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Is CBT-based anger management effective?

Is CBT-based anger management effective?



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I have no doubt that some (aggressive) medication will definitely work in cutting people's anger-outburst potential. But is the usual CBT-based anger management class effective? There's a 2013 BBC article which says the systematic evidence isn't too convincing, although (of course) practitioners say it works if the patient has enough commitment.

In particular, most doubt seem to be whether such class-based approach can affect real-life "heat of the moment" events/outburst. So what does the scientific evidence on this look like? Are there substantial well-designed studies on this, are there enough studies for meta-analyses etc.?


What Childhood and Teen Issues Can CBT Best Address?

Cognitive-behavioral therapy challenges maladaptive thoughts and unhelpful behaviors – replacing them with more realistic thinking patterns and more adaptive coping strategies (Scott, 2010).

These adjustments can help bring about changes in the symptoms of a number of issues associated with childhood and adolescence.

Eating Disorders

Eating disorders are relatively prevalent and serious psychological disorders that commonly emerge during adolescence. Around 40-60% of girls aged 6-12 expressed concerns regarding their weight, with around 13% suffering from an eating disorder by age 20 (Smolak, 2011).

Studies of adolescent boys with eating disorders suggest that the prevalence of eating disorders is increasing, with boys most commonly being admitted to hospital for an eating disorder at age 13 (Stice, Marti, Shaw, & Jaconi, 2010).

Cognitive-behavioral therapy for eating disorders addresses distorted thoughts about weight and self-image through ongoing cognitive restructuring.

Adolescents with recurrent binge-eating demonstrated abstinence from binging following group CBT treatment. Furthermore, CBT treatment adapted for adolescents has demonstrated significant improvements in weight gain, weight maintenance, and reductions in eating pathologies at a 60-week follow-up (Kass, Kolko, & Wilfley, 2013).

Oppositional Defiant Disorder

Disruptive behaviors such as outbursts of anger and aggression are among the most frequent reasons for childhood outpatient mental health referrals (Sukhodolsky et al., 2016).

Oppositional Defiant Disorder (ODD) is a repetitive pattern of negative, defiant, and hostile behavior toward authority figures.

Children with ODD may exhibit a broad array of problem behaviors ranging from physical aggression, destructiveness, defiance, resentment, and hostile behavior toward peers, parents, teachers, and other authority figures (Lochman, 2011).

CBT has been shown to produce significant reductions in ODD, providing methods by which a child can learn to solve problems and communicate in a controlled manner. Battagliese (2015) found that greater reductions in aggressive behaviors occurred when treatment was delivered to children in the presence of a trusted parent or guardian.

Deliberate Self-Harm

Recurrent deliberate self-harm (DSH) commonly begins during early teenage years and is strongly associated with suicide (Hawton et al, 2015). The average lifetime prevalence of DSH is estimated to vary from 7.5%-8% for pre-adolescents, increasing to 12%-23% for adolescents (Washburn et al, 2012).

DSH behaviors can range from repetitive head-banging (more commonly found in young children) to intentional self-poisoning and cutting.

Cognitive-behavioral therapies show promise in treating DSH – particularly dialectical behavior therapy (DBT), a modified form of CBT that focuses on skills like mindfulness, regulating emotions, and tolerating distress.

Research by Taylor et al, (2011) indicated a marked improvement in DSH behavior in adolescents following 8-12 sessions of individual DBT treatment. Crucially, the progress made during treatment was maintained at follow-up.

Low Self-Esteem

Low self-esteem has been associated with a number of different psychiatric diagnoses including depression, obsessive-compulsive disorder, eating disorders, self-harm, and substance abuse (McManus, Waite, & Shafran, 2009).

Taylor & Montgomery (2007) assessed the efficacy of cognitive-behavioral therapy in improving self-esteem among depressed adolescents aged 13 to 18. Results from this study indicated that when compared with interpersonal therapy, CBT appeared to be an effective treatment in improving self-esteem among adolescents.

Bedwetting

Bedwetting, known clinically as Nocturnal Enuresis, is a potential source of low self-esteem and has been associated with emotional and behavioral disorders.

While the occurrence of bedwetting is most common in younger children, the prevalence of bedwetting in children aged 12-15 is estimated to be around 3% (NICE, 2010).

Ronen (1992) found that children and adolescents treated with cognitive behavior therapy were more likely to be dry for 3 consecutive weeks compared to those who received no treatment.

Additionally, those receiving CBT were less likely to relapse when compared with subjects using an enuresis alarm – a commonly utilized method in the treatment of bedwetting. CBT can also assist in the amelioration of symptoms associated with bedwetting such as low self-esteem, anxiety, and embarrassment.

