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Return to PTSD topic area National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs

An Anger Management Intervention Model For Veterans With PTSD

By April Gerlock, R.N., C.N.S.

NCP Clinical Quarterly 6(3): Summer 1996

Anger and rage are prevalent emotions in individuals experiencing posttraumatic stress disorder (PTSD; 1), as well as in male veterans with PTSD (2-4). Vietnam combat veterans experience more anger and hostility than their civilian counterparts (5-6), and Vietnam combat veterans with PTSD experience more anger than Vietnam combat veterans without PTSD (7). A greater capacity for violence also figures predominantly in veterans with PTSD (8-10). Vietnam theater veterans with PTSD report statistically higher rates of hostility and physical aggression towards their partners than their non-PTSD counterparts (11-12). This predilection for hostility and assaultive behaviors contribute greatly to readjustment difficulties in veterans with PTSD (13).

Attention to and treatment of the anger component of PTSD is considered an essential element in trauma recovery work (14-17). Despite highly variable approaches to anger management intervention, goals include a reduction in the level of anger experienced by the veteran as well as learning constructive ways to manage and express anger. The model presented here combines a cognitive and behavioral approach (developed in consultation with Anne Ganley, April, 1984). It is currently used in outpatient treatment with veterans (with and without PTSD), and has been adapted for inpatient PTSD treatment as well. However, the treatment model was designed for veterans with generic anger management problems, and not as treatment for those who are domestically violent. Anger management fails to account for the premeditated controlling behaviors associated with domestic violence (18-19).

The Intervention Model

Two key components to the successful application of anger management intervention for the veteran with PTSD are responsibility and accountability and the use of anger logs. Accountability and responsibility provide two guiding principles for both the intervention and the structure for the class. Group guidelines are designed specifically to promote and teach responsible and accountable behaviors. These include confidentiality, using non-racist and non-sexist language, being clean and sober, arriving on time, attending a minimum of seven group sessions, and bringing completed written anger logs to each class. Participants are further expected to be an active member in the group, working on their own anger problems and helping other group members reach their goals.

Self-monitoring, a key tool used in treatment, is accomplished via the use of "anger logs" (Figure 1, 20). The anger log is completed weekly by the participants and brought to treatment. This treatment model is designed to be maximally effective in eight, once-a-week, two hour group sessions. Only male veterans are included in the class, however, a variation of this model is available for female veterans. The anger log serves several functions: It provides an opportunity for the individual to view the experience objectively; it breaks the anger response down into its component parts; it prevents rambling "anger stories"; and it affords the participant the chance to exercise control over the one thing he has control of...himself, thus providing alternatives to angry/hostile outcomes (14).

Figure 1. The Anger Log (Reprinted With The Permission Of Anne Ganley)

Trigger

Anger Level

0 - 10

Anger Up Thoughts

Anger Down Thoughts

Behavior

Other Feelings

 

 

 

 

 

 

 

 

The framework for each class includes: 1. review of completed written logs; 2. didactic information presented by the facilitator; and 3. group process, discussion, and group exercises. The make up of each of the 8 sessions are briefly presented below.

Class #1. Cues To The Anger Response

Introduction. At the initial class the group guidelines are presented and reviewed and the two interlocking principles of the class, responsibility and accountability, are described and discussed. Participants are encouraged to help each other in achieving their anger management goals and, in doing so, are trained to judge their feedback by using the following question. "Does the feedback given encourage the participant to take responsibility for his anger and behaviors, and express himself in a manner that is personally accountable?" This question is used throughout the 8 week sessions to minimize blaming and externalization of responsibility for expression of anger.

Didactic: A group generated definition of anger is facilitated. The clinician must carefully monitor the group process and facilitate a definition of anger that includes that anger is one of many other emotional responses, it is not "out of control", everyone experiences anger, and it is not a behavior. The nature of anger, including the physiological, behavioral, and cognitive components, is presented. Participants are asked to identify their physiological responses (e.g. flushed face, increased heart rate). These are listed on the board. Behavioral choices are examined, including the "fight or flight" response as well as the "posture or submit" (22) option in response to a threat (real or perceived). Participants are again asked to generate a list of behaviors that serve as cues to escalating levels of anger. Lastly, the cognitive aspect of anger is addressed. How do participants describe their thoughts when they are angry? Are they thinking in shades of gray, or rigid "back and white" thoughts?

Process. Participants are asked to think of a time they felt threatened and responded with anger. Group members are asked to focus on the logic behind the physiological, behavioral, and cognitive responses to anger. The facilitator leads a discussion on how the three of these result in a highly adaptive response to a threat. The physiological response prepares an organism to survive a challenge. The optimal behavioral response is one of action...conditioned to be expressed as aggression in basic training. The cognitive response takes the form of "black and white" decisive decision making (also conditioned in basic training) and not "I’m OK, you’re OK" thoughts. In addition, thoughts tend to be those that objectify or dehumanize another person, thus providing the impetus for aggressive responses (21-22). These may be highly adaptive in a war zone or extreme emergency, however, these responses may be detrimental under "normal" civilian conditions. Before the group is dismissed, the anger log is introduced and explained (Table 1).

