psychology self help anger management a cognitive behavioral therapy manual

ANGER

ANGER

MANAGEMENT

MANAGEMENT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

www.samhsa.gov

for Substance Abuse and

Mental Health Clients

A Cognitive Behavioral

Therapy Manual

for Subst ance Abuse and

Ment al Heal t h Cl i ent s

A Cogni t i ve Behavi or al Ther apy Manual

Patric k M. Re illy, Ph.D. Mic hae l S. Sho pshire , Ph.D.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n Ce nte r fo r Substanc e Abuse Tre atme nt

Ro c kwall II

5 6 0 0 Fishe rs Lane Ro c kville , MD 2 0 8 57

Acknowledgm ents

Nume ro us pe o ple c o ntribute d to the de ve lo pme nt o f this manual (se e appe ndix). The do c u-me nt was writte n by Patric k M. Re illy, Ph.D., and Mic hae l S. Sho pshire , Ph.D., o f the San Franc isc o Tre atme nt Re se arc h Ce nte r. Sharo n Hall, Ph.D., was the Tre atme nt Re se arc h Ce nte r’ s Princ ipal Inve stigato r.

Disclaim er

This do c ume nt is, in part, a pro duc t o f re se arc h c o nduc te d with suppo rt fro m the Natio nal Institute o n Drug Abuse , Grant DA 0 9 2 5 3 , and the De partme nt o f Ve te rans Affairs to the San Franc isc o VA Me dic al Ce nte r, San Franc isc o Tre atme nt Re se arc h Ce nte r, De partme nt o f Psyc hiatry, Unive rsity o f Califo rnia, San Franc isc o . The do c ume nt was pro duc e d by Jo hnso n, Bassin & Shaw, Inc ., unde r Co ntrac t No . 27 0 -9 9 -7 07 2 with the Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n (SAMHSA), U.S. De partme nt o f He alth and Human Se rvic e s (DHHS). Karl White , Ed.D., se rve d as the Ce nte r fo r Substanc e Abuse Tre atme nt (CSAT)

Kno wle dge Applic atio n Pro gram (KAP) Pro je c t Offic e r. The c o nte nt o f this public atio n do e s no t ne c e ssarily re fle c t the vie ws o r po lic ie s o f CSAT, SAMHSA, o r DHHS.

Public Dom ain Notice

All mate rial appe aring in this re po rt is in the public do main and may be re pro duc e d o r c o pie d witho ut pe rmissio n fro m SAMHSA o r CSAT. Citatio n o f the so urc e is appre c iate d. Ho we ve r, this public atio n may no tbe re pro duc e d o r distribute d fo r a fe e witho ut the spe c ific , writte n autho ri-zatio n o f the Offic e o f Co mmunic atio ns, SAMHSA, DHHS.

Electronic Access and Copies of Publication

This public atio n c an be ac c e sse d e le c tro nic ally thro ugh the fo llo wing Inte rne t Wo rld Wide We b c o nne c tio n: www.samhsa.go v/ . Fo r additio nal fre e c o pie s o f this do c ume nt, ple ase c all

SAMHSA’ s Natio nal Cle aringho use fo r Alc o ho l and Drug Info rmatio n at 1 -8 0 0 -7 2 9 -6 6 8 6 o r 1 -8 0 0 -4 8 7 -4 8 8 9 (TDD).

Recom m ended Citation

Re illy PM and Sho pshire MS. Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : A Co gnitive Be havio ral The rapy Manual. DHHS Pub. No . (SMA) 0 2 -3 6 6 1 . Ro c kville , MD: Ce nte r fo r Substanc e Abuse Tre atme nt, Substanc e Abuse and Me ntal He alth Se rvic e s

Administratio n, 2 0 0 2 .

Originating Office

Offic e o f Evaluatio n, Sc ie ntific Analysis and Synthe sis, Ce nte r fo r Substanc e Abuse Tre atme nt, Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n, 5 6 0 0 Fishe rs Lane , Ro c kville , MD 2 0 8 57.

DHHS Public atio n No . (SMA) 0 2 -3 6 6 1 Printe d 2 0 0 2

Substanc e use and abuse o fte n c o e xist with ange r and vio le nc e . Data fro m the Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n’ s Natio nal Ho use ho ld Surve y o n Drug Abuse , fo r e xample , indic ate d that 4 0 pe rc e nt o f fre que nt c o c aine use rs re po rte d e ngaging in so me fo rm o f vio le nt be havio r. Ange r and vio le nc e o fte n c an have a c ausal ro le in the initiatio n o f drug and alc o ho l use and c an also be a c o nse que nc e asso c iate d with substanc e abuse . Individuals who e xpe rie nc e traumatic e ve nts, fo r e xample , o fte n e xpe rie nc e ange r and ac t vio -le ntly, as we ll as abuse drugs o r alc o ho l.

Clinic ians o fte n se e ho w ange r and vio le nc e and substanc e use are linke d.

Many substanc e abuse and me ntal he alth c lie nts are vic tims o f traumatic life e ve nts, whic h, in turn, le ad to substanc e use , ange r, and vio le nc e .

De spite the c o nne c tio n o f ange r and vio le nc e to substanc e abuse , few tre atme nts have be e n deve lo pe d to addre ss ange r and vio le nc e pro ble ms amo ng pe o ple who abuse substanc e s. Clinic ians have fo und the de arth o f tre atme nt appro ac he s fo r this impo rtant issue dishe arte ning. To pro vide c linic ians with to o ls to he lp de al with this impo rtant issue , the Ce nte r fo r Substanc e Abuse Tre atme nt o f the Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n is

ple ase d to pre se nt Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : A Co gnitive Be havio ral The rapy Manualand its c o mpanio n bo o k Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : Partic ipant Wo rkbo o k.

The ange r manage me nt tre atme nt de sign in this manual, whic h has be e n de live re d to hun-dre ds o f c lie nts o ve r the past 8 ye ars, has be e n po pular with bo th c linic ians and c lie nts. This tre atme nt de sign c an be use d in a varie ty o f c linic al se ttings and will be be ne fic ial to the fie ld. Charle s G. Curie , M.A., A.C.S.W.

Administrato r

Substanc e Abuse and Me ntal He alth Se rvic e s Administratio n H. We stle y Clark, M.D., J.D., M.P.H., CAS, FASAM

Dire c to r

Ce nte r fo r Substanc e Abuse Tre atme nt Washingto n, D.C.

Fo re wo rd . . . iii

Intro duc tio n . . . 1

Ho w To Use This Manual . . . 5

Se ssio n 1 Ove rvie w o f Gro up Ange r Manage me nt Tre atme nt. . . 7

Se ssio n 2 Eve nts and Cue s: A Co nc e ptual Frame wo rk fo r Unde rstanding Ange r . . . 1 5 Se ssio n 3 Ange r Co ntro l Plans: He lping Gro up Me mbe rs De ve lo p a Plan fo r Co ntro lling Ange r . . . 2 1 Se ssio n 4 The Aggre ssio n Cyc le : Ho w To Change the Cyc le . . . 27

Se ssio n 5 Co gnitive Re struc turing: The A-B-C-D Mo de l and Tho ught Sto pping . . . . 3 3 Se ssio n 6 Re vie w Se ssio n # 1 : Re info rc ing Le arne d Co nc e pts . . . 37

Se ssio ns 7 & 8 Asse rtive ne ss Training and the Co nflic t Re so lutio n Mo de l: Alte rnative s fo r Expre ssing Ange r . . . 3 9 Se ssio ns 9 & 1 0 Ange r and the Family: Ho w Past Le arning Can Influe nc e Pre se nt Be havio r. . . 4 5 Se ssio n 1 1 Re vie w Se ssio n # 2 : Re info rc ing Le arne d Co nc e pts . . . 4 9 Se ssio n 1 2 Clo sing and Graduatio n: Clo sing Exe rc ise and Awarding o f Ce rtific ate s . . . 51

Re fe re nc e s . . . 5 3 Appe ndix: Autho rs’ Ac kno wle dgme nts . . . 57

This manual was de signe d fo r use by qualifie d substanc e abuse and me ntal he alth c linic ians who wo rk with substanc e abuse and me ntal he alth c lie nts with c o nc urre nt ange r pro ble ms. The manual de sc ribe s a 1 2 -we e k c o gnitive be havio ral ange r manage me nt gro up tre atme nt. Eac h o f the 1 2 9 0 -minute we e kly se ssio ns is de sc ribe d in de tail with spe c ific instruc tio ns fo r gro up le ade rs, table s and figure s that illustrate the ke y c o nc e ptual c o mpo ne nts o f the tre at-me nt, and ho at-me wo rk assignat-me nts fo r the gro up partic ipants. An ac c o mpanying Partic ipant Wo rkbo o k is available (se e Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : Partic ipant Wo rkbo o k, Re illy, Sho pshire , Durazzo , & Campbe ll, 2 0 0 2 ) and sho uld be use d in c o njunc tio n with this manual to e nable the partic ipants to be tte r le arn, prac tic e , and inte grate the tre atme nt strate gie s pre se nte d in the gro up se ssio ns. This inte rve ntio n was de ve l-o pe d fl-o r studie s at the San Franc isc l-o Ve te rans Affairs (SFVA) Me dic al Ce nte r and San

Franc isc o Ge ne ral Ho spital.

Co gnitive be havio ral the rapy (CBT) tre atme nts have be e n fo und to be e ffe c tive , time -limite d tre atme nts fo r ange r pro ble ms (Be c k & Fe rnande z, 1 9 9 8 ; De ffe nbac he r, 1 9 9 6 ; Trafate , 1 9 9 5 ). Fo ur type s o f CBT inte rve ntio ns, the o re tic ally unifie d by princ iple s o f so c ial le arning the o ry, are mo st o fte n use d whe n tre ating ange r diso rde rs:

• Re laxatio n inte rve ntio ns ,whic h targe t e mo tio nal and physio lo gic al c o mpo ne nts o f ange r • Co gnitive inte rve ntio ns , whic h targe t c o gnitive pro c e sse s suc h as ho stile appraisals and

attributio ns, irratio nal be lie fs, and inflammato ry thinking

• Co mmunic atio n s kills inte rve ntio ns , whic h targe t de fic its in asse rtive ne ss and c o nflic t re so -lutio n skills

• Co mbine d inte rve ntio ns ,whic h inte grate two o r mo re CBT inte rve ntio ns and targe t multiple re spo nse do mains (De ffe nbac he r, 1 9 9 6 , 1 9 9 9 ).

Me ta-analysis studie s (Be c k & Fe rnande z, 1 9 9 8 ; Edmo ndso n & Co nge r, 1 9 9 6 ; Trafate , 1 9 9 5 ) c o nc lude that the re are mo de rate ange r re duc tio n e ffe c ts fo r CBT inte rve ntio ns, with ave rage e ffe c t size s ranging fro m 0 .7 to 1 .2 (De ffe nbac he r, 1 9 9 9 ). Fro m the se studie s, it c an be

infe rre d that the ave rage partic ipant unde r CBT c o nditio ns fare d be tte r than 76 pe rc e nt o f c o n-tro l partic ipants. The se re sults are c o nsiste nt with o the r me ta-analysis studie s e xamining the e ffe c tive ne ss o f CBT inte rve ntio ns in the tre atme nt o f de pre ssio n (Do bso n, 1 9 8 9 ) and anxie ty (Van Balko m e t al., 1 9 9 4 ).

The tre atme nt mo de l de sc ribe d in this manual is a c o mbine d CBT appro ac h that e mplo ys re lax-atio n, c o gnitive , and c o mmunic lax-atio n skills inte rve ntio ns.

This c o mbine d appro ac h pre se nts the partic ipants with o ptio ns that draw o n the se diffe re nt inte rve ntio ns and the n e nc o urage s the m to de ve lo p individualize d ange r c o ntro l plans using as many o f the te c hnique s as po ssible . No t all the partic ipants use all the te c hnique s and inte r-ve ntio ns pre se nte d in the tre atme nt (e .g., c o gnitir-ve re struc turing), but almo st all finish the tre atme nt with mo re than o ne te c hnique o r inte rve ntio n o n the ir ange r c o ntro l plans. The o re tic ally, the mo re te c hnique s and inte rve ntio ns an individual has o n his o r he r ange r c o ntro l plan, the be tte r e quippe d he o r she will be to manage ange r in re spo nse to ange r-pro vo king e ve nts.