Bullying

Bullying is a widespread phenomenon among children and adolescents. Characterized by an imbalance of power, aggressive behavior and repetitive intentional ‘harm doing’, victims of childhood bullying are at higher risk of sleep problems, self-harm, anxiety, and depression (Wolke & Lereya, 2015).

Berry & Hunt (2009) tested the efficacy of CBT interventions for adolescent boys experiencing bullying at school. CBT was found to significantly reduce self-reported anxiety and depression associated with being bullied, with intervention gains being maintained at a 3-month follow-up.

Substance Misuse

The ages of 12–17 years old are a critical risk period for the initiation of substance use in adolescents (UNODC, 2018). Many young people use drugs to cope with the social and psychological challenges they may experience during different phases of their development from adolescence to adulthood.

Research indicates that CBT is effective in the treatment of adolescent substance misuse.

However, the combination of CBT with motivational enhancement therapy is equally effective but also ensures that teenage clients are motivated to change their behavior and committed to treatment before CBT begins (Hogue et al, 2014).


Anger Self Help

Anger is a normal reaction. It energises us into action and can help us make life saving and vital actions. Anger can be very useful. However, it can become a problem if it seems like we're getting angry very often, and it is affecting our mood, working life, relationships or mental wellbeing.

Anger is a result of thinking that we have been unfairly treated or disrespected, or something is unjust, and we won't stand for it.

Thinking this way leads us to feel angry, which stimulates the body's adrenaline response which is our body's way of helping us to cope with either fighting, or running away ('fight or flight' response). We respond to those thoughts and feelings, by acting, or feeling an urge to act, in threatening or aggressive ways.


Typical Thoughts

I'm being treated unfairly


Physical Sensations
- Alarming Adrenaline When there is real, or we believe there is a real, threat or danger, our bodies' automatic survival mechanism kicks in very quickly. This helps energise us to fight or run away ('fight or flight response'). The action urge associated with anger is the urge to attack. We will notice lots of physical sensations, which might include:

heart racing or pounding - enabling good blood supply around our bodies

breathing quickly - allowing more oxygen around the body

tense muscles - a state of readiness to fight or flee

stomach churning or butterflies

physical urge to go towards whatever is making us angry


Angry Behaviours

staring & facial expression

move towards what is making us angry

hit out (or urge to hit out)


The Angry Cycle

We all feel angry some times. Some people tend to become angry easily (a "short fuse"), and some have problems controlling their anger. Anger has consequences, and they often involve hurting other people - more usually their feelings, but sometimes physically.

Anger can cause problems in our personal lives, and affect work and study. After an angry outburst, we can think very critically of ourselves and our actions, leading us to feel guilty, ashamed and lower our mood, which might result in our withdrawing from others, not wanting to do anything (see depression cycle).

To help overcome a persistent anger problem, we need to understand what we are REALLY angry about - which may well be NOT what we are directing our anger towards at that time. It is often due to something related to something from our past, and the current situation FEELS similar, so it triggers our angry response now.


Vicious Cogs of Anger
By looking at the "cogs" that keep the central problem going, we can target and make positive changes in each of the cogs, which will at least, slow down, and at best, stop, the central problem, for example:

Print a blank Cogs PDF and fill in the factors that keep your anger going.


Anger Self Help
- video

Making Positive Changes

Identify your triggers

What or when are the times when you are more likely to get angry? If you can see the patterns, then maybe you can do something about those situations, and do something different.


What to do when you feel angry

STOPP! Pause, take a breath, don't react automatically.

Walk away - you can come back and talk later.

What is it that's really pushing my buttons here?

Am I getting things out of proportion?

How important is this really?

How important will it be in 6 months time?

What harm has actually been done?

Am I expecting something from this person or situation that is unrealistic?

What's the worst (and best) that could happen? What's most likely to happen?

Am I jumping to conclusions about what this person meant? Am I (mis)reading between the lines?

Is it possible that they didn't mean that?

What do I want or need from this person or situation? What do they want or need from me? Is there a compromise?

What would be the consequences of responding angrily?

Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for the other person)

Visualise yourself dealing with the situation in a calm, non-aggressive but assertive way, respecting the rights and opinions of all others involved.


How to deal with the physical sensations of anger

Counteract the body's adrenaline response - it's readiness for action, by using that energy healthily.

Practice calming or mindful breathing - this one act alone will help reduce the physical sensations, emotions and intensity of thoughts.

Breathe in blue (for calm) and/or green (for balance), and breathe out red.

Go for a walk, run or cycle, or maybe do some gardening or housework.

