Anger Management, a Neglected Topic in Substance Abuse Intervention

A long standing issue

Problems managing anger have always been a concern for patients suffering from addictive disorders. Pioneering research by my mentor, Dr. Sidney Cohen, at the UCLA Neuro-psychiatric Institute demonstrated the relationship between, anger, violence and the use of alcohol and/or cocaine. One of the most popular articles written by Dr. Cohen was entitled, “Alcohol, the most dangerous drug known to man”. In this and other publications, Dr. Cohen systematically demonstrated the causal relationship between cocaine and alcohol abuse and aggression. Much of this research was done in the 70s and 80s.

Anger has always been a factor in substance abuse intervention. Unfortunately, until recently, it has been overlooked or treated as an after thought by substance abuse programs nationwide. Substance use and abuse often coexist with anger, aggressive behavior and person-directed violence. Data from the Substance Abuse and Mental Health Administration’s National Household Survey on Drug Abuse indicated that 40 % of frequent cocaine users reported engaging in some form of violence or aggressive behavior. Anger and aggression often can have a causal role in the initiation of drug and alcohol use and can also be a consequence associated with substance abuse. Persons who experience traumatic events, for example, often experience anger and act violently, as well as abuse drugs or alcohol. This is currently occurring with recently returned combat veterans from Iraq.

ANGER AND SUBSTANCE ABUSE

Substance abuse and dependence has grown beyond even the bleakest predictions of the past. In the United States alone, there are an estimated 23 million people who are struggling (on a daily basis) with some form of substance abuse or dependence. The toll it is having on our society is dramatically increased when we factor in the number of families who suffer the consequences of living with a person with an addiction, such as:

• Job loss
• Incarceration
• Loss of child Custody
• DUI's
• Domestic Violence/Aggression
• Marital problems/divorce
• Accidents/injuries
• Financial problems
• Depression/anxiety/chronic anger

Unfortunately, most substance abusers may not even be aware that they have an underlying anger problem and do not "connect" their anger problem to their alcoholism, drug addiction and substance abuse. Therefore, they do not seek (or get) help for their anger problem. But more often than not, their anger is the underlying source of their disorder.

Anger precedes the use of cocaine and alcohol for many alcohol and cocaine dependent individuals. Anger is an emotional and mental form of "suffering" that occurs whenever our desires and expectations of life, others or self are thwarted or unfulfilled. Addictive behavior and substance abuse is an addict's way of relieving themselves of the agony of their anger by "numbing" themselves with drugs, alcohol and so on. This is not "managing their anger", but self medication.

When we do not know how to manage our anger appropriately, we try to keep the anger inside ourselves. Over time, it festers and often gives rise to even more painful emotions, such as depression and anxiety. Thus, the individual has now created an additional problem for themselves besides their substance abuse, and must be treated with an additional disorder. Several clinical studies have demonstrated that anger management intervention for individuals with substance abuse problems is very effective in reducing, or altogether, eliminating a relapse.

Medical research has found that alcohol, cocaine and methamphetamine dependence are medical diseases associated with biochemical changes in the brain. Traditional treatment approaches for drug and alcohol dependency focus mainly on group therapy and cognitive behavior modification, which very often does not deal with either the anger or the "physiological" components underlying the addictive behavior.

Anger precedes the use of cocaine for many cocaine-dependent individuals; thus, cocaine-dependent individuals who experience frequent and intense episodes of anger may be more likely to relapse to cocaine use than individuals who can control their anger effectively. Several clinical trials have demonstrated that cognitive-behavioral interventions for the treatment of mood and anxiety disorders can be used to help individuals with anger control problems reduce the frequency and intensity with which they experience anger. Although studies have indirectly examined anger management group treatments in populations with a high prevalence of substance abuse, few studies have directly examined the efficacy of an anger management treatment for cocaine-dependent individuals. A number of studies demonstrating the effectiveness of an anger management treatment in a sample of participants who had a primary diagnosis of post-traumatic stress disorder have been conducted by the Department of Veterans Affairs. Although many participants in these studies had a history of drug or alcohol dependence, the sample was not selected based on inclusion criteria for a substance dependence disorder, such as cocaine dependence. Considering the possible mediating role of anger for substance abuse, a study examining the efficacy of anger management treatment in a sample of cocaine-dependent patients would be informative.

