Anger Management For Substance Abuse And Mental Health Clients: A Cognitive Behavioral Therapy Manual 0508

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AAnnggeer r MMaannaaggeemmeennt t

for Substance Abuse and

Mental Health Clients

A Cognitive Behavioral Therapy Manual

Patrick M. Reilly, Ph.D.

Michael S. Shopshire, Ph.D.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857

AAnnggeer r MMaannaaggeemmeennt tfor Substance Abuse and Mental Health Clients

Acknowledgments

Numerous people contributed to the development of this manual (see appendix). The docu-

ment was written by Patrick M. Reilly, Ph.D., and Michael S. Shopshire, Ph.D., of the San

Francisco Treatment Research Center. Sharon Hall, Ph.D., was the Treatment Research

Center’s Principal Investigator.

Disclaimer

This document is, in part, a product of research conducted with support from the National

Institute on Drug Abuse, Grant DA 09253, and the Department of Veterans Affairs to the San

Francisco VA Medical Center, San Francisco Treatment Research Center, Department of

Psychiatry, University of California, San Francisco. The document was produced by Johnson,

Bassin & Shaw, Inc., under Contract No. 270-99-7072 with the Substance Abuse and Mental

Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

(DHHS). Karl White, Ed.D., served as the Center for Substance Abuse Treatment (CSAT)

Knowledge Application Program (KAP) Project Officer. The content of this publication does not

necessarily reflect the views or policies of CSAT, SAMHSA, or DHHS.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied

without permission from SAMHSA or CSAT. Citation of the source is appreciated. However, this

publication may not be reproduced or distributed for a fee without the specific, written authori-

zation of the Office of Communications, SAMHSA, DHHS.

Electronic Access and Copies of Publication

This publication can be accessed electronically through the following Internet World Wide Web

connection: www.kap.samhsa.gov. For additional free copies of this document, please call

SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686

or 1-800-487-4889 (TDD).

Recommended Citation

Reilly PM and Shopshire MS. Anger Management for Substance Abuse and Mental Health

Clients: A Cognitive Behavioral Therapy Manual. DHHS Pub. No. (SMA) 08-4213. Rockville, MD:

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services

Administration, 2002, reprinted 2003, 2005, 2006, 2007, and 2008.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement,

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services

Administration, 1 Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 08-4213

Printed 2002

Reprinted 2003, 2005, 2006, 2007, and 2008

FFoorreewwoorrd d

Substance use and abuse often coexist with anger and violence. Data from the Substance

Abuse and Mental Health Services Administration’s National Household Survey on Drug Abuse,

for example, indicated that 40 percent of frequent cocaine users reported engaging in some

form of violent behavior. Anger and violence often can have a causal role in the initiation of

drug and alcohol use and can also be a consequence associated with substance abuse.

Individuals who experience traumatic events, for example, often experience anger and act vio-

lently, as well as abuse drugs or alcohol.

Clinicians often see how anger and violence and substance use are linked.

Many substance abuse and mental health clients are victims of traumatic life events, which,

in turn, lead to substance use, anger, and violence.

Despite the connection of anger and violence to substance abuse, few treatments have been

developed to address anger and violence problems among people who abuse substances.

Clinicians have found the dearth of treatment approaches for this important issue disheartening.

To provide clinicians with tools to help deal with this important issue, the Center for Substance

Abuse Treatment of the Substance Abuse and Mental Health Services Administration is

pleased to present Anger Management for Substance Abuse and Mental Health Clients:

A Cognitive Behavioral Therapy Manual and its companion book Anger Management for

Substance Abuse and Mental Health Clients: Participant Workbook.

The anger management treatment design in this manual, which has been delivered to hun-

dreds of clients over the past 8 years, has been popular with both clinicians and clients. This

treatment design can be used in a variety of clinical settings and will be beneficial to the field.

Terry L. Cline, Ph.D.

Administrator

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Washington, D.C.

iii

CCoonntteenntts s

Foreword

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Introduction

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How To Use This Manual

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Session 1 Overview of Group Anger Management Treatment

. . . . . . . . . . . . . . . . . . . . 7

Session 2 Events and Cues: A Conceptual Framework for

Understanding Anger

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Session 3 Anger Control Plans: Helping Group Members Develop a

Plan for Controlling Anger

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Session 4 The Aggression Cycle: How To Change the Cycle

. . . . . . . . . . . . . . . . . . . . 27

Session 5 Cognitive Restructuring: The A-B-C-D Model and Thought Stopping

. . . . . 33

Session 6 Review Session #1: Reinforcing Learned Concepts

. . . . . . . . . . . . . . . . . . 37

Sessions 7 & 8 Assertiveness Training and the Conflict Resolution Model:

Alternatives for Expressing Anger

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Sessions 9 & 10 Anger and the Family: How Past Learning Can

Influence Present Behavior

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Session 11 Review Session #2: Reinforcing Learned Concepts

. . . . . . . . . . . . . . . . . . 49

Session 12 Closing and Graduation: Closing Exercise and

Awarding of Certificates

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

References

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Appendix: Authors’ Acknowledgments

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

IInnttrroodduuccttiioon n

This manual was designed for use by qualified substance abuse and mental health clinicians

who work with substance abuse and mental health clients with concurrent anger problems.

The manual describes a 12-week cognitive behavioral anger management group treatment.

Each of the 12 90-minute weekly sessions is described in detail with specific instructions for

group leaders, tables and figures that illustrate the key conceptual components of the treat-

ment, and homework assignments for the group participants. An accompanying Participant

Workbook is available (see Anger Management for Substance Abuse and Mental Health

Clients: Participant Workbook, Reilly, Shopshire, Durazzo, & Campbell, 2002) and should be

used in conjunction with this manual to enable the participants to better learn, practice, and

integrate the treatment strategies presented in the group sessions. This intervention was devel-

oped for studies at the San Francisco Veterans Affairs (SFVA) Medical Center and San

Francisco General Hospital.

Cognitive behavioral therapy (CBT) treatments have been found to be effective, time-limited

treatments for anger problems (Beck & Fernandez, 1998; Deffenbacher, 1996; Trafate, 1995).

Four types of CBT interventions, theoretically unified by principles of social learning theory, are

most often used when treating anger disorders:

• Relaxation interventions, which target emotional and physiological components of anger

• Cognitive interventions, which target cognitive processes such as hostile appraisals and

attributions, irrational beliefs, and inflammatory thinking

• Communication skills interventions, which target deficits in assertiveness and conflict reso-

lution skills

• Combined interventions, which integrate two or more CBT interventions and target multiple

response domains (Deffenbacher, 1996, 1999).

Meta-analysis studies (Beck & Fernandez, 1998; Edmondson & Conger, 1996; Trafate, 1995)

conclude that there are moderate anger reduction effects for CBT interventions, with average

effect sizes ranging from 0.7 to 1.2 (Deffenbacher, 1999). From these studies, it can be

inferred that the average participant under CBT conditions fared better than 76 percent of con-

trol participants. These results are consistent with other meta-analysis studies examining the

effectiveness of CBT interventions in the treatment of depression (Dobson, 1989) and anxiety

(Van Balkom et al., 1994).

The treatment model described in this manual is a combined CBT approach that employs relax-

ation, cognitive, and communication skills interventions.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

This combined approach presents the participants with options that draw on these different

interventions and then encourages them to develop individualized anger control plans using as

many of the techniques as possible. Not all the participants use all the techniques and inter-

ventions presented in the treatment (e.g., cognitive restructuring), but almost all finish the

treatment with more than one technique or intervention on their anger control plans.

Theoretically, the more techniques and interventions an individual has on his or her anger

control plan, the better equipped he or she will be to manage anger in response to anger-

provoking events.

In studies at the SFVA Medical Center and San Francisco General Hospital using this treatment

model, significant reductions in self-reported anger and violence have consistently been found,

as well as decreased substance use (Reilly, Clark, Shopshire, & Delucchi, 1995; Reilly,

Shopshire, & Clark, 1999; Reilly & Shopshire, 2000; Shopshire, Reilly, & Ouaou, 1996). Most

participants in these studies met Diagnostic and Statistical Manual of Mental Disorders, 4th

Edition (DSM-IV) (American Psychiatric Association, 1994) criteria for substance dependence,

and many also met DSM-IV criteria for posttraumatic stress disorder. A study comparing

Caucasian and African-American patients found that patients from both groups reduced their

anger significantly (Clark, Reilly, Shopshire, & Campbell, 1996). Another study showed that

women also benefited from the intervention—that is, reported decreased levels of anger (Reilly

et al., 1996).

In the anger management studies using this manual, the majority of patients were from ethnic

minority groups. Consistent reductions in anger and aggressive behavior occurred in these

groups, indicating that anger management group treatment is effective. The treatment model

is flexible and can accommodate racial, cultural, and gender issues. The events or situations

that trigger someone’s anger may vary somewhat depending on his or her culture or gender.

The cues or warning signs of anger may vary in this regard as well. Nevertheless, the overall

treatment model still applies and was found effective with different ethnic groups and with

both men and women. A person still has to identify the triggering event, recognize the cues to

anger, and develop anger management (cognitive behavioral) strategies in response to the

event and cues, regardless of whether these events and cues are different for other men and

women or for people in other cultural groups.

The intervention involves developing individualized anger control plans. For example, some

women identified their relationships with their boyfriends or partners or parenting concerns as

events that triggered their anger but men rarely identified these issues. Effective individual

strategies could be developed, however, to address these issues, provided the women accept

the concepts of monitoring anger (using the anger meter) and having (and using) an anger con-

trol plan.

This treatment model was also used successfully with non–substance-abusing clients seen in

the outpatient SFVA Mental Health Clinic. These clients were diagnosed with a variety of prob-

lems, including mood, anxiety, and thought disorders. The treatment components described in

this manual served as the core treatment in these studies.