Learn effective skills to manage emotion online - The Decider Skills for Self Help online course


CBT in a Caribbean Context: A Controlled Trial of Anger Management in Trinidadian Prisons

Background : Anger causes significant problems in offenders and to date few interventions have been described in the Caribbean region. Aim : To evaluate a package of CBT-based Anger Management Training provided to offenders in prison in Trinidad. Method : A controlled clinical trial with 85 participants who participated in a 12-week prison-based group anger management programme, of whom 57 (67%: 16 control, 41 intervention) provided pretrial and posttrial outcome data at Times 1 and 2. Results : Intervention and control groups were not directly comparable so outcome was analysed using t -tests. Reductions were noted for state and trait anger and anger expression, with an increase in coping skills for the intervention group. No changes were noted in the control group. The improvements seen on intervention were maintained at 4 month follow-up for a sub-group of participants for whom data were available. Several predictors of outcomes were identified.


Demandingness (DEM)

Things should or have to occur as I prefer, like, or in the way that I believe is right. Some times demands are referred to as musts. Here are three major musts:

i) I must do well or get approval (or I’m inadequate)

ii) You must treat me nicely (or you’re inadequate)

iii) The world (life) must give me what I want quickly, easily, and with great certainty (or it’s Awful)

Awfulizing

Something is magnified to be 100% completely bad. It is also called catastrophizing. Words like awful, horrible, terrible, and catastrophic may indicate awfulizing is occurring, especially if the event is seemingly insignificant compared to other bad events in one’s life.

Low-frustration Tolerance (LFT)

This is a thought that underestimates one’s capacity to tolerate or experience an event, situation, or experience. I can’t stand it, or this is unbearable, or I can’t take it may indicate that there is some LFT taking place.

Global Evaluations of Worth

These beliefs are global ratings of worth placed on the self, others, or even life, the world, or the future. Examples would be calling oneself a loser, winner, success, or failure. Rather than rating particular behaviors, individuals may globally evaluate the worth of a particular subject in a way that does not accurately capture its value to different stakeholders.


How Cognitive Behavior Therapy Helps Anger Management

Anger is typically considered to be a negative feeling. This means, most people, most of the time, attempt to prevent feeling this way or would like to turn down the intensity, or shorten its length. But, unlike other negative feelings, e.g., guilt, sadness, anxiety, and disgust, some people report positive aspects of their anger. Anger often gives people a sense of righteousness, and is often referred to as a moral emotion. It is often related to themes (or values) of morality, justice, fairness, and respect. But, it can also be triggered by other emotional material and have less to do with morality. At times, an individual may not realize there is a connection between anger and another emotion. For example, it may feel much better to be angry at a loved one then to feel the hurt associated with rejection. Early aggression theories proposed that mounting frustration could lead to aggression, and it seems likely anger would mediate this relationship.

Aggression Hypothesis

A newer theory, Berkowitz’s Neoassociationistic Model, reformulates Dollard and Doob’s Frustration-Aggression Hypothesis. He proposes negative affect (emotions) all accumulate, and once a threshold is reached, aggression is likely to occur. This would mean that even anxiety, guilt, and embarrassment could precipitate anger and aggression. This is somewhat counter-intuitive since these emotions are typically associated with withdrawal and escape behavioral tendencies. This also means that the act of anger/aggression may have less to do with the target than previous aversive interactions or issues. In these cases, the emotional expression (i.e., the motor behavior associated with the anger episode) may be “misplaced.” Misplaced anger may be perceived by both the target and the actor as disproportionate to the apparent trigger.

Adaptive Anger

Anger, like anxiety, may feel uncomfortable, but can be associated with adaptive behaviors or unhealthy consequences, the same way fear, and the related constructs of anxiety and panic are. For example, anger can alert people that an injustice is being committed, or that someone is taking advantage of him or her. On a larger scale, it may lead groups of people to organize and motivate them to take action in favor or social change. Examples of this could be Mothers Against Drunk Driving (M.A.D.D.), protestors of a war, or unfair law. But, like fear, if anger becomes intense, lasts for long periods of time, or leads to unhealthy (risky) behaviors (e.g., domestic violence, child-abuse, drinking, drug use, or road rage), it can become very self-defeating and even lead to medical problems (e.g., heart attacks, strokes, high blood pressure, gastrointestinal problems, binge eating, etc.).

Anger Treatment

Anger can be successfully treated with a number of cognitive-behavioral techniques (CBT) in an anger management program. Components of cognitive-behavior therapy have been studied more than other psychotherapies, and have proven to be effective. In as little as 8-12 weeks, many techniques have shown promising results. Cognitive restructuring, problem solving, relaxation training, communication skills, and combinations of these techniques have reduced both the experience of anger and many of the associated behaviors.

Cognitive-behavior Therapy

Cognitive-behavior therapy (CBT) is a form of treatment that focuses on alleviating current symptoms by addressing current causes of the problem(s). Specifically, it is based on the theory that emotional problems are the result of the combination of situations and people’s beliefs about these events. Thoughts about how other people should behave, how mistreated I was when I was younger, the amount of respect I should be given, how frequently people should be polite and fair, etc.

