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Anger Management

Dunbar
10.1177/1078390303261168

Anger Management: A Holistic Approach


Berthenya Dunbar

Anger is often a difficult emotion to express and understand. However, the consequences of unmanaged anger are manifested in
the physical, emotional, and interpersonal arenas of many lives everyday. The program presented in this article uses cognitive
behavioral therapy in a holistic approach to anger management treatment. Twelve anger management treatment concepts, par-
ticipant assessment, group design, and facilitator characteristics are addressed. This article provides a guide for advanced-
practice registered nurses to use in the development of a program that respects the complexity of patients who present for anger
management treatment. J Am Psychiatr Nurses Assoc, 2004; 10(1), 16-23.

Keywords: anger management; groups; cognitive behavioral therapy

Anger is an uncomfortable emotional feeling that var- work, and in social situations. The program is not de-
ies from mild irritation to rage. Thomas (1998) re- signed to address domestic violence issues. Because
ported that anger is a normal response to an assault to the dynamics of domestic violence treatment differs
ones self-esteem or sense of integrity. Many people find significantly from the treatment of anger manage-
anger to be an emotion that is difficult to use in a pro- ment, patients with domestic violence issues will bene-
ductive manner. Primary goals of anger management fit from treatment that specifically addresses domestic
treatment are to assist participants in recognizing that violence issues.
anger is a normal emotion and to develop skills that
will enable them to express emotions, needs, and de- BACKGROUND
sires in a manner that displays respect for themselves
and others. It is not merely assertiveness training or Ellis (1993), a pioneer in the field of anger manage-
stress management.
ment, suggested that anger occurs as a result of ones
Evidence of the negative effect of anger can be seen
perceptions and thus can be managed by thinking
in the lives of those who present for individual, group
ones way out of unhealthy anger expression. His ap-
or couples therapy. Dyer (2000) commented on the dif-
proach is designed to help clients become aware of how
ficulty associated with calculating the cost of dysfunc-
thoughts and feelings are related. Individuals emo-
tional anger. Ineffective management of anger can
tions are influenced by their perception of an event in
have devastating consequences manifested as physi-
their lives; this is an assumption of cognitive behav-
cal, emotional, and/or interpersonal costs. These in-
ioral therapy (Beck, 1995). For example, it is not the
clude damaged relationships, unmet needs, loss of self-
event that causes the anger, it is what the person
esteem, lost jobs, and feelings of powerlessness.
thinks about the event that causes the anger. The per-
This article presents a comprehensive, literature-
ception of the event is embedded in the persons core
based anger management treatment program. Cogni-
beliefs about himself or herself. Another important
tive behavioral therapy is the basis of the program,
concept of cognitive behavior therapy is that one can
which promotes a holistic approach to treating persons
change ones response to an occurrence by changing
who manage anger unhealthily. The treatment pro-
ones thoughts about the occurrence. Cognitive behav-
gram is intended to treat those persons who exhibit an-
ioral therapy includes rapport building, patient educa-
ger management problems in relationships at home,
tion, instillation of hope, data gathering, and goal de-
velopment (Beck, 1995). Cognitive behavioral therapy
Berthenya Dunbar, APRN, CS, MSN, is a psychiatric nurse practi-
is a process that is designed to help patients under-
tioner in the mental health clinic at the James A. Haley Veterans stand how and why they act the way they do. With this
Hospital, Tampa, FL; Bertd28@aol.com. insight, patients will have better success at
DOI: 10.1177/1078390303261168 maintaining any changes that occur in treatment.