A Cognitive Behavioral Therapy Manual

The anger management treatment should be delivered in a group setting. The ideal number of

participants in a group is 8, but groups can range from 5 to 10 members. There are several

reasons for this recommendation. First, solid empirical support exists for group cognitive

behavioral interventions (Carroll, Rounsaville, & Gawin, 1991; Maude-Griffin et al., 1998;

Smokowski & Wodarski, 1996); second, group treatment is efficient and cost-effective (Hoyt,

1993; Piper & Joyce, 1996); and third, it provides a greater range of possibilities and flexibility

in roleplays (Yalom, 1995) and behavioral rehearsal activities (Heimberg & Juster, 1994; Juster

& Heimberg, 1995). Counselors and social workers should have training in cognitive behavioral

therapy, group therapy, and substance abuse treatment (preferably, at the master’s level or

higher; doctoral-level psychologists have delivered the anger management treatment as well).

Although a group format is recommended for the anger management treatment, it is possible

for qualified clinicians to use this manual in individual sessions with their clients. In this case,

the same treatment format and sequence can be used. Individual sessions provide more time

for in-depth instruction and individualized behavioral rehearsal.

The anger management treatment manual is designed for adult male and female substance

abuse and mental health clients (age 18 years and above). The groups studied at SFVA

Medical Center and San Francisco General Hospital have included patients who have used

many substances (e.g., cocaine, alcohol, heroin, methamphetamine). These patients have been

able to use the anger management materials and benefit from the group treatment despite dif-

ferences in their primary drug of abuse.

It is recommended that participants be abstinent from drugs and alcohol for at least 2 weeks

prior to joining the anger management group. If a participant had a “slip” during his or her

enrollment in the group, he or she was not discharged from the group. However, if he or she

had repeated slips or a full-blown relapse, the individual was referred to a more intensified

treatment setting and asked to start the anger management treatment again.

Many group participants were diagnosed with co-occurring disorders (e.g., posttraumatic stress

disorder [PTSD], mood disorder, psychosis) but benefited from the anger management group

treatment. Patients were compliant with their psychiatric medication regimen and were moni-

tored by interdisciplinary treatment teams. The San Francisco group found that, if patients

were compliant with their medication regimen and abstinent from drugs and alcohol, they

could comprehend the treatment material and effectively use concepts such as timeouts and

thought stopping to manage anger. However, if a participant had a history of severe mental ill-

ness, did not comply with instructions on his or her psychiatric medication regimen, and had

difficulty processing the material or accepting group feedback, he or she was referred to his or

her psychiatrist for better medication management.

Several practitioners have requested the manual to work with adolescent clients in substance

abuse treatment, but no preliminary data from these treatment encounters are available.

Because of the many problems often experienced by substance abuse and mental health

clients, this intervention should be used as an adjunctive treatment to substance abuse and

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

mental health treatment. Certain issues, such as anger related to clients’ family of origin and

past learning, for example, may best be explored in individual and group therapy outside the

anger management group.

Finally, the authors stress the importance of providing ongoing anger management aftercare

groups. Participants at the SFVA Medical Center repeatedly asked to attend aftercare groups

where they could continue to practice and integrate the anger management strategies they

learned in this treatment. At the SFVA Medical Center, both an ongoing drop-in group and a

more structured 12-week phase-two group were provided as aftercare components. These

groups help participants maintain (and further reduce) the decreased level of anger and

aggression they achieved during the initial 12-week anger management group treatment.

Participants can also be referred to anger management groups in the community.

It is hoped that this anger management manual will help substance abuse and mental health

clinicians provide effective anger management treatment to clients who experience anger prob-

lems. Reductions in frequent and intense anger and its destructive consequences can lead to

improved physical and mental health of individuals and families.

HHoow w TTo o UUsse e TThhiis s MMaannuuaal l

The information presented in this manual is intended to allow qualified mental health and sub-

stance abuse professionals to deliver group cognitive behavioral anger management treatment

to clients with substance abuse and mental health disorders. Each of the 12 90-minute weekly

sessions is divided into four sections:

• Instructions to Group Leaders

• Check-In Procedure (beginning in the second session)

• Suggested Remarks

• Homework Assignments.

The Instructions to Group Leaders section summarizes the information to be presented in the

session and outlines the key conceptual components. The Check-In Procedure section provides

a structured process by which group members check in at each session and report on the

progress of their homework assignments from the previous week. The Suggested Remarks sec-

tion provides narrative scripts for the group leader presenting the material in the session.

Although the group leader is not required to read the scripts verbatim, the group leader should

deliver the information as closely as possible to the way it is in the script. The Homework

Assignment section provides instructions for group members on what tasks to review and prac-

tice for the next meeting. Session 1 also includes a special section that provides an overview

of the anger management treatment and outlines the group rules.

This manual should be used in conjunction with the Anger Management for Substance Abuse

and Mental Health Clients: Participant Workbook (Reilly, Shopshire, Durazzo, & Campbell,

2002). The workbook provides group members with a summary of the information presented in

each session, worksheets for completing homework assignments, and space to take notes dur-

ing each session. The workbook will facilitate the completion of homework assignments and

help reinforce the concepts presented over the course of the anger management treatment

program.

Although participants are kept busy in each session, 90 minutes should be enough time to

complete the tasks at hand. The group leader needs to monitor and, at times, limit the

responses of participants, however. This can be done by redirecting them to the question or

activity.

OOvveerrvviieew w oof f GGrroouup p AAnnggeer r

MMaannaaggeemmeennt t TTrreeaattmmeennt t

Outline of Session 1

• Instructions to Group Leaders

• Suggested Remarks

– Purpose and Overview

– Group Rules

– The Problem of Anger:

Some Operational Definitions

– Myths About Anger

– Anger as a Habitual Response

– Breaking the Anger Habit

– Participant Introductions

– Anger Meter

• Homework Assignment

Session 1

Instructions to Group Leaders

In the first session, the purpose, overview, group

rules, conceptual framework, and rationale for the

anger management treatment are presented. Most

of this session is spent presenting conceptual infor-

mation and verifying that the group members

understand it. Then the leader takes the group

members through an introductory exercise and a

presentation of the anger meter.

Suggested Remarks

(Present the following script or put this in your

own words.)

Purpose and Overview

The purpose of the anger management group is to:

1. Learn to manage anger

2. Stop violence or the threat of violence

3. Develop self-control over thoughts and actions

4. Receive support and feedback from others.

Group Rules

1. Group Safety: No violence or threats toward staff and other group members is allowed. It is

important that members perceive the group as a safe place to share their experiences and

feelings without threats or possible physical harm.

2. Confidentiality: Group members should not discuss outside the group what group members

say during group sessions. There are limits to confidentiality, however. In every State, health

laws govern how and when professionals must report certain actions to the proper authori-

ties. These actions may include any physical or sexual abuse inflicted on a child younger

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

than age 18, a person older than age 65, or a dependent adult. A dependent adult is

someone between 18 and 64 years who has physical or mental limitations that restrict his

or her ability to carry out normal activities or to protect his or her rights. Reporting abuse of

these persons supersedes confidentiality laws involving clients and health professionals.

Similarly, if a group member makes threats to physically harm or kill another person, the

group leader is required, under the Tarasoff Ruling (Tarasoff v. Regents of the University of

California, 529 P.2d 553 (Cal. 1974), vacated, reheard en bank, and affirmed, 131 Cal.

Rptr. 14, 551 P.2d 334 (1976)), to warn the intended victim and notify the police.

3. Homework Assignments: Brief homework assignments will be given each week. Doing the

homework assignments will improve group members’ anger management skills and allow

them to get the most from the group experience. Like any type of skill acquisition, anger

management requires time and practice. Homework assignments provide the opportunity

for skill development and refinement.

4. Absences and Cancellations: Members should call or otherwise notify the group leader in

advance when they cannot attend a session. Because of the amount of material presented

in each session, members may not miss more than 3 of the 12 sessions. If a group mem-

ber misses more than three sessions, he or she would not be able to adequately learn,

practice, and apply the concepts and skills that are necessary for effective anger manage-

ment. He or she can continue to attend the group sessions, but the group member will not

receive a certificate of completion. He or she can join another session as space becomes

available.

5. Timeout: The group leader reserves the right to call for a timeout. If a group member’s

anger begins to escalate out of control during a session, the leader will ask that member to

take a timeout from the topic and the discussion. This means that the member, along with

the rest of the members of the group, will immediately stop talking about the issue that is

causing the member’s anger to escalate. If the participant’s anger has escalated to the

point that he or she cannot tolerate sitting in the group, the leader may ask the person to

leave the group for 5 or 10 minutes or until he or she can cool down. The participant is

then welcomed back to the group, provided he or she can tolerate continued discussion in

the group.

A timeout is an effective anger management strategy and will be discussed in more detail

later in this session and in session 3. Eventually, group members will learn to call a timeout

themselves when they feel they may be losing control as the result of escalation of their

anger. For this session, however, it is essential that the leader calls for a timeout and that

members comply with the rule. This rule helps ensure that the group will be a safe place to

discuss and share experiences and feelings. Therefore, failure to comply with the timeout

rule may lead to termination from the group.

6. Relapses: If a participant has a relapse during his or her enrollment in the group, he or she

is not discharged. However, if the participant has repeated relapses, he or she will be

asked to start the treatment again and will be referred to a more intense treatment setting.

A Cognitive Behavioral Therapy Manual

The Problem of Anger: Some Operational Definitions

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 threat-

ened, 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. In addition, anger may result from frustration when

our needs, desires, and goals are not being met. When we become angry, we may lose our

patience and act impulsively, aggressively, or violently.

People often confuse anger with aggression. Aggression is behavior that is intended to cause

harm to another person or damage property. This behavior can include verbal abuse, threats,

or violent acts. Anger, on the other hand, is an emotion and does not necessarily lead to

aggression. Therefore, a person can become angry without acting aggressively.

A term related to anger and aggression is hostility. Hostility refers to a complex set of attitudes

and judgments that motivate aggressive behaviors. Whereas anger is an emotion and

aggression is a behavior, hostility is an attitude that involves disliking others and evaluating

them negatively.

In this group, clients will learn helpful strategies and techniques to manage anger, express

anger in alternative ways, change hostile attitudes, and prevent aggressive acts, such as verbal

abuse and violence.

When Does Anger Become a Problem?