The common model for conceptualizing this idea is Albert Ellis’ ABC model, where “A” stands for Activating Events, “B” stands for Beliefs, and “C” stands for Consequences.

Activating events (A’s), are anything real or imagined that activates our belief system (B’s) and results in an emotional consequence (C). Emotional Consequences (Ce’s), set the stage for behavioral consequences (Cb’s).

If you bumped by someone with a backpack while walking on the sidewalk, that could be an A. You may then believe (B), “He should watch where he is going, and at a minimum apologize.” The combination of this activating event (A) and belief (B), may result in anger, and an emotional consequence (C).

Anger Symptoms

Anger symptoms vary and cross many domains. Symptom domains for anger include physiological, cognitive, and behavioral. These symptoms may result in detrimental effects in the family, love life, medical profile, or work life of a person. They may also lead to more risky behaviors resulting in serious physical threat and even legal problems (e.g., assault and battery, reckless driving, drug possession charges).

Physiological symptoms can include rapid heart rate, palpitations, perspiration, shaking muscles, urges to hit others. Cognitive symptoms may include difficulties concentrating, remembering, rumination about events, or revenge fantasies. Behavioral symptoms could be severe, as in the case of physical altercations, reckless driving, or alcohol consumption, or mild procrastination or small accidents.

When left untreated there is mounting evidence that these symptoms over time wreak havoc on our physical bodies and lead to medical problems. Surges in blood pressure, frequent activation of the nervous and endocrine systems, and tendencies to neglect self-care put angry individuals at risk for all kinds of problems. Certain types of anger can predict all-cause-mortality and reliably predict heart disease as well as blood pressure and cholesterol do.


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Anger management for people with mild to moderate learning disabilities: Study protocol for a multi-centre cluster randomized controlled trial of a manualized intervention delivered by day-service staff

Cognitive behaviour therapy (CBT) is the treatment of choice for common mental health problems, but this approach has only recently been adapted for people with learning disabilities, and there is a limited evidence base for the use of CBT with this client group. Anger treatment is the one area where there exists a reasonable number of small controlled trials. This study will evaluate the effectiveness of a manualized 12-week CBT intervention for anger. The intervention will be delivered by staff working in the day services that the participants attend, following training to act as 'lay therapists' by a Clinical Psychologist, who will also provide supervision.

Methods/Design

This is a multi-centre cluster randomized controlled trial of a group intervention versus a 'support as usual' waiting-list control group, with randomization at the level of the group. Outcomes will be assessed at the end of the intervention and again 6-months later. After completion of the 6-month follow-up assessments, the intervention will also be delivered to the waiting-list groups. The study will include a range of anger/aggression and mental health measures, some of which will be completed by service users and also by their day service key-workers and by home carers. Qualitative data will be collected to assess the impact of the intervention on participants, lay therapists, and services, and the study will also include a service-utilization cost and consequences analysis.

Discussion

This will be the first trial to investigate formally how effectively staff working in services providing day activities for people with learning disabilities are able to use a therapy manual to deliver a CBT based anger management intervention, following brief training by a Clinical Psychologist. The demonstration that service staff can successfully deliver anger management to people with learning disabilities, by widening the pool of potential therapists, would have very significant benefits in relation to the current policy of improving access to psychological therapies, in addition to addressing more effectively an important and often unmet need of this vulnerable client group. The economic analysis will identify the direct and indirect costs (and/or savings) of the intervention and consider these in relation to the range of observed effects. The qualitative analyses will enhance the interpretation of the quantitative data, and if the study shows positive results, will inform the roll-out of the intervention to the wider community.

Trial registration


Abstract

This meta-analysis sought to investigate the effectiveness of CBT based anger management interventions on reducing recidivism amongst adult male offenders. Studies were selected after a bibliographic database search, a hand-search of references from similar studies and an electronic search on apposite Correctional websites. The outcome measures of interest were general and violent recidivism rates. These were considered to be evidence of long term behavioral change. Studies that included appropriate data were analysed using risk ratio analysis. The analysis of the effect of exposure to CBT based treatment on general recidivism showed an overall effect of 0.77, indicating a risk reduction of 23%, whereas the overall effect on violent recidivism was 0.72, indicating a risk reduction of 28%. The meta-analysis also explored the effects of treatment completion in comparison to attrition groups. The effects of treatment completion on general recidivism through risk ratios was 0.58, indicating a 42% risk reduction. For violent recidivism, the risk ratio was 0.44, indicating a 56% risk reduction. Subgroup analysis based on the treatment modality and the analysis of the risk of bias carried out on the selected studies was conducted to explore the significant heterogeneity noted in the results. Overall, anger management appeared to be effective in reducing the risk of recidivism, especially violent recidivism. Moderate-intensity anger management were associated with larger effect than the high-intensity correctional programs for violence reduction.


