The Science to Service Task Force recognizes that the following section, "Group Treatment of Problematic Anger," is different from the prior sections which are each diagnostic-specific summaries of available evidence based practice results. The next section is not about group treatment of a specific diagnosis. Rather, problematic or excessive anger can be thought of as a problem that cuts across diagnoses. It can be found among those patients who are diagnosed with mood disorders, just as it can be found among those diagnosed with psychotic disorders or those with personality disorders. Because it is a commonly encountered clinical problem and there is a growing literature about the treatment of problematic anger in groups, we decided that it would be worthwhile to include a review of that literature here to supplement the prior diagnostic-specific reviews.

 Group Treatment of Problematic Anger

    •    Although anger management interventions are popular and found in
    many different treatment settings (e.g., educational, correctional,
    community), the scientific evaluation of anger treatments has lagged
    behind that of common mental health concerns such as anxiety and
    depression. A primary research issue is the lack of a diagnostic category
    for anger as a disorder or a “problem of excess.”

    •    Most research studies in the past two decades have evaluated the
    efficacy of cognitive or behavioral type approaches, or combinations of the
    two (i.e., cognitive-behavioural therapy or CBT) to treat anger problems
    (Del Vecchio & O’Leary, 2004; DiGuiseppe & Tafrate, 2001, 2003; Saini,
    2009). CBT-based interventions (e.g., stress inoculation training or SIT,
    popularly known as “anger management”) teach skills to dampen anger-
    related physiological arousal and develop more adaptive thinking and
    responses to anger triggers. Relaxation treatments and skills-oriented
    treatments (e.g., Social Skills Training or SST) have also received
    attention. The vast majority of studies since the 1980s (>80%) have
    employed a group format for interventions.

    •    The bulk of the literature finds no difference between anger
    treatments provided in an individual versus group format (DiGiuseppe &
    Tafrate, 2003). Recent work has identified that individual format
    treatments may have an advantage in bringing about increases in positive
    behaviors (Saini, 2009).

    •    More recent conceptual work has defined anger in terms of a
    multidimensional construct (DiGuiseppe & Tafrate, 2001).
    Correspondingly, multi-component treatment interventions have emerged
    in the last decade and have garnered strong empirical support. As a
    primary example, modifications of Dialectical Behavioral Therapy (DBT)
    have been evaluated as potentially effective for anger problems, both in
    the context of personality disorder (primarily Borderline PD) or
    externalizing behavior problems (e.g., inmates convicted of violent
    crimes). In an integrated fashion, DBT addresses impulsive, aggressive
    behaviors by teaching distress tolerance, mindfulness and interpersonal
    effectiveness skills (Frazier & Vela, 2014). 

    •    Medications—primarily mood stabilizers and atypical anti-
    psychotics—should be evaluated more frequently as adjuncts to therapy
    interventions.

 Findings Regarding Group Treatments of Anger

Since the early 1990s, a number of comprehensive meta-analytic reviews have been completed regarding the psychological treatment of anger in adult outpatients (Beck & Fernande, 1998; Del Vecchio & O’Leary, 2004; DiGiuseppe & Tafrate, 2001, 2003; Edmondson & Conger, 1996; Mayne & Ambrose, 1999; Olatunji & Lohr, 2005; Saini, 2009). The overall effect size for anger treatments is moderate in size (i.e., .7-.9) indicating that treated patients certainly fare better than those not receiving treatment; however, effect sizes in the anxiety or depression treatment literature are consistently much larger (i.e., 1.1-2.0). Treatments of anger problems are implemented in a diversity of settings, encompassing educational, correctional, and community facilities. Two themes are predominant in the reviews. First, the lack of a clear diagnostic operationalization for “anger problems” or “anger disorder” means that cross-study comparisons can be problematic. Second, a large proportion of studies make use of “convenience samples” of volunteers, when, clinically, the majority of participants may be mandated into treatment. It is not clear how participant self-selection may impact treatment effects reported in the literature. In the larger context of psychiatric disorder, studies of treatment for anger are relatively infrequent—for each study of anger as the target issue, there are 7 studies of anxiety disorder and 10 studies of mood disorder.

Studies of cognitive and cognitive-behavioral treatment dominate the literature (Deffenbacher, Oetting & DiGiuseppe, 2002). One of the first of these interventions—Novaco’s (1976) modification of Meichenbaum’s (1975) stress inoculation training approach—became known popularly as “anger management.” Other forms of CBT are characterized by similar approaches to “cognitive restructuring” (e.g., self-instructional training, rational-emotive therapy). CBT-based approaches have proven to be moderately to strongly effective across age groups, different populations, and different settings, with mean effect sizes ranging between 0.6-1.2 (DiGiuseppe & Tafrate, 2001, 2003). Relaxation-based interventions (including progressive muscle relaxation and systematic desensitization) have also received strong support (Edmonson & Conger, 1996). Behavioral skills-training interventions (e.g., SST) and exposure strategies also appear to be helpful (DiGuiseppe & Tafrate, 2001). Generally speaking, the majority of these treatments have been implemented in a group format. Apart from being more cost-effective than the individual format, clinicians can capitalize on the supportive, motivating, and modeling functions of the group format (Mayne & Ambrose, 1999). More recently, mindfulness procedures and process-oriented group therapy (after Yalom) have shown promise as treatments for anger problems (Del Vecchio & O’Leary, 2004). Treatments explicitly defined as psychodynamic in orientation appear infrequently in the literature; Saini’s (2009) meta-analysis identified two such studies but noted that these treatments produced the largest overall effect sizes of all studies (1.4) in the review.