In studie s at the SFVA Me dic al Ce nte r and San Franc isc o Ge ne ral Ho spital using this tre atme nt mo de l, signific ant re duc tio ns in se lf-re po rte d ange r and vio le nc e have c o nsiste ntly be e n fo und, as we ll as de c re ase d substanc e use (Re illy, Clark, Sho pshire , & De luc c hi, 1 9 9 5 ; Re illy,

Sho pshire , & Clark, 1 9 9 9 ; Re illy & Sho pshire , 2 0 0 0 ; Sho pshire , Re illy, & Ouao u, 1 9 9 6 ). Mo st partic ipants in the se studie s me t Diagno stic and Statistic al Manual o f Me ntal Dis o rde rs, 4 th Editio n (DSM-IV) (Ame ric an Psyc hiatric Asso c iatio n, 1 9 9 4 ) c rite ria fo r substanc e de pe nde nc e , and many also me t DSM-IV c rite ria fo r po sttraumatic stre ss diso rde r. A study c o mparing Cauc asian and Afric an-Ame ric an patie nts fo und that patie nts fro m bo th gro ups re duc e d the ir ange r signific antly (Clark, Re illy, Sho pshire , & Campbe ll, 1 9 9 6 ). Ano the r study sho we d that wo me n also be ne fite d fro m the inte rve ntio n—that is, re po rte d de c re ase d le ve ls o f ange r (Re illy e t al., 1 9 9 6 ).

In the ange r manage me nt studie s using this manual, the majo rity o f patie nts we re fro m e thnic mino rity gro ups. Co nsiste nt re duc tio ns in ange r and aggre ssive be havio r o c c urre d in the se gro ups, indic ating that ange r manage me nt gro up tre atme nt is e ffe c tive . The tre atme nt mo de l is fle xible and c an ac c o mmo date rac ial, c ultural, and ge nde r issue s. The e ve nts o r situatio ns that trigge r so me o ne ’ s ange r may vary so me what de pe nding o n his o r he r c ulture o r ge nde r. The c ue s o r warning signs o f ange r may vary in this re gard as we ll. Ne ve rthe le ss, the o ve rall tre atme nt mo de l still applie s and was fo und e ffe c tive with diffe re nt e thnic gro ups and with bo th me n and wo me n. A pe rso n still has to ide ntify the trigge ring e ve nt, re c o gnize the c ue s to ange r, and de ve lo p ange r manage me nt (c o gnitive be havio ral) strate gie s in re spo nse to the e ve nt and c ue s, re gardle ss o f whe the r the se e ve nts and c ue s are diffe re nt fo r o the r me n and wo me n o r fo r pe o ple in o the r c ultural gro ups.

The inte rve ntio n invo lve s de ve lo ping individualize d ange r c o ntro l plans. Fo r e xample , so me wo me n ide ntifie d the ir re latio nships with the ir bo yfrie nds o r partne rs o r pare nting c o nc e rns as e ve nts that trigge re d the ir ange r but me n rare ly ide ntifie d the se issue s. Effe c tive individual strate gie s c o uld be de ve lo pe d, ho we ve r, to addre ss the se issue s, pro vide d the wo me n ac c e pt the c o nc e pts o f mo nito ring ange r (using the ange r me te r) and having (and using) an ange r c o n-tro l plan.

This tre atme nt mo de l was also use d suc c e ssfully with no n– substanc e -abusing c lie nts se e n in the o utpatie nt SFVA Me ntal He alth Clinic . The se c lie nts we re diagno se d with a varie ty o f pro b-le ms, inc luding mo o d, anxie ty, and tho ught diso rde rs. The tre atme nt c o mpo ne nts de sc ribe d in this manual se rve d as the c o re tre atme nt in the se studie s.

The ange r manage me nt tre atme nt sho uld be de live re d in a gro up se tting. The ide al numbe r o f partic ipants in a gro up is 8 , but gro ups c an range fro m 5 to 1 0 me mbe rs. The re are se ve ral re aso ns fo r this re c o mme ndatio n. First, so lid e mpiric al suppo rt e xists fo r gro up c o gnitive be havio ral inte rve ntio ns (Carro ll, Ro unsaville , & Gawin, 1 9 9 1 ; Maude -Griffin e t al., 1 9 9 8 ; Smo ko wski & Wo darski, 1 9 9 6 ); se c o nd, gro up tre atme nt is e ffic ie nt and c o st-e ffe c tive (Ho yt, 1 9 9 3 ; Pipe r & Jo yc e , 1 9 9 6 ); and third, it pro vide s a gre ate r range o f po ssibilitie s and fle xibility in ro le plays (Yalo m, 1 9 9 5 ) and be havio ral re he arsal ac tivitie s (He imbe rg & Juste r, 1 9 9 4 ; Juste r & He imbe rg, 1 9 9 5 ). Co unse lo rs and so c ial wo rke rs sho uld have training in c o gnitive be havio ral the rapy, gro up the rapy, and substanc e abuse tre atme nt (pre fe rably, at the maste r’ s le ve l o r highe r; do c to ral-le ve l psyc ho lo gists have de live re d the ange r manage me nt tre atme nt as we ll). Altho ugh a gro up fo rmat is re c o mme nde d fo r the ange r manage me nt tre atme nt, it is po ssible fo r qualifie d c linic ians to use this manual in individual se ssio ns with the ir c lie nts. In this c ase , the same tre atme nt fo rmat and se que nc e c an be use d. Individual se ssio ns pro vide mo re time fo r in-de pth instruc tio n and individualize d be havio ral re he arsal.

The ange r manage me nt tre atme nt manual is de signe d fo r adult male and fe male substanc e abuse and me ntal he alth c lie nts (age 1 8 ye ars and abo ve ). The gro ups studie d at SFVA Me dic al Ce nte r and San Franc isc o Ge ne ral Ho spital have inc lude d patie nts who have use d many substanc e s (e .g., c o c aine , alc o ho l, he ro in, me thamphe tamine ). The se patie nts have be e n able to use the ange r manage me nt mate rials and be ne fit fro m the gro up tre atme nt de spite dif-fe re nc e s in the ir primary drug o f abuse .

It is re c o mme nde d that partic ipants be abstine nt fro m drugs and alc o ho l fo r at le ast 2 we e ks prio r to jo ining the ange r manage me nt gro up. If a partic ipant had a “slip” during his o r he r e nro llme nt in the gro up, he o r she was no t disc harge d fro m the gro up. Ho we ve r, if he o r she had re pe ate d slips o r a full-blo wn re lapse , the individual was re fe rre d to a mo re inte nsifie d tre atme nt se tting and aske d to start the ange r manage me nt tre atme nt again.

Many gro up partic ipants we re diagno se d with c o -o c c urring diso rde rs (e .g., po sttraumatic stre ss diso rde r [PTSD], mo o d diso rde r, psyc ho sis) but be ne fite d fro m the ange r manage me nt gro up tre atme nt. Patie nts we re c o mpliant with the ir psyc hiatric me dic atio n re gime n and we re mo ni-to re d by inte rdisc iplinary tre atme nt te ams. The San Franc isc o gro up fo und that, if patie nts we re c o mpliant with the ir me dic atio n re gime n and abstine nt fro m drugs and alc o ho l, the y c o uld c o mpre he nd the tre atme nt mate rial and e ffe c tive ly use c o nc e pts suc h as time o uts and tho ught sto pping to manage ange r. Ho we ve r, if a partic ipant had a histo ry o f se ve re me ntal ill-ne ss, did no t c o mply with instruc tio ns o n his o r he r psyc hiatric me dic atio n re gime n, and had diffic ulty pro c e ssing the mate rial o r ac c e pting gro up fe e dbac k, he o r she was re fe rre d to his o r he r psyc hiatrist fo r be tte r me dic atio n manage me nt.

Se ve ral prac titio ne rs have re que ste d the manual to wo rk with ado le sc e nt c lie nts in substanc e abuse tre atme nt, but no pre liminary data fro m the se tre atme nt e nc o unte rs are available . Be c ause o f the many pro ble ms o fte n e xpe rie nc e d by substanc e abuse and me ntal he alth c lie nts, this inte rve ntio n sho uld be use d as an adjunc tive tre atme nt to substanc e abuse and

me ntal he alth tre atme nt. Ce rtain issue s, suc h as ange r re late d to c lie nts’ family o f o rigin and past le arning, fo r e xample , may be st be e xplo re d in individual and gro up the rapy o utside the ange r manage me nt gro up.

Finally, the autho rs stre ss the impo rtanc e o f pro viding o ngo ing ange r manage me nt afte rc are gro ups. Partic ipants at the SFVA Me dic al Ce nte r re pe ate dly aske d to atte nd afte rc are gro ups whe re the y c o uld c o ntinue to prac tic e and inte grate the ange r manage me nt strate gie s the y le arne d in this tre atme nt. At the SFVA Me dic al Ce nte r, bo th an o ngo ing dro p-in gro up and a mo re struc ture d 1 2 -we e k phase -two gro up we re pro vide d as afte rc are c o mpo ne nts. The se gro ups he lp partic ipants maintain (and furthe r re duc e ) the de c re ase d le ve l o f ange r and aggre ssio n the y ac hie ve d during the initial 1 2 -we e k ange r manage me nt gro up tre atme nt. Partic ipants c an also be re fe rre d to ange r manage me nt gro ups in the c o mmunity.

It is ho pe d that this ange r manage me nt manual will he lp substanc e abuse and me ntal he alth c linic ians pro vide e ffe c tive ange r manage me nt tre atme nt to c lie nts who e xpe rie nc e ange r pro b-le ms. Re duc tio ns in fre que nt and inte nse ange r and its de struc tive c o nse que nc e s c an b-le ad to impro ve d physic al and me ntal he alth o f individuals and familie s.

The info rmatio n pre se nte d in this manual is inte nde d to allo w qualifie d me ntal he alth and sub-stanc e abuse pro fe ssio nals to de live r gro up c o gnitive be havio ral ange r manage me nt tre atme nt to c lie nts with substanc e abuse and me ntal he alth diso rde rs. Eac h o f the 1 2 9 0 -minute we e kly se ssio ns is divide d into fo ur se c tio ns:

• Instruc tio ns to Gro up Le ade rs

• Che c k-In Pro c e dure (be ginning in the se c o nd se ssio n)

• Sugge ste d Re marks

• Ho me wo rk Assignme nts.

The Instruc tio ns to Gro up Le ade rs se c tio n summarize s the info rmatio n to be pre se nte d in the se ssio n and o utline s the ke y c o nc e ptual c o mpo ne nts. The Che c k-In Pro c e dure se c tio n pro vide s a struc ture d pro c e ss by whic h gro up me mbe rs c he c k in at e ac h se ssio n and re po rt o n the pro gre ss o f the ir ho me wo rk assignme nts fro m the pre vio us we e k. The Sugge ste d Re marks se c -tio n pro vide s narrative sc ripts fo r the gro up le ade r pre se nting the mate rial in the se ssio n.

Altho ugh the gro up le ade r is no t re quire d to re ad the s c ripts ve rbatim, the gro up le ade r s ho uld de live r the info rmatio n as c lo s e ly as po s s ible to the way it is in the s c ript.The Ho me wo rk Assignme nt se c tio n pro vide s instruc tio ns fo r gro up me mbe rs o n what tasks to re vie w and prac -tic e fo r the ne xt me e ting. Se ssio n 1 also inc lude s a spe c ial se c tio n that pro vide s an o ve rvie w o f the ange r manage me nt tre atme nt and o utline s the gro up rule s.

This manual sho uld be use d in c o njunc tio n with the Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : Partic ipant Wo rkbo o k (Re illy, Sho pshire , Durazzo , & Campbe ll, 2 0 0 2 ). The wo rkbo o k pro vide s gro up me mbe rs with a summary o f the info rmatio n pre se nte d in e ac h se ssio n, wo rkshe e ts fo r c o mple ting ho me wo rk assignme nts, and spac e to take no te s dur-ing e ac h se ssio n. The wo rkbo o k will fac ilitate the c o mple tio n o f ho me wo rk assignme nts and he lp re info rc e the c o nc e pts pre se nte d o ve r the c o urse o f the ange r manage me nt tre atme nt pro gram.