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CBT in a Caribbean Context: A Controlled Trial of Anger Management in Trinidadian Prisons

Background : Anger causes significant problems in offenders and to date few interventions have been described in the Caribbean region. Aim : To evaluate a package of CBT-based Anger Management Training provided to offenders in prison in Trinidad. Method : A controlled clinical trial with 85 participants who participated in a 12-week prison-based group anger management programme, of whom 57 (67%: 16 control, 41 intervention) provided pretrial and posttrial outcome data at Times 1 and 2. Results : Intervention and control groups were not directly comparable so outcome was analysed using t -tests. Reductions were noted for state and trait anger and anger expression, with an increase in coping skills for the intervention group. No changes were noted in the control group. The improvements seen on intervention were maintained at 4 month follow-up for a sub-group of participants for whom data were available. Several predictors of outcomes were identified.


What Childhood and Teen Issues Can CBT Best Address?

Cognitive-behavioral therapy challenges maladaptive thoughts and unhelpful behaviors – replacing them with more realistic thinking patterns and more adaptive coping strategies (Scott, 2010).

These adjustments can help bring about changes in the symptoms of a number of issues associated with childhood and adolescence.

Eating Disorders

Eating disorders are relatively prevalent and serious psychological disorders that commonly emerge during adolescence. Around 40-60% of girls aged 6-12 expressed concerns regarding their weight, with around 13% suffering from an eating disorder by age 20 (Smolak, 2011).

Studies of adolescent boys with eating disorders suggest that the prevalence of eating disorders is increasing, with boys most commonly being admitted to hospital for an eating disorder at age 13 (Stice, Marti, Shaw, & Jaconi, 2010).

Cognitive-behavioral therapy for eating disorders addresses distorted thoughts about weight and self-image through ongoing cognitive restructuring.

Adolescents with recurrent binge-eating demonstrated abstinence from binging following group CBT treatment. Furthermore, CBT treatment adapted for adolescents has demonstrated significant improvements in weight gain, weight maintenance, and reductions in eating pathologies at a 60-week follow-up (Kass, Kolko, & Wilfley, 2013).

Oppositional Defiant Disorder

Disruptive behaviors such as outbursts of anger and aggression are among the most frequent reasons for childhood outpatient mental health referrals (Sukhodolsky et al., 2016).

Oppositional Defiant Disorder (ODD) is a repetitive pattern of negative, defiant, and hostile behavior toward authority figures.

Children with ODD may exhibit a broad array of problem behaviors ranging from physical aggression, destructiveness, defiance, resentment, and hostile behavior toward peers, parents, teachers, and other authority figures (Lochman, 2011).

CBT has been shown to produce significant reductions in ODD, providing methods by which a child can learn to solve problems and communicate in a controlled manner. Battagliese (2015) found that greater reductions in aggressive behaviors occurred when treatment was delivered to children in the presence of a trusted parent or guardian.

Deliberate Self-Harm

Recurrent deliberate self-harm (DSH) commonly begins during early teenage years and is strongly associated with suicide (Hawton et al, 2015). The average lifetime prevalence of DSH is estimated to vary from 7.5%-8% for pre-adolescents, increasing to 12%-23% for adolescents (Washburn et al, 2012).

DSH behaviors can range from repetitive head-banging (more commonly found in young children) to intentional self-poisoning and cutting.

Cognitive-behavioral therapies show promise in treating DSH – particularly dialectical behavior therapy (DBT), a modified form of CBT that focuses on skills like mindfulness, regulating emotions, and tolerating distress.

Research by Taylor et al, (2011) indicated a marked improvement in DSH behavior in adolescents following 8-12 sessions of individual DBT treatment. Crucially, the progress made during treatment was maintained at follow-up.

Low Self-Esteem

Low self-esteem has been associated with a number of different psychiatric diagnoses including depression, obsessive-compulsive disorder, eating disorders, self-harm, and substance abuse (McManus, Waite, & Shafran, 2009).

Taylor & Montgomery (2007) assessed the efficacy of cognitive-behavioral therapy in improving self-esteem among depressed adolescents aged 13 to 18. Results from this study indicated that when compared with interpersonal therapy, CBT appeared to be an effective treatment in improving self-esteem among adolescents.

Bedwetting

Bedwetting, known clinically as Nocturnal Enuresis, is a potential source of low self-esteem and has been associated with emotional and behavioral disorders.

While the occurrence of bedwetting is most common in younger children, the prevalence of bedwetting in children aged 12-15 is estimated to be around 3% (NICE, 2010).

