
(DiGiuseppe & Tafrate, 2007). For this reason, we have
recommended motivational enhancement strategies as
the first step in therapy. Such interventions need to
validate the nature of the client's perceived transgression
and the short-term positive consequences of anger, while
helping the client recognize the long-term destructive
nature of anger.
People seem to learn anger by operant learning
systems. We have uncovered no research supporting the
acquisition of learning through classical conditioning
(DiGiuseppe, Cannella & Kelter, 2007; DiGiuseppe &
Tafrate, 2007). This has two implications for treatment.
First, exposure treatments designed for treating anxiety
problems that require emotional reprocessing and long
exposure to the triggering stimuli may not be the best
strategy for anger. Second, clients need to learn
alternative responses to anger triggers that can receive
naturalistic reinforcers in the real world (DiGiuseppe
et al., 2007).
236
Anger is associated with certain cognitions, including
attributions for hostile intent by others, blaming and
condemning others, and demanding that desires become
reality (DiGiuseppe & Froh, 2002). Cognitive restructur-
ing with the angry client can result in alliance ruptures
because the client often perceives a therapist's attempts to
change their thinking as the therapist siding with the
transgressor. Therefore, some validation of the occur-
rence of the transgression may be required before a
therapist focuses on a client's maladaptive, dysfunctional
thoughts (DiGiuseppe & Tafrate, 2007). The cognitions
associated with anger are often overlearned, leading to
automaticity (Power & Dalgleish, 2008). Imaginal expo-
sure or other rehearsal or behavioral-based interventions
may be necessary to break the connection between the
triggering stimulus and the anger. The imagery recom-
mended here involves pairing the triggering stimulus with
a new response. Thus, our model includes several
components. These include validation of the occurrence
of a transgression, motivational enhancements, cognitive
restructuring emphasizing functional challenges to the
dysfunctional thoughts and building adaptive ones,
challenging the rigid demanding nature of these
thoughts, relaxation, imaginal exposure that links the
anger triggers with a new cognitive and affective response,
and assertive training that teaches new response to resolve
conflicts. An open trial study (Fuller, DiGiuseppe,
O'Leary, Fountain, 2010)ofthistreatmentfound
significant improvements from pre- to posttreatment on
the trait anger scale of the State-Trait Anger Expression
Inventory-II (STAXI-II; Spielberger, 1999); the Anger
Disorder Scale (ADS; DiGiuseppe & Tafrate, 2004) Total
Score; and idiosyncratic anger measurements of situa-
tional intensity and symptom severity (Deffenbacher &
McKay, 2000).
Case Conceptualization
Mr. P represents a prototype of cases seen for anger
treatment. Most noteworthy is that he meets no Axis I or II
diagnoses in DSM-IV-TR. Although he displays poor
adjustment and a long history of occupational and family
dysfunction, the present DSM failed to confirm that he
had a disorder. The lack of a diagnostic category results in
the lack of a schema to guide professionals in assessing
and conceptualizing a treatment plan for angry clients
(Lachmund et al., 2005). Because our present diagnostic
taxonomy excludes anger, the therapists involved in this
case have accumulated a notable lack of relevant
information concerning Mr. P's anger and aggression.
We know little about the relevant dimensions of Mr. P's
disturbed anger, such as the intensity, frequency, or
duration of his anger episodes, his degree of rumination,
resentment, suspiciousness, or his justifications for his
feelings and behaviors. We do not know if his anger
DiGiuseppe
motivates revenge, coercion, or experiential avoidance.
Knowing his motives would lead to a better understanding
of the function of his anger. We also do not know the
extent of his aggressive behaviors when angered. Mr. P.
has a history of both verbal aggression, aggression toward
objects and people. However, we do not know if he also
engages in secretive destruction of others' property,
passive, or relational aggression. He also might ruminate
and hold his anger in before exhibiting aggression. A full
evaluation of Mr. P's anger with either a structured
interview or an instrument that assesses many dimensions
of disturbed anger (i.e., Anger Disorders Scale [DiGiuseppe
&Tafrate,2004] or the Novaco Anger Inventory [Novaco,
2003]) would be helpful. From the available information,
Mr. P may meet the criteria for the Anger Regulation
and Expression Disorder: Combined Type (subjective
and expressive dysfunctional anger; DiGiuseppe &
Tafrate, 2007).