Anger becomes a problem when it is felt too intensely, is felt too frequently, or is expressed

inappropriately. Feeling anger too intensely or frequently places extreme physical strain on the

body. During prolonged and frequent episodes of anger, certain divisions of the nervous sys-

tem become highly activated. Consequently, blood pressure and heart rate increase and stay

elevated for long periods. This stress on the body may produce many different health problems,

such as hypertension, heart disease, and diminished immune system efficiency. Thus, from a

health standpoint, avoiding physical illness is a motivation for controlling anger.

Another compelling reason to control anger concerns the negative consequences that result

from expressing anger inappropriately. In the extreme, anger may lead to violence or physical

aggression, which can result in numerous negative consequences, such as being arrested or

jailed, being physically injured, being retaliated against, losing loved ones, being terminated

from a substance abuse treatment or social service program, or feeling guilt, shame, or regret.

Even when anger does not lead to violence, the inappropriate expression of anger, such as ver-

bal abuse or intimidating or threatening behavior, often results in negative consequences. For

example, it is likely that others will develop fear, resentment, and lack of trust toward those

who subject them to angry outbursts, which may cause alienation from individuals, such as

family members, friends, and coworkers.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Payoffs and Consequences

The inappropriate expression of anger initially has many apparent payoffs. One payoff is being

able to manipulate and control others through aggressive and intimidating behavior; others

may comply with someone’s demands because they fear verbal threats or violence. Another

payoff is the release of tension that occurs when one loses his or her temper and acts aggres-

sively. The individual may feel better after an angry outburst, but everyone else may feel worse.

In the long term, however, these initial payoffs lead to negative consequences. For this reason

they are called “apparent” payoffs because the long-term negative consequences far outweigh

the short-term gains. For example, consider a father who persuades his children to comply with

his demands by using an angry tone of voice and threatening gestures. These behaviors imply

to the children that they will receive physical harm if they are not obedient. The immediate pay-

off for the father is that the children obey his commands. The long-term consequence, howev-

er, may be that the children learn to fear or dislike him and become emotionally detached from

him. As they grow older, they may avoid contact with him or refuse to see him altogether.

Myths About Anger

Myth #1: Anger Is Inherited. One misconception or myth about anger is that the way we

express anger is inherited and cannot be changed. Sometimes, we may hear someone say, “I

inherited my anger from my father; that’s just the way I am.” This statement implies that the

expression of anger is a fixed and unalterable set of behaviors. Evidence from research stud-

ies, however, indicates that people are not born with set, specific ways of expressing anger.

These studies show, rather, that because the expression of anger is learned behavior, more

appropriate ways of expressing anger also can be learned.

It is well established that much of people’s behavior is learned by observing others, particularly

influential people. These people include parents, family members, and friends. If children

observe parents expressing anger through aggressive acts, such as verbal abuse and violence,

it is very likely that they will learn to express anger in similar ways. Fortunately, this behavior

can be changed by learning new and appropriate ways of anger expression. It is not necessary

to continue to express anger by aggressive and violent means.

Myth #2: Anger Automatically Leads to Aggression. A related myth involves the misconception

that the only effective way to express anger is through aggression. It is commonly thought that

anger is something that builds and escalates to the point of an aggressive outburst. As has

been said, however, anger does not necessarily lead to aggression. In fact, effective anger man-

agement involves controlling the escalation of anger by learning assertiveness skills, changing

negative and hostile “self-talk,” challenging irrational beliefs, and employing a variety of behav-

ioral strategies. These skills, techniques, and strategies will be discussed in later sessions.

Myth #3: People Must Be Aggressive To Get What They Want. Many people confuse assertive-

ness with aggression. The goal of aggression is to dominate, intimidate, harm, or injure another

person—to win at any cost. Conversely, the goal of assertiveness is to express feelings of anger

A Cognitive Behavioral Therapy Manual

in a way that is respectful of other people. For example, if you were upset because a friend was

repeatedly late for meetings, you could respond by shouting obscenities and name-calling. This

approach is an attack on the other person rather than an attempt to address the behavior that

you find frustrating or anger provoking.

An assertive way of handling this situation might be to say, “When you are late for a meeting

with me, I get pretty frustrated. I wish that you would be on time more often.” This statement

expresses your feelings of frustration and dissatisfaction and communicates how you would

like the situation changed. This expression does not blame or threaten the other person and

minimizes the chance of causing emotional harm. We will discuss assertiveness skills in more

detail in sessions 7 and 8.

Myth #4: Venting Anger Is Always Desirable. For many years, the popular belief among numer-

ous mental health professionals and laymen was that the aggressive expression of anger, such

as screaming or beating on pillows, was healthy and therapeutic. Research studies have found,

however, that people who vent their anger aggressively simply get better at being angry

(Berkowitz, 1970; Murray, 1985; Straus, Gelles, & Steinmetz, 1980). In other words, venting

anger in an aggressive manner reinforces aggressive behavior.

Anger as a Habitual Response

Not only is the expression of anger learned, but it can become a routine, familiar, and pre-

dictable response to a variety of situations. When anger is displayed frequently and aggressive-

ly, it can become a maladaptive habit because it results in negative consequences. Habits, by

definition, are performed over and over again, without thinking. People with anger manage-

ment problems often resort to aggressive displays of anger to solve their problems, without

thinking about the negative consequences they may suffer or the debilitating effects it may

have on the people around them.

Breaking the Anger Habit

Becoming Aware of Anger. To break the anger habit, you must develop an awareness of the

events, circumstances, and behaviors of others that “trigger” your anger. This awareness also

involves understanding the negative consequences that result from anger. For example, you may

be in line at the supermarket and become impatient because the lines are too long. You could

become angry, then boisterously demand that the checkout clerk call for more help. As your

anger escalates, you may become involved in a heated exchange with the clerk or another cus-

tomer. The store manager may respond by having a security officer remove you from the store.

The negative consequences that result from this event are not getting the groceries that you

wanted and the embarrassment and humiliation you suffer from being removed from the store.

Strategies for Controlling Anger. In addition to becoming aware of anger, you need to develop

strategies to effectively manage it. These strategies can be used to stop the escalation of

anger before you lose control and experience negative consequences. An effective set of

strategies for controlling anger should include both immediate and preventive strategies.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Immediate strategies include taking a timeout, deep-breathing exercises, and thought stopping.

Preventive strategies include developing an exercise program and changing your irrational

beliefs. These strategies will be discussed in more detail in later sessions.

One example of an immediate anger management strategy worth exploring at this point is the

timeout. The timeout can be used formally or informally. For now, we will only describe the

informal use of a timeout. This use involves leaving a situation if you feel your anger is escalat-

ing out of control. For example, you may be a passenger on a crowded bus and become angry

because you perceive that people are deliberately bumping into you. In this situation, you can

simply get off the bus and wait for a less crowded bus.

The informal use of a timeout may also involve stopping yourself from engaging in a discussion

or argument if you feel that you are becoming too angry. In these situations, it may be helpful

to actually call a timeout or to give the timeout sign with your hands. This lets the other person

know that you wish to immediately stop talking about the topic and are becoming frustrated,

upset, or angry.

In this group, you should call a timeout if you feel that your anger is escalating out of control.

You also are encouraged to leave the room for a short period of time if you feel that you need

to do so. However, please come back for the remainder of the group session after you have

calmed down.

Participant Introductions

At this point, ask group members to give their names, the reasons they are interested in partic-

ipating in the anger management group, and what they hope to achieve in the group. After

each member’s introduction, offer a supportive comment that validates his or her decision to

participate in the group. Experience shows that this helps members feel the group will meet

their needs and helps reduce the anxiety associated with the introductions and the first group

session in general.

Anger Meter

One technique that is helpful in increasing the awareness of anger is learning to monitor it. A

simple way to monitor anger is to use the “anger meter.” A 1 on the anger meter represents a

complete lack of anger or a total state of calm, whereas a 10 represents a very angry and

explosive loss of control that leads to negative consequences. Points between 1 and 10 repre-

sent feelings of anger between these extremes. The purpose of the anger meter is to monitor

the escalation of anger as it moves up the scale. For example, when a person encounters an

anger-provoking event, he or she does not reach a 10 immediately, although it may sometimes

feel that way. In reality, the individual’s anger starts at a low number and rapidly moves up the

scale. There is always time, provided one has learned effective coping skills, to stop anger from

escalating to a 10.

• Explosion

• Violence

• Loss of Control

• Negative Consequences

• You Lose!

• You have a choice!

5 • Use your anger control

plan to avoid reaching 10!

A Cognitive Behavioral Therapy Manual

One difficulty people have when learning to use the anger meter is misunderstanding the

meaning of a 10. A 10 is reserved for instances when an individual suffers (or could suffer)

negative consequences. An example is when an individual assaults another person and is

arrested by the police.

A second point to make about the anger meter is that people may interpret the numbers on

the scale differently. These differences are acceptable. What may be a 5 for one person may

be a 7 for someone else. It is much more important to personalize the anger meter and

become comfortable and familiar with your readings of the numbers on the scale. For the

group, however, a 10 is reserved for instances when someone loses control and suffers (or

could suffer) negative consequences.

Exhibit 1. The Anger Meter

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Homework Assignment

Have group members refer to the participant workbook. Ask them to review the group’s pur-

pose, rules, definitions of anger and aggression, myths about anger, anger as a habitual

response, and the anger meter. Ask them to monitor their levels of anger on the anger meter

during the upcoming week and report their highest level of anger during the Check-In

Procedure of next week’s session.

EEvveenntts s aannd d CCuuees s

A Conceptual Framework for Understanding Anger

Outline of Session 2

• Instructions to Group Leaders

• Suggested Remarks

– Events That Trigger Anger

– Cues to Anger

• Explaining the Check-In

Procedure

• Homework Assignment

Session 2

Instructions to Group Leaders

This session teaches group members how to ana-

lyze an anger episode and to identify the events

and cues that indicate an escalation of anger.

Begin the session with a check in (following up

on the homework assignment from the last

week, namely, have group members report on

the highest level of anger they reached on the

anger meter during the past week) and follow with

a presentation and discussion of events and cues. A more complete Check-In Procedure will be

used in session 3 after members have been taught to identify specific anger-provoking events

and the cues that indicate an escalation of anger.