The predominant emphasis on group approaches means that direct comparisons of group versus individual formats for anger treatments have been infrequent; these comparisons have generally not provided evidence of differential effectiveness. The two formats have demonstrated equivalent effects on most outcomes (e.g., self-reported anger and aggression). More recent reviews have identified a slight advantage for individual treatments impacting directly on the frequency of positive (non-angry) behaviors (DiGiuseppe & Tafrate, 2003). Treatments administered in a group format also demonstrated more variability in effect sizes than those administered in an individual format, suggesting that individual treatments may produce more consistent results on anger and aggressive behaviors (DiGiuseppe & Tafrate, 2003).

Clinical theories regarding anger since 2000 have adopted a multidimensional perspective, addressing anger as an affect with various attitudinal biases, cognitive processes, and behavioral expressions. The guiding hope with such conceptualizations is that different interventions would have larger effects on those aspects of anger most directly reflecting the conceptual target of each intervention (e.g., cognitive therapy would have greater effects on the cognitive processes associated with an angry predisposition), though to date this expectation has not been borne out. Earlier research with adult populations suggested relatively similar outcomes for differing therapeutic approaches (Deffenbacher et al., 2002; Olatunji & Lohr, 2005), but a recent meta-analytic review suggested that the effectiveness of different interventions does vary, with multi-component interventions displaying the largest effect sizes overall (Saini, 2009). Multi-component interventions may better address the varied dimensions of anger involving the experience, expression, and management of this emotion prominent in different types of angry clients. Multi-component interventions are also more likely to produce effects that are long-lasting (DiGiuseppe & Tafrate, 2001).

Dialectical Behavior Therapy (DBT) is a well-known example of a multi-component treatment intervention, originally developed for patients with Borderline personality disorder characterized by frequent episodes of non-suicidal self-harm (Lynch, Trost, Salsman, & Linehan, 2007). The DBT model features a skills-oriented group component; other components include weekly individual therapy, weekly therapist consultation meetings, and access to 24-hour/day telephone coaching. These components are combined to target impulsive behaviors and the underlying cognitive-emotional processes by teaching distress tolerance, mindfulness and interpersonal effectiveness skills. The DBT approach has been evaluated as a treatment for anger and aggression (Frazier & Vela, 2014), in the context of treating BPD or for patients without BPD but struggling with anger problems and behaviors (e.g., individuals incarcerated for violent offenses). Modified forms of DBT have been found to significantly reduce anger problems, with improvements also noted in comorbid symptoms of psychopathology (e.g., anxiety, self-harming behavior, suicidal ideation). Caution is warranted in interpreting these findings, as the modifications to the DBT protocol to accommodate the needs of specific populations might be regarded as constituting a completely new treatment intervention (Frazier & Vela, 2014). Further, these modified DBT protocols have not been directly compared to other empirically-supported treatments for anger problems, so questions regarding relative effectiveness remain unanswered.

There are reports that mood stabilizers and atypical anti-psychotic medications may have a beneficial effect on self-reported anger (Comai, Tau, Pavlovic, & Gobbi, 2012; Imgenhoven, Lafay, Rinne, Passchier, & Buivenvoorden, 2008). There are, however, no head-to-head trials comparing psychosocial approaches and medications in the treatment of anger, so the differential effectiveness of these interventions is unknown. At this juncture, these medications can be viewed as useful adjuncts to the treatment of anger problems.

 Future Directions

Although reviews indicate that group-based treatment of anger can be beneficial, some caution is required due to the somewhat skewed nature of the research samples, i.e., the majority of anger treatment studies have employed volunteer participants. Most service providers in clinical settings treat individuals who have been mandated into treatment by the court system or facing demands for treatment from employers or family members. Modifications of treatment approaches to account for varying degrees of patient motivation may thus be critical.

