Anger: Helping Behavioral Health Clients to Choose Their Responses to This Very Normal Emotion

“If you are patient in one moment of anger, you will escape a hundred days of sorrow.” -Chinese Proverb

The Catalyst blog post for this week is about the Anger Management for Substance Abuse and Mental Health Clients: A Cognitive-Behavioral Therapy Manual and the accompanying Anger Management for Substance Use Disorder and Mental Health Clients: Participant Workbook which have both been newly revised as of October 2019—this month. The manuals were originally developed to provide tools for clinicians, who often see the link between anger, violence, and substance use (Shopshire & Reilly, 2013). With a focus on Cognitive Behavioral Therapy, the manual was the product of a National Institute on Drug Abuse grant and was funded by the Department of Veterans Affairs San Francisco Veterans Affairs Medical Center.

Anger, A Definition

To quote the therapy manual, “In the most general sense, anger is a feeling or emotion that ranges from mild irritation to intense fury and rage. Anger is a natural response to those situations where we feel threatened, we believe harm will come to us, or we believe that another person has unnecessarily wronged us. We may also become angry when we feel another person, like a child or someone close to us, is being threatened or harmed. Anger can be a positive emotion—a moral response to injustice or a rational response to a threat—and it can be expressed in assertive and productive ways. In addition, anger may result from frustration when our needs, desires, and goals are not being met” (Reilly & Shopshire, 2019). Anger is not negative, it isn’t bad to feel angry, and in fact, positive things can come from it. Out of control, however, anger can be very destructive and can potentially lead to problems in every area of life. In fact, negative consequences of anger out of control is why these manuals exist.

What is New in 2019: A Side by Side Comparison of Both Therapy Manuals

Authors listed for the Forward for the 2013 therapy manual are  Pamela S. Hyde, J.D., then Administrator for the Substance Abuse and Mental Health Services (SAMHSA) Administration, and Dr. H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, then Director of the Center for Substance Abuse Treatment (CSAT). For the 2019 revision, Elinore F. McCance-Katz, M.D., Ph.D., Assistant Secretary for Mental Health and Substance Use, SAMHSA, is listed. The Forwards for both the old and the new manuals are remarkably similar, only with updated dates to account for the 30 years the manual has been in use and the thousands of clients who have benefitted from the approach. One key focus of both Forewords is on the connection between anger, violence, trauma, and substance use, and the need for tools for treatment that can be used in the clinical setting.

The Table of contents for Both Manuals are essentially the same wording, indicating that the basic format is sound and was not changed in the revision. In the introductory section, what becomes obvious is that the references have been updated considerably, with some supporting the effectiveness of CBT being as recent as 2018. Within the introductions, both documents describe four types of CBT with foundations in social learning theory that are highlighted for use by clinicians:

• Relaxation training focusing on emotional and physiological components of anger
• Cognitive interventions using cognitive processes like building awareness of cues and trigger, hostile appraisals and attribution, maladaptive beliefs, and inflammatory thinking.
• Communication skill interventions for strengthening assertiveness and conflict resolution skills
• Combined intervention for integrating two or more CBT interventions and help clients aim for multiple response domains.

The “How to Use This Manual” section is a bit longer in the 2019 version. While the content is largely similar, some things appear to be emphasized more in the 2019 version, such as the design being for group therapy, encouragement for using the narrative scripts provided in the manual for presenting the material in each session, a new “Between-Session Challenge,” replaces -perhaps to reframe the concept in a more positive light- the “Homework Assignments,” and a caution that although some practitioners are using the manual for self-directed learning, there is little research supporting its effectiveness in producing behavior change in anger management.

Both manuals are divided into 12 sessions, with specific directions for each session, and the information is much the same in the new manual. Sessions begin with instructions to group leaders (an overview of what will be covered and some tips for each concept). In the 2019 revision the group leader instructions are more detailed and provide prompts and actions for responding to group members, with reasons provided for what they are being prompted to do or say. One example is that during session one, after a member has introduced himself and stated reasons for participating the anger management group and what they hope to achieve, it is suggested that the leader offer a supportive comment validating that decision. The reason given for this response is “Experience shows that this helps members feel the group will meet their needs and reduces the anxiety associated with the introductions and the first group session in general.” Knowing that the suggested response is purposeful will likely encourage the group leader to use the prompts and in doing so, improve the effectiveness of this anger management group therapy. Each group session begins with a check-in procedure where members of the group report on their anger events and how the techniques from previous sessions are working. The sessions are:

Session 1 Overview of Group Anger Management Treatment: This session covers things like instructions to group leaders, the purpose and rules of the group, a definition of anger and why it is a problem, myths about anger, the habitual nature of anger and how to change that, an overview of some strategies, the “Anger Meter,” and the introduction of the “Between-Session Challenge.” One thing new in the 2019 revision that was absent in the earlier version is setting time aside to check in with group members and some suggestions for facilitating discussion.

Session 2 Events and Cues: A Conceptual Framework for Understanding Anger: This session is about clients learning that their own thoughts are the basis for anger, learning to identify the events and triggers for anger, and learning to develop awareness of physical, behavioral, emotional, or cognitive/thoughts cues, or warning signs of anger. Tracking awareness as an introduction to coping with anger is also covered.