After the Check-In Procedure, ask group members to list specific events that trigger their anger.

Pay special attention to helping them distinguish between the events and their interpretation of

these events. Events refer to facts. Interpretations refer to opinions, value judgments, or per-

ceptions of the events. For example, a group member might say, “My boss criticized me

because he doesn’t like me.” Point out that the specific event was that the boss criticized the

group member and that the belief that his boss doesn’t like him is an interpretation that may

or may not be accurate.

Be aware of gender differences. Women participants often identify relationships with their

boyfriend or partner or parenting concerns as events that trigger their anger. Men, however,

may rarely identify these issues as triggers.

Finally, present the four cues to anger categories. After describing each category, ask group

members to provide examples. It is important to emphasize that cues may be different for each

individual. Members should identify cues that indicate an escalation of their anger.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Suggested Remarks

(Use the following script or put this in your own words.)

Events That Trigger Anger

When you get angry, it is because an event has provoked your anger. For example, you may

get angry when the bus is late, when you have to wait in line at the grocery store, or when a

neighbor plays his stereo too loud. Everyday events such as these can provoke your anger.

Many times, specific events touch on sensitive areas in your life. These sensitive areas or “red

flags” usually refer to long-standing issues that can easily lead to anger. For example, some of

us may have been slow readers as children and may have been sensitive about our reading

ability. Although we may read well now as adults, we may continue to be sensitive about this

issue. This sensitivity may be revealed when someone rushes us while we are completing an

application or reviewing a memorandum and may trigger anger because we may feel that we

are being criticized or judged as we were when we were children. This sensitivity may also

show itself in a more direct way, such as when someone calls us “slow” or “stupid.”

In addition to events experienced in the here-and-now, you may also recall an event from

your past that made you angry. You might remember, for example, how the bus always seemed

to be late before you left home for an important appointment. Just thinking about how late

the bus was in the past can make you angry in the present. Another example may be when

you recall a situation involving a family member who betrayed or hurt you in some way.

Remembering this situation, or this family member, can raise your number on the anger

meter. Here are examples of events or issues that can trigger anger:

• Long waits to see your doctor

• Traffic congestion

• Crowded buses

• A friend joking about a sensitive topic

• A friend not paying back money owed to you

• Being wrongly accused

• Having to clean up someone else’s mess

• Having an untidy roommate

• Having a neighbor who plays the stereo too loud

• Being placed on hold for long periods of time while on the telephone

• Being given wrong directions

A Cognitive Behavioral Therapy Manual

• Rumors being spread about your relapse that are not true

• Having money or property stolen from you.

Cues to Anger

A second important aspect of anger monitoring is to identify the cues that occur in response to

the anger-provoking event. These cues serve as warning signs that you have become angry and

that your anger is continuing to escalate. They can be broken down into four cue categories:

physical, behavioral, emotional, and cognitive (or thought) cues.

Physical Cues. Physical cues involve the way our bodies respond when we become angry. For

example, our heart rates may increase, we may feel tightness in our chests, or we may feel hot

and flushed. These physical cues can also warn us that our anger is escalating out of control

or approaching a 10 on the anger meter. We can learn to identify these cues when they occur

in response to an anger-provoking event.

Can you identify some of the physical cues that you have experi-

enced when you have become angry?

Behavioral Cues. Behavioral cues involve the behaviors we display when we get angry, which

are observed by other people around us. For example, we may clench our fists, pace back and

forth, slam a door, or raise our voices. These behavioral responses are the second cue of our

anger. As with physical cues, they are warning signs that we may be approaching a 10 on the

anger meter.

What are some of the behavioral cues that you have experienced

when you have become angry?

Emotional Cues. Emotional cues involve other feelings that may occur concurrently with our

anger. For example, we may become angry when we feel abandoned, afraid, discounted, disre-

spected, guilty, humiliated, impatient, insecure, jealous, or rejected. These kinds of feelings are

the core or primary feelings that underlie our anger. It is easy to discount these primary feel-

ings because they often make us feel vulnerable. An important component of anger manage-

ment is to become aware of, and to recognize, the primary feelings that underlie our anger. In

this group, we will view anger as a secondary emotion to these more primary feelings.

Can you identify some of the primary feelings that you have experi-

enced during an episode of anger?

Cognitive Cues. Cognitive cues refer to the thoughts that occur in response to the anger-

provoking event. When people become angry, they may interpret events in certain ways. For

example, we may interpret a friend’s comments as criticism, or we may interpret the actions

of others as demeaning, humiliating, or controlling. Some people call these thoughts “self-talk”

because they resemble a conversation we are having with ourselves. For people with anger

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

problems, this self-talk is usually very critical and hostile in tone and content. It reflects beliefs

about the way they think the world should be; beliefs about people, places, and things.

Closely related to thoughts and self-talk are fantasies and images. We view fantasies and

images as other types of cognitive cues that can indicate an escalation of anger. For example,

we might fantasize about seeking revenge on a perceived enemy or imagine or visualize our

spouse having an affair. When we have these fantasies and images, our anger can escalate

even more rapidly.

Can you think of other examples of cognitive or thought cues?

Explaining the Check-In Procedure

In this session, group members began to monitor their anger and identify anger-provoking

events and situations. In each weekly session, there will be a Check-In Procedure to follow up

on the homework assignment from the previous week and to report the highest level of anger

reached on the anger meter during the week.

Have participants identify the event that triggered their anger, the cues that were associated

with their anger, and the strategies they used to manage their anger in response to the event.

They will be using the following questions to check in at the beginning of each session:

1. What was the highest number you reached on the anger meter during the past week?

2. What was the event that triggered your anger?

3. What cues were associated with the anger-provoking event? For example, what were the

physical, behavioral, emotional, or cognitive cues?

4. What strategies did you use to avoid reaching 10 on the anger meter?

They will also be asked to monitor and record the highest number they reach on the anger

meter for each day of the upcoming week after each session.

Exhibit 2. Cues to Anger: Four Cue Categories

1. Physical (examples: rapid heartbeat, tightness in chest, feeling hot or

flushed)

2. Behavioral (examples: pacing, clenching fists, raising voice, staring)

3. Emotional (examples: fear, hurt, jealousy, guilt)

4. Cognitive/Thoughts (examples: hostile self-talk, images of aggression

and revenge)

A Cognitive Behavioral Therapy Manual

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the upcoming week. In addition, ask them to

identify the event that made them angry and list the cues that were associated with the anger-

provoking event. Tell participants they should be prepared to report on these assignments dur-

ing the Check-In Procedure in next week’s session.

AAnnggeer r CCoonnttrrool l PPllaanns s

Helping Group Members Develop a Plan

for Controlling Anger

Outline of Session 3

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

– Anger Control Plans

– Relaxation Through Breathing

• Homework Assignment

Session 3

Instructions to Group Leaders

In this session, begin teaching group members

cognitive behavioral strategies for controlling

their anger. By now, participants have begun to

learn how to monitor their anger and identify

anger-provoking events and situations. At this

point, it is important to help them develop a

repertoire of anger management strategies. This

repertoire of strategies is called an anger control

plan. This plan should consist of immediate strategies, those that can be used in the heat of

the moment when anger is rapidly escalating, and preventive strategies, those that can be

used to avoid escalation of anger before it begins. It is important to encourage members to

use strategies that work best for them. Some find cognitive restructuring (e.g., challenging hos-

tile self-talk or irrational beliefs) very effective. Others might prefer using strategies such as a

timeout or thought stopping. The main point is to help group members individualize their anger

control plans and to help them develop strategies that they are comfortable with and that they

will readily use. In the remaining sessions, you will continue to help group members develop

effective strategies for controlling their anger and clarify and reinforce these strategies during

the Check-In Procedure.

Participants should be encouraged to seek support and feedback from people they can trust to

support their recovery, including anger management strategies that will de-escalate, rather

than escalate, the situation. Participants should seek advice from one another and other

patients who are in recovery and from members in support networks, including members of

12-Step groups, 12-Step sponsors, or religious group members.

In addition to helping group members begin to develop their anger control plans, start the ses-

sion with the Check-In Procedure, and end the session with a breathing exercise as a form of

relaxation training. Before leading members in the breathing exercise, ask whether anyone has

had experience with different forms of relaxation. Describe the continuum of relaxation tech-

niques, which can range from simple breathing exercises to elaborate guided imagery. Explain

that in the group, they will practice two short and simple relaxation exercises, deep-breathing

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

EEvveenntt CCuueess SSttrraatteeggiieess

and progressive muscle relaxation. Further explain that experience shows that group members

are more likely to use these simple forms of relaxation.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter

during the past week. Make sure they reserve the number 10 for situations where they lost

control of their anger and experienced negative consequences. Ask them to describe the

anger-provoking event that led to their highest level of anger. Help them identify the cues that

occurred in response to the anger-provoking event, and help them classify these cues into the

four cue categories.

Exhibit 3. Event, Cues, and Strategies Identified

During the Check-In Procedure

Suggested Remarks

(Use the following script or put this in your own words.)

Anger Control Plans

Up to this point, you have been focusing on how to monitor your anger. In the first session, you

learned how to use the anger meter to rate your anger. Last week, you learned how to identify

the events that trigger anger, as well as the physical, behavioral, emotional, and cognitive cues

associated with each event. Today, you will begin to discuss how to develop an anger control

plan and how you can use specific strategies, such as timeouts and relaxation, to control your

anger. In later sessions, you will cover other strategies, such as learning to change negative or

hostile self-talk and using the Conflict Resolution Model (see page 39). These more advanced

strategies can be used along with timeouts and relaxation.

A Cognitive Behavioral Therapy Manual

The basic idea in developing an anger control plan is to try many different strategies and find

the anger control techniques that work best for you. Once you identify these strategies, you can

add them to your anger control plans and use them when you start to get angry. Some people

refer to their anger control plans as their toolbox and the specific strategies they use to control

their anger as their tools. This analogy may be very helpful. Again, it is important to identify the

specific anger control strategies that work best for you. These strategies should be put down in

a formal anger control plan for referral when you encounter an anger-provoking event.