16 Copyright 2004 American Psychiatric Nurses Association


Anger Management

Anger is a major issue in the treatment of post- PROGRAM CONCEPTS


traumatic stress disorder (PTSD). Gerlock (1994) used
a pre/posttest design to determine the efficacy of a Twelve concepts are addressed in the program.
group therapy anger management treatment interven- When used together, the concepts provide participants
tion with male veterans (N = 51). In the study, veterans with an opportunity to learn how their thinking, feel-
who had combat trauma had higher mean anger scores ings, and behavioral choices contribute to healthy an-
than those who did not have exposure to combat. The ger management.
participants were in groups of 6 to 12 for an 8-week The concepts are open-mindedness, anger does not
class; 38 of the veterans completed the program. Partic- equal bad, responsibility for management of ones own
ipants were evaluated preintervention and post- anger, physical cues, relaxation, identification of under-
intervention. The investigator found a 4.80 mean score lying emotion, negative thoughts, reasoned assertive
drop in state anger and a 5.26 mean score drop in trait responses, physical exercise, self-esteem, the should
anger; lower scores indicate less anger. Twenty of the system, and resentment. The 12 concepts selected for
38 participants improved their immediate and general inclusion in the program relate to healthy anger man-
levels of anger when compared to their preintervention agement and appear regularly in the anger
levels. management treatment literature.
Cognitive behavioral therapy has been used to help
patients lower the intensity of their anger episodes. Open Mind
Tang (2001), in a retrospective study of 64 clients, eval-
uated the effectiveness of anger management treat- Open-mindedness is necessary to learn tolerance
ment that focused on a cognitive behavioral approach. (Williams & Williams, 1993). It is a willingness to listen
The posttreatment scores indicated a significant reduc- to different viewpoints even when one thinks he or she
tion of the participants overall experience of intense is right. An open mind allows one to determine if the
anger and significant improvement in cognitive situation is important enough to pursue, compromise,
behavioral coping and anger control. or ignore. Many who have difficulty managing their an-
Deffenbacher and colleagues (2002) used cognitive ger healthily are intolerant of the opinions of others.
behavioral therapy and relaxation training in a study The group discussion in this session explores the defi-
of 55 high-anger drivers. The experimental group re- nition of open-mindedness. Members are invited to de-
ported significantly lower risk-seeking behaviors and fine the concept and give examples to support the
trait anger than the control group. Additionally, their definition.
adaptive and constructive responses were higher than In the treatment program, participants are given a
the controls. therapeutic exercise that will help them develop an
The health benefits gained from learning to effec- open mind. For instance, when participants are given
tively manage ones anger are documented. Larkin and homework on the concept open-mindedness, partici-
Zayfert (1996) studied 13 patients with hypertension in pants are asked to have someone give him or her direc-
a 6-week anger management treatment program tions to a place already known to the participant. The
that incorporated role-play, relaxation training, self- participant is directed to respond only with the com-
statement modification, and assertiveness. At the end ment thank you. The assignment is a building block
of treatment, patients significantly increased their as- for learning tolerance and listening to others. Partici-
sertiveness skills and significantly lowered their blood pants discuss their successes or difficulties in the next
pressure rates. session.
Although there are many treatment models for Participants, who are trying to grasp this concept,
anger management, programs that include a holis- may benefit from asking themselves, Would I rather
tic approach to the physical, emotional, and social be right or happy? This question may help lessen argu-
issues related to anger expression are lacking. In addi- mentative behavior and help open lines of communica-
tion to the use of cognitive behavioral therapy, tion. It certainly offers the opportunity for participants
psychosocial and medical assessment, a psycho-educa- to assess a personal need to control the outcome of a
tional focus, individual support, patient goal setting, given situation.
and patient self-assessment need to be integrated into
the treatment program. The rationale for such an ap- Anger Does Not Equal Bad
proach is to acknowledge that anger management
treatment is complex and requires a multidimensional Anger does not equal bad is a difficult concept to
perspective. grasp. Many people have been socialized to believe that

Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1 17


Dunbar

even a healthy expression of anger is bad. Individuals of personal empowerment as they learn to use cues to
often avoid expressing their anger because they fear help them make early decisions to use deep breathing,
the anger will emerge in an uncontrolled state (Egelko take timeouts, and make affirmations (Powell, 1992).
& Galanter, 1993). Therefore, they vacillate between The group discussion focuses on participants begin-
outbursts of anger and passivity. ning to view themselves as bigger than their anger, in-
During the group discussion, participants are en- stead of feeling consumed by their anger. Localizing the
couraged to refrain from describing their responses to physical feelings of anger to specific areas helps to
anger-provoking situations as bad or good. Instead, decrease feelings of being consumed by ones anger.
they are encouraged to assess their behavior as effec- Participants are asked to begin to identify where
tive or ineffective; thus, there is less chance of self- they feel their anger in their bodies during anger-
labeling in punitive terms if the attempt at assertive- provoking situations. This is discussed in the next
ness was not successful. session.
As homework, participants are asked to explore one
anger-provoking situation that occurs prior to the next Relaxation
session as an opportunity to view the resulting anger as
simply an emotion that is neither bad nor good. Partici- As participants become more aware of their physical
pants are invited to discuss the situation, in detail, in cues, they are better able to conceptualize the value of
the next session, to determine their level of success or relaxation. Relaxation has long been thought to be use-
lack of success in thinking about their anger without ful in the management of anger. Deep breathing and
labeling the anger. progressive relaxation have been found to be effective
(Moore, Adams, Elsworth, & Lewis, 1997). Deep breath-
Responsibility for Management of Anger ing is a method of relaxation that is easy and simple
and can be used in conjunction with other components
Anger is often accompanied by emotional pain. It is in the program. Participants are taught deep breathing
important for those who decide to do something about as well as progressive relaxation in combination with
their anger to refrain from blaming others for their imagery in this session.
pain and dissatisfaction. Healthy anger management Relaxation alone is not a viable treatment approach
involves ones taking responsibility for ones own anger to anger management. However, because anger-
(Grogan, 1991). The tendency to blame others for ones provoking situations are thought to be stressful, the
pain can be quite compelling. However, blaming does role of relaxation in anger management treatment can-
not allow for a healthy development of self-awareness not be minimized. As homework, participants are
and the development of emotional empowerment. asked to practice (2 to 3 times) deep breathing and pro-
In this session, participants are introduced to sev- gressive relaxation during the week. Participants ex-
eral coping statements to be used when a tendency to periences with this exercise are discussed in the next
blame occurs in an anger-provoking situation during weeks group.
the next week. The coping statements may include,
Blame is not helpful. It will not change the situation. Underlying Emotion
Is it possible for me to compromise? Or, How can I
help myself in this situation? Participants are encour- Anger masks other primary emotions (Reilly, Clark,
aged to use one or more coping statements and discuss Shopshire, Lewis, & Sorensen, 1994). The underlying
at the next session their success or lack of success and emotion can be shame, fear, powerlessness, hurt, hu-
thoughts and feelings during the situation miliation, guilt, abandonment, loss of respect, or any
other feeling or combination of feelings. Once the un-
Physical Cues derlying feeling is identified, one can deal honestly
with the primary emotion. For example, a fathers 15
Anger gives the body early physical symptoms called year-old son says something disrespectful to him. The
cues. Gottlieb (1999) reported that one of the first steps father gets angry, yells, and curses. The father will
to managing ones anger is to recognize these cues. An- probably have more success at handling his anger in a
ger is not sudden or unpredictable. These cues can be healthy manner if he is able to talk to the son about
manifested as clenched jaw, sweaty palms, queasy how bothered he is about being disrespected. If he acts
stomach, warm face or ears, tics, pain in the neck, and only on his anger, the primary feeling gets lost in the
shallow breathing. Program participants gain a sense yelling and the cursing. An understanding of this con-