Table 1. Instructions On Filling Out The Anger Log.

Trigger: A description of the event, "what happened", and not an interpretation of the event.

Anger Level: Rated 0 - 10, with zero being no anger, "10" being the maximum level of anger.

Anger Up Thoughts: Anger escalating thoughts, e.g., dehumanization of the other person, or externalization of their responsibility for their behavioral response. Participants are asked how these thoughts affected their level of anger and the choices they were making.

Anger Down Thinking: The anger de-escalating thoughts, e.g., those thoughts thatassess some of the consequences of their behaviors, or thoughts that take responsibility for their emotions and behaviors.

Behavior: What did they do?

Other feelings: This section is added to the log after class #5, and addresses other emotions they were having at the time.

Class #2: Early learning experiences with anger

Review of logs: As many written logs as possible are written on the board and reviewed.

Didactic: Focus is on early exposure to anger and aggression and the impact that had on choices of anger expression in their adult lives.

Process: Participants are asked to reflect back to what it was like for them to have anger (and often violence) directed at them as children, and to share their thoughts, feelings, and responses to those experiences.

Class #3: Anger triggers and when are they more vulnerable to their anger?

Review of logs:

Didactic: Factors that contribute to anger and aggression are reviewed such as physical states (hunger, fatigue, pain), emotional states (anxiety, worry, grief, fear), foods and other substances (drugs, alcohol, certain medications), environmental conditions (noise), anniversary times and holidays, and triggers and the anger themes in their lives.

Process: A film is shown that portrays a violent incident in the life of a fictional family. Participants are asked to identify triggers for the family members as well as contributing factors that impacted how anger was expressed.

Class #4: Anger payoffs and anger consequences

Review of logs:

Didactic: The facilitator defines a payoff as the short term reinforcement of anger expression. A consequence is defined as the longer term result of aggressive and hostile anger expression.

Process: It is fairly easy to identify the consequences of anger (e.g., loss of jobs), but more difficult to understand the reinforcers to individual anger responses. Anger expression for a desired outcome may include getting their way, getting someone to do something, getting someone to stop doing something, and ventilating frustration and angry energy.

Class #5: Other emotions: What stands behind the anger?

Review of logs: During this class an additional column, other feelings, is added to the log.

Didactic: The facilitator provides participants with a list of emotions that include several primary emotions with three levels of adjective descriptors that signal intensity.

Process: A discussion is lead on how emotions are expressed in the communities/cultures of the participants. What is acceptable or not to show, and how? How did the men in their lives express emotions when they were growing up? What emotions were acceptable and not acceptable to show during their military service?

Class #6: Steps at solving abusive anger problems

Review of logs:

Didactic: The "cool down" (also called time outs) is introduced.

Process: Specific guidelines are given on how to take cool downs (handout developed by A. Ganley and not included in this paper) and a discussion of these guidelines is facilitated.

Class #7: Practicing cool downs

Review of logs: Focusing on the use of cool downs, participants are asked at what point they took their cool down and how it went.

Didactic: An in-depth discussion is conducted on common problems in taking cool downs (Table 2).

Process: Participants that are having difficulty with the cool downs are asked what their agenda was in taking the cool down: Was it to manage anger in an appropriate way, or was it taken for another reason? Participants are asked to develop a daily anger management plan as an additional assignment for the next week.

Class #8: Practice/Wrap-up

Review of logs: Focus on use of cool downs.

Didactic: The purpose and components of an anger management plan is discussed.

Process: Daily anger management plans are shared by each group member. These plans may include "passive activities" (e.g. listening to music), or "active activities" (e.g. cool down, exercise). An exercise on "alternative perspectives" is facilitated (23).

Treatment outcome

A four-year evaluation was undertaken to evaluate the effectiveness of this intervention. A significant decrease in both state and trait anger was identified by the majority of the participants. The results of two years of this data is available for review (14).

 

 

 

 

 

 

 

Table 2: Cool down "cop-outs."

Cop-out

Agenda

1. "She/he wouldn’t let me leave!"

1. He may use name-calling on the way out to bait his partner/friend into continuing the argument.

2. Using the cool down for other purposes.

2. Veterans have described taking off for days to even weeks; when they leave, their partner does not know when they will return.

3. Avoiding the issues.

3. The veteran may actually stir up an argument, with the intent of getting out of house, thus using the cool down as a way to "blow her/him off" and avoid negotiation and mutual dialogue.

4. "I couldn’t leave."

4. When anger is allowed to continue to escalate it becomes more difficult to take a cool down.

References

1. American Psychiatric Association (1994 ). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC: Author.

2. Figley, C.R. (1985). Trauma and its wake: The study and treatment of post-traumatic stress disorder. New York: Brunner/Mazel.