Altho ugh partic ipants are ke pt busy in e ac h se ssio n, 9 0 minute s sho uld be e no ugh time to c o mple te the tasks at hand. The gro up le ade r ne e ds to mo nito r and, at time s, limit the re spo nse s o f partic ipants, ho we ve r. This c an be do ne by re dire c ting the m to the que stio n o r ac tivity.

M a n a g em en t Tr ea t m en t

Session 1

Instructions to Group Leaders

In the first se ssio n, the purpo se , o ve rvie w, gro up rule s, c o nc e ptual frame wo rk, and ratio nale fo r the ange r manage me nt tre atme nt are pre se nte d. Mo st o f this se ssio n is spe nt pre se nting c o nc e ptual info r-matio n and ve rifying that the gro up me mbe rs

unde rstand it. The n the le ade r take s the gro up me mbe rs thro ugh an intro duc to ry e xe rc ise and a pre se ntatio n o f the ange r me te r.

Suggested Rem arks

(Pre s e nt the fo llo wing s c ript o r put this in yo ur o wn wo rds .)

Purpo s e and Ove rvie w

The purpo se o f the ange r manage me nt gro up is to : 1 . Le arn to manage ange r

2 . Sto p vio le nc e o r the thre at o f vio le nc e

3 . De ve lo p se lf-c o ntro l o ve r tho ughts and ac tio ns 4 . Re c e ive suppo rt and fe e dbac k fro m o the rs.

Gro up Rule s

1 . Gro up Safe ty: No vio le nc e o r thre ats to ward staff and o the r gro up me mbe rs is allo we d. It is impo rtant that me mbe rs pe rc e ive the gro up as a safe plac e to share the ir e xpe rie nc e s and fe e lings witho ut thre ats o r po ssible physic al harm.

2 . Co nfide ntiality: Gro up me mbe rs sho uld no t disc uss o utside the gro up what gro up me mbe rs say during gro up se ssio ns. The re are limits to c o nfide ntiality, ho we ve r. In e ve ry State , he alth laws go ve rn ho w and whe n pro fe ssio nals must re po rt c e rtain ac tio ns to the pro pe r autho ri-tie s. The se ac tio ns may inc lude any physic al o r se xual abuse inflic te d o n a c hild yo unge r

7

Outline of Session 1

• Instructions to Group Leaders

• Suggested Rem arks

– Purpose and Overview

– Group Rules

– The Problem of Anger:

Som e Operational Definitions

– Myths About Anger

– Anger as a Habitual Response

– Breaking the Anger Habit

– Participant Introductions

– Anger Meter

than age 1 8 , a pe rso n o lde r than age 6 5 , o r a de pe nde nt adult. A de pe nde nt adult is so me o ne be twe e n 1 8 and 6 4 ye ars who has physic al o r me ntal limitatio ns that re stric t his o r he r ability to c arry o ut no rmal ac tivitie s o r to pro te c t his o r he r rights. Re po rting abuse o f the se pe rso ns supe rse de s c o nfide ntiality laws invo lving c lie nts and he alth pro fe ssio nals. Similarly, if a gro up me mbe r make s thre ats to physic ally harm o r kill ano the r pe rso n, the gro up le ade r is re quire d, unde r the Taraso ff Ruling (Taras o ffv. Re ge nts o f the Unive rs ity o f Califo rnia,5 2 9 P.2 d 5 5 3 (Cal. 1 974 ), vac ate d, re he ard e n bank, and affirme d, 1 31 Cal. Rptr. 1 4 , 5 51 P.2 d 3 3 4 (1 976 )), to warn the inte nde d vic tim and no tify the po lic e .

3 . Ho me wo rk Assignme nts: Brie f ho me wo rk assignme nts will be give n e ac h we e k. Do ing the ho me wo rk assignme nts will impro ve gro up me mbe rs’ ange r manage me nt skills and allo w the m to ge t the mo st fro m the gro up e xpe rie nc e . Like any type o f skill ac quisitio n, ange r manage me nt re quire s time and prac tic e . Ho me wo rk assignme nts pro vide the o ppo rtunity fo r skill de ve lo pme nt and re fine me nt.

4 . Abse nc e s and Canc e llatio ns: Me mbe rs sho uld c all o r o the rwise no tify the gro up le ade r in advanc e whe n the y c anno t atte nd a se ssio n. Be c ause o f the amo unt o f mate rial pre se nte d in e ac h se ssio n, me mbe rs may no t miss mo re than 3 o f the 1 2 se ssio ns. If a gro up me m-be r misse s mo re than thre e se ssio ns, he o r she wo uld no t m-be able to ade quate ly le arn, prac tic e , and apply the c o nc e pts and skills that are ne c e ssary fo r e ffe c tive ange r manage -me nt. He o r she c an c o ntinue to atte nd the gro up se ssio ns, but the gro up -me mbe r will no t re c e ive a c e rtific ate o f c o mple tio n. He o r she c an jo in ano the r se ssio n as spac e be c o me s available .

5 . Time o ut: The gro up le ade r re se rve s the right to c all fo r a time o ut. If a gro up me mbe r’ s ange r be gins to e sc alate o ut o f c o ntro l during a se ssio n, the le ade r will ask that me mbe r to take a time o ut fro m the to pic and the disc ussio n. This me ans that the me mbe r, alo ng with the re st o f the me mbe rs o f the gro up, will imme diate ly sto p talking abo ut the is s ue that is c ausing the me mbe r’ s ange r to e sc alate . If the partic ipant’ s ange r has e sc alate d to the po int that he o r she c anno t to le rate sitting in the gro up, the le ade r may ask the pe rso n to le ave the gro up fo r 5 o r 1 0 minute s o r until he o r she c an c o o l do wn. The partic ipant is the n we lc o me d bac k to the gro up, pro vide d he o r she c an to le rate c o ntinue d disc ussio n in the gro up.

A time o ut is an e ffe c tive ange r manage me nt strate gy and will be disc usse d in mo re de tail late r in this se ssio n and in se ssio n 3 . Eve ntually, gro up me mbe rs will le arn to c all a time o ut the mse lve s whe n the y fe e l the y may be lo sing c o ntro l as the re sult o f e sc alatio n o f the ir ange r. Fo r this se ssio n, ho we ve r, it is e sse ntial that the le ade r c alls fo r a time o ut and that me mbe rs c o mply with the rule . This rule he lps e nsure that the gro up will be a safe plac e to disc uss and share e xpe rie nc e s and fe e lings. The re fo re , failure to c o mply with the time o ut rule may le ad to te rminatio n fro m the gro up.

6 . Re lapse s: If a partic ipant has a re lapse during his o r he r e nro llme nt in the gro up, he o r she is no t disc harge d. Ho we ve r, if the partic ipant has re pe ate d re lapse s, he o r she will be aske d to start the tre atme nt again and will be re fe rre d to a mo re inte nse tre atme nt se tting.

The Pro ble m o f Ange r: So me Ope ratio nal De finitio ns

In the mo st ge ne ral se nse , ange r is a fe e ling o r e mo tio n that range s fro m mild irritatio n to inte nse fury and rage . Ange r is a natural re spo nse to tho se situatio ns whe re we fe e l thre at-e nat-e d, wat-e bat-e liat-e vat-e harm will c o mat-e to us, o r wat-e bat-e liat-e vat-e that ano that-e r pat-e rso n has unnat-e c at-e ssarily wro nge d us. We may also be c o me angry whe n we fe e l ano the r pe rso n, like a c hild o r so me o ne c lo se to us, is be ing thre ate ne d o r harme d. In additio n, ange r may re sult fro m frustratio n whe n o ur ne e ds, de sire s, and go als are no t be ing me t. Whe n we be c o me angry, we may lo se o ur patie nc e and ac t impulsive ly, aggre ssive ly, o r vio le ntly.

Pe o ple o fte n c o nfuse ange r with aggre ssio n. Aggre ssio n is be havio rthat is inte nde d to c ause harm to ano the r pe rso n o r damage pro pe rty. This be havio r c an inc lude ve rbal abuse , thre ats, o r vio le nt ac ts. Ange r, o n the o the r hand, is an e mo tio n and do e s no t ne c e ssarily le ad to aggre ssio n. The re fo re , a pe rso n c an be c o me angry witho ut ac ting aggre ssive ly.

A te rm re late d to ange r and aggre ssio n is ho stility. Ho stility re fe rs to a c o mple x se t o f attitude s and judgme nts that mo tivate aggre ssive be havio rs. Whe re as ange r is an e mo tio n and

aggre ssio n is a be havio r, ho stility is an attitude that invo lve s disliking o the rs and e valuating the m ne gative ly.

In this gro up, c lie nts will le arn he lpful strate gie s and te c hnique s to manage ange r, e xpre ss ange r in alte rnative ways, c hange ho stile attitude s, and pre ve nt aggre ssive ac ts, suc h as ve rbal abuse and vio le nc e .

Whe n Do e s Ange r Be c o me a Pro ble m?

Ange r be c o me s a pro ble m whe n it is fe lt to o inte nse ly, is fe lt to o fre que ntly, o r is e xpre sse d inappro priate ly. Fe e ling ange r to o inte nse ly o r fre que ntly plac e s e xtre me physic al strain o n the bo dy. During pro lo nge d and fre que nt e piso de s o f ange r, c e rtain divisio ns o f the ne rvo us sys-te m be c o me highly ac tivasys-te d. Co nse que ntly, blo o d pre ssure and he art rasys-te inc re ase and stay e le vate d fo r lo ng pe rio ds. This stre ss o n the bo dy may pro duc e many diffe re nt he alth pro ble ms, suc h as hype rte nsio n, he art dise ase , and diminishe d immune syste m e ffic ie nc y. Thus, fro m a he alth standpo int, avo iding physic al illne ss is a mo tivatio n fo r c o ntro lling ange r.

Ano the r c o mpe lling re aso n to c o ntro l ange r c o nc e rns the ne gative c o nse que nc e s that re sult fro m e xpre ssing ange r inappro priate ly. In the e xtre me , ange r may le ad to vio le nc e o r physic al aggre ssio n, whic h c an re sult in nume ro us ne gative c o nse que nc e s, suc h as be ing arre ste d o r jaile d, be ing physic ally injure d, be ing re taliate d against, lo sing lo ve d o ne s, be ing te rminate d fro m a substanc e abuse tre atme nt o r so c ial se rvic e pro gram, o r fe e ling guilt, shame , o r re gre t. Eve n whe n ange r do e s no t le ad to vio le nc e , the inappro priate e xpre ssio n o f ange r, suc h as ve r-bal abuse o r intimidating o r thre ate ning be havio r, o fte n re sults in ne gative c o nse que nc e s. Fo r e xample , it is like ly that o the rs will de ve lo p fe ar, re se ntme nt, and lac k o f trust to ward tho se who subje c t the m to angry o utbursts, whic h may c ause alie natio n fro m individuals, suc h as family me mbe rs, frie nds, and c o wo rke rs.

Payo ffs and Co ns e que nc e s

The inappro priate e xpre ssio n o f ange r initially has many appare nt payo ffs. One payo ff is be ing able to manipulate and c o ntro l o the rs thro ugh aggre ssive and intimidating be havio r; o the rs may c o mply with so me o ne ’ s de mands be c ause the y fe ar ve rbal thre ats o r vio le nc e . Ano the r payo ff is the re le ase o f te nsio n that o c c urs whe n o ne lo se s his o r he r te mpe r and ac ts aggre s-sive ly. The individual may fe e l be tte r afte r an angry o utburst, but e ve ryo ne e lse may fe e l wo rse . In the lo ng te rm, ho we ve r, the se initial payo ffs le ad to ne gative c o nse que nc e s. Fo r this re aso n the y are c alle d “appare nt” payo ffs be c ause the lo ng-te rm ne gative c o nse que nc e s far o utwe igh the sho rt-te rm gains. Fo r e xample , c o nside r a fathe r who pe rsuade s his c hildre n to c o mply with his de mands by using an angry to ne o f vo ic e and thre ate ning ge sture s. The se be havio rs imply to the c hildre n that the y will re c e ive physic al harm if the y are no t o be die nt. The imme diate pay-o ff fpay-o r the fathe r is that the c hildre n pay-o be y his c pay-o mmands. The lpay-o ng-te rm c pay-o nse que nc e , hpay-o we v-e r, may bv-e that thv-e c hildrv-e n lv-e arn to fv-e ar o r dislikv-e him and bv-e c o mv-e v-e mo tio nally dv-e tac hv-e d fro m him. As the y gro w o lde r, the y may avo id c o ntac t with him o r re fuse to se e him alto ge the r.