18 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1


Anger Management

cept helps participants determine how their percep- uncomfortable feelings until they pass in an effort to
tions contribute to the anger process. When partici- begin to express anger in a manner that is not harmful
pants understand the process, they are better able to to ones self or others. Role-play is an excellent way to
manage the underlying primary emotion instead of re- practice this concept. Participants in the program use
lenting to acting on the anger or rage. The understand- real-life scenarios or events. Using their own experi-
ing provides participants with a sense that they are in ences allows participants to relate better to one an-
charge of their emotions instead of thinking and feeling other and to feel more accomplished at the end of the
their emotions are in charge of them. Group partici- session.
pants are asked to practice underlying feeling identifi-
cation in anger-provoking situations over the next Physical Activity
week, record them, and discuss them in the next
session. Stored anger or anger that is not expressed has long
been recognized as a contributor to stress. In the 1960s
Negative Thoughts and early 1970s, therapists recommended punching
bags, pillow beating, and yelling as a healthy means of
Beck (1995) stressed the importance of the relation- avoiding the storage of anger. It is now understood that
ship between thinking and anger management. Nega- this kind of physical activity is at best a temporary re-
tive thoughts can sometimes result from misinterpre- lease. Physical activity lowers the adrenalin that
tation of data. The message or the motive is simply causes the feelings of anger. The thoughts that pro-
misunderstood. Negative thoughts can include state- duced the adrenalin are still present, and the anger
ments such as Who do you think you are? Ill show and the feelings of aggression return (Bilodeau, 1992).
you! I am not going to let her get the best of me. These However, physical exercise continues to be a recom-
thoughts add fuel to the situation. In the program, par- mendation to help relieve stress and replenish the en-
ticipants involve themselves in identifying how their dorphin stores of the body. Regular exercise works to
thoughts influence their responses to anger-provoking reduce stress over time and not just for the moment.
situations. Understanding how ones perception of an The benefits of such a program need to be stressed in
anger-provoking situation can affect the outcome of a relationship to healthy anger management. Program
situation is a major key to effective management of an- participants are instructed to clear any physical activ-
ger. Often participants in anger management treat- ity with their primary health care giver. Any progress,
ment do not recognize how the thinking process influ- or lack of progress, related to starting an exercise
ences the intensity of ones anger and behavioral program is discussed during the next session.
choices. Group process is helpful when working with
this concept. In the group, participants are asked to re- Self-Esteem
late their experiences in terms of identification of the
anger-provoking situation, their thoughts and feelings The inability to ask for what one wants is a classic
about the situation, their chosen action, and the symptom of low self-esteem (McKay & Fanning, 1992)
resulting consequence of their action. and is often seen in passive and indirect expressions of
For the next session, participants are asked to iden- anger. In the passive approach, one does not express
tify how they may use negative thought in anger- how he or she thinks or feels. In the indirect expression
provoking situations. Participants are asked to choose of anger, one does not express anger directly to the per-
one anger-provoking situation during the next week, son or persons involved in the anger-provoking situa-
list any negative thoughts that may have occurred, and tion. Neither approach to the expression of anger pro-
discuss how the thoughts affected the anger-provoking vides resolution of angry feelings. The consistent use of
situation. either approach is an ineffectual behavior pattern that
perpetuates decreased feelings of self-worth. One has
Assertive Responses to feel good about oneself in order to manage anger
healthily. Additionally, Ellis (1993) suggested that
One goal of healthy management of anger is to learn to when people devalue themselves instead of their be-
make reasoned assertive responses to anger-provoking havior, it interferes with their ability to think through
situations. Such responses reflect rational thinking their anger.
and respectful verbal and nonverbal expressions. Participants are asked to list their character
Schmidt (1993) reported that one can learn to tolerate strengths and begin to develop a self-esteem affirma-

Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1 19


Dunbar

tion list. The list is to be discussed in the next session and (c) What would happen if I gave up the
and evaluated and modified throughout the treatment resentment?
process. Participants are encouraged to use journaling,
tapes, imagery, and affirmation to begin the long pro-
Should System cess of dealing with resentments. Because this is an ex-
tended process, members are invited to discuss their
thoughts and feelings about their early work related to
Persons who have difficulty managing their anger in
this concept in the next session.
a healthy manner often have a well-defined should sys-
tem. A should system is a persons values and expecta-
ASSESSMENT
tions that he or she imposes upon others. Most people
respond in ways that meet their own needs rather than
the needs of others. Ellis (1993) reported that imposing Each prospective program participant is seen for in-
ones values on others causes disastrous results when take and assessment prior to the first group session. In-
others do not live up to ones values and/or expecta- formation is obtained about how the participant ex-
tions. These expectations of others lead to angry, unpro- presses his or her anger; alcohol and drug usage;
ductive feelings. domestic violence history; medical history; previous an-
ger management intervention; history of any trauma
People usually do what they think they should do,
such as sexual, physical, and combat involvement; level
rather than what others think they should do and
of education; spirituality; and mental status. The data
hence the potential for unmet expectations and a con-
collection is the basis for the holistic approach to treat-
flict of values. During the group, participants are asked
ment, and the background information is used to help
to identify their top three values and discuss how they
the facilitator address problems that may be contribut-
may impose their value system onto others. Partici-
ing to the participants anger management issues. As-
pants are asked to list their top three values. These are
sessment and planning increase the chances of a suc-
compared with those of others in the group. Partici-
cessful outcome. For example, if a participant cannot
pants can identify how the differences can cause con-
read or has chronic pain or nightmares secondary to
flict if compromise cannot be reached. A scenario of con-
posttraumatic stress issues, anger management skill-
flicting values is used to have patients identify how
building interventions alone will not produce a success-
thoughts of defining what others should do can affect
ful outcome. During the assessment phase of treat-
the outcome of anger-provoking situations. Patients
ment, referrals are made for prerequisite or concurrent
are asked to use the affirmation, I will not should on
intervention for identified outstanding contributing
others or myself today when confronted with conflict-
issues that may interfere with treatment success.
ing situations. The outcomes are to be discussed in the
Additionally, prospective participants are required
next group sessions.
to identify a treatment goal. A goal is a necessary
agreement for successful treatment (Beck, 1995). The
Resentment participants goal is listed as a quoted statement in the
intake note and on the Anger Management Self-
Resentment is based on stored anger. Powell (1992) Assessment Scale (AMSAS). This tool (Figure 1) incor-
referred to resentment as old baggage. This old anger porates the program concepts and was developed by
prevents one from enjoying the present. Many times the author so program participants could monitor their
the person who has difficulty with anger management progress while in treatment. An item on the AMSAS
feels justified in holding onto his or her anger. Partici- represents each of the 12 group concepts. The items
pants are encouraged to ask themselves, Would I have a Likert-type scale of 1 to 10, with 1 = never and
rather be right or happy? Participants can begin to re- 10 = always. Participants can track any changes in
solve some feelings of resentment by writing letters or their ratings. Participants are asked to rate themselves
poems or arranging face-to-face encounters, when pos- prior to the first group session, 4 weeks into the pro-
sible. Role-play can be a useful tool. Participants also gram, and again within 2 weeks of completing the pro-
benefit from the use of imagery to do resentment work. gram. This self-rating process becomes the partici-
During the group session, the concept of resentment is pants skill-building marker. Participants must be able
discussed. Additionally, participants are asked to iden- to conceptualize and have the potential to gain insight
tify a resentment and answer the following: (a) If I hold from program participation. Thus, prospective pro-
on to this resentment, who will this hurt the most? (b) gram participants who are acutely psychotic, manic, ac-
Who still cares that I am holding on to this resentment? tively abusing alcohol or other substances, severely de-

20 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1


Anger Management

Name______________________________________ This is my 1st, 2nd, 3rd Rating (Circle One)

Directions: Circle the number that best describes your response.