Anger management as an after thought

In spite of the information available to all professional substance abuse treatment providers, anger management has not received the attention which is deserved and needed for successful substance abuse treatment. Many, if not most, substance abuse programs claim to offer anger management as one of the topics in its treatment, yet few substance abuse counseling programs include anger certification for these counselors.

Typically, new substance abuse counselors are simply told that they will need to teach a certain number of hours or sessions on anger management, and then they are left to find their own anger management information and teaching material. These counselors tend to piece together whatever they can find and present it as anger management.

Despite the connection of anger and violence to substance abuse, few substance abuse providers have attempted to either connect the two or provide intervention for both. In the Los Angeles area, a number of primarily upscale residential rehab programs for drug and alcohol treatment have contracted with Certified Anger Management Providers to offer anger management either in groups on an individual basis for inpatient substance abuse clients. Malibu based Promises (which caters to the stars) has contracted with Certified Providers to offer anger management on an individual coaching basis.

It may also be of interest to note that SAMSHA has published an excellent client workbook along with teacher’s manual entitled, Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual [and] Participant Workbook.

This publication is free and any program can order as many copies as needed without cost. There is simply no excuse for shortchanging substance abuse clients by not providing real anger management classes.

Limited anger management research

What has been offered as anger management in substance abuse programs has lacked integrity. The Canadian Bureau of Prisons has conducted a 15 year longitudinal study on the effectiveness of anger management classes for incarcerated defendants whose original crime included substance abuse, aggression and violence. One of the first findings was that in order to be useful, the anger management model used must have integrity. Integrity is defined as using a client workbook containing all of the material needed for an anger management class, consistency among trainers in terms of how the material is taught, and a pre and post testto document change made by clients who complete the class.
It is not possible to determine the effectiveness of anger management, which is fragmented and not based on any particular structure of theoretical base.

Anger management training is rarely integrated into substance abuse treatment

At the present time, anger management is rarely integrated into any model of substance abuse intervention. Rather, it is simply filler tacked on to a standard twelve step program.

Trends in anger management and substance abuse treatment.

Several years ago, the California state legislature established statewide guidelines for all state and locally supported substance abuse programs. This legislation is included in what is commonly referred to as proposition 36. As a result of this legislation, all substance abuse counselors must have documented training in anger management facilitator certification. This training requires 40 hours of core training plus 16 hours of continuing anger management education on a yearly basis.

What is Anger Management?

Anger management is rapidly becoming the most requested intervention in human services. It may be worthwhile to define what anger management is and is not. According to the American Psychiatric Association, anger is a normal human emotion. It is not a pathological condition; therefore, it is not listed as a defined illness in the Diagnostic and Statistical Manual of Nervous and Mental Disorders. Rather, anger is considered a lifestyle issue. This means that psychotherapy or psychotropic medication is not an appropriate intervention for teaching skills for managing anger.

The American Association of Anger Management Providers defines anger management as a skill enhancement course which teaches skills in recognizing and managing anger, stress, assertive communication and emotional intelligence. Anger is seen as a normal human emotion, which is a problem when it occurs too frequently, lasts too long, is too intense, is harmful to self or others, or leads to person or property directed aggression.

The Anderson & Anderson anger management curriculum is currently the most widely used model of anger management in the world. This model includes an assessment at intake which is designed to determine the client’s level of functioning in the following four areas: anger, stress, communication and emotional intelligence. The intervention/classes, which are provided, teach skills in these four areas. Post tests are administered after course completion to determine the success or lack thereof of the program.

In Summary

All anger management programs should conduct an assessment at intake for substance abuse and psychopathology and all substance abuse programs should assess all participants for the current level of functioning in recognizing anger, stress, assertive communication and emotional intelligence.
All substance abuse programs should have their intervention staff certified in anger management facilitation.
Guidelines should be established to determine the number of hours/sessions that each client will receive in teaching skill enhancement in anger management, stress management, communication and emotional intelligence.

George Anderson, MSW, BCD, CAMF
www.andersonservices.com
www.aaamp.org
www.anger-management-resources.org