Myths Abo ut Ange r

Myth # 1 : Ange r Is Inhe rite d.One misc o nc e ptio n o r myth abo ut ange r is that the way we e xpre ss ange r is inhe rite d and c anno t be c hange d. So me time s, we may he ar so me o ne say, “I inhe rite d my ange r fro m my fathe r; that’ s just the way I am.” This state me nt implie s that the e xpre ssio n o f ange r is a fixe d and unalte rable se t o f be havio rs. Evide nc e fro m re se arc h stud-ie s, ho we ve r, indic ate s that pe o ple are no t bo rn with se t, spe c ific ways o f e xpre ssing ange r. The se studie s sho w, rathe r, that be c ause the e xpre ssio n o f ange r is le arne d be havio r, mo re appro priate ways o f e xpre ssing ange r also c an be le arne d.

It is we ll e stablishe d that muc h o f pe o ple ’ s be havio r is le arne d by o bse rving o the rs, partic ularly influe ntial pe o ple . The se pe o ple inc lude pare nts, family me mbe rs, and frie nds. If c hildre n o bse rve pare nts e xpre ssing ange r thro ugh aggre ssive ac ts, suc h as ve rbal abuse and vio le nc e , it is ve ry like ly that the y will le arn to e xpre ss ange r in similar ways. Fo rtunate ly, this be havio r c an be c hange d by le arning ne w and appro priate ways o f ange r e xpre ssio n. It is no t ne c e ssary to c o ntinue to e xpre ss ange r by aggre ssive and vio le nt me ans.

Myth # 2 : Ange r Auto matic ally Le ads to Aggre ssio n.A re late d myth invo lve s the misc o nc e ptio n that the o nly e ffe c tive way to e xpre ss ange r is thro ugh aggre ssio n. It is c o mmo nly tho ught that ange r is so me thing that builds and e sc alate s to the po int o f an aggre ssive o utburst. As has be e n said, ho we ve r, ange r do e s no t ne c e ssarily le ad to aggre ssio n. In fac t, e ffe c tive ange r man-age me nt invo lve s c o ntro lling the e sc alatio n o f ange r by le arning asse rtive ne ss skills, c hanging ne gative and ho stile “se lf-talk,” c halle nging irratio nal be lie fs, and e mplo ying a varie ty o f be hav-io ral strate gie s. The se skills, te c hnique s, and strate gie s will be disc usse d in late r se sshav-io ns.

Myth # 3 : Pe o ple Must Be Aggre s s ive To Ge t What The y Want.Many pe o ple c o nfuse asse rtive -ne ss with aggre ssio n. The go al o f aggre ssio n is to do minate , intimidate , harm, o r injure ano the r pe rso n—to win at any c o st. Co nve rse ly, the go al o f asse rtive ne ss is to e xpre ss fe e lings o f ange r

in a way that is re spe c tful o f o the r pe o ple . Fo r e xample , if yo u we re upse t be c ause a frie nd was re pe ate dly late fo r me e tings, yo u c o uld re spo nd by sho uting o bsc e nitie s and name -c alling. This appro ac h is an attac k o n the o the r pe rso n rathe r than an atte mpt to addre ss the be havio r that yo u find frustrating o r ange r pro vo king.

An asse rtive way o f handling this situatio n might be to say, “ Whe n yo u are late fo r a me e ting with me , I ge t pre tty frustrate d. I wish that yo u wo uld be o n time mo re o fte n.” This state me nt e xpre sse s yo ur fe e lings o f frustratio n and dissatisfac tio n and c o mmunic ate s ho w yo u wo uld like the situatio n c hange d. This e xpre ssio n do e s no t blame o r thre ate n the o the r pe rso n and minimize s the c hanc e o f c ausing e mo tio nal harm. We will disc uss asse rtive ne ss skills in mo re de tail in se ssio ns 7 and 8 .

Myth # 4 : Ve nting Ange r Is Always De s irable .Fo r many ye ars, the po pular be lie f amo ng nume r-o us me ntal he alth prr-o fe ssir-o nals and layme n was that the aggre ssive e xpre ssir-o n r-o f ange r, suc h as sc re aming o r be ating o n pillo ws, was he althy and the rape utic . Re se arc h studie s have fo und, ho we ve r, that pe o ple who ve nt the ir ange r aggre ssive ly simply ge t be tte r at be ing angry

(Be rko witz, 1 97 0 ; Murray, 1 9 8 5 ; Straus, Ge lle s, & Ste inme tz, 1 9 8 0 ). In o the r wo rds, ve nting ange r in an aggre ssive manne r re info rc e s aggre ssive be havio r.

Ange r as a Habitual Re s po ns e

No t o nly is the e xpre ssio n o f ange r le arne d, but it c an be c o me a ro utine , familiar, and pre dic table re spo nse to a varie ty o f situatio ns. Whe n ange r is displaye d fre que ntly and aggre ssive -ly, it c an be c o me a maladaptive habit be c ause it re sults in ne gative c o nse que nc e s. Habits, by de finitio n, are pe rfo rme d o ve r and o ve r again, witho ut thinking. Pe o ple with ange r manage -me nt pro ble ms o fte n re so rt to aggre ssive displays o f ange r to so lve the ir pro ble ms, witho ut thinking abo ut the ne gative c o nse que nc e s the y may suffe r o r the de bilitating e ffe c ts it may have o n the pe o ple aro und the m.

Bre aking the Ange r Habit

Be c o ming Aware o f Ange r. To bre ak the ange r habit, yo u must de ve lo p an aware ne ss o f the e ve nts, c irc umstanc e s, and be havio rs o f o the rs that “trigge r” yo ur ange r. This aware ne ss also invo lve s unde rstanding the ne gative c o nse que nc e s that re sult fro m ange r. Fo r e xample , yo u may be in line at the supe rmarke t and be c o me impatie nt be c ause the line s are to o lo ng. Yo u c o uld be c o me angry, the n bo iste ro usly de mand that the c he c ko ut c le rk c all fo r mo re he lp. As yo ur ange r e sc alate s, yo u may be c o me invo lve d in a he ate d e xc hange with the c le rk o r ano the r c us-to me r. The sus-to re manage r may re spo nd by having a se c urity o ffic e r re mo ve yo u fro m the sus-to re . The ne gative c o nse que nc e s that re sult fro m this e ve nt are no t ge tting the gro c e rie s that yo u wante d and the e mbarrassme nt and humiliatio n yo u suffe r fro m be ing re mo ve d fro m the sto re .

Strate gie s fo r Co ntro lling Ange r.In additio n to be c o ming aware o f ange r, yo u ne e d to de ve lo p strate gie s to e ffe c tive ly manage it. The se strate gie s c an be use d to sto p the e sc alatio n o f ange r be fo re yo u lo se c o ntro l and e xpe rie nc e ne gative c o nse que nc e s. An e ffe c tive se t o f strate gie s fo r c o ntro lling ange r sho uld inc lude bo th imme diate and pre ve ntive strate gie s.

Imme diate strate gie s inc lude taking a time o ut, de e p-bre athing e xe rc ise s, and tho ught sto pping. Pre ve ntive strate gie s inc lude de ve lo ping an e xe rc ise pro gram and c hanging yo ur irratio nal be lie fs. The se strate gie s will be disc usse d in mo re de tail in late r se ssio ns.

One e xample o f an imme diate ange r manage me nt strate gy wo rth e xplo ring at this po int is the time o ut. The time o ut c an be use d fo rmally o r info rmally. Fo r no w, we will o nly de sc ribe the info rmal use o f a time o ut. This use invo lve s le aving a situatio n if yo u fe e l yo ur ange r is e sc alat-ing o ut o f c o ntro l. Fo r e xample , yo u may be a passe nge r o n a c ro wde d bus and be c o me angry be c ause yo u pe rc e ive that pe o ple are de libe rate ly bumping into yo u. In this situatio n, yo u c an simply ge t o ff the bus and wait fo r a le ss c ro wde d bus.

The info rmal use o f a time o ut may also invo lve sto pping yo urse lf fro m e ngaging in a disc ussio n o r argume nt if yo u fe e l that yo u are be c o ming to o angry. In the se situatio ns, it may be he lpful to ac tually c all a time o ut o r to give the time o ut sign with yo ur hands. This le ts the o the r pe rso n kno w that yo u wish to imme diate ly sto p talking abo ut the to pic and are be c o ming frustrate d, upse t, o r angry.

In this gro up, yo u sho uld c all a time o ut if yo u fe e l that yo ur ange r is e sc alating o ut o f c o ntro l. Yo u also are e nc o urage d to le ave the ro o m fo r a sho rt pe rio d o f time if yo u fe e l that yo u ne e d to do so . Ho we ve r, ple ase c o me bac k fo r the re mainde r o f the gro up se ssio n afte r yo u have c alme d do wn.

Partic ipant Intro duc tio ns

At this po int, ask gro up me mbe rs to give the ir name s, the re aso ns the y are inte re ste d in partic -ipating in the ange r manage me nt gro up, and what the y ho pe to ac hie ve in the gro up. Afte r e ac h me mbe r’ s intro duc tio n, o ffe r a suppo rtive c o mme nt that validate s his o r he r de c isio n to partic ipate in the gro up. Expe rie nc e sho ws that this he lps me mbe rs fe e l the gro up will me e t the ir ne e ds and he lps re duc e the anxie ty asso c iate d with the intro duc tio ns and the first gro up se ssio n in ge ne ral.

Ange r Me te r

One te c hnique that is he lpful in inc re asing the aware ne ss o f ange r is le arning to mo nito r it. A simple way to mo nito r ange r is to use the “ange r me te r.” A 1 o n the ange r me te r re pre se nts a c o mple te lac k o f ange r o r a to tal state o f c alm, whe re as a 1 0 re pre se nts a ve ry angry and e xplo sive lo ss o f c o ntro l that le ads to ne gative c o nse que nc e s. Po ints be twe e n 1 and 1 0 re pre -se nt fe e lings o f ange r be twe e n the -se e xtre me s. The purpo -se o f the ange r me te r is to mo nito r the e sc alatio n o f ange r as it mo ve s up the sc ale . Fo r e xample , whe n a pe rso n e nc o unte rs an ange r-pro vo king e ve nt, he o r she do e s no t re ac h a 1 0 imme diate ly, altho ugh it may so me time s fe e l that way. In re ality, the individual’ s ange r starts at a lo w numbe r and rapidly mo ve s up the sc ale . The re is always time , pro vide d o ne has le arne d e ffe c tive c o ping skills, to sto p ange r fro m e sc alating to a 1 0 .

One diffic ulty pe o ple have whe n le arning to use the ange r me te r is misunde rstanding the me aning o f a 1 0 . A 1 0 is re se rve d fo r instanc e s whe n an individual suffe rs (o r c o uld suffe r) ne gative c o nse que nc e s. An e xample is whe n an individual assaults ano the r pe rso n and is arre ste d by the po lic e .

A se c o nd po int to make abo ut the ange r me te r is that pe o ple may inte rpre t the numbe rs o n the sc ale diffe re ntly. The se diffe re nc e s are ac c e ptable . What may be a 5 fo r o ne pe rso n may be a 7 fo r so me o ne e lse . It is muc h mo re impo rtant to pe rso nalize the ange r me te r and be c o me c o mfo rtable and familiar with yo ur re adings o f the numbe rs o n the sc ale . Fo r the gro up, ho we ve r, a 1 0 is re se rve d fo r instanc e s whe n so me o ne lo se s c o ntro l and suffe rs (o r c o uld suffe r) ne gative c o nse que nc e s.

Exhibit 1 . The Anger Meter

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• Explo sio n • Vio le nc e

• Lo ss o f Co ntro l

• Ne gative Co nse que nc e s • Yo u Lo se !