Despite previous treatment and his self-initiated return
to treatment, Mr. P appears unmotivated to change. Like
many of our clients, Mr. P was “strongly encouraged” to
seek treatment by his girlfriend. He revealed his lack of
motivation for change by stating that he does not believe
that he has an “anger issue” and “I'm doing this to get my
girlfriend off my back.” More evidence that he is
unmotivated to change comes from Mr. P's claim that
he would benefit from treatment that allowed him to
“vent about people” during the sessions. He seems to
enjoy expressing his anger, and fails to see that such
expression is destructive and will strengthen his anger
(Olatunji, Lohr, & Bushman, 2007).
Mr. P failed to establish a therapeutic alliance with his
previous therapists. He reported that he did not believe
that his therapist listened to him about his problems and
never believed that he and his therapist were “on the
same page.” He interpreted his therapist's suggestions
that he change his behavior as blaming him for his
problems. These statements suggest that Mr. P experi-
ences considerable resentment toward life, and perhaps
toward his harsh parents. He might believe that no one
has validated his complaints about life. He seeks
justification for his anger, and considers attempts to
change his anger invalidating. He reported that minor
inconveniences, such as long lines at the grocery store,
precipitate his anger episodes. He recognizes that he is
also angry at his “nagging” girlfriend, ungrateful, rotten
children, idiot drivers, the government, and people in
general. Almost anything or anyone can trigger his anger.
This suggests a more generalized rather than a situational
anger disorder, and that he has displaced anger toward
whoever is present in his environment.
It would be best to start therapy by changing his anger
reaction to one set of stimuli and then generalizing his
new reactions to other triggers. Mr. P's anger appears
 Comprehensive Treatment for Anger
triggered by immediate proximate annoyances, but he
has a reservoir of resentment towards the world that drives
this displaced anger. We would target treatment aimed at
the proximal stimuli before dealing with these distal
triggers of his anger (Robins & Novaco, 1999).
Mr. P has a very lonely life. His anger has alienated
many of those to whom he could be close. They, of course,
are all to blame. Most likely, he has little positive social
reinforcement or affection in his life. He has created a
system of internal self-talk that justifies and reinforces his
attitudes and behaviors, resulting in a life devoid of
intimacy. A final stage of his therapy would help him
develop the skills to form close relationships.
Mr. P's successful intimidation of his therapists is likely
to interfere with the therapeutic alliance in any additional
therapy. Mr. P has created relationships with his therapists
that mimic his relationships in the world. Somehow, a new
therapist needs to acknowledge and address this.
Specific Interventions
Developing a Therapeutic Alliance
The development of a good therapeutic alliance would
be the first task of therapy. Because Mr. P has intimidated
his previous therapists, I would assume that he would try
this with me, and I would prepare myself not to be
intimidated. Avoiding his intimidation or looking fearful
will reinforce his coercive behavior in the session. I would
assume that Mr. P intimidates others as well. The first time
he attempted to intimidate me, I would reflect the nature
of his behavior in a firm, nonemotional manner, so I
could earn his respect. I would offer him feedback about
how I perceived his presentation and discuss the functions
this behavior may have for him. I might say something
like, “I perceived some anger and hostility in your voice
when you said that. When people speak to me that way I
tend to want to distance myself from them and not want to
be close to them. Did you recognize that in your voice?”
Angry clients often do not recognize anger in their
intonation. If Mr. P was in a group, I might ask the group
for feedback. I also might suggest that he ask significant
others for feedback of how they perceive his voice. I would
follow up with another comment, “Did you intend for me
to back off or become distant to you when you said that?” I
would use such an episode as an opportunity to motivate
him to change by exploring the effect such behavior may
have on others. I might say, “Perhaps my reaction to the
way you spoke was unique to me, or perhaps others
experience you and react to you the way I did. What are
your thoughts on that?”
Next, I would build his motivation to change. We have
done this with a cost benefit analysis that asks clients to
complete an anger episode form (DiGiuseppe & Tafrate,
2007). This form has the client identify a specific anger
episode. Then we ask clients to Socratically review the
237
short- and long-term consequences of the episode. Most
likely, his coercion of others leads to some short-term
compliance with his demands but longer-term estrange-
ment. Next, clients rate the degree to which they find the
anger episode helpful. Most angry clients rate their anger
as functional, despite reporting many more negative than
positive consequences. Often, angry clients make errors of
selective abstraction (Beck, 1976). They rate the func-
tional outcome of an anger episode based on one
outcome and ignore the other consequences. I would
stick with this intervention until Mr. P reported that he
had an anger episode that he wished had not occurred.