1. I am able to accept the opinion of others without interrupting.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
2. I can get angry without thinking my anger is bad.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
3. I can get angry without blaming others for my anger.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
4. When I get angry, I know where I feel my anger in my body.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
5. I use relaxation techniques to help me manage my anger.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
6. When I get angry, I am able to identify the feeling I have underneath the anger, for example, fear, hurt, disappointment.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
7. When I get angry, I can express it in a respectful way.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
8. When I get angry, I can use positive thoughts to help me through my anger.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
9. I use physical exercise to help me manage my anger.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
10. I feel good about myself.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
11. I get angry when people dont do what I think they should do.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
12. When I get angry, I hold on to my anger.
Never Hardly Ever Sometimes Always
0 1 2 3 4 5 6 7 8 9 10
My treatment goal is: (Only fill in goal the first time you complete this assessment)
______________________________________________________________________________________
Since starting the program, I have made:
No progress Very Little Progress Some Progress Very Much Progress
0 1 2 3 4 5 6 7 8 9 10
The most important thing I have learned: ___________________________________________________________________________________

The thing that was of no help to me at all: __________________________________________________________________________________


FIGURE 1. A. nger Management Self-Assessment Scale. Anger Management Self-Assessment Scale by B. Dunbar. Used
with permission of the author.

pressed, or who have moderate to severe traumatic THE GROUP


brain injuries will not benefit from treatment. Also,
those who have medical conditions that prevent them The group is most manageable with 9 to 15 partici-
from participating in a 1-hour weekly group are not ad- pants. Participants who are both voluntary and court
mitted to the program. Appropriate referrals should be ordered can benefit from program involvement. The
made for any prospective participant who is not ac- anger management program is designed to present the
cepted into treatment. Additionally, domestic violence 12 concepts over a 16-week period.
perpetrators should be referred to domestic violence Some participants enter an anger management
treatment. treatment program in an attempt to validate their be-

Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1 21


Dunbar

lief that the program will not work for them. Therefore, cess. Participants are referred to individual therapy for
participants benefit if the facilitator ensures inclusion more deep-seated issues.
during each session. It is helpful to ask each participant Some participants exhibit a need for individual ther-
to express his or her thoughts about the session mate- apy to address complex issues such as trauma, resent-
rial and to avoid the appearance of one-way communi- ment, or depression. If this was not manifested in the
cation from instructor to participant. Participant assessment phase of treatment, it is addressed as the
questions and comments are strongly encouraged. need becomes evident to the facilitator. Only a small
The first session of the program begins with a dis- number of participants will need to end anger manage-
cussion of open-mindedness and a definition of anger ment treatment until individual issues can be
that is a composite of the facilitators and participants addressed.
input. One concept is discussed each week, with the ex- Each participant is seen for a 20-minute session ev-
ception of assertiveness and self-esteem. Assertiveness ery 4 weeks to review progress and follow-up on any re-
is discussed in a 3-week format that explores passive, ferrals. This is not to be considered an individual ther-
indirect, and aggressive anger styles and basic asser- apy session.
tive rights, and uses role-play. Self-esteem is discussed Group exercises are used to enhance the partici-
over a 2-week period. The concepts are presented each pants understanding of a particular concept. For ex-
week in the order discussed in this article. Each concept ample, a writing exercise is used when discussing
is linked to the next. shoulds. Participants list their top three personal val-
ues, and one participant may list family, attending
Each group meets for 1 hour weekly and integrates
church, and being on time. A discussion may include
components of psycho-education and cognitive behav-
how ones values can become a list of destructive
ioral therapy. The first half of the group is dedicated to
shoulds that can be the source of anger when others
a review of the previous weeks concept and a discus-
choose to respond to their own should list. At the end of
sion of the homework assignment. During the first part
the group, the facilitator leads the group in a discussion
of the group session, participants are encouraged to that recaps the high points. The group ends when the
share real-life experiences as part of their homework. facilitator gives homework, which is based on the con-
Others in the group offer their thoughts and feelings cept discussed. Homework is always a practical
about the shared experience. The second half of the experience.
group is used to discuss the next concept. This may be
accomplished with exercises written and/or in active THE FACILITATOR
participation format. Again, participants are encour-
aged to share personal experiences during this phase of The facilitator must be aware of his or her own anger
the group. At the end of the second half of the group, (Levin & Spauster, 1994) and avoid treating anger as
homework is explained and questions about the assign- positive or negative. It is not helpful for patients to be
ment are encouraged. Participants questions are treated as naughty school children who need to learn to
invited and addressed throughout the entire fast-paced be good. Modeling of healthy anger management is a
session. necessary facilitator characteristic. If the facilitator
The seating is arranged so that all participants can has a tendency to deny, misdirect, or spew anger, this
see each other. The group has an open-ended format. may encourage participants to continue with such inef-
An open-ended format affords participants an opportu- fective approaches. Participants must sense the facili-
nity to enter the program at any point. A major advan- tator is not frightened of his or her anger and will lead a
tage of an open-ended format is that participants al- therapeutic session that is safe. A psychiatric ad-
ready in the program offer newer attendees valuable vanced-practice registered nurse certainly has the skill
feedback, model healthy anger management, and dem- set to serve as a facilitator for an anger management
onstrate the progress they can expect to make. Another group.
advantage is that there is no waiting list for prospec- Because those who have anger management diffi-
tive participants. Although one concept leads into an- culties often take themselves and others too seriously,
other, most participants say they feel on target in about it is helpful for the facilitator to model the use of hu-
3 weeks, even when they may not get the first concepts mor in the healthy management of anger-provoking
in the 16-week cycle for several weeks. The group pro- situations, when appropriate. A nonjudgmental ap-
cess is limited to helping the participant gain insight proach, wherein the facilitator periodically assesses
into how his or her behavior related to anger manage- his or her own personal attitude, motives, and limita-
ment is ineffective or interferes with the learning pro- tions will lend itself to the most therapeutic interven-