• Yo u have a c ho ic e ! • Use yo ur ange r c o ntro l

plan to avo id re ac hing 1 0 !

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9

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6

5

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3

2

1

Hom ework Assignm ent

Have gro up me mbe rs re fe r to the partic ipant wo rkbo o k. Ask the m to re vie w the gro up’ s pur-po se , rule s, de finitio ns o f ange r and aggre ssio n, myths abo ut ange r, ange r as a habitual re spo nse , and the ange r me te r. Ask the m to mo nito r the ir le ve ls o f ange r o n the ange r me te r during the upc o ming we e k and re po rt the ir highe st le ve l o f ange r during the Che c k-In

Pro c e dure o f ne xt we e k’ s se ssio n.

A Concept ual Fr amewor k for Under st andi ng Anger

Session 2

Instructions to Group Leaders

This se ssio n te ac he s gro up me mbe rs ho w to ana-lyze an ange r e piso de and to ide ntify the e ve nts and c ue s that indic ate an e sc alatio n o f ange r. Be gin the se ssio n with a c he c k in (fo llo wing up o n the ho me wo rk assignme nt fro m the last we e k, name ly, have gro up me mbe rs re po rt o n the highe st le ve l o f ange r the y re ac he d o n the ange r me te r during the past we e k) and fo llo w with

a pre se ntatio n and disc ussio n o f e ve nts and c ue s. A mo re c o mple te Che c k-In Pro c e dure will be use d in se ssio n 3 afte r me mbe rs have be e n taught to ide ntify spe c ific ange r-pro vo king e ve nts and the c ue s that indic ate an e sc alatio n o f ange r.

Afte r the Che c k-In Pro c e dure , ask gro up me mbe rs to list spe c ific e ve nts that trigge r the ir ange r. Pay spe c ial atte ntio n to he lping the m distinguish be twe e n the e ve nts and the ir inte rpre tatio n o f the se e ve nts. Eve nts re fe r to fac ts. Inte rpre tatio ns re fe r to o pinio ns, value judgme nts, o r pe r-c e ptio ns o f the e ve nts. Fo r e xample , a gro up me mbe r might say, “My bo ss r-c ritir-c ize d me be c ause he do e sn’ t like me .” Po int o ut that the spe c ific e ve nt was that the bo ss c ritic ize d the gro up me mbe r and that the be lie f that his bo ss do e sn’ t like him is an inte rpre tatio n that may o r may no t be ac c urate .

Be aware o f ge nde r diffe re nc e s. Wo me n partic ipants o fte n ide ntify re latio nships with the ir bo yfrie nd o r partne r o r pare nting c o nc e rns as e ve nts that trigge r the ir ange r. Me n, ho we ve r, may rare ly ide ntify the se issue s as trigge rs.

Finally, pre se nt the fo ur c ue s to ange r c ate go rie s. Afte r de sc ribing e ac h c ate go ry, ask gro up me mbe rs to pro vide e xample s. It is impo rtant to e mphasize that c ue s may be diffe re nt fo r e ac h individual. Me mbe rs sho uld ide ntify c ue s that indic ate an e sc alatio n o f the ir ange r.

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Outline of Session 2

• Instructions to Group Leaders

• Suggested Rem arks

– Events That Trigger Anger

– Cues to Anger

• Explaining the Check-In

Suggested Rem arks

(Us e the fo llo wing s c ript o r put this in yo ur o wn wo rds .)

Eve nts That Trigge r Ange r

Whe n yo u ge t angry, it is be c ause an e ve nt has pro vo ke d yo ur ange r. Fo r e xample , yo u may ge t angry whe n the bus is late , whe n yo u have to wait in line at the gro c e ry sto re , o r whe n a ne ighbo r plays his ste re o to o lo ud. Eve ryday e ve nts suc h as the se c an pro vo ke yo ur ange r. Many time s, spe c ific e ve nts to uc h o n se nsitive are as in yo ur life . The se se nsitive are as o r “re d flags” usually re fe r to lo ng-standing issue s that c an e asily le ad to ange r. Fo r e xample , so me o f us may have be e n slo w re ade rs as c hildre n and may have be e n se nsitive abo ut o ur re ading ability. Altho ugh we may re ad we ll no w as adults, we may c o ntinue to be se nsitive abo ut this issue . This se nsitivity may be re ve ale d whe n so me o ne rushe s us while we are c o mple ting an applic atio n o r re vie wing a me mo randum and may trigge r ange r be c ause we may fe e l that we are be ing c ritic ize d o r judge d as we we re whe n we we re c hildre n. This se nsitivity may also sho w itse lf in a mo re dire c t way, suc h as whe n so me o ne c alls us “slo w” o r “stupid.” In additio n to e ve nts e xpe rie nc e d in the he re -and-no w, yo u may also re c all an e ve nt fro m yo ur past that made yo u angry. Yo u might re me mbe r, fo r e xample , ho w the bus always se e me d to be late be fo re yo u le ft ho me fo r an impo rtant appo intme nt. Just thinking abo ut ho w late the bus was in the past c an make yo u angry in the pre se nt. Ano the r e xample may be whe n yo u re c all a situatio n invo lving a family me mbe r who be traye d o r hurt yo u in so me way. Re me mbe ring this situatio n, o r this family me mbe r, c an raise yo ur numbe r o n the ange r me te r. He re are e xample s o f e ve nts o r issue s that c an trigge r ange r:

• Lo ng waits to se e yo ur do c to r • Traffic c o nge stio n

• Cro wde d buse s

• A frie nd jo king abo ut a se nsitive to pic • A frie nd no t paying bac k mo ne y o we d to yo u • Be ing wro ngly ac c use d

• Having to c le an up so me o ne e lse ’ s me ss

• Having an untidy ro o mmate

• Having a ne ighbo r who plays the ste re o to o lo ud

• Be ing plac e d o n ho ld fo r lo ng pe rio ds o f time while o n the te le pho ne • Be ing give n wro ng dire c tio ns

• Rumo rs be ing spre ad abo ut yo ur re lapse that are no t true • Having mo ne y o r pro pe rty sto le n fro m yo u.

Cue s to Ange r

A se c o nd impo rtant aspe c t o f ange r mo nito ring is to ide ntify the c ue s that o c c ur in re spo nse to the ange r-pro vo king e ve nt. The se c ue s se rve as warning signs that yo u have be c o me angry and that yo ur ange r is c o ntinuing to e sc alate . The y c an be bro ke n do wn into fo ur c ue c ate go rie s: physic al, be havio ral, e mo tio nal, and c o gnitive (o r tho ught) c ue s.

Phys ic al Cue s . Physic al c ue s invo lve the way o ur bo die s re spo nd whe n we be c o me angry. Fo r e xample , o ur he art rate s may inc re ase , we may fe e l tightne ss in o ur c he sts, o r we may fe e l ho t and flushe d. The se physic al c ue s c an also warn us that o ur ange r is e sc alating o ut o f c o ntro l o r appro ac hing a 1 0 o n the ange r me te r. We c an le arn to ide ntify the se c ue s whe n the y o c c ur in re spo nse to an ange r-pro vo king e ve nt.

Can yo u ide ntify so me o f the physic al c ue s that yo u have e xpe ri-e nc ri-e d whri-e n yo u havri-e bri-e c o mri-e angry?

Be havio ral Cue s .Be havio ral c ue s invo lve the be havio rs we display whe n we ge t angry, whic h are o bse rve d by o the r pe o ple aro und us. Fo r e xample , we may c le nc h o ur fists, pac e bac k and fo rth, slam a do o r, o r raise o ur vo ic e s. The se be havio ral re spo nse s are the se c o nd c ue o f o ur ange r. As with physic al c ue s, the y are warning signs that we may be appro ac hing a 1 0 o n the ange r me te r.

What are so me o f the be havio ral c ue s that yo u have e xpe rie nc e d whe n yo u have be c o me angry?

Emo tio nal Cue s .Emo tio nal c ue s invo lve o the r fe e lings that may o c c ur c o nc urre ntly with o ur ange r. Fo r e xample , we may be c o me angry whe n we fe e l abando ne d, afraid, disc o unte d, disre -spe c te d, guilty, humiliate d, impatie nt, inse c ure , je alo us, o r re je c te d. The se kinds o f fe e lings are the c o re o r primary fe e lings that unde rlie o ur ange r. It is e asy to disc o unt the se primary fe e lings be c ause the y o fte n make us fe e l vulne rable . An impo rtant c o mpo ne nt o f ange r manage -me nt is to be c o -me aware o f, and to re c o gnize , the primary fe e lings that unde rlie o ur ange r. In this gro up, we will vie w ange r as a se c o ndary e mo tio n to the se mo re primary fe e lings.

Can yo u ide ntify so me o f the primary fe e lings that yo u have e xpe ri-e nc ri-e d during an ri-e piso dri-e o f angri-e r?

Co gnitive Cue s . Co gnitive c ue s re fe r to the tho ughts that o c c ur in re spo nse to the ange r-pro vo king e ve nt. Whe n pe o ple be c o me angry, the y may inte rpre t e ve nts in c e rtain ways. Fo r e xample , we may inte rpre t a frie nd’ s c o mme nts as c ritic ism, o r we may inte rpre t the ac tio ns o f o the rs as de me aning, humiliating, o r c o ntro lling. So me pe o ple c all the se tho ughts “se lf-talk” be c ause the y re se mble a c o nve rsatio n we are having with o urse lve s. Fo r pe o ple with ange r

pro ble ms, this se lf-talk is usually ve ry c ritic al and ho stile in to ne and c o nte nt. It re fle c ts be lie fs abo ut the way the y think the wo rld sho uld be ; be lie fs abo ut pe o ple , plac e s, and things.

Clo se ly re late d to tho ughts and se lf-talk are fantasie s and image s. We vie w fantasie s and image s as o the r type s o f c o gnitive c ue s that c an indic ate an e sc alatio n o f ange r. Fo r e xample , we might fantasize abo ut se e king re ve nge o n a pe rc e ive d e ne my o r imagine o r visualize o ur spo use having an affair. Whe n we have the se fantasie s and image s, o ur ange r c an e sc alate e ve n mo re rapidly.

Can yo u think o f o the r e xample s o f c o gnitive o r tho ught c ue s?

Explaining the Check-In Procedure

In this se ssio n, gro up me mbe rs be gan to mo nito r the ir ange r and ide ntify ange r-pro vo king e ve nts and situatio ns. In e ac h we e kly se ssio n, the re will be a Che c k-In Pro c e dure to fo llo w up o n the ho me wo rk assignme nt fro m the pre vio us we e k and to re po rt the highe st le ve l o f ange r re ac he d o n the ange r me te r during the we e k.

Have partic ipants ide ntify the e ve nt that trigge re d the ir ange r, the c ue s that we re asso c iate d with the ir ange r, and the strate gie s the y use d to manage the ir ange r in re spo nse to the e ve nt. The y will be using the fo llo wing que stio ns to c he c k in at the be ginning o f e ac h se ssio n:

1 . What was the highe st numbe r yo u re ac he d o n the ange r me te r during the past we e k? 2 . What was the e ve nt that trigge re d yo ur ange r?

3 . What c ue s we re asso c iate d with the ange r-pro vo king e ve nt? Fo r e xample , what we re the physic al, be havio ral, e mo tio nal, o r c o gnitive c ue s?

4 . What strate gie s did yo u use to avo id re ac hing 1 0 o n the ange r me te r?

The y will also be aske d to mo nito r and re c o rd the highe st numbe r the y re ac h o n the ange r me te r fo r e ac h day o f the upc o ming we e k afte r e ac h se ssio n.

Exhibit 2. Cues to Anger: Four Cue Categories

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1 . Physical

(e xample s: rapid he artbe at, tightne ss in c he st, fe e ling ho t o r flushe d)

2. Behavioral

(e xample s: pac ing, c le nc hing fists, raising vo ic e , staring)

3. Emotional

(e xample s: fe ar, hurt, je alo usy, guilt)

4. Cognitive/ Thoughts

(e xample s: ho stile se lf-talk, image s o f aggre ssio n and re ve nge )

Hom ework Assignm ent

Have gro up me mbe rs re fe r to the partic ipant wo rkbo o k. Ask the m to mo nito r and re c o rd the ir highe st le ve l o f ange r o n the ange r me te r during the upc o ming we e k. In additio n, ask the m to ide ntify the e ve nt that made the m angry and list the c ue s that we re asso c iate d with the ange r-pro vo king e ve nt. Te ll partic ipants the y sho uld be pre pare d to re po rt o n the se assignme nts dur-ing the Che c k-In Pro c e dure in ne xt we e k’ s se ssio n.