Once he reported such an event, I would seize on the
moment and suggest that we try some strategies to bring
about that change. Even when he has developed some
motivation to change and we moved on to other
interventions, I would assess motivation for change on
each anger episode he brought up and we might start
each session with this intervention, assuming that his
motivation to change would remain precarious.
Next, we would set clear goals of controlling his anger
in specific situations. Many angry clients set goals on what
they want other people to do. This is the external
attribution of blame that goes with this emotion. Most
likely, he would set goals of his girlfriend being nicer to
him, gaining and keeping jobs, forming and keeping
friendships, or his children accepting him. Although
these things are desirable, they are not changes in his
emotions or behaviors. I would try to refocus the
conversation on what he could do to achieve these
goals. I would link the control of his anger, reductions in
his verbal aggression, and lack of prosocial behaviors with
achieving these longer-term goals.
Once Mr. P has developed sufficient motivation and
has clear goals, I would address agreement on the tasks
of therapy. He believes that venting his anger is
therapeutic. I would explain that we have substantial
research demonstrating that such activities will not help
him. I would explain how such activities feel good in the
short run, but they allow him to practice becoming angry
and often lead to more of this behavior in the long term.
Then I would attempt to explain how we could work at
tasks that could help him achieve the goals we already
stated. If he maintained his resistant attitude, I would ask
him to take an experimental attitude to my suggestions.
Since he has been angry for a long time, he has nothing
to lose if he tries these tasks. I would not begin any
cognitive or behavioral activities until he at least agreed
to try them.
Cognitive restructuring would be my next intervention.
I would ask Mr. P to collect records of his anger triggers
and the corresponding automatic thoughts. Given his
history, two types of thoughts are likely to emerge. The
first concerns threats to his esteem, and the second
238
involves thoughts of fairness and resentment about bad
treatment from specific people, the world, and from
everyone in his life.
Overcoming Ego-Threat
Many therapists still believe that anger results from low
self-esteem. The opposite is true (Baumeister, Campbell,
Krueger, Vohs, 2005). Angry and aggressive people
appear to have high but unstable self-esteem. In session,
they often report thoughts such as, “Who do they think
they are talking to?” or “I am better than they think I am.”
When I first started working with angry clients, I would try
to have them endorse the principle of REBT (Walen,
DiGiuseppe & Dryden, 1992)—that all humans have
equal worth and that they are no more or less worthy than
others. Although I still have this as a goal, I have learned
to reach it in successful approximations. It would be
difficult for Mr. P to surrender his narcissistic superiority
in one step. The first step might be to have Mr. P
surrender the belief that he needs others to acknowledge
his specialness. I would ask him why he needed their
recognition. I would validate his view that he might have
superior traits or skills compared with others. However,
does he need confirmation of his esteem by others? If he
is so superior, why does he need the recognition of others
to verify his worth? He can accept that others just do not
see things his way. He can spend his time becoming upset
with them, trying to convince them he is superior, or he
can get on with living and enjoying his life. I would
propose we work at adopting an alternative belief such as,
“I am an important person, but I do not need others to
recognize this for this to be true.” Personally, I feel
uncomfortable challenging clients' sense of superiority
this way. However, separating their reaction to ego threat
from the truth of their actual superiority has worked
better than seeking their acceptance that they are just as
worthwhile as everyone else is. As we progress in therapy,
Mr. P may discuss other episodes of anger at people for
not recognize his specialness, in which case I would
propose slightly different replacement beliefs: “I am just a
person in their life, and I might not seem special to them”
or “They are people just like me.” Most angry clients do
come around to viewing themselves as less superior as
they make progress.
Overcoming Resentment
Mr. P harbors resentment about his harsh treatment as
a child. Although his memories of such abuse might be
true, it may be irrelevant to his relationships after his
childhood. He blamed others for unsatisfying relation-
ships and did not take responsibility for any failed
relationships. Directly confronting him and telling him
to take responsibility for his actions will most likely result
DiGiuseppe
in an alliance rupture. I suspect I would fail in trying to get
at the truth of his memories. The data are not available.
He may have had a brutal and painful childhood.