Ronen (1992) found that children and adolescents treated with cognitive behavior therapy were more likely to be dry for 3 consecutive weeks compared to those who received no treatment.

Additionally, those receiving CBT were less likely to relapse when compared with subjects using an enuresis alarm – a commonly utilized method in the treatment of bedwetting. CBT can also assist in the amelioration of symptoms associated with bedwetting such as low self-esteem, anxiety, and embarrassment.

Bullying

Bullying is a widespread phenomenon among children and adolescents. Characterized by an imbalance of power, aggressive behavior and repetitive intentional ‘harm doing’, victims of childhood bullying are at higher risk of sleep problems, self-harm, anxiety, and depression (Wolke & Lereya, 2015).

Berry & Hunt (2009) tested the efficacy of CBT interventions for adolescent boys experiencing bullying at school. CBT was found to significantly reduce self-reported anxiety and depression associated with being bullied, with intervention gains being maintained at a 3-month follow-up.

Substance Misuse

The ages of 12–17 years old are a critical risk period for the initiation of substance use in adolescents (UNODC, 2018). Many young people use drugs to cope with the social and psychological challenges they may experience during different phases of their development from adolescence to adulthood.

Research indicates that CBT is effective in the treatment of adolescent substance misuse.

However, the combination of CBT with motivational enhancement therapy is equally effective but also ensures that teenage clients are motivated to change their behavior and committed to treatment before CBT begins (Hogue et al, 2014).


Demandingness (DEM)

Things should or have to occur as I prefer, like, or in the way that I believe is right. Some times demands are referred to as musts. Here are three major musts:

i) I must do well or get approval (or I’m inadequate)

ii) You must treat me nicely (or you’re inadequate)

iii) The world (life) must give me what I want quickly, easily, and with great certainty (or it’s Awful)

Awfulizing

Something is magnified to be 100% completely bad. It is also called catastrophizing. Words like awful, horrible, terrible, and catastrophic may indicate awfulizing is occurring, especially if the event is seemingly insignificant compared to other bad events in one’s life.

Low-frustration Tolerance (LFT)

This is a thought that underestimates one’s capacity to tolerate or experience an event, situation, or experience. I can’t stand it, or this is unbearable, or I can’t take it may indicate that there is some LFT taking place.

Global Evaluations of Worth

These beliefs are global ratings of worth placed on the self, others, or even life, the world, or the future. Examples would be calling oneself a loser, winner, success, or failure. Rather than rating particular behaviors, individuals may globally evaluate the worth of a particular subject in a way that does not accurately capture its value to different stakeholders.


Abstract

This meta-analysis sought to investigate the effectiveness of CBT based anger management interventions on reducing recidivism amongst adult male offenders. Studies were selected after a bibliographic database search, a hand-search of references from similar studies and an electronic search on apposite Correctional websites. The outcome measures of interest were general and violent recidivism rates. These were considered to be evidence of long term behavioral change. Studies that included appropriate data were analysed using risk ratio analysis. The analysis of the effect of exposure to CBT based treatment on general recidivism showed an overall effect of 0.77, indicating a risk reduction of 23%, whereas the overall effect on violent recidivism was 0.72, indicating a risk reduction of 28%. The meta-analysis also explored the effects of treatment completion in comparison to attrition groups. The effects of treatment completion on general recidivism through risk ratios was 0.58, indicating a 42% risk reduction. For violent recidivism, the risk ratio was 0.44, indicating a 56% risk reduction. Subgroup analysis based on the treatment modality and the analysis of the risk of bias carried out on the selected studies was conducted to explore the significant heterogeneity noted in the results. Overall, anger management appeared to be effective in reducing the risk of recidivism, especially violent recidivism. Moderate-intensity anger management were associated with larger effect than the high-intensity correctional programs for violence reduction.


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Anger management for people with mild to moderate learning disabilities: Study protocol for a multi-centre cluster randomized controlled trial of a manualized intervention delivered by day-service staff

Cognitive behaviour therapy (CBT) is the treatment of choice for common mental health problems, but this approach has only recently been adapted for people with learning disabilities, and there is a limited evidence base for the use of CBT with this client group. Anger treatment is the one area where there exists a reasonable number of small controlled trials. This study will evaluate the effectiveness of a manualized 12-week CBT intervention for anger. The intervention will be delivered by staff working in the day services that the participants attend, following training to act as 'lay therapists' by a Clinical Psychologist, who will also provide supervision.