Hel pi ng Gr oup Member s Devel op a Pl an

for Cont r ol l i ng Anger

Session 3

Instructions to Group Leaders

In this se ssio n, be gin te ac hing gro up me mbe rs c o gnitive be havio ral strate gie s fo r c o ntro lling the ir ange r. By no w, partic ipants have be gun to le arn ho w to mo nito r the ir ange r and ide ntify ange r-pro vo king e ve nts and situatio ns. At this po int, it is impo rtant to he lp the m de ve lo p a re pe rto ire o f ange r manage me nt strate gie s. This re pe rto ire o f strate gie s is c alle d an ange r c o ntro l

plan. This plan sho uld c o nsist o f imme diate strate gie s, tho se that c an be use d in the he at o f the mo me nt whe n ange r is rapidly e sc alating, and pre ve ntive strate gie s, tho se that c an be use d to avo id e sc alatio n o f ange r be fo re it be gins. It is impo rtant to e nc o urage me mbe rs to use strate gie s that wo rk be st fo r the m. So me find c o gnitive re struc turing (e .g., c halle nging ho s-tile se lf-talk o r irratio nal be lie fs) ve ry e ffe c tive . Othe rs might pre fe r using strate gie s suc h as a time o ut o r tho ught sto pping. The main po int is to he lp gro up me mbe rs individualize the ir ange r c o ntro l plans and to he lp the m de ve lo p strate gie s that the y are c o mfo rtable with and that the y will re adily use . In the re maining se ssio ns, yo u will c o ntinue to he lp gro up me mbe rs de ve lo p e ffe c tive strate gie s fo r c o ntro lling the ir ange r and c larify and re info rc e the se strate gie s during the Che c k-In Pro c e dure .

Partic ipants sho uld be e nc o urage d to se e k suppo rt and fe e dbac k fro m pe o ple the y c an trust to suppo rt the ir re c o ve ry, inc luding ange r manage me nt strate gie s that will de -e sc alate , rathe r than e sc alate , the situatio n. Partic ipants sho uld se e k advic e fro m o ne ano the r and o the r patie nts who are in re c o ve ry and fro m me mbe rs in suppo rt ne two rks, inc luding me mbe rs o f 1 2 -Ste p gro ups, 1 2 -Ste p spo nso rs, o r re ligio us gro up me mbe rs.

In additio n to he lping gro up me mbe rs be gin to de ve lo p the ir ange r c o ntro l plans, start the se s-sio n with the Che c k-In Pro c e dure , and e nd the se ss-sio n with a bre athing e xe rc ise as a fo rm o f re laxatio n training. Be fo re le ading me mbe rs in the bre athing e xe rc ise , ask whe the r anyo ne has had e xpe rie nc e with diffe re nt fo rms o f re laxatio n. De sc ribe the c o ntinuum o f re laxatio n te c h-nique s, whic h c an range fro m simple bre athing e xe rc ise s to e labo rate guide d image ry. Explain that in the gro up, the y will prac tic e two sho rt and simple re laxatio n e xe rc ise s, de e p-bre athing

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Outline of Session 3

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Rem arks

– Anger Control Plans

– Relaxation Through Breathing

and pro gre ssive musc le re laxatio n. Furthe r e xplain that e xpe rie nc e sho ws that gro up me mbe rs are mo re like ly to use the se simple fo rms o f re laxatio n.

Check-In Procedure

Ask gro up me mbe rs to re po rt the highe st le ve l o f ange r the y re ac he d o n the ange r me te r during the past we e k. Make sure the y re se rve the numbe r 1 0 fo r situatio ns whe re the y lo st c o ntro l o f the ir ange r and e xpe rie nc e d ne gative c o nse que nc e s. Ask the m to de sc ribe the ange r-pro vo king e ve nt that le d to the ir highe st le ve l o f ange r. He lp the m ide ntify the c ue s that o c c urre d in re spo nse to the ange r-pro vo king e ve nt, and he lp the m c lassify the se c ue s into the fo ur c ue c ate go rie s.

Exhibit 3. Event, Cues, and Strategies Identified

During the Check-In Procedure

Suggested Rem arks

(Us e the fo llo wing s c ript o r put this in yo ur o wn wo rds .) Ange r Co ntro l Plans

Up to this po int, yo u have be e n fo c using o n ho w to mo nito r yo ur ange r. In the first se ssio n, yo u le arne d ho w to use the ange r me te r to rate yo ur ange r. Last we e k, yo u le arne d ho w to ide ntify the e ve nts that trigge r ange r, as we ll as the physic al, be havio ral, e mo tio nal, and c o gnitive c ue s asso c iate d with e ac h e ve nt. To day, yo u will be gin to disc uss ho w to de ve lo p an ange r c o ntro l plan and ho w yo u c an use spe c ific strate gie s, suc h as time o uts and re laxatio n, to c o ntro l yo ur ange r. In late r se ssio ns, yo u will c o ve r o the r strate gie s, suc h as le arning to c hange ne gative o r ho stile se lf-talk and using the Co nflic t Re so lutio n Mo de l (se e page 3 9 ). The se mo re advanc e d strate gie s c an be use d alo ng with time o uts and re laxatio n.

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The basic ide a in de ve lo ping an ange r c o ntro l plan is to try many diffe re nt strate gie s and find the ange r c o ntro l te c hnique s that wo rk be st fo r yo u. Onc e yo u ide ntify the se strate gie s, yo u c an add the m to yo ur ange r c o ntro l plans and use the m whe n yo u start to ge t angry. So me pe o ple re fe r to the ir ange r c o ntro l plans as the ir to o lbo x and the spe c ific strate gie s the y use to c o ntro l the ir ange r as the ir to o ls. This analo gy may be ve ry he lpful. Again, it is impo rtant to ide ntify the spe c ific ange r c o ntro l strate gie s that wo rk be st fo r yo u. The se strate gie s sho uld be put do wn in a fo rmal ange r c o ntro l plan fo r re fe rral whe n yo u e nc o unte r an ange r-pro vo king e ve nt.

An e ffe c tive strate gy that many pe o ple use , fo r e xample , is to talk abo ut the ir fe e lings with a suppo rtive frie nd who was no t invo lve d with the e ve nt that made the m angry. By disc ussing ange r, yo u c an be gin to ide ntify the primary e mo tio ns that unde rlie it and de te rmine whe the r yo ur thinking and e xpe c tatio ns in re spo nse to the ange r-pro vo king e ve nt are ratio nal. Ofte n a frie nd who m yo u trust c an pro vide a diffe re nt pe rspe c tive o n what is go ing o n in yo ur life . Eve n if yo ur frie nd just liste ns, e xpre ssing yo ur fe e lings c an o fte n make yo u fe e l be tte r.

The lo ng-te rm o bje c tive o f the ange r manage me nt tre atme nt is to de ve lo p a se t o f strate gie s that yo u c an use appro priate ly fo r spe c ific ange r-pro vo king e ve nts. Late r se ssio ns will intro duc e a me nu o f strate gie s and te c hnique s that are he lpful in managing ange r. Onc e yo u have se le c t-e d tht-e stratt-e git-e s that wo rk bt-e st, yo u sho uld rt-e fint-e tht-e m by applying tht-e m in rt-e al-lift-e situatio ns. To use the to o lbo x analo gy, diffe re nt to o ls may be ne e de d fo r diffe re nt situatio ns. We will re turn to this c o nc e pt in late r se ssio ns and highlight the impo rtanc e o f de ve lo ping an ange r c o ntro l plan that he lps yo u manage ange r e ffe c tive ly in a varie ty o f situatio ns.

Time o ut.As me ntio ne d in se ssio n 1 , the c o nc e pt o f a time o ut is e spe c ially impo rtant to ange r manage me nt. It is the basic ange r manage me nt strate gy re c o mme nde d fo r inc lusio n in e ve ry-o ne ’ s ange r c ry-o ntrry-o l plan. Infry-o rmally, a time ry-o ut is de fine d as le aving the situatiry-o n that is c aus-ing the e sc alatio n o f ange r o r simply sto ppaus-ing the disc ussio n that is pro vo kaus-ing it.

Fo rmally, a time o ut invo lve s re latio nships with o the r pe o ple : it invo lve s an agre e me nt o r a pre -arrange d plan. The se re latio nships may invo lve family me mbe rs, frie nds, and c o wo rke rs. Any o f the partie s invo lve d may c all a time o ut in ac c o rdanc e with rule s that have be e n agre e d o n by e ve ryo ne in advanc e . The pe rso n c alling the time o ut c an le ave the situatio n, if ne c e ssary. It is agre e d, ho we ve r, that he o r she will re turn to e ithe r finish the disc ussio n o r po stpo ne it, de pe nding o n whe the r all tho se invo lve d fe e l the y c an suc c e ssfully re so lve the issue .

Time o uts are impo rtant be c ause the y c an be e ffe c tive in the he at o f the mo me nt. Eve n if yo ur ange r is e sc alating quic kly o n the ange r me te r, yo u c an pre ve nt re ac hing 1 0 by taking a time -o ut and le aving the situati-o n.

Time o uts are also e ffe c tive whe n the y are use d with o the r strate gie s. Fo r e xample , yo u c an take a time o ut and go fo r a walk. Yo u c an also take a time o ut and c all a truste d frie nd o r fami-ly me mbe r o r write in yo ur jo urnal. The se o the r strate gie s sho uld he lp yo u c alm do wn during the time o ut pe rio d.

Can yo u think o f spe c ific strate gie s that yo u might use to c o ntro l yo ur ange r?

Sho uld the se strate gie s be inc lude d o n yo ur ange r c o ntro l plan?

Exhibit 4. Sam ple of an Anger Control Plan

Re laxatio n Thro ugh Bre athing

We have disc usse d the physic al c ue s to ange r, suc h as an inc re ase d he artbe at, fe e ling ho t o r flushe d, o r musc le te nsio n. The se type s o f physic al c ue s are e xample s o f what is c o mmo nly c alle d the stre ss re spo nse . In the stre ss re spo nse , the ne rvo us syste m is e ne rgize d, and in this agitate d state , a pe rso n is like ly to have tro uble re turning to lo we r le ve ls o n the ange r me te r. In this state , additio nal ange r-pro vo king situatio ns and e ve nts are like ly to c ause a furthe r e sc ala-tio n o f ange r.

An inte re sting aspe c t o f the ne rvo us syste m is that e ve ryo ne has a re laxatio n re spo nse that c o unte rac ts the stre ss re spo nse . It is physic ally impo ssible to be bo th agitate d and re laxe d at the same time . If yo u c an re lax suc c e ssfully, yo u c an c o unte rac t the stre ss o r ange r re spo nse . We will e nd this se ssio n by prac tic ing a de e p-bre athing e xe rc ise as a re laxatio n te c hnique . In se ssio n 4 , we will prac tic e pro gre ssive musc le re laxatio n as a se c o ndary type o f re laxatio n te c hnique .

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Anger Control Plan

1 . Take a time o ut (fo rmal o r info rmal) 2 . Talk to a frie nd (so me o ne yo u trust)

3 . Use the Co nflic t Re so lutio n Mo de l to e xpre ss ange r 4 . Exe rc ise (take a walk, go to the gym, e tc .)

5 . Atte nd 1 2 -Ste p me e tings

Note to Group Leader:

Lead a Breathing Exercise

(Us e this s c ript o r put this in yo ur o wn wo rds .)

Ge t c o mfo rtable in yo ur c hair. If yo u like , c lo se yo ur e ye s; o r just gaze at the flo o r.