Session 3 Anger Control Plans: Helping Group Members Develop a Plan for Controlling Anger covers Cognitive-Behavioral Therapy and why it is so useful, developing anger control plans, developing strategies for anger-related events, and learning to tap into various social support systems when the need arises. Relaxation and deep-breathing techniques are introduced for use when physical cues to anger are felt.

Session 4 The Aggression Cycle: How to Change the Cycle, explains the aggression cycle, buildup, explosion, and aftermath, and introduces progressive muscle relaxation as a guided exercise for clients. The concept of thought stopping is taught as a means of interrupting the A-B-C-D

Session 5 Cognitive Restructuring: The A-B-C-D Model and Thought Stopping introduces the A-B-C-D Model (or rational-emotive model) and the concept of how feelings are determined by an individual’s interpretation and beliefs about an event.

Session 6 Practice Session #1: Reinforcing Learned Concepts is a session primarily for reviewing and reinforcing the first five sessions by having each participant describe the concepts as they understand them.

Sessions 7 & 8 Assertiveness Training and the Conflict Resolution Model: Alternatives for Expressing Anger covers the behaviors and skills that will help participants to manage their anger and avoid progressing to aggression. This information is quite lengthy and detailed compared to previous sessions, so two sessions are allowed to provide adequate time for all participants to learn and share the concepts as they manifest in their own lives.

Sessions 9 & 10 Anger and the Family: How Past Learning Can Influence Present Behavior continues the work of sessions 7 & 8 by allowing plenty of time for group members to process and share and to address any questions that might arise.

Session 11 Practice Session #2: Reinforcing Learned Concepts is another session primarily for reviewing and reinforcing previous sessions through review by the group leader and by having each participant describe the concepts as they understand them and relate their experiences in implementing them in their own lives.

Session 12 Closing and Graduation: Closing Exercise and Awarding of Certificates allows group members to review their anger control plans, rate components of the treatment, and engage in a closing exercise. The group leader also reviews each plan and provides corrective feedback if warranted.

Anger Management for Diverse Populations

Research showing the applicability of these CBT approaches for Veterans were mentioned in the original publication (and, in fact, the intervention was developed for studies at the San Francisco Veterans Affairs (SFVA) Medical Center and San Francisco General Hospital). Updated references and follow-up studies from the original research support the effectiveness and applicability of the manual for veterans, strengthening its usefulness for those populations. Similarly, studies from a variety of different countries support its applicability for people from other countries, increasing the cultural competence of this approach and the materials. The usefulness for those with substance use disorders (SUD) is supported by an experimental randomized controlled trial study that compared outcomes for two groups: one group was given a 12-session alcohol-adapted anger management treatment similar to that contained in the revised manual, and the other group was given a 12-step facilitation treatment. Levels of anger were decreased in both groups, but only in the anger management treatment group did those who lowered their anger levels reduce the likelihood of experiencing negative consequences related to alcohol consumption (Walitzer, Deffenbacher, & Shyhalla, 2015). The anger management model has also been shown to be effective for people with mood, anxiety, and thought disorders (SAMHSA, 2019).

The fact that the main “updates” to the October 2019 Anger Management manual and workbook revisions consist mainly of more current  studies supporting its effectiveness, studies supporting the effectiveness of Cognitive-Behavioral Therapy in treating other mental health issues, such as depression, traumatic stress, and anxiety, and an updated but similar cover design really underscores the usefulness, usability, and practicality of behavioral health providers having these tools in their “toolkits of therapy modalities”. Both the therapy manual and the client workbook are available in Korean and Spanish. For behavioral health providers who would like additional training on how to understand this issue in their clients and who would like to be more effective in helping clients understand, identify, and make behavioral choices around emotions with a focus on anger, CASAT Training is offering a workshop on Anger Management on Friday, November 1, 2019  from 9:00 AM – 4:30 PM PST in Las Vegas, Nevada. The learning objectives for the workshop are to help clinicians learn to:

• Be able to identify a range of human emotions and their adaptive functions
• Develop an understanding of emotions and their relationship to violence, thus identifying various risk factors for violence
• Develop a cursory knowledge of other potential causes of violence (e.g., substance use and medical conditions)
• Learn about different ways to assess for violence, including biopsychosocial information as well as formal assessment instruments

For additional related resources, check out our Resources and Uploads section.

Participate in the discussion in our comments section: Have you used the old anger management manual? Have you used the new anger management manual? If so how do they compare in your estimation? How have they worked for you and your clients?

References

Reilly, P.M., & Shopshire, M.S. Anger Management for Substance Use Disorder and Mental Health Clients: A Cognitive–Behavioral Therapy Manual. SAMHSA Publication No. PEP19-02-01-001. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2019.

Shopshire, M. S., & Reilly, P. M. (2013). Anger Management Treatment and Substance Use Disorders. In E. Fernandez (Ed.) Treatments for anger in specific populations: Theory, application, and outcome. Oxford University Press, United States.

Walitzer, K. S., Ph.D., Deffenbacher, J. L., Ph.D., & Shyhalla, K., Ph.D. (2015). Alcohol-adapted anger management treatment: A randomized controlled trial of an innovative therapy for alcohol dependence. Journal of Substance Abuse Treatment, 59, 83-93. doi:10.1016/j.jsat.2015.08.003

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