Therefore, I would validate his perceptions of poor
treatment. In some areas, he has experienced abuse as a
child, and most likely real trauma in the military, or at the
hands of others. I would acknowledge that his losses and
pains are real. Acknowledging his resentments rather
than challenging their reality is the best strategy. I would
ask Mr. P to tell me what actions by the original
perpetrators would make life fair. How could he attain
real retribution and fairness? In discussing these issues
most clients recognize that they cannot undo the abuses
of their past, and that the perpetrators cannot undo the
past or make sufficient restitution, even if they were
willing to try. If the perpetrator is unwilling or unavailable
to make restitution, the client is stuck waiting to get better
on the whim or actions of someone else. I would propose
to Mr. P that he would benefit from accepting that bad
things have happened to him and that he cannot undo
them. Demanding that the past should not have
happened will only keep him in the pain of the past.
Demanding that the perpetrators make restitution for his
suffering makes him their prisoner. Mr. P could accept
that these events occurred and plan to move forward.
Acceptance means that he can move on with his life, so he
can live in the present and move toward achieving his
life's goals. I would work with Mr. P. on what behaviors he
can do to achieve a better life now.
Exposure Imagery
Once Mr. P can recognize the new alternative beliefs
and recognize that these elicit a different emotional
experience of annoyance or less intense anger, we would
work at exposure imagery tasks. I would stress to Mr. P the
importance of rehearsing new responses to his triggers. I
would ask Mr. P to imagine a specific trigger to his anger.
Once he has the image in his mind, I would have him
imagine thinking the new attitudes and the new affective/
emotional responses to these situations. These exposure
exercises focus on responding to triggers with new
responses and not on holding the image of the situations
until he experiences anger and then letting him habituate
to the anger (DiGiuseppe et al., 2007).
Problem Solving New Behaviors
After Mr. P could respond with a more functional
emotional response to his anger triggers, we would discuss
alternative behavioral response to the triggers. I would
rely on problem-solving therapy (D'Zurilla & Nezu, 2006)
and assertiveness training (Duckworth & Mercer, 2006)to
guide this phase of therapy. For example, Mr. P feels
angry with his children for not being close to him. I would
240 ComprehensiveDiGiuseppe
Treatment for Anger
Spielberger, C. when
D. (1999).
imagine that he Manual for with
interacts the State Traithis
them, Anger Expression
resentment
Inventory-2. Odessa, FL: Psychological Assessment Resources.
and anger lead to nasty behavior on his part that does not
Stevens, A., & Price, J. (1996). Evolutionary psychiatry: A new beginning.
makeNewtheYork:
visitRoutledge.
reinforcing for him. If we had covered the
steps
Walen,presented above,
S., DiGiuseppe, and
R., & he could
Dryden, have Aa practitioner's
W. (1992). different guide to
emotional reactiontherapy
rational-emotive to his (2nd
children, weYork:
ed.). New couldOxford.
plan new
things to say to them. It would be best if Mr. P started with
some assertive responses to his children's infrequent
contact. I would ask him to generate alternative things he
could say to them that would communicate his disap-
pointment but not express hostility. He would review the
alternatives, consider the consequences of each, and pick
one to rehearse. After several iterations of modeling,
coaching rehearsal, and feedback, we might decide that it
is time to try these new responses with his children.
People like Mr. P, who have a long history of anger,
often have extinguished overtures of friendship and
affection of the significant others in their lives. I would
suspect that this is true in this case. Mr. P's children might
have surrendered having a relationship with him, and
most likely come to each encounter with expectation that
their father will be sarcastic and nasty. I would try to have
Mr. P understand that he needs to take the initiative to
restore the relationship. This may involve his initiating
contact with his children many times. He may have to plan
pleasant, considerate interactions with them. Problem
solving about how to restore his old, damaged relation-
ships, how to build new ones, and role-playing and
rehearsing the means to accomplish these tasks would be
the final stage of therapy.
Conclusion
Mr. P has had a long history of anger problems, many
failures at therapy, success at intimidating his therapists,
little desire to change, and belief in a treatment strategy
known to exacerbate anger. This suggests that treatment
must first focus on developing a strong therapeutic
alliance, addressing his attempts to intimidate therapists
and securing agreement on the goals and tasks of therapy.
These elements are crucial before we can start on
cognitive, acceptance, and behavioral interventions that
could improve his situation. Mr. P's overrehearsed anger
will make treatment difficult. I think it is important to take
a structured and slow approach. I would anticipate slow
progress and periodic setbacks as he encounters anger
triggers that we had not discussed in therapy. I would look
out for Mr. P interpreting such events as evidence that he
cannot change.