An effective strategy that many people use, for example, is to talk about their feelings with a

supportive friend who was not involved with the event that made them angry. By discussing

anger, you can begin to identify the primary emotions that underlie it and determine whether

your thinking and expectations in response to the anger-provoking event are rational. Often a

friend whom you trust can provide a different perspective on what is going on in your life. Even

if your friend just listens, expressing your feelings can often make you feel better.

The long-term objective of the anger management treatment is to develop a set of strategies

that you can use appropriately for specific anger-provoking events. Later sessions will introduce

a menu of strategies and techniques that are helpful in managing anger. Once you have select-

ed the strategies that work best, you should refine them by applying them in real-life situations.

To use the toolbox analogy, different tools may be needed for different situations. We will

return to this concept in later sessions and highlight the importance of developing an anger

control plan that helps you manage anger effectively in a variety of situations.

Timeout. As mentioned in session 1, the concept of a timeout is especially important to anger

management. It is the basic anger management strategy recommended for inclusion in every-

one’s anger control plan. Informally, a timeout is defined as leaving the situation that is caus-

ing the escalation of anger or simply stopping the discussion that is provoking it.

Formally, a timeout involves relationships with other people: it involves an agreement or a pre-

arranged plan. These relationships may involve family members, friends, and coworkers. Any of

the parties involved may call a timeout in accordance with rules that have been agreed on by

everyone in advance. The person calling the timeout can leave the situation, if necessary. It is

agreed, however, that he or she will return to either finish the discussion or postpone it,

depending on whether all those involved feel they can successfully resolve the issue.

Timeouts are important because they can be effective in the heat of the moment. Even if your

anger is escalating quickly on the anger meter, you can prevent reaching 10 by taking a time-

out and leaving the situation.

Timeouts are also effective when they are used with other strategies. For example, you can

take a timeout and go for a walk. You can also take a timeout and call a trusted friend or fami-

ly member or write in your journal. These other strategies should help you calm down during

the timeout period.

Can you think of specific strategies that you might use to control

your anger?

Should these strategies be included on your anger control plan? 23

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Exhibit 4. Sample of an Anger Control Plan

Anger Control Plan

1. Take a timeout (formal or informal)

2. Talk to a friend (someone you trust)

3. Use the Conflict Resolution Model to express anger

4. Exercise (take a walk, go to the gym, etc.)

5. Attend 12-Step meetings

6. Explore primary feelings beneath the anger

Relaxation Through Breathing

We have discussed the physical cues to anger, such as an increased heartbeat, feeling hot or

flushed, or muscle tension. These types of physical cues are examples of what is commonly

called the stress response. In the stress response, the nervous system is energized, and in this

agitated state, a person is likely to have trouble returning to lower levels on the anger meter. In

this state, additional anger-provoking situations and events are likely to cause a further escala-

tion of anger.

An interesting aspect of the nervous system is that everyone has a relaxation response that

counteracts the stress response. It is physically impossible to be both agitated and relaxed at

the same time. If you can relax successfully, you can counteract the stress or anger response.

We will end this session by practicing a deep-breathing exercise as a relaxation technique. In

session 4, we will practice progressive muscle relaxation as a secondary type of relaxation

technique.

A Cognitive Behavioral Therapy Manual

Note to Group Leader:

Lead a Breathing Exercise

(Use this script or put this in your own words.)

Get comfortable in your chair. If you like, close your eyes; or just gaze at the floor.

Take a few moments to settle yourself. Now make yourself aware of your body. Check your

body for tension, beginning with your feet, and scan upward to your head. Notice any ten-

sion you might have in your legs, your stomach, your hands and arms, your shoulders,

your neck, and your face. Try to let go of the tension you are feeling.

Now, make yourself aware of your breathing. Pay attention to your breath as it enters and

leaves your body. This can be very relaxing.

Let’s all take a deep breath together. Notice your lungs and chest expanding. Now slowly

exhale through your nose. Again, take a deep breath. Fill your lungs and chest. Notice how

much air you can take in. Hold it for a second. Now release it and slowly exhale. One more

time, inhale slowly and fully. Hold it for a second, and release.

Now on your own, continue breathing in this way for another couple of minutes. Continue

to focus on your breathing. With each inhalation and exhalation, feel your body becoming

more and more relaxed. Use your breathing to wash away any remaining tension.

(Allow group members to practice breathing for 1 to 2 minutes in silence.)

Now let’s take another deep breath. Inhale fully, hold it for a second, and release. Inhale

again, hold, and release. Continue to be aware of your breath as it fills your lungs. Once

more, inhale fully, hold it for a second, and release.

When you feel ready, open your eyes.

How was that? Did you notice any new sensations while you were breathing? How do you

feel now?

This breathing exercise can be shortened to just three deep inhalations and exhalations.

Even that much can be effective in helping you relax when your anger is escalating. You

can practice this at home, at work, on the bus, while waiting for an appointment, or even

while walking. The key to making deep-breathing an effective relaxation technique is to

practice it frequently and to apply it in a variety of situations.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the upcoming week. Ask them to identify the

event that made them angry, the cues that were associated with the anger-provoking event,

and the strategies that they used to manage their anger in response to the event. Ask them to

practice the deep-breathing exercise, preferably once a day during the upcoming week, and

develop a preliminary version of their anger control plans. Inform group members that they

should be prepared to report on these assignments during the Check-In Procedure at the next

week’s session.

TThhe e AAggggrreessssiioon n CCyycclle e

How To Change the Cycle

Outline of Session 4

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

– The Aggression Cycle

– Progressive Muscle Relaxation

• Homework Assignment

Session 4

Instructions to Group Leaders

This session presents the aggression cycle and

introduces progressive muscle relaxation. As in

the previous two sessions, begin with the

Check-In Procedure. Then present the three-

phase aggression cycle, which consists of esca-

lation, explosion, and postexplosion. It serves as

a framework that incorporates the concepts of

the anger meter, cues to anger, and the anger

control plan.

End the session by presenting a progressive muscle relaxation exercise. Progressive muscle

relaxation is another technique that has been effective in reducing anger levels. An alternative

to the deep-breathing exercise introduced in last week’s session, it is straightforward and easy

to learn.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter

during the past week. Make sure they reserve the number 10 for situations where they lost

control of their anger and experienced negative consequences. Ask them to describe the

anger-provoking event that led to their highest level of anger. Help them identify the cues that

occurred in response to the anger-provoking event, and help them classify those cues into the

four cue categories. Include, as part of the Check-In Procedure, a followup on the homework

assignment from the previous week’s session. Ask participants to report on the specific anger

management strategies listed, thus far, on their anger control plans. In addition, inquire

whether they practiced the deep-breathing exercise that was introduced in last week’s session.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Suggested Remarks

(Use the following script or put this in your own words.)

The Aggression Cycle

In the last three sessions, we reviewed the anger meter, cues to anger, and the anger control

plan; in this session, the framework for integrating these anger management concepts is pre-

sented. This framework is the aggression cycle.

From an anger management perspective, an episode of anger can be viewed as consisting of

three phases: escalation, explosion, and postexplosion. Together, they make up the aggression

cycle. In this process, the escalation phase is characterized by cues that indicate anger is

building. As stated in session 2, these cues can be physical, behavioral, emotional, or cognitive

(thoughts). As you may recall, cues are warning signs, or responses, to anger-provoking events.

Events, on the other hand, are situations that occur every day that may lead to escalations of

anger if effective anger management strategies are not used. Red-flag events are types of situ-

ations that are unique to you and that you are especially sensitive to because of past events.

These events can involve internal processes (e.g., thinking about situations that were anger

provoking in the past) or external processes (e.g., experiencing real-life, anger-provoking situa-

tions in the here and now).

If the escalation phase is allowed to continue, the explosion phase will follow. The explosion

phase is marked by an uncontrollable discharge of anger displayed as verbal or physical

aggression. This discharge, in turn, leads to negative consequences; it is synonymous with the

number 10 on the anger meter.

The final stage of the aggression cycle is the postexplosion phase. It is characterized by nega-

tive consequences resulting from the verbal or physical aggression displayed during the explo-

sion phase. These consequences may include going to jail, making restitution, being terminat-

ed from a job or discharged from a drug treatment or social service program, losing family and

loved ones, or feelings of guilt, shame, and regret.

The intensity, frequency, and duration of anger in the aggression cycle varies among individu-

als. For example, one person’s anger may escalate rapidly after a provocative event and, within

just a few minutes, reach the explosion phase. Another person’s anger may escalate slowly but

steadily over several hours before reaching the explosion phase. Similarly, one person may

experience more episodes of anger and progress through the aggression cycle more often than

the other. However, both individuals, despite differences in how quickly their anger escalates

and how frequently they experience anger, will undergo all three phases of the aggression

cycle.

The intensity of these individuals’ anger also may differ. One person may engage in more vio-

lent behavior than the other in the explosion phase. For example, he or she may use weapons

or assault someone. The other person may express his or her anger during the explosion phase

A Cognitive Behavioral Therapy Manual

by shouting at or threatening other people. Regardless of these individual differences,

the explosion phase is synonymous with losing control and becoming verbally or physically

aggressive.

Notice that the escalation and explosion phases of the aggression cycle correspond to the lev-

els on the anger meter. The points below 10 on the anger meter represent the escalation

phase, the building up of anger. The explosion phase, on the other hand, corresponds to 10 on

the anger meter. Again 10 on the anger meter is the point at which one loses control and

expresses anger through verbal or physical aggression that leads to negative consequences.

One of the primary objectives of anger management treatment is to keep from reaching the

explosion phase. This is accomplished by using the anger meter to monitor changes in your

anger, attending to the cues or warning signs that indicate anger is building, and employing the

appropriate strategies from your anger control plans to stop the escalation of anger. If the

explosion phase is prevented from occurring, the postexplosion phase will not occur, and the

aggression cycle will be broken. If you use your anger control plans effectively, your anger

should ideally reach between a 1 and a 9 on the anger meter. This is a reasonable goal to aim

for. By preventing the explosion phase (10), you will not experience the negative consequences

of the postexplosion phase, and you will break the cycle of aggression.