Take a fe w mo me nts to se ttle yo urse lf. No w make yo urse lf aware o f yo ur bo dy. Che c k yo ur bo dy fo r te nsio n, be ginning with yo ur fe e t, and sc an upward to yo ur he ad. No tic e any te n-sio n yo u might have in yo ur le gs, yo ur sto mac h, yo ur hands and arms, yo ur sho ulde rs, yo ur ne c k, and yo ur fac e . Try to le t go o f the te nsio n yo u are fe e ling.

No w, make yo urse lf aware o f yo ur bre athing. Pay atte ntio n to yo ur bre ath as it e nte rs and le ave s yo ur bo dy. This c an be ve ry re laxing.

Le t’ s all take a de e p bre ath to ge the r. No tic e yo ur lungs and c he st e xpanding. No w slo wly e xhale thro ugh yo ur no se . Again, take a de e p bre ath. Fill yo ur lungs and c he st. No tic e ho w muc h air yo u c an take in. Ho ld it fo r a se c o nd. No w re le ase it and slo wly e xhale . One mo re time , inhale slo wly and fully. Ho ld it fo r a se c o nd, and re le ase .

No w o n yo ur o wn, c o ntinue bre athing in this way fo r ano the r c o uple o f minute s. Co ntinue to fo c us o n yo ur bre athing. With e ac h inhalatio n and e xhalatio n, fe e l yo ur bo dy be c o ming mo re and mo re re laxe d. Use yo ur bre athing to wash away any re maining te nsio n.

(Allo w gro up me mbe rs to prac tic e bre athing fo r 1 to 2 minute s in s ile nc e .)

No w le t’ s take ano the r de e p bre ath. Inhale fully, ho ld it fo r a se c o nd, and re le ase . Inhale again, ho ld, and re le ase . Co ntinue to be aware o f yo ur bre ath as it fills yo ur lungs. Onc e mo re , inhale fully, ho ld it fo r a se c o nd, and re le ase .

Whe n yo u fe e l re ady, o pe n yo ur e ye s.

Ho w was that? Did yo u no tic e any ne w se nsatio ns while yo u we re bre athing? Ho w do yo u fe e l no w?

This bre athing e xe rc ise c an be sho rte ne d to just thre e de e p inhalatio ns and e xhalatio ns. Eve n that muc h c an be e ffe c tive in he lping yo u re lax whe n yo ur ange r is e sc alating. Yo u c an prac tic e this at ho me , at wo rk, o n the bus, while waiting fo r an appo intme nt, o r e ve n while walking. The ke y to making de e p-bre athing an e ffe c tive re laxatio n te c hnique is to prac tic e it fre que ntly and to apply it in a varie ty o f situatio ns.

Hom ework Assignm ent

Have gro up me mbe rs re fe r to the partic ipant wo rkbo o k. Ask the m to mo nito r and re c o rd the ir highe st le ve l o f ange r o n the ange r me te r during the upc o ming we e k. Ask the m to ide ntify the e ve nt that made the m angry, the c ue s that we re asso c iate d with the ange r-pro vo king e ve nt, and the strate gie s that the y use d to manage the ir ange r in re spo nse to the e ve nt. Ask the m to prac tic e the de e p-bre athing e xe rc ise , pre fe rably o nc e a day during the upc o ming we e k, and de ve lo p a pre liminary ve rsio n o f the ir ange r c o ntro l plans. Info rm gro up me mbe rs that the y sho uld be pre pare d to re po rt o n the se assignme nts during the Che c k-In Pro c e dure at the ne xt we e k’ s se ssio n.

How To Change t he Cycl e

Session 4

Instructions to Group Leaders

This se ssio n pre se nts the aggre ssio n c yc le and intro duc e s pro gre ssive musc le re laxatio n. As in the pre vio us two se ssio ns, be gin with the Che c kIn Pro c e dure . The n pre se nt the thre e -phase aggre ssio n c yc le , whic h c o nsists o f e sc a-latio n, e xplo sio n, and po ste xplo sio n. It se rve s as a frame wo rk that inc o rpo rate s the c o nc e pts o f the ange r me te r, c ue s to ange r, and the ange r c o ntro l plan.

End the se ssio n by pre se nting a pro gre ssive musc le re laxatio n e xe rc ise . Pro gre ssive musc le re laxatio n is ano the r te c hnique that has be e n e ffe c tive in re duc ing ange r le ve ls. An alte rnative to the de e p-bre athing e xe rc ise intro duc e d in last we e k’ s se ssio n, it is straightfo rward and e asy to le arn.

Check-In Procedure

Ask gro up me mbe rs to re po rt the highe st le ve l o f ange r the y re ac he d o n the ange r me te r during the past we e k. Make sure the y re se rve the numbe r 1 0 fo r situatio ns whe re the y lo st c o ntro l o f the ir ange r and e xpe rie nc e d ne gative c o nse que nc e s. Ask the m to de sc ribe the ange r-pro vo king e ve nt that le d to the ir highe st le ve l o f ange r. He lp the m ide ntify the c ue s that o c c urre d in re spo nse to the ange r-pro vo king e ve nt, and he lp the m c lassify tho se c ue s into the fo ur c ue c ate go rie s. Inc lude , as part o f the Che c k-In Pro c e dure , a fo llo wup o n the ho me wo rk assignme nt fro m the pre vio us we e k’ s se ssio n. Ask partic ipants to re po rt o n the spe c ific ange r manage me nt strate gie s liste d, thus far, o n the ir ange r c o ntro l plans. In additio n, inquire

whe the r the y prac tic e d the de e p-bre athing e xe rc ise that was intro duc e d in last we e k’ s se ssio n.

27

Outline of Session 4

• Instructions to Group Leaders • Check-In Procedure

• Suggested Rem arks – The Aggression Cycle

– Progressive Muscle Relaxation • Hom ework Assignm ent

Suggested Rem arks

(Us e the fo llo wing s c ript o r put this in yo ur o wn wo rds .) The Aggre s s io n Cyc le

In the last thre e se ssio ns, we re vie we d the ange r me te r, c ue s to ange r, and the ange r c o ntro l plan; in this se ssio n, the frame wo rk fo r inte grating the se ange r manage me nt c o nc e pts is pre -se nte d. This frame wo rk is the aggre ssio n c yc le .

Fro m an ange r manage me nt pe rspe c tive , an e piso de o f ange r c an be vie we d as c o nsisting o f thre e phase s: e s c alatio n, e xplo s io n, and po ste xplo s io n. To ge the r, the y make up the aggre ssio n c yc le . In this pro c e ss, the e sc alatio n phase is c harac te rize d by c ue s that indic ate ange r is building. As state d in se ssio n 2 , the se c ue s c an be physic al, be havio ral, e mo tio nal, o r c o gnitive (tho ughts). As yo u may re c all, c ue s are warning signs, o r re spo nse s, to ange r-pro vo king e ve nts. Eve nts, o n the o the r hand, are situatio ns that o c c ur e ve ry day that may le ad to e sc alatio ns o f ange r if e ffe c tive ange r manage me nt strate gie s are no t use d. Re d-flag e ve nts are type s o f situ-atio ns that are unique to yo u and that yo u are e spe c ially se nsitive to be c ause o f past e ve nts. The se e ve nts c an invo lve inte rnal pro c e sse s (e .g., thinking abo ut situatio ns that we re ange r pro vo king in the past) o r e xte rnal pro c e sse s (e .g., e xpe rie nc ing re al-life , ange r-pro vo king situa-tio ns in the he re and no w).

If the e sc alatio n phase is allo we d to c o ntinue , the e xplo sio n phase will fo llo w. The e xplo sio n phase is marke d by an unc o ntro llable disc harge o f ange r displaye d as ve rbal o r physic al aggre ssio n. This disc harge , in turn, le ads to ne gative c o nse que nc e s; it is syno nymo us with the numbe r 1 0 o n the ange r me te r.

The final stage o f the aggre ssio n c yc le is the po ste xplo sio n phase . It is c harac te rize d by ne gative c o nse que nc e s re sulting fro m the ve rbal o r physic al aggre ssio n displaye d during the e xplo -sio n phase . The se c o nse que nc e s may inc lude go ing to jail, making re stitutio n, be ing te rminat-e d fro m a jo b o r disc hargrminat-e d fro m a drug trrminat-e atmrminat-e nt o r so c ial srminat-e rvic rminat-e pro gram, lo sing family and lo ve d o ne s, o r fe e lings o f guilt, shame , and re gre t.

The inte nsity, fre que nc y, and duratio n o f ange r in the aggre ssio n c yc le varie s amo ng individu-als. Fo r e xample , o ne pe rso n’ s ange r may e sc alate rapidly afte r a pro vo c ative e ve nt and, within just a fe w minute s, re ac h the e xplo sio n phase . Ano the r pe rso n’ s ange r may e sc alate slo wly but ste adily o ve r se ve ral ho urs be fo re re ac hing the e xplo sio n phase . Similarly, o ne pe rso n may e xpe rie nc e mo re e piso de s o f ange r and pro gre ss thro ugh the aggre ssio n c yc le mo re o fte n than the o the r. Ho we ve r, bo th individuals, de spite diffe re nc e s in ho w quic kly the ir ange r e sc alate s and ho w fre que ntly the y e xpe rie nc e ange r, will unde rgo all thre e phase s o f the aggre ssio n c yc le .

The inte nsity o f the se individuals’ ange r also may diffe r. One pe rso n may e ngage in mo re vio -le nt be havio r than the o the r in the e xplo sio n phase . Fo r e xamp-le , he o r she may use we apo ns o r assault so me o ne . The o the r pe rso n may e xpre ss his o r he r ange r during the e xplo sio n phase

by sho uting at o r thre ate ning o the r pe o ple . Re gardle ss o f the se individual diffe re nc e s, the e xplo sio n phase is syno nymo us with lo sing c o ntro l and be c o ming ve rbally o r physic ally aggre ssive .

No tic e that the e sc alatio n and e xplo sio n phase s o f the aggre ssio n c yc le c o rre spo nd to the le v-e ls o n thv-e angv-e r mv-e tv-e r. Thv-e po ints bv-e lo w 1 0 o n thv-e angv-e r mv-e tv-e r rv-e prv-e sv-e nt thv-e v-e sc alatio n phase , the building up o f ange r. The e xplo sio n phase , o n the o the r hand, c o rre spo nds to 1 0 o n the ange r me te r. Again 1 0 o n the ange r me te r is the po int at whic h o ne lo se s c o ntro l and e xpre sse s ange r thro ugh ve rbal o r physic al aggre ssio n that le ads to ne gative c o nse que nc e s. One o f the primary o bje c tive s o f ange r manage me nt tre atme nt is to ke e p fro m re ac hing the e xplo sio n phase . This is ac c o mplishe d by using the ange r me te r to mo nito r c hange s in yo ur ange r, atte nding to the c ue s o r warning signs that indic ate ange r is building, and e mplo ying the appro priate strate gie s fro m yo ur ange r c o ntro l plans to sto p the e sc alatio n o f ange r. If the e xplo sio n phase is pre ve nte d fro m o c c urring, the po ste xplo sio n phase will no t o c c ur, and the aggre ssio n c yc le will be bro ke n. If yo u use yo ur ange r c o ntro l plans e ffe c tive ly, yo ur ange r sho uld ide ally re ac h be twe e n a 1 and a 9 o n the ange r me te r. This is a re aso nable go al to aim fo r. By pre ve nting the e xplo sio n phase (1 0 ), yo u will no t e xpe rie nc e the ne gative c o nse que nc e s o f the po ste xplo sio n phase , and yo u will bre ak the c yc le o f aggre ssio n.

Exhibit 5. The Aggression Cycle

* Base d o n the Cyc le o f Vio le nc e by Le no re Walke r (1 97 9 ). The Batte re d Wo man. Ne w Yo rk: Harpe r & Ro w.

Cl o si n g a n d Gr a d u a t i o n

Cl osi ng Exer ci se and Awar di ng of Cer t i fi cat es

Session 1 2

Instructions to Group Leaders

In the final se ssio n, gro up me mbe rs re vie w the ir

ange r c o ntro l plans, rate the tre atme nt c o mpo ne nts fo r the ir use fulne ss and familiarity, and c o mple te a c lo sing e xe rc ise . Re vie w e ac h ange r c o ntro l plan to balanc e c o gnitive , be havio ral, imme diate and pre ve ntive strate gie s. Give c o rre c tive fe e dbac k if ne c e ssary. Co ngratulate the gro up me mbe rs fo r c o mple ting the ange r manage me nt tre atme nt. Pro vide e ac h me mbe r with a c e rtific ate o f c o mple tio n (se e sample o n the fo llo wing page ).