The evidence largely suggests that different treatment approaches produce equivalent effects, suggesting that non-specific factors may primarily be accounting for outcomes (Olatunji & Lohr, 2005). This is not an uncommon finding in studies of group-based treatment approaches (Burlingame, Strauss, & Joyce, 2013). Clinical approaches to anger problems likely utilize similar common factors as mechanisms of treatment. For example, all treatments implicitly or explicitly work to change the internal and external cues that elicit anger (e.g., avoiding triggers, or learning to regulate cognitive, physiological, or behavioral responses, by employing imaginal or actual practice in anger-provoking situations). Further, all approaches rely on anger activation in the moment as key for efforts at change (Mayne & Ambrose, 1999). More sophisticated research designs are required to identify the specific and non-specific mechanisms of change within and across anger treatments, and to evaluate the efficacy of matching these components with the dimensions of anger prominent in different populations (Edmondson & Conger, 1996; Del Vecchio & O’Leary, 2004; Olatunji & Lohr, 2005). Studies with a molecular focus on the components of treatment approaches have the greatest potential of enhancing therapy outcomes.

As noted, attention to the deficits and strengths of the participant in anger treatments has also been recommended as a critical dimension of future research. The readiness of the individual to accept and engage in treatment likely has a significant influence on the outcomes of anger interventions (Howells & Day, 2003). Even with voluntary participants, dropout from treatment programs range between 30-50%, particularly if the intervention has a duration of greater than eight weeks (Saini, 2009). Developing better methods of assessing readiness, preparing patients for treatment, and facilitating motivation is strongly recommended. Finally, cultural factors have a major bearing on how individuals express and evaluate their anger. Culturally adapted approaches to anger treatment require further development and evaluation (Griner & Smith, 2006).

References

Beck, R., & Fernande, E. (1998). Cognitive-behavioral therapy in the treatment of anger: A meta-analysis. Cognitive Therapy and Research, 22, 64-74. doi: 10.1023/A:1018763902991

Burlingame, G. M., Strauss, B., & Joyce, A. S. (2013). Change mechanisms and effectiveness of small group treatments. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 640-690). New York: Wiley.

Comai, S., Tau, M., Pavlovic, Z., & Gobbi, G. (2012). The psychopharmacology of aggressive behavior: A translational approach. Part 2: Clinical studies using atypical antipsychotics, anticonvulsants, and lithium. Journal of Clinical Psychopharmacology, 32, 237-260. doi: 10.1097/JCP.0b013e31824929d6

Edmondson, C. B., & Conger, J. C. (1996). A review of treatment efficacy for individuals with anger problems: Conceptual assessment and methodological issues. Clinical Psychology Review, 16, 251-275. doi: 10.1016/S0272-7358(96)90003-3

Deffenbacher, J. L., Oetting, E. R., & DiGuiseppe, R. A. (2002). Principles of empirically supported interventions applied to anger management. The Counselling Psychologist, 30, 262-280. doi: 10.1177/0011000002302004

Del Vecchio, T. D., & O’Leary, D. (2004). Effectiveness of anger treatments for specific anger problems: A meta-analytic review. Clinical Psychology Review, 24, 15-34. doi: 10.1015/j.cpr.2003.09.006

DiGiuseppe, R., & Tafrate, R. C. (2001). A comprehensive treatment model for anger disorders. Psychotherapy, 38, 262-271. doi: 10.1037/0033-3204.38.3.262

DiGiuseppe, R., & Tafrate, R. C. (2003). Anger treatment for adults: A meta-analytic review. Clinical Psychology: Science and Practice, 10, 70-84. doi: 10.1093/clipsy/10.1.70

Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43, 531-548. doi: 10.1037/0033-3204.43.4.531

Frazier, A., & Vela, J. (2014). Dialectical behavior therapy for the treatment of anger and aggressive behavior: A review. Aggression and Violent Behavior, 19, 156-163. doi: 10.1016/j.avb.2014.02.001

Howells, K., & Day, A. (2003). Readiness for anger management: Clinical and theoretical issues. Clinical Psychology Review, 23, 319-337. doi: 10.1016/S0272-7358(02)00228-3

Ingenhoven, T., Lafay, P., Rinne, T., Passchier, J., & Duivenvoorden, H. (2010). Effectiveness of pharmacotherapy for severe personality disorders: Meta-analyses of randomized controlled trials. Journal of Clinical Psychiatry, 71, 14-25. doi: 10.4088/JCP.08r04526gre

Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007). Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181-205. doi: 10.1146/annurev.clinpsy.2.022305.095229

Mayne,. J., & Ambrose, T. K. (1999). Research review on anger in psychotherapy. Journal of Clinical Psychology/In Session: Psychotherapy in Practice, 55, 353-363. Meichenbaum, D. H. (1975). Stress inoculation training. New York: Pergamon Press.

Novaco, R. W. (1976). Treatment of chronic anger through cognitive and relaxation controls. Journal of Consulting and Clinical Psychology, 4, 681.

Olatunji, B. O., & Lohr, J. M. (2005). Nonspecific factors and the efficacy of psychosocial treatments of anger. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 3, 1-24.

Saini, M. (2009). A meta-analysis of the psychological treatment of anger: Developing guidelines for evidence-based practice. Journal of the American Academy of Psychiatry and the Law, 37, 473-488.

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