Exhibit 5. The Aggression Cycle

*Based on the Cycle of Violence by Lenore Walker (1979). The Battered Woman. New York: Harper & Row.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Note to Group Leader:

Lead a Progressive Muscle Relaxation Exercise

(Use this script or put this in your own words.)

Last week you practiced deep-breathing as a relaxation technique. Today I will introduce

progressive muscle relaxation. Start by getting comfortable in your chairs. Close your eyes

if you like. Take a moment to really settle in. Now, as you did last week, begin to focus on

your breathing. Take a deep breath. Hold it for a second. Now exhale fully and completely.

Again, take a deep breath. Fill your lungs and chest. Now release and exhale slowly.

Again, one more time, inhale slowly, hold, and release.

Now, while you continue to breathe deeply and fully, bring your awareness to your hands.

Clench your fists very tightly. Hold that tension. Now relax your fists, letting your fingers

unfold and letting your hands completely relax. Again, clench your fists tightly. Hold and

release the tension. Imagine all the tension being released from your hands down to your

fingertips. Notice the difference between the tension and complete relaxation.

Now bring your awareness to your arms. Curl your arms as if you are doing a bicep curl.

Tense your fists, forearms, and biceps. Hold the tension and release it. Let the tension in

your arms unfold and your hands float back to your thighs. Feel the tension drain out of

your arms. Again, curl your arms to tighten your biceps. Notice the tension, hold, and

release. Let the tension flow out of your arms. Replace it with deep muscle relaxation.

Now raise your shoulders toward your ears. Really tense your shoulders. Hold them up for a

second. Gently drop your shoulders, and release all the tension. Again, lift your shoulders,

hold the tension, and release. Let the tension flow from your shoulders all the way down

your arms to your fingers. Notice how different your muscles feel when they are relaxed.

Now bring your awareness to your neck and face. Tense all those muscles by making a

face. Tense your neck, jaw, and forehead. Hold the tension, and release. Let the muscles

of your neck and jaw relax. Relax all the lines in your forehead. One final time, tense all

the muscles in your neck and face, hold, and release. Be aware of your muscles relaxing

at the top of your head and around your eyes. Let your eyes relax in their sockets, almost

as if they were sinking into the back of your head. Relax your jaw and your throat. Relax

all the muscles around your ears. Feel all the tension in your neck muscles release.

Now just sit for a few moments. Scan your body for any tension and release it. Notice how

your body feels when your muscles are completely relaxed.

When you are ready, open your eyes. How was that? Did you notice any new sensations?

How does your body feel now? How about your state of mind? Do you notice any

difference now from when we started?

A Cognitive Behavioral Therapy Manual

Homework Assignment

Have group members refer to the participant workbook. During the coming week have them

monitor and record their highest level of anger on the anger meter. Ask them to identify the

event that made them angry, the cues associated with the anger-provoking event, and the

strategies they used to manage their anger in response to the event. Ask them to review the

aggression cycle and practice progressive muscle relaxation, preferably once a day, during the

coming week. Remind them to continue to develop their anger control plans.

CCooggnniittiivve e RReessttrruuccttuurriinng g

The A-B-C-D Model and Thought Stopping

Outline of Session 5

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

– The A-B-C-D Model

– Thought Stopping

• Homework Assignment

Session 5

Instructions to Group Leaders

In this session, present the A-B-C-D Model (a

form of cognitive restructuring originally devel-

oped by Albert Ellis [Ellis, 1979; Ellis & Harper,

1975]) and the technique of thought stopping.

Cognitive restructuring is an advanced anger

management technique that requires group

members to examine and change their thought

processes. People differ in their ability to learn and apply these techniques. Some may be

generally familiar with cognitive restructuring, whereas others may have little or no experience

with this concept. In addition, some people may initially have difficulty understanding the con-

cept or may not yet be ready to challenge or change their irrational beliefs. It is important to

accept these group members, whatever their level of readiness and understanding, and help

them identify how their irrational beliefs perpetuate anger and how modifying these beliefs can

prevent further escalation of anger.

In addition to presenting the A-B-C-D Model, include a discussion on thought stopping. Thought

stopping is accepted and readily understood by most clients. Regardless of whether they view

particular beliefs as irrational or maladaptive, most people recognize that these specific beliefs

increase anger and lead to the explosion phase (10 on the anger meter). Thought stopping

provides an immediate and direct strategy for helping people manage the beliefs that cause

their anger to escalate.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter

during the past week. Make sure they reserve 10 for situations where they lost control of their

anger and experienced negative consequences. Ask them to describe the anger-provoking

event that led to their highest level of anger and to identify the cues that occurred in response

to the anger-provoking event. Help them classify these cues into the four cue categories.

Include, as part of the Check-In Procedure, a followup of the homework assignment from last

week’s session. Specifically ask group members to report on the development of their anger

control plans. In addition, inquire whether they practiced the progressive muscle relaxation

exercise.

AAnnggeer r MMaannaaggeemmeennt tfor Substance Abuse and Mental Health Clients

Suggested Remarks

(Use the following script or put this in your own words.)

The A-B-C-D Model

Albert Ellis developed a model that is consistent with the way we conceptualize anger manage-

ment treatment. He calls his model the A-B-C-D or rational-emotive model. In this model, “A”

stands for an activating event, what we have been calling the red-flag event. “B” represents the

beliefs people have about the activating event. Ellis claims that it is not the events themselves

that produce feelings such as anger, but our interpretations of and beliefs about the events.

“C” stands for the emotional consequences of events. In other words, these are the feelings

people experience as a result of their interpretations of and beliefs concerning the event.

According to Ellis and other cognitive behavioral theorists, as people become angry, they

engage in an internal dialog, called “self-talk.” For example, suppose you were waiting for a

bus to arrive. As it approaches, several people push in front of you to board. In this situation,

you may start to get angry. You may be thinking, “How can people be so inconsiderate! They

just push me aside to get on the bus. They obviously don’t care about me or other people.”

Examples of the irrational self-talk that can produce anger escalation are reflected in state-

ments such as “People should be more considerate of my feelings,” “How dare they be so

inconsiderate and disrespectful,” and “They obviously don’t care about anyone but themselves.”

Ellis says that people do not have to get angry when they encounter such an event. The event

itself does not get them upset and angry; rather, it is people’s interpretations of and beliefs

concerning the event that cause the anger. Beliefs underlying anger often take the form of

“should” and “must.” Most of us may agree, for example, that respecting others is an

admirable quality. Our belief might be, “People should always respect others.” In reality, how-

ever, people often do not respect each other in everyday encounters. You can choose to view

the situation more realistically as an unfortunate defect of human beings, or you can let your

anger escalate every time you witness, or are the recipient of, another person’s disrespect.

Unfortunately, your perceived disrespect will keep you angry and push you toward the explosion

phase. Ironically, it may even lead you to show disrespect to others, which would violate your

own fundamental belief about how people should be treated.

Ellis’ approach consists of identifying irrational beliefs and disputing them with more rational

or realistic perspectives (in Ellis’ model, “D” stands for dispute). You may get angry, for exam-

ple, when you start thinking, “I must always be in control. I must control every situation.” It is

not possible or appropriate, however, to control every situation. Rather than continue with

these beliefs, you can try to dispute them. You might tell yourself, “I have no power over things

I cannot control,” or “I have to accept what I cannot change.” These are examples of ways to

dispute beliefs that you may have already encountered in 12-Step programs such as Alcoholics

Anonymous or Narcotics Anonymous.

People may have many other irrational beliefs that may lead to anger. Consider an example

where a friend of yours disagrees with you. You may start to think, “Everyone must like me and

A Cognitive Behavioral Therapy Manual

give me approval.” If you hold such a belief, you are likely to get upset and angry when you

face rejection. However, if you dispute this irrational belief by saying, “I can’t please everyone;

some people are not going to approve of everything I do,” you will most likely start to calm

down and be able to control your anger more easily.

Another common irrational belief is, “I must be respected and treated fairly by everyone.” This

also is likely to lead to frustration and anger. Most folks, for example, live in an urban society

where they may, at times, not be given the common courtesy they expect. This is unfortunate,

but from an anger management perspective, it is better to accept the unfairness and lack of

interpersonal connectedness that can result from living in an urban society. Thus, to dispute

this belief, it is helpful to tell yourself, “I can’t be expected to be treated fairly by everyone.”

Other beliefs that may lead to anger include “Everyone should follow the rules,” or “Life should

be fair,” or “Good should prevail over evil,” or “People should always do the right thing.” These

are beliefs that are not always followed by everyone in society, and, usually, there is little you

can do to change that. How might you dispute these beliefs? In other words, what thoughts

that are more rational and adaptive and will not lead to anger can be substituted for such

beliefs?

For people with anger control problems, these irrational beliefs can lead to the explosion phase

(10 on the anger meter) and to the negative consequences of the postexplosion phase. It is

often better to change your outlook by disputing your beliefs and creating an internal dialog or

self-talk that is more rational and adaptive.

Exhibit 6. The A-B-C-D Model

AA--BB--CC--D D MMooddeell* *

A = Activating Situation or Event

B = Belief System

What you tell yourself about the event (your self-talk)

Your beliefs and expectations of others

C = Consequence

How you feel about the event based on your self-talk

D = Dispute

Examine your beliefs and expectations

Are they unrealistic or irrational?

*Based on the work of Albert Ellis, 1979, and Albert Ellis and R.A. Harper, 1975.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Thought Stopping

A second approach to controlling anger is called thought stopping. It provides an immediate

and direct alternative to the A-B-C-D Model. In this approach, you simply tell yourself (through a

series of self-commands) to stop thinking the thoughts that are getting you angry. For example,

you might tell yourself, “I need to stop thinking these thoughts. I will only get into trouble if I

keep thinking this way,” or “Don’t buy into this situation,” or “Don’t go there.” In other words,

instead of trying to dispute your thoughts and beliefs as outlined in the A-B-C-D Model

described above, the goal is to stop your current pattern of angry thoughts before they lead to

an escalation of anger and loss of control.