22 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 1


Anger Management

tion. Each participant brings a set of talents and tools develop their own specific treatment goal, think
to treatment. It is the facilitators role to help partici- through anger-provoking situations, and monitor their
pants learn to enhance the skills they bring to treat- own success. Each success improves the participants
ment in order to achieve what they want from self-esteem level.
treatment.
The facilitator is challenged to keep monopolization REFERENCES
and disruption of sessions at a minimum. He or she
needs to be able to address disruptive occurrences with Beck, J. S. (1995). Cognitive behavioral therapy: Basics and beyond.
firmness and respect and solicit the help of the group New York: Guilford.
when appropriate. Participants usually respond with Bilodeau, L. (1992). The anger management workbook. Minneapolis,
MN: Hazelden Educational Materials Center.
respect when treated with respect. The facilitators re-
Deffenbacher, J., Filetti, L., Rebekah, S., Lynch, E., Dahlen, E., &
spectful approach will nurture and support patients ef- Oetting, E. (2002). Cognitive-behavioral treatment of high anger
forts to become participants in their treatment. drivers. Behavior Research and Therapy, 40, 895-910.
Dyer, I. (2000). Cognitive behavioral group anger management for
OUTCOMES/EVALUATION outpatients: A retrospective study. International Journal of Psy-
chiatric Nursing Research, 5, 602-621.
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training into a self-help drug treatment program. Psychotherapy,
over a 12-year period. It began as an assertiveness 30, 214-221.
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sessment was done. Participants had no formal means Citadel Press Books.
of self-monitoring. As participant needs were identi- Gerlock, A. (1994). Veterans response to anger management inter-
fied, the program evolved. vention. Issues in Mental Health Nursing, 15, 393-408.
Most participants (98%) have been male. Partici- Gottlieb, M. (1999). The angry self: A comprehensive approach to an-
ger management. Phoenix, AZ: Zeig, Tucker, & Co.
pant completion rates improved from a less-than-15%
Grogan, G. (1991). Anger management: Clinical applications for occu-
completion rate (2000) to a greater than 50% comple- pational therapy. Occupational Therapy in Mental Health, 11,
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healthy anger management style begins to replace in- cognitive techniques for assessing, improving and maintaining
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Powell, T. (1992). Mental health handbook. Bicester, UK: Winslow.
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Schmidt, T. (1993). Anger management and violence prevention. Min-
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The program can be used by the psychiatric
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HarperCollins.
tive behavioral approach encourages participants to

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