The treatment plan suggested here rests on alliance-
building interventions in combination with more com-
monly used CBT approaches. The second part of this
treatment plan uses interventions that, when used alone,
have empirical support for their effectiveness (DiGiuseppe
& Tafrate, 2003). Combining these traditional CBT
approaches with alliance building and validation is a
239
Address correspondence to Raymond DiGiuseppe. John's University, St.
new approach. Only one open trial study of our treatment
John's University, Queens, NY 11439; e-mail: digiuser@stjohns.edu.
manual exists (Fuller et al., 2010). However, motivational
interventions have
Received: February 24,received
2009 empirical support for other
Accepted: October
problems 6, 2009
that show the same low motivation as anger
does (Miller
Available online&20Rollnick,
November2002).
2010
References
American Psychiatric Association (2004). Diagnostic and statistical
manual of mental disorders (4th ed., text revision). Washington,
DC: Author.
Baumeister, R. F., Campbell, Jennifer D., Krueger, J. I., & Vohs, K. D.
(2005). Exploding the self-esteem myth. Scientific American Mind,
16,50–57.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders.New York:
Meridian.
Deffenbacher, J., & McKay, M. (2000). Overcoming situational and general
anger: A protocol for the treatment of anger based on relaxation, cognitive
restructuring, and coping skills training. Oakland, CA: New Harbinger
Publications.
Deffenbacher, J., Oetting, E., Lynch, R., & Morris, C. (1996). The
expression of anger and its consequences. Behaviour Research and
Therapy, 34, 575–590.
DiGiuseppe, R., Cannella, C., & Kelter, J. (2007). Effective anger
treatments require a functional analysis of the anger response. In
T. A. Cavell & K.T. Malcolm (Eds.), Anger, aggression, and
interventions for interpersonal violence Mahwah, NJ: Lawrence
Erlbaum Associates.
DiGiuseppe, R. A., & Froh, J. J. (2002). What cognitions predict state
anger?Journal of Rational-Emotive and Cognitive-Behavior Therapy, 20,
133–150.
DiGiuseppe, R., & Tafrate, R. (2003). Anger treatment for adults: A
meta-analytic review. Clinical Psychology: Science and Practice, 10,
70–84.
DiGiuseppe, R., & Tafrate, R. (2004). The anger disorder scale: Manual.
Toronto, Ontario, Canada: MultiHealth Systems.
DiGiuseppe, R., & Tafrate, R. (2007). Understanding anger disorders. New
York: Oxford University Press.
Duckworth, M. P., & Mercer, V. (2006). Assertiveness training. In J. E.
Fisher & W.T. O'Donohue (Eds.), Practitioner's guide to evidence-
based psychotherapy (pp. 80–92). New York: Springer Science.
D'Zurilla, T., & Nezu, A. M. (2006). Problem-solving therapy: A positive
approach to clinical intervention (3rd ed.). New York: Springer.
Frijda, N. H. (1986). The emotions. London: Cambridge University Press.
Fuller, J. R., DiGiuseppe, R., O'Leary, S., & Fountain, T. (2010). An open
trial of a comprehensive anger treatment program on an outpatient
sample. Behavioural and Cognitive Psychotherapy, 38,485–490.
Lachmund, E., DiGiuseppe, R., & Fuller, J. R. (2005). Clinicians'
diagnosis of a case with anger problems. Journal of Psychiatric
Research, 39, 439–447.
Miller, W., & Rollnick, S (2002). Motivational interviewing: Preparing people
to change addictive behavior (2nd ed.). New York: Guilford Press.
Novaco, R. W. (2003). Novaco Anger Scale and provocation inventory. Los
Angeles: Western Psychological Services.
Olatunji, B., Lohr, J. M., & Bushman, B. J. (2007). The pseudopsychology
ofventing in the treatment of anger: Implications and alternatives for
mentalhealthpractice.InT.A.Cavell&K.T.Malcolm(Eds.),Anger,
aggression, and interventions for interpersonal violence (pp. 119–141).
Mahwah, NJ: Lawrence Erlbaum Associates.
Power, M., & Dalgleish, T. (2008). Cognition and emotion: From order to
disorder (2nd ed.). Hove, UK: Psychology Press.
Robins, S., & Novaco, R. (1999). A systems conceptualization and
treatment of anger. Journal of Clinical Psychology, 55, 325–337.
Santanello, A. P. (2011). A composite case study of an individual with
angeras a presenting problem. Cognitive and Behavioral Practice, 18,
209–211.
Scherer, K. R., & Wallbott, H. G. (1994). Evidence for the universality
and cultural variation of differential emotional response patterns.
Journal of Personality and Social Psychology, 67,55–65.