Scientifically Supported Anger Management
Empirically Based Anger Management Groups
Empirically based medicine has become more common in the vernacular of treating physicians in recent years. Likewise, empirically supported treatments have been favored by scientifically minded psychologists for almost two decades.
Barriers to the Scientific Study of Anger Management
Treating anger has presented somewhat of a challenge to the therapeutic communities, but perhaps not in the ways one might think. There have been a few challenges.
Anger is not a discrete diagnosis. This hampers evaluating efficacy in a programmatic way. Without a DSM IV-TR diagnosis it is more difficult to receive funding for treatment outcome studies. It also creates confusion around what specifically constitutes an anger problem, i.e., what symptoms at what intensity creating what kinds of impairment can be considered as disordered behavior in need of treatment. Additionally, efficacy studies typically require participants to have a single diagnosis in common, and be free of any comorbidities. Anger problems are frequently accompanied by numerous other Axis 1 and Axis 2 disorders.
Making Anger Management Affordable- In-Network Insurance Coverage
Another practical and perhaps the most significant barrier to treatment is that without anger as a DSM IV-TR based disorder, third party reimbursement may not be possible. Therefore, although anger is associated with some of the most critical threats to public health, e.g., school shootings, domestic violence, sexual assault, substance abuse, and child abuse, many individuals may not enter treatment due to their insurance plans not paying for treatment. Regardless of the carrier, e.g., AETNA, Oxford, United Healthcare, GHI, etc., the optional riders, or whether the plan allows for out-of-network coverage for mental health or behavioral health, at the time of this manuscript, the author is unaware of any plan that would cover (even in part) treatment of any individual presenting with anger problems as the exclusive reason for seeking treatment.
There are also numerous theoretical disagreements about the etiology of anger and its treatment. For example, one conceptualization of depression by Freud viewed depression as anger toward inward. Therefore, some anger “expression” can be viewed as therapeutic by some clinicians, while others view it as problematic. Treatment of anger in the field has also historically been replete with disagreements as to the approach. Despite the scientific literature being more monolithic. Therapies have included yelling, hitting objects with pillows, and other types of cathartic behaviors “to get it out.”
Anger Treatments that Work
Although anger has not been studied as an emotion, disorder, or public health issue to the extent of anxiety and mood disorders, the treatment literature offers hope for those suffering with problematic anger. Skills training, Cognitive Interventions, and combined interventions have demonstrated again and again that those who complete treatment frequently report a decrease in anger related distress and aggressive behaviors, both verbal and physical.
Anger Treatment Mode
The most common (almost exclusively) form of anger management treatment is anger management group therapy. Anger groups typically meet for eight to 16 sessions. Group membership consists of anywhere from six to 10 members. There is a great deal of psychoeducation and there is didactic skills training in session, as well as homework given to be completed by the next session. Studies have even indicated a reduction in mood disorder and other symptoms for participants attending the programs just for anger management.
Anger Management Group Feasibility
When group therapy proves to be effective, and the space and other logistical factors are not obstacles, there are many reasons why it may be preferable to individual therapy. One or two clinicians can service higher numbers of clients in the same duration of time. From a financial standpoint, since more clients can receive treatment with the same amount of clinical coverage, fees can often be reduced, which may allow a greater number of those in need to afford treatment.
High Prevalence of Anger Symptoms Coupled with Low Prevalence of Competent and Willing Psychotherapists
Although a single diagnosis does not exist in the DSM IV-TR, that has no impact on the prevalence of symptoms. According to scientific surveys, psychotherapists report treating clients with anger problems at commensurate rates as those with anxiety issues (approximately 2% of the population at any one time). Many clinicians also share their discomfort in treating angry clients, likely due to limited training given anger’s status in the scientific literature, and perhaps also due to anxiety around anger sequelae. Therefore large numbers of those seeking treatment exhibit symptoms, but few psychotherapists may be equipped or willing to provide anger management services. In addition, cultural notions of anger and even aggression, may be neutral or positive. Especially for men, anger expressions and even physical aggression are not only considered healthy, but may be associated with values like honor, virility, and manhood generally. Therefore, many individuals (especially men) may not seek treatment for anger and aggression, which they view as normal or even optimal functioning.
Detrimental Effects of Anger
Although the psychiatric community may not have reached a consensus regarding the need for an anger diagnosis that fits the most common syndromes observed by those seeking outpatient psychotherapy services for anger, there is plenty of evidence correlating anger with pernicious effects on the individual, couple, family, and community. Anger problems and some overlap in symptomology have been linked to various psychological disorders including bipolar disorder, Borderline Personality Disorder, Post-traumatic Stress Disorder (PTSD), General Anxiety Disorder (GAD), Substance Abuse, and Substance Dependence, etc. It is reasonable to assume that some individuals may fall short of meeting the full criteria for one of these disorders, while still presenting with intense and harmful anger symptoms, which impair vocational, social, or academic functioning and/or result in significant distress. It is also correlated with a number of medical conditions including Gastrointestinal (GI) problems, stroke, cardiac arrest, hypertension, and cancer. It is also rarely absent in cases of physical aggression, certainly when the aggression is not legally or culturally sanctioned. Finally, it has also been found to be a predictor of suicide, a behavior that is very difficult to predict despite the level of harm and permanence of the decision.
The Future of Anger Management
Given the level of harm associate with anger, large number of people in need of treatment, the efficacy of anger management treatments, the low numbers of those trained in those treatments, and the logistical and practical advantages of anger management in a group format, hopefully the field will take steps to address the diagnostic issues surrounding anger problems. An idealistic perspective would be that diagnostic developments would lead to more funding for treatment, increased inclusion of scientifically based anger management in graduate training of psychologists, social workers, and counselors, and increased dissemination for practicing clinicians.