3. Figley, C.R. (1986). Trauma and its wake: Vol. 2. Traumatic stress theory, research, and intervention. New York: Brunner/Mazel.

4. Sonnenberg, S.M., Blank, A.S., & Talbott, J.A. (Eds.) (1985). The trauma of war: Stress and recovery in Viet Nam veterans. Washington, DC: American Psychiatric Press.

5. Laufer, R.S., Yager, T., Frey-Wouters, E., & Donnellan, J. (1981). Postwar trauma: Social and psychological problems of Vietnam veterans in the aftermath of the Vietnam war. In A. Egendorf, C. Kadushin, R. Laufer, G. Rothbart, & L. Sloan (Eds.), Legacies of Vietnam: Comparative adjustment of veterans and their peers (pp. 45-158). New York: Center for Policy Research.

6. Strayer, R., & Ellenhorn, L. (1975). Vietnam veterans: A study exploring adjustment patterns and attitudes. Journal of Social Issues, 31, 81-93.

7. Chemtob, C.M., Hamada, R.S., Roitblat, H.L., & Muraoka, M.Y. (1994). Anger, impassivity, and anger control in combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 62, (4), 827-832.

8. Boulanger, G., & Kadushin, C. (1985). The Vietnam veteran redefined. Hillsdale, NJ: Lawrence Erlbaum.

9. Buchbinder, J.T. (1979). Self-report assessment of the post-Vietnam syndrome. Dissertation Abstracts International, 40, 1880B.

10. Petrick, N., Rosenberg, A.M., & Watson, C.G. (1983). Combat experience and youth: Influences on reported violence against women. Professional Psychology: Research and Practice, 14, 895-899.

11. Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, K.B., Marmar, C.R., Weiss, D.S., & Grady, D.A. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.

12. Carroll, E.M., Rueger, D.B., Foy, D.W., & Donahoe Jr., C.P. (1985). Vietnam combat veterans with posttraumatic disorder: Analysis of marital and cohabitating adjustment. Journal of Abnormal Psychology, 94, 329-337.

13. Lasko, N.B., T.V. Gurvits T.V., Kuhne, A.A., Orr, S.P., & Pitman, R.K. (September/October, 1994). Aggression and its correlates in Vietnam veterans with and without chronic posttraumatic stress disorder. Comprehensive Psychiatry, 35, (5), 373-381.

14. Gerlock, A.A. (1994). Veterans’ responses to anger management intervention. Issues in Mental Health Nursing, 15, 393-408.

15. Keane, T.M., Fairbank, J.A., Caddell, J.M., Zimering, R.T., & Bender, M.E. (1985). A behavioral approach to assessing and treating post-traumatic stress disorder in Vietnam veterans. In C.R. Figley (Ed.), Stress disorders among Vietnam veterans: Theory, research, and treatment (pp. 257-294). New York: Brunner/Mazel.

16. McWhirter, J.J., & Liebman, P.C. (1988). Working with groups: A description of anger-control therapy groups to help Vietnam veterans with posttraumatic stress disorder. Journal for Specialists in Group Work, 13, 9-16.

17. Smith, J.R. (1985). Individual psychotherapy with Viet Nam veterans. In S.M. Sonnenberg, A.S. Blank, & J.A. Talbott (Eds.), The trauma of war: Stress and recovery in Viet Nam veterans (pp. 125-163). Washington, DC: American Psychiatric Press.

18. Gondolf, E.W., & Russell, D. (1986). The case against anger control treatment programs for batterers. Response to the Victimization of Women and Children, 3, 2-5.

19. Gerlock, A.A. (in press). New directions in the treatment of men who batter women. Health Care for Women International.

20. Ganley, A.L. (1981). Court-mandated counseling for men who batter: A three-day workshop for health professionals, participant’s manual, (p. 84). Washington, DC: Center for Women Policy Studies.

21. Grossman, D.A. (1995). On killing: The psychological cost of learning to kill in war and society. New York, NY: Little, Brown, and Company.

22. Dyer, G. (1985). War. New York, NY: Crown Publishers, Inc.

23. Covey, S.R. (1989). The 7 habits of highly effective people (pp. 23-32). New York, NY: Simon & Schuster.

April Gerlock is a Clinical Nurse Specialist and coordinator of the combined American Lake Division and Madigan Army Medical Center Domestic Violence Treatment Program for the VA Puget Sound Health Care System. She is an Assistant Clinical Professor, Department of Psychological and Community Health Nursing, University of Washington School of Nursing and Clinical Faculty for the Pacific Lutheran University School of Nursing. She is also a pre-doctoral student at the University of Washington, School of Nursing.
Correspondence concerning this article should be addressed to April A. Gerlock, Mental Health Clinic (116M), VA Puget Sound Health Care System, American Lake Division, Tacoma, WA. 98493. E-mail may be sent to GERLOCK.APRIL A@SEATTLE.VA.GOV.

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