Methods/Design

This is a multi-centre cluster randomized controlled trial of a group intervention versus a 'support as usual' waiting-list control group, with randomization at the level of the group. Outcomes will be assessed at the end of the intervention and again 6-months later. After completion of the 6-month follow-up assessments, the intervention will also be delivered to the waiting-list groups. The study will include a range of anger/aggression and mental health measures, some of which will be completed by service users and also by their day service key-workers and by home carers. Qualitative data will be collected to assess the impact of the intervention on participants, lay therapists, and services, and the study will also include a service-utilization cost and consequences analysis.

Discussion

This will be the first trial to investigate formally how effectively staff working in services providing day activities for people with learning disabilities are able to use a therapy manual to deliver a CBT based anger management intervention, following brief training by a Clinical Psychologist. The demonstration that service staff can successfully deliver anger management to people with learning disabilities, by widening the pool of potential therapists, would have very significant benefits in relation to the current policy of improving access to psychological therapies, in addition to addressing more effectively an important and often unmet need of this vulnerable client group. The economic analysis will identify the direct and indirect costs (and/or savings) of the intervention and consider these in relation to the range of observed effects. The qualitative analyses will enhance the interpretation of the quantitative data, and if the study shows positive results, will inform the roll-out of the intervention to the wider community.

Trial registration


How Cognitive Behavior Therapy Helps Anger Management

Anger is typically considered to be a negative feeling. This means, most people, most of the time, attempt to prevent feeling this way or would like to turn down the intensity, or shorten its length. But, unlike other negative feelings, e.g., guilt, sadness, anxiety, and disgust, some people report positive aspects of their anger. Anger often gives people a sense of righteousness, and is often referred to as a moral emotion. It is often related to themes (or values) of morality, justice, fairness, and respect. But, it can also be triggered by other emotional material and have less to do with morality. At times, an individual may not realize there is a connection between anger and another emotion. For example, it may feel much better to be angry at a loved one then to feel the hurt associated with rejection. Early aggression theories proposed that mounting frustration could lead to aggression, and it seems likely anger would mediate this relationship.

Aggression Hypothesis

A newer theory, Berkowitz’s Neoassociationistic Model, reformulates Dollard and Doob’s Frustration-Aggression Hypothesis. He proposes negative affect (emotions) all accumulate, and once a threshold is reached, aggression is likely to occur. This would mean that even anxiety, guilt, and embarrassment could precipitate anger and aggression. This is somewhat counter-intuitive since these emotions are typically associated with withdrawal and escape behavioral tendencies. This also means that the act of anger/aggression may have less to do with the target than previous aversive interactions or issues. In these cases, the emotional expression (i.e., the motor behavior associated with the anger episode) may be “misplaced.” Misplaced anger may be perceived by both the target and the actor as disproportionate to the apparent trigger.

Adaptive Anger

Anger, like anxiety, may feel uncomfortable, but can be associated with adaptive behaviors or unhealthy consequences, the same way fear, and the related constructs of anxiety and panic are. For example, anger can alert people that an injustice is being committed, or that someone is taking advantage of him or her. On a larger scale, it may lead groups of people to organize and motivate them to take action in favor or social change. Examples of this could be Mothers Against Drunk Driving (M.A.D.D.), protestors of a war, or unfair law. But, like fear, if anger becomes intense, lasts for long periods of time, or leads to unhealthy (risky) behaviors (e.g., domestic violence, child-abuse, drinking, drug use, or road rage), it can become very self-defeating and even lead to medical problems (e.g., heart attacks, strokes, high blood pressure, gastrointestinal problems, binge eating, etc.).

Anger Treatment

Anger can be successfully treated with a number of cognitive-behavioral techniques (CBT) in an anger management program. Components of cognitive-behavior therapy have been studied more than other psychotherapies, and have proven to be effective. In as little as 8-12 weeks, many techniques have shown promising results. Cognitive restructuring, problem solving, relaxation training, communication skills, and combinations of these techniques have reduced both the experience of anger and many of the associated behaviors.

Cognitive-behavior Therapy

Cognitive-behavior therapy (CBT) is a form of treatment that focuses on alleviating current symptoms by addressing current causes of the problem(s). Specifically, it is based on the theory that emotional problems are the result of the combination of situations and people’s beliefs about these events. Thoughts about how other people should behave, how mistreated I was when I was younger, the amount of respect I should be given, how frequently people should be polite and fair, etc.

The common model for conceptualizing this idea is Albert Ellis’ ABC model, where “A” stands for Activating Events, “B” stands for Beliefs, and “C” stands for Consequences.

Activating events (A’s), are anything real or imagined that activates our belief system (B’s) and results in an emotional consequence (C). Emotional Consequences (Ce’s), set the stage for behavioral consequences (Cb’s).

If you bumped by someone with a backpack while walking on the sidewalk, that could be an A. You may then believe (B), “He should watch where he is going, and at a minimum apologize.” The combination of this activating event (A) and belief (B), may result in anger, and an emotional consequence (C).