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the coming week. Ask them to identify the

event that made them angry, the cues that were associated with the anger-provoking event,

and the strategies they used to manage their anger in response to the event. Ask members to

review the A-B-C-D Model and to record at least two irrational beliefs and how they would dis-

pute these beliefs. In addition, instruct them to use the thought-stopping technique, preferably

once a day during the coming week. Remind them to continue to develop their anger control

plans.

RReevviieew w SSeessssiioon n ##1 1

Reinforcing Learned Concepts

Outline of Session 6

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

• Review of Learned Concepts

• Homework Assignment

Session 6

Instructions to Group Leaders

In this session, you will review and summarize the

basic concepts of anger management presented

thus far. Special attention should be given to clari-

fying and reinforcing concepts (i.e., the anger meter,

cues to anger, anger control plans, the aggression

cycle, and cognitive restructuring). Provide encouragement and support for efforts to develop

anger control plans and to balance cognitive, behavioral, immediate, and preventive strategies.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter during

the past week. Make sure they reserve 10 for situations where they lost control of their anger

and experienced negative consequences. Ask them to describe the anger-provoking event that

led to their highest level of anger. Help them identify the cues that occurred in response to the

anger-provoking event and help them classify these cues into the four cue categories. Include,

as part of the Check-In Procedure, a followup of the homework assignment from last week’s

session. Ask group members to report on their use of the A-B-C-D Model during the past week

and to provide a brief update on the ongoing development of their anger control plans.

Suggested Remarks

(Use the following script or put this in your own words.)

This session will serve as a review session for the anger management material we have cov-

ered thus far. We will review each concept and clarify any questions that you may have.

Discussion is encouraged during this review, and you will be asked to describe your under-

standing of the anger management concepts.

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the coming week. Ask them to identify the

event that made them angry, the cues that were associated with the anger-provoking event,

and the strategies they used to manage their anger in response to the event. Remind them to

continue to develop their anger control plans.

AAsssseerrttiivveenneesss s TTrraaiinniinng g aannd d tthhe e

CCoonnfflliicct t RReessoolluuttiioon n MMooddeel l

Alternatives for Expressing Anger

Outline of Sessions 7 & 8

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

– Assertiveness Training

– Conflict Resolution Model

• Homework Assignment

Sessions 7 & 8

Instructions to Group Leaders

Sessions 7 and 8 are combined because it takes

more than one session to adequately address

assertiveness, aggression, passivity, and the

Conflict Resolution Model.

Assertiveness is such a fundamental skill in inter-

personal interactions and anger management that

the group will spend 2 weeks developing and practicing

this concept. These two 90-minute sessions will present an introduction to assertiveness train-

ing. The majority of this week’s session will be spent reviewing the definitions of assertiveness,

aggression, and passivity and presenting the Conflict Resolution Model. The Conflict Resolution

Model is an assertive device for resolving conflicts with others. It consists of a series of prob-

lem solving steps that, when followed closely, minimize the potential for anger escalation. Next

week’s session, in contrast, will focus on group members roleplaying real-life situations using

the Conflict Resolution Model. It is important to emphasize that assertive, aggressive, and pas-

sive responses are learned behaviors and not innate, unchangeable traits. The goal of these

two sessions is to teach members how to use the Conflict Resolution Model to develop

assertive responses rather than aggressive or passive responses.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter dur-

ing the past week. Make sure they reserve 10 for situations where they lost control of their

anger and experienced negative consequences. Ask them to describe the anger-provoking

event that led to their highest level of anger. Help them identify the cues that occurred in

response to the anger-provoking event, and help them classify these cues into the four cue cat-

egories. Ask members to report on the ongoing development of their anger control plans.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Suggested Remarks

(Use the following script or put this in your own words.)

Assertiveness Training

Sessions 7 and 8 provide an introduction to assertiveness training and the Conflict Resolution

Model. Assertiveness involves a set of behaviors and skills that require time and practice to

learn and master. In this group, we focus on one important aspect of assertiveness training,

that is, conflict resolution. The Conflict Resolution Model can be particularly effective for help-

ing individuals manage their anger.

Many interpersonal conflicts occur when you feel that your rights have been violated. Before

entering anger management treatment, you may have tended to respond with aggressive

behavior when you believed that another person showed you disrespect or violated your rights.

In today’s session, we will discuss several ways to resolve interpersonal conflicts without

resorting to aggression.

As we discussed in session 1, aggression is behavior that is intended to cause harm or injury to

another person or damage property. This behavior can include verbal abuse, threats, or violent

acts. Often, when another person has violated your rights, your first reaction is to fight back or

retaliate. The basic message of aggression is that my feelings, thoughts, and beliefs are impor-

tant and that your feelings, thoughts, and beliefs are unimportant and inconsequential.

One alternative to using aggressive behavior is to act passively or in a nonassertive manner.

Acting in a passive or nonassertive way is undesirable because you allow your rights to be vio-

lated. You may resent the person who violated your rights, and you may also be angry with

yourself for not standing up for your rights. In addition, it is likely that you will become even

more angry the next time you encounter this person. The basic message of passivity is that

your feelings, thoughts, and beliefs are important, but my feelings, thoughts, and beliefs are

unimportant and inconsequential. Acting in a passive or nonassertive way may help you avoid

the negative consequences associated with aggression, but it may also ultimately lead to nega-

tive personal consequences, such as diminished self-esteem, and prevent you from having

your needs satisfied.

From an anger management perspective, the best way to deal with a person who has violated

your rights is to act assertively. Acting assertively involves standing up for your rights in a way that

is respectful of other people. The basic message of assertiveness is that my feelings, thoughts,

and beliefs are important, and that your feelings, thoughts, and beliefs are equally important. By

acting assertively, you can express your feelings, thoughts, and beliefs to the person who violated

your rights without suffering the negative consequences associated with aggression or the devalu-

ation of your feelings, which is associated with passivity or nonassertion.

It is important to emphasize that assertive, aggressive, and passive responses are learned

behaviors; they are not innate, unchangeable traits. Using the Conflict Resolution Model, you

can learn to develop assertive responses that allow you to manage interpersonal conflicts in a

more effective way.

A Cognitive Behavioral Therapy Manual

In summary, aggression involves expressing feelings, thoughts, and beliefs in a harmful and

disrespectful way. Passivity or nonassertiveness involves failing to express feelings, thoughts,

and beliefs or expressing them in an apologetic manner that others can easily disregard.

Assertiveness involves standing up for your rights and expressing feelings, thoughts, and

beliefs in direct, honest, and appropriate ways that do not violate the rights of others or show

disrespect.

It is helpful to think of real-life situations to help you understand what is meant by assertive-

ness. Suppose you have been attending an Alcoholics Anonymous meeting several times a

week with a friend. Suppose you have been driving your friend to these meetings for several

weeks. In the last few days, however, he has not been ready when you have come to pick him

up. His tardiness has resulted in both of you being late for meetings. Because you value being

on time, this is something that bothers you a great deal. Consider the different ways you might

act in this situation. You can behave in an aggressive manner by yelling at your friend for being

late and refusing to pick him up in the future. The disadvantage of this response is that he may

no longer want to continue the friendship. Another response would be to act passively, or in a

nonassertive fashion, by ignoring the problem and not expressing how you feel. The disadvan-

tage of this response is that the problem will most likely continue and that this will inevitably

lead to feelings of resentment toward your friend. Again, from an anger management perspec-

tive, the best way to deal with this problem is to act assertively by expressing your feelings,

thoughts, and beliefs in a direct and honest manner, while respecting the rights of your friend.

Conflict Resolution Model

One method of acting assertively is to use the Conflict Resolution Model, which involves five

steps that can easily be memorized. The first step involves identifying the problem that is caus-

ing the conflict. It is important to be specific when identifying the problem. In this example, the

problem causing the conflict is that your friend is late. The second step involves identifying the

feelings associated with the conflict. In this example, you may feel annoyance, frustration, or

taken for granted. The third step involves identifying the specific impact of the problem that is

causing the conflict. In this example, the impact or outcome is that you are late for the meet-

ing. The fourth step involves deciding whether to resolve the conflict or let it go. This may best

be phrased by the questions, “Is the conflict important enough to bring up? If I do not try to

resolve this issue, will it lead to feelings of anger and resentment?” If you decide that the con-

flict is important enough, then the fifth step is necessary. The fifth step is to address and

resolve the conflict. This involves checking out the schedule of the other person. The schedule

is important because you might bring up the conflict when the other person does not have the

time to address it or when he or she may be preoccupied with another issue. Once you have

agreed on a time with the person, you can describe the conflict, your feelings, and the impact

of the conflict and ask for a resolution.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

For example, the interaction may sound like this:

Joe: Hey, Frank, sorry I’m late.

Frank: Hi, Joe. Can I talk to you about that?

Joe: Sure. Is something wrong?

Frank: Joe, I’ve noticed you’ve been late for the last few days when I’ve come to

pick you up. Today, I realized that I was starting to feel frustrated and a

bit taken for granted. When you are late, we are both late for the meeting,

which makes me uncomfortable. I like to be on time. I’m wondering if you

can make an effort to be on time in the future.

Joe: Frank, I didn’t realize how bothered you were about that. I apologize for

being late, and I will be on time in the future. I’m glad you brought this

problem up to me.

Of course, this is an idealized version of an outcome that may be achieved with the Conflict

Resolution Model. Joe could have responded unfavorably, or defensively, by accusing Frank of

making a big deal out of nothing. Joe may have minimized and discounted Frank’s feelings,

leaving the conflict unresolved.

The Conflict Resolution Model is useful even when conflicts are not resolved. Many times, you

will feel better about trying to resolve a conflict in an assertive manner rather than acting pas-

sively or aggressively. Specifically, you may feel that you have done all that you could do to

resolve the conflict. In this example, if Frank decided not to give Joe a ride in the future, or if

Frank decided to end his friendship with Joe, he could do so knowing that he first tried to

resolve the conflict in an assertive manner.