Suggested Rem arks

(Us e the fo llo wing s c ript o r put this in yo ur o wn wo rds .)

1 . What have yo u le arne d abo ut ange r manage me nt?

2 . List ange r manage me nt strate gie s o n yo ur ange r c o ntro l plan. Ho w c an yo u use the se strate gie s to be tte r manage yo ur ange r?

3 . In what ways c an yo u c o ntinue to impro ve yo ur ange r manage me nt skills? Are the re spe c ific are as that ne e d impro ve me nt?

51

Outline of Session 12

• Instructions to Group Leaders • Suggested Rem arks

5

2

An

g e r M a n a g e m e n t fo r S u b st a n ce A b u se a n d M en ta l H ea lt h C li en ts

CON GRATU LATI ON S

Thom as Sm ith

In Re c o gnitio n o f Co mple ting the Phas e One Ange r Manage me nt Gro up in the Substanc e Abus e Outpatie nt Clinic

(ADD NAME)

[DATE]

[NAME], Chief, Substance Abuse

[NAME OF COUNSELOR]

Ref er en c es

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Barkle y, R.A. (1 9 97 ). De fiant Childre n: A Clinic ian’s Manual fo r As s e s s me nt and Pare nt Training.2 nd e d. Ne w Yo rk: Guilfo rd Pre ss.

Be c k, R., and Fe rnande z, E. (1 9 9 8 ). Co gnitive be havio ral the rapy in the tre atme nt o f ange r: A me ta-analysis. Co gnitive The rapy and Re s e arc h, 2 2 , 6 3 -74 .

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Carro ll, K.M.; Ro unsaville , B.J.; and Gawin, F.H. (1 9 9 1 ). A c o mparative trial o f psyc ho the rapie s fo r ambulato ry c o c aine abuse rs: Re lapse pre ve ntio n and inte rpe rso nal psyc ho the rapy.

Ame ric an Jo urnal o f Drug and Alc o ho l Abus e, 17 , 2 2 9 -247.

Clark, H.W.; Re illy, P.M.; Sho pshire , M.S.; and Campbe ll, T.A. (1 9 9 6 ). Ange r manage me nt tre at-me nt in c ulturally dive rse substanc e abuse patie nts. In: NIDA Re s e arc h Mo no graph: Pro ble ms o f Drug De pe nde nc e , Pro c e e dings o f the 5 8 th Annual Sc ie ntific Me e ting, Co lle ge o n Pro ble ms o f Drug De pe nde nc e . Ro c kville , MD: Natio nal Institute o n Drug Abuse .

De ffe nbac he r, J.L. (1 9 9 6 ). Co gnitive be havio ral appro ac he s to ange r re duc tio n. In: Do bso n, K.S., and Craig, K.D. (Eds.), Advanc e s in Co gnitive Be havio ral The rapy(pp. 31 -6 2 ). Tho usand Oaks, CA: Sage Public atio ns.

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Psyc ho lo gic al Asso c iatio n, Bo sto n.

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Edmo ndso n, C.B., and Co nge r, J.C. (1 9 9 6 ). A re vie w o f tre atme nt e ffic ac y fo r individuals with ange r pro ble ms: Co nc e ptual, asse ssme nt, and me tho do lo gic al issue s. Clinic al Ps yc ho lo gy Re vie w, 1 0 , 2 51 -27 5 .

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Juste r, H.R., and He imbe rg, R.G. (1 9 9 5 ). So c ial pho bia: Lo ngitudinal c o urse and lo ng-te rm o ut-c o me o f ut-c o gnitive be havio ral tre atme nt. Ps yc hiatric Clinic s o f No rth Ame ric a, 1 8 , 8 2 1 -8 4 2 . Maude -Griffin, P.M.; Ho he nste in, J.M.; Humfle e t, G.L.; Re illy, P.M.; Tuse l, D.J.; and Hall, S.M. (1 9 9 8 ). Supe rio r e ffic ac y o f c o gnitive be havio ral the rapy fo r urban c rac k c o c aine abuse rs: Main and matc hing e ffe c ts. Jo urnal o f Co ns ulting and Clinic al Ps yc ho lo gy, 6 6 , 8 3 2 -8 37.

Murray, E. (1 9 8 5 ). Co ping and ange r. In: Fie ld, T., Mc Cabe , P., and Sc hne ide rman, N. (Eds.),

Stre s s and Co ping (pp. 24 3 -2 6 1 ). Hillsdale , NJ: Erlbaum.

Pipe r, W.E., and Jo yc e , A.S. (1 9 9 6 ). A c o nside ratio n o f fac to rs influe nc ing the utilizatio n o f time -limite d, sho rt-te rm gro up the rapy. Inte rnatio nal Jo urnal o f Gro up Ps yc ho the rapy, 4 6 , 31 1 -3 2 8 . Re illy, P.M.; Clark, H.W.; Sho pshire , M.S.; and De luc c hi, K.L. (1 9 9 5 ). Ange r manage me nt, po st-traumatic stre ss diso rde r, and substanc e abuse . In: NIDA Re s e arc h Mo no graph: Pro ble ms o f Drug De pe nde nc e , Pro c e e dings o f the 57 th Annual Sc ie ntific Me e ting (p. 3 2 2 ), Co lle ge o n Pro ble ms o f Drug De pe nde nc e . Ro c kville , MD: Natio nal Institute o n Drug Abuse .

Re illy, P.M., and Grusznski, R. (1 9 8 4 ). A struc ture d didac tic mo de l fo r me n fo r c o ntro lling family vio le nc e . Inte rnatio nal Jo urnal o f Offe nde r The rapy and Co mparative Crimino lo gy, 2 8 , 2 2 3 -2 3 5 . Re illy, P.M., and Sho pshire , M.S. (2 0 0 0 ). Ange r manage me nt gro up tre atme nt fo r c o c aine de pe nde nc e : Pre liminary o utc o me s. Ame ric an Jo urnal o f Drug and Alc o ho l Abus e, 2 6 (2 ), 1 6 1 -17 7.

Re illy, P.M.; Sho pshire , M.S.; and Clark, H.W. (1 9 9 9 ). Ange r manage me nt tre atme nt fo r c o c aine de pe nde nt c lie nts. In: NIDA Re s e arc h Mo no graph: Pro ble ms o f Drug De pe nde nc e , Pro c e e dings o f the 6 0 th Annual Sc ie ntific Me e ting (p. 1 6 7 ), Co lle ge o n Pro ble ms o f Drug De pe nde nc e . Ro c kville , MD: Natio nal Institute o n Drug Abuse .

Re illy, P.M.; Sho pshire , M.S.; Clark, H.W.; Campbe ll, T.A.; Ouao u, R.H.; and Llane s, S. (1 9 9 6 ). Substanc e use asso c iate d with de c re ase d ange r ac ro ss a 1 2 -we e k c o gnitive -be havio ral ange r manage me nt tre atme nt. In: NIDA Re s e arc h Mo no graph: Pro ble ms o f Drug De pe nde nc e , Pro c e e dings o f the 5 8 th Annual Sc ie ntific Me e ting, Co lle ge o n Pro ble ms o f Drug De pe nde nc e . Ro c kville , MD: Natio nal Institute o n Drug Abuse .

Re illy, P.M.; Sho pshire , M.S.; Durazzo , T.C.; and Campbe ll, T.A. (2 0 0 2 ). Ange r Manage me nt fo r Substanc e Abus e and Me ntal He alth Clie nts : Partic ipant Wo rkbo o k. Ro c kville , MD: Ce nte r fo r Substanc e Abuse Tre atme nt.

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Sho pshire , M.S.; Re illy, P.M.; and Ouao u, R.H. (1 9 9 6 ). Ange r manage me nt strate gie s asso c iat-e d with diat-e c riat-e asiat-e d angiat-e r in substanc iat-e abusiat-e c liiat-e nts. In: NIDA Re s e arc h Mo no graph: Pro ble ms o f Drug De pe nde nc e , Pro c e e dings o f the 5 8 th Annual Sc ie ntific Me e ting (p. 2 2 6 ), Co lle ge o n Pro ble ms o f Drug De pe nde nc e . Ro c kville , MD: Natio nal Institute o n Drug Abuse .

Smo ko wski, P.R., and Wo darski, J.S. (1 9 9 6 ). Co gnitive be havio ral gro up and family tre atme nt o f c o c aine addic tio n. In: The Hathe rle igh Guide to Tre ating Substanc e Abus e, Part 1 . (pp. 171 -1 8 9 ). Ne w Yo rk: Hathe rle igh Pre ss.

Straus, M.; Ge lle s, R.; and Ste inme tz, S. (1 9 8 0 ). Be hind Clo s e d Do o rs : Vio le nc e in the Ame ric an Family. Garde n City, NY: Do uble day.

Trafate , R.C. (1 9 9 5 ). Evaluatio n o f tre atme nt strate gie s fo r adult ange r diso rde rs. In: Kassino ve , H. (Ed.), Ange r Dis o rde rs : De finitio n, Diagno s is , and Tre atme nt(pp. 1 0 9 -1 3 0 ). Washingto n, DC: Taylo r and Franc is.

Van Balko m, A.J.L.M.; Van Oppe n, P.; Ve rme ule n, A.W.A.; Van Dyc k, R.; Nauta, M.C.E.; and Vo rst, H.C.M. (1 9 9 4 ). A me ta-analysis o n the tre atme nt o f o bse ssive c o mpulsive diso rde r: A c o mpari-so n o f antide pre ssants, be havio r, and c o gnitive the rapy. Clinic al Ps yc ho lo gy Re vie w, 1 4 , 3 5 9 -3 8 1 .

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We bste r-Stratto n, C., and Hammo nd, M. (1 9 97 ). Tre ating c hildre n with e arly-o nse t c o nduc t pro ble ms: A c o mpariso n o f c hild and pare nt training inte rve ntio ns. Jo urnal o f Co ns ulting and Clinic al Ps yc ho lo gy, 6 5 (1 ), 9 3 -1 0 9 .

Yalo m, I.D. (1 9 9 5 ). The The o ry and Prac tic e o f Gro up Ps yc ho the rapy. 4 th e d. Ne w Yo rk: Basic Bo o ks, Inc .

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A ppen d i x :

Aut hor s’ Acknowl edgment s

The autho rs wo uld like to ac kno wle dge the fo llo wing c linic ians and re se arc he rs fo r the ir vario us c o ntributio ns to the de ve lo pme nt o f this manual:

Ro be rt Awalt, Psy.D., Pe te r Banys, M.D., To rri Campe ll, Ph.D., Darc y Co x, Ph.D., Jo hn Co yne , M.A., Timo thy Durazzo , Ph.D., Sharo n Hall, Ph.D., Antho ny Janne tti, Ph.D., Mo nika Ko c h, M.D., Pe g Maude -Griffin, Ph.D., Ro be rt Ouao u, Ph.D., Te ro n Park, Ph.D., Amy Ro se n, Psy.D., She ila Shive s, M.A., Jame s So re nse n, Ph.D., David Tho mso n, LCSW, Do nald Tuse l, M.D., David Wasse rman, Ph.D., and Lisa Wasse rman, M.A.

We wo uld also like to ac kno wle dge H. We stle y Clark, M.D., J.D., M.P.H., CAS, FASAM, Dire c to r o f the Ce nte r fo r Substanc e Abuse Tre atme nt, fo r his valuable c o ntributio ns to the e arly stage s o f this tre atme nt manual and the ange r manage me nt pro je c t. Dr. Durazzo assiste d in e diting the manual.

Jo hnso n, Bassin & Shaw, Inc ., pe rso nne l invo lve d in the pro duc tio n o f this manual and the ac c o mpanying partic ipant wo rkbo o k inc lude d Barbara Fink, M.P.H., Pro je c t Dire c to r; Nanc y He gle , Quality Co ntro l Manage r; Franc e s Ne be sky, M.A., Edito r; and Te rrie Yo ung, Graphic De signe r.