Anger Symptoms

Anger symptoms vary and cross many domains. Symptom domains for anger include physiological, cognitive, and behavioral. These symptoms may result in detrimental effects in the family, love life, medical profile, or work life of a person. They may also lead to more risky behaviors resulting in serious physical threat and even legal problems (e.g., assault and battery, reckless driving, drug possession charges).

Physiological symptoms can include rapid heart rate, palpitations, perspiration, shaking muscles, urges to hit others. Cognitive symptoms may include difficulties concentrating, remembering, rumination about events, or revenge fantasies. Behavioral symptoms could be severe, as in the case of physical altercations, reckless driving, or alcohol consumption, or mild procrastination or small accidents.

When left untreated there is mounting evidence that these symptoms over time wreak havoc on our physical bodies and lead to medical problems. Surges in blood pressure, frequent activation of the nervous and endocrine systems, and tendencies to neglect self-care put angry individuals at risk for all kinds of problems. Certain types of anger can predict all-cause-mortality and reliably predict heart disease as well as blood pressure and cholesterol do.


Anger Self Help

Anger is a normal reaction. It energises us into action and can help us make life saving and vital actions. Anger can be very useful. However, it can become a problem if it seems like we're getting angry very often, and it is affecting our mood, working life, relationships or mental wellbeing.

Anger is a result of thinking that we have been unfairly treated or disrespected, or something is unjust, and we won't stand for it.

Thinking this way leads us to feel angry, which stimulates the body's adrenaline response which is our body's way of helping us to cope with either fighting, or running away ('fight or flight' response). We respond to those thoughts and feelings, by acting, or feeling an urge to act, in threatening or aggressive ways.


Typical Thoughts

I'm being treated unfairly


Physical Sensations
- Alarming Adrenaline When there is real, or we believe there is a real, threat or danger, our bodies' automatic survival mechanism kicks in very quickly. This helps energise us to fight or run away ('fight or flight response'). The action urge associated with anger is the urge to attack. We will notice lots of physical sensations, which might include:

heart racing or pounding - enabling good blood supply around our bodies

breathing quickly - allowing more oxygen around the body

tense muscles - a state of readiness to fight or flee

stomach churning or butterflies

physical urge to go towards whatever is making us angry


Angry Behaviours

staring & facial expression

move towards what is making us angry

hit out (or urge to hit out)


The Angry Cycle

We all feel angry some times. Some people tend to become angry easily (a "short fuse"), and some have problems controlling their anger. Anger has consequences, and they often involve hurting other people - more usually their feelings, but sometimes physically.

Anger can cause problems in our personal lives, and affect work and study. After an angry outburst, we can think very critically of ourselves and our actions, leading us to feel guilty, ashamed and lower our mood, which might result in our withdrawing from others, not wanting to do anything (see depression cycle).

To help overcome a persistent anger problem, we need to understand what we are REALLY angry about - which may well be NOT what we are directing our anger towards at that time. It is often due to something related to something from our past, and the current situation FEELS similar, so it triggers our angry response now.


Vicious Cogs of Anger
By looking at the "cogs" that keep the central problem going, we can target and make positive changes in each of the cogs, which will at least, slow down, and at best, stop, the central problem, for example:

Print a blank Cogs PDF and fill in the factors that keep your anger going.


Anger Self Help
- video

Making Positive Changes

Identify your triggers

What or when are the times when you are more likely to get angry? If you can see the patterns, then maybe you can do something about those situations, and do something different.


What to do when you feel angry

STOPP! Pause, take a breath, don't react automatically.

Walk away - you can come back and talk later.

What is it that's really pushing my buttons here?

Am I getting things out of proportion?

How important is this really?

How important will it be in 6 months time?

What harm has actually been done?

Am I expecting something from this person or situation that is unrealistic?

What's the worst (and best) that could happen? What's most likely to happen?

Am I jumping to conclusions about what this person meant? Am I (mis)reading between the lines?

Is it possible that they didn't mean that?

What do I want or need from this person or situation? What do they want or need from me? Is there a compromise?

What would be the consequences of responding angrily?

Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for the other person)

Visualise yourself dealing with the situation in a calm, non-aggressive but assertive way, respecting the rights and opinions of all others involved.


How to deal with the physical sensations of anger

Counteract the body's adrenaline response - it's readiness for action, by using that energy healthily.

Practice calming or mindful breathing - this one act alone will help reduce the physical sensations, emotions and intensity of thoughts.

Breathe in blue (for calm) and/or green (for balance), and breathe out red.

Go for a walk, run or cycle, or maybe do some gardening or housework.

Learn effective skills to manage emotion online - The Decider Skills for Self Help online course


External links



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