Exhibit 7. The Conflict Resolution Model

1. Identify the problem that is causing the conflict

2. Identify the feelings that are associated with the conflict

3. Identify the impact of the problem that is causing the conflict

4. Decide whether to resolve the conflict

5. Work for resolution of the conflict

How would you like the problem to be resolved?

Is a compromise needed?

A Cognitive Behavioral Therapy Manual

Have the group members practice using the Conflict Resolution Model by roleplaying. Be care-

ful not to push group members into a roleplay situation if they are not comfortable about it or

ready. Exercise your clinical judgment.

The following are some topics for roleplays:

• Dealing with a rude or unhelpful salesclerk

• Dealing with a physician who will not take the time to explain how a medication works

• Dealing with a supervisor who does not listen to you

• Dealing with a counselor who repeatedly cancels your therapy/counseling sessions

• Dealing with a friend who does not respect your privacy.

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the coming week. Ask them to identify the

event that made them angry, the cues that were associated with the anger-provoking event,

and the strategies they used to manage their anger in response to the event. Ask them to

review the definitions of assertiveness, aggression, and passivity. Instruct them to practice

using the Conflict Resolution Model, preferably once a day during the coming week. Remind

them to continue to develop their anger control plans.

AAnnggeer r aannd d tthhe e FFaammiillyy

How Past Learning Can

Influence Present Behavior

Outline of Sessions 9 & 10

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

– Anger and the Family

• Homework Assignment

Sessions 9 & 10

Instructions to Group Leaders

As with sessions 7 and 8, sessions 9 and 10 are

combined because it takes more than one

session to answer the questions beginning on page

46 and connect the responses to current behavior.

Sessions 9 and 10 (comprising two 90-minute sessions) help group members gain a better

understanding of their anger with regard to the interactions they had with their parents and

the families that they grew up in (Reilly & Grusznski, 1984). Help them see how these past

interactions have influenced their current behavior, thoughts, feelings, and attitudes and the

way they now interact with others as adults.

Many people are unaware of the connection between past learning and current behavior.

Present a series of questions to the group members that will help them understand how their

learning histories relate to current patterns of behavior. Because of the nature and content of

this exercise, with its focus on family interactions, it is important that you monitor and structure

the exercise carefully, but at the same time provide a warm and supportive environment.

Experience has shown there is a tendency for group members to elaborate on many detailed

aspects of their family backgrounds that are beyond the scope of this exercise. Keep in mind

that family issues may bring up difficult and painful memories that could potentially trigger

anxiety, depression, or relapse to drug and alcohol use. It is important, therefore, to tell group

members that they are not required to answer any questions if they feel that they would be

emotionally overwhelmed by doing so. Instead, tell them that they can pursue these and other

issues with their individual or group therapist.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter

during the past week. Make sure they reserve 10 for situations where they lost control of their

anger and experienced negative consequences. Ask them to describe the anger-provoking

event that led to their highest level of anger. Help them identify the cues that occurred in

response to the anger-provoking event, and help them classify these cues into the four cue

categories. Ask them to report on their use of the Conflict Resolution Model and the ongoing

development of their anger control plans.

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

Suggested Remarks

(Use the following script or put this in your own words.)

Anger and the Family

In these sessions, you will explore how anger and other emotions were displayed by your par-

ents and in the families in which you grew up. For many of us, the interactions we have had

with our parents have strongly influenced our behaviors, thoughts, feelings, and attitudes as

adults. With regard to anger and its expression, these feelings and behaviors usually were

modeled for us by our parents or parental figures. The purpose of these sessions is to examine

the connection between what you have learned in the past, in the families in which you grew

up, and your current behavior and interactions with others now as adults. You will be asked a

series of questions concerning your parents and families. This is an involved and often emo-

tionally charged topic, so if you are not comfortable answering any questions, you do not have

to do so. Also, because there is a natural tendency to want to elaborate on family issues

because of their emotional content, please focus on answering the specific questions:

1. Describe your family. Did you live with both parents? Did you have any brothers and sisters?

Where did you grow up?

2. How was anger expressed in your family while you were growing up? How did your father

express anger? How did your mother express anger? (Possible probes to use: Did your par-

ents yell or throw things? Were you ever threatened with physical violence? Was your father

abusive to your mother or you?)

3. How were other emotions such as happiness and sadness expressed in your family? Were

warm emotions expressed frequently, or was emotional expression restricted to feelings of

anger and frustration? Were pleasant emotions expressed at birthdays or holidays?

4. How were you disciplined and by whom? Did this discipline involve being spanked or hit

with belts, switches, or paddles? (An assumption of the anger management treatment is

that no form of physical discipline is beneficial to a child. Empirical studies have shown that

nonphysical forms of discipline are very effective in shaping childhood behavior [Barkley,

1997; Ducharme, Atkinson, & Poulton, 2000; Webster-Stratton & Hammond, 1997]).

5. What role did you take in your family? For example, were you the hero, the rescuer, the vic-

tim, or the scapegoat?

6. What messages did you receive about your father and men in general? In other words, in

your experience, how were men supposed to act in society? What messages did you receive

about your mother and women in general? How were women supposed to act in society?

(Note: Many of the messages group members have received differ from messages that are

socially appropriate today. Point out the changing roles of men and women during the past

three decades.)

A Cognitive Behavioral Therapy Manual

7. What behaviors, thoughts, feelings, and attitudes carry over into your relationships as

adults today? What purpose do these behaviors serve? What would happen if you gave up

these behaviors? (The group leader should help group members see the connection

between past social learning and their current behavior.)

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the coming week. Ask them to identify the

event that made them angry, the cues associated with the anger-provoking event, and the

strategies they used to manage their anger in response to the event. Remind them to continue

to develop their anger control plans.

RReevviieew w SSeessssiioon n ##2 2

Reinforcing Learned Concepts

Outline of Session 11

• Instructions to Group Leaders

• Check-In Procedure

• Suggested Remarks

• Homework Assignment

Session 11

Instructions to Group Leaders

In this session, the basic concepts of anger man-

agement that were presented are reviewed and

summarized. Give special attention to clarifying

and reinforcing concepts (i.e., the anger meter, cues

to anger, anger control plans, the aggression cycle, cognitive restructuring, and conflict

resolution). Provide encouragement and support for efforts to develop anger control plans

and to balance cognitive, behavioral, immediate, and preventive strategies.

Check-In Procedure

Ask group members to report the highest level of anger they reached on the anger meter

during the past week. Make sure they reserve 10 for situations where they lost control of their

anger and experienced negative consequences. Ask them to describe the anger-provoking

event that led to their highest level of anger. Help them identify the cues that occurred in

response to the anger-provoking event, and help them classify these cues into the four cue

categories. Ask them to report on the ongoing development of their anger control plans.

Suggested Remarks

(Use the following script or put this in your own words.)

This session involves a second review of the anger management material covered in all the

sessions. We will review each concept and clarify any questions that you may have. We encour-

age discussion during this review, and we will be asking you for your understanding of the

anger management concepts.

Homework Assignment

Have group members refer to the participant workbook. Ask them to monitor and record their

highest level of anger on the anger meter during the coming week. Ask them to identify the

event that made them angry, the cues that were associated with the anger-provoking event, and

the strategies they used to manage their anger in response to the event. Ask them to update

their anger control plans and to be prepared to present them in the final session next week.

CClloossiinng g aannd d GGrraadduuaattiioon n

Closing Exercise and Awarding of Certificates

Outline of Session 12

• Instructions to Group Leaders

• Suggested Remarks

Session 12

Instructions to Group Leaders

In the final session, group members review their

anger control plans, rate the treatment components for their usefulness and familiarity, and

complete a closing exercise. Review each anger control plan to balance cognitive, behavioral,

immediate and preventive strategies. Give corrective feedback if necessary. Congratulate the

group members for completing the anger management treatment. Provide each member with

a certificate of completion (see sample on the following page).

Suggested Remarks

(Use the following script or put this in your own words.)

1. What have you learned about anger management?

2. List anger management strategies on your anger control plan. How can you use these

strategies to better manage your anger?

3. In what ways can you continue to improve your anger management skills? Are there

specific areas that need improvement?

AAnnggeerr MMaannaaggeemmeenntt for Substance Abuse and Mental Health Clients

CCOONNGGRRAATTUULLAATTIIOONNSS

Thomas Smith

In Recognition of Completing the Phase One Anger Management Group

in the Substance Abuse Outpatient Clinic

(ADD NAME)

[DATE]

[NAME], Chief, Substance Abuse [NAME OF COUNSELOR]

Outpatient Clinic

RReeffeerreennccees s

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AAppppeennddiixx: :

Authors’ Acknowledgments

The authors would like to acknowledge the following clinicians and researchers for their various

contributions to the development of this manual:

Robert Awalt, Psy.D., Peter Banys, M.D., Torri Campell, Ph.D., Darcy Cox, Ph.D., John Coyne,

M.A., Timothy Durazzo, Ph.D., Sharon Hall, Ph.D., Anthony Jannetti, Ph.D., Monika Koch, M.D.,

Peg Maude-Griffin, Ph.D., Robert Ouaou, Ph.D., Teron Park, Ph.D., Amy Rosen, Psy.D., Sheila

Shives, M.A., James Sorensen, Ph.D., David Thomson, LCSW, Donald Tusel, M.D., David

Wasserman, Ph.D., and Lisa Wasserman, M.A.

We would also like to acknowledge H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, Director of

the Center for Substance Abuse Treatment, for his valuable contributions to the early stages of

this treatment manual and the anger management project. Dr. Durazzo assisted in editing the

manual.

Johnson, Bassin & Shaw, Inc., personnel involved in the production of this manual and the

accompanying participant workbook included Barbara Fink, M.P.H., Project Director; Nancy

Hegle, Quality Control Manager; Frances Nebesky, M.A., Editor; and Terrie Young, Graphic

Designer.

DHHS Publication No. (SMA) 08-4213

Substance Abuse and Mental Health Services Administration

Printed 2002

Reprinted 2003, 2005, 2006, 2007, and 2008

Anger Management For Substance Abuse And Mental Health Clients: A Cognitive Behavioral Therapy Manual 0508

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