| SHORT-TERM OBJECTIVES | THERAPEUTIC INTERVENTIONS |
| Work cooperatively with the therapist toward agreed-upon therapeutic goals while being as open and honest as comfort and trust allow. (1, 2) | Establish rapport with the client toward building a strong therapeutic alliance; convey caring, support, warmth, and empathy; provide nonjudgmental support and develop a level of trust with the client toward his/her/their feeling safe to discuss his/her/their anger control issues and their impact on his/her/their life. |
| | Strengthen powerful relationship factors within the therapy process and foster the therapy alliance through paying special attention to these empirically supported factors: work collaboratively with the client in the treatment process; reach agreement on the goals and expectations of therapy; demonstrate consistent empathy toward the client's feelings and struggles; verbalize positive regard toward and affirmation of the client; and collect and deliver client feedback as to the client's perception of his/her/their progress in therapy (see Psychotherapy Relationships That Work: Vol. 1 by Norcross & Lambert and Psychotherapy Relationships That Work: Vol. 2 by Norcross & Wampold). |
| Identify situations, thoughts, and feelings associated with anger, angry verbal, and/or behavioral actions, and the targets of those actions. (3) | Thoroughly assess the various stimuli (e.g. situations, people, thoughts) that have triggered the client's anger and the thoughts, feelings, and actions that have characterized his/her/their anger responses. |
| Complete psychological testing or objective questionnaires for assessing anger expression. (4) | Administer to the client psychometric instruments designed to objectively assess anger expression (e.g. Anger, Irritability, and Assault Questionnaire, Buss-Durkee Hostility Inventory; State-Trait Anger Expression Inventory); give the client feedback regarding the results of the assessment; readminister as indicated to assess treatment response. |
| Cooperate with a complete medical evaluation. (5) | Arrange for a medical evaluation to rule out nonpsychiatric medical and substance-induced etiologies for poorly controlled anger (e.g. brain injury, tumor, elevated testosterone levels, stimulant use). |
| Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (6, 7, 8, 9) | Assess the client's level of insight (syntonic versus dystonic) toward the presenting problems (e.g. demonstrates good insight into the problematic nature of the described behavior, agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the problem described and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the problem described, is not concerned, and has no motivation to change). |
| | Assess the client for evidence of research-based correlated disorders (e.g. oppositional defiant behavior with attention-deficit/hyperactivity disorder [ADHD], depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g. increased suicide risk when comorbid depression is evident). |
| | Assess for any issues of age, gender, or culture that could help explain the client's currently defined problem behavior and factors that could offer a better understanding of the client's behavior. |
| | Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g. the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g. the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment). |
| Explore the consequences of anger, motivation and willingness to participate in treatment, and agree to participate to learn new ways to think about and manage anger. (10, 11, 12) | As part of exploring the client's decisional balance to engage in treatment, assist the client in identifying the positive consequences of managing anger (e.g. respect from others and self, cooperation from others, improved physical health, etc.) or supplement with “Alternatives to Destructive Anger” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce. |
| | As part of exploring the client's decisional balance to engage in treatment, ask the client to list and discuss ways anger has negatively affected his/her/their daily life (e.g. hurting others or self, legal conflicts, loss of respect from self and others, destruction of property); process this list. |
| | Use motivational interviewing techniques toward clarify the client stage of change, moving the client toward the action stage in which he/she/they agree to take specific actions to more effectively conceptualize and manage anger (see Motivational Interviewing by Miller & Rollnick). |
| Verbalize an understanding of how angry thoughts and feelings can lead to increased risk of addiction. (13, 14) | Use guided discovery (e.g. Socratic questioning) to educate the client about his/her/their tendency to engage in addictive behavior as a means of relieving uncomfortable feelings; develop a list of several instances of occurrence. |
| | Teach the client about high-risk triggers of substance use including strong negative emotions, social pressure, interpersonal conflict, strong positive emotions, and other stressors; discuss examples of how triggers can lead to substance use, the consequences of this pattern, and the availability of alternatives in preventing and managing the risk. |
| Agree to learn new alternative ways to recognize and manage anger. (15) | Confirm with the client that he/she/they agree to try to learn new ways to recognize and manage anger. |
| Cooperate with a medication evaluation for possible treatment with psychotropic medications to assist in anger control; take medications consistently, if prescribed. (16, 17) | Assess the client for the need and willingness to take psychotropic medication to assist in control of anger; refer him/her/them to a prescriber for an evaluation and prescription of medication, if needed. |
| | Monitor the client's psychotropic medication adherence, side effects, and effectiveness; confer as indicated with the prescriber. |
| Keep a daily journal of persons, situations, and other triggers of anger; record thoughts, feelings, and actions taken or not. (18, 19) | Ask the client to self-monitor, keeping a daily journal in which he/she/they document persons, situations, thoughts, feelings, and actions associated with moments of anger, irritation, or disappointment (or supplement with “Anger Journal” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); routinely process the journal toward helping the client understand his/her/their contributions to generating his/her/their anger. |
| | Assist the client in generating a list of anger triggers (or supplement with “Is My Anger Due to Feeling Threatened?” or “Is My Anger Due to Unmet Expectations?” in the Addiction Treatment Homework Planner by Lenz, Finley, & Jongsma); process the list toward helping the client understand the causes and expressions of his/her/their anger. |
| Verbalize increased awareness of anger expression patterns, their causes, and their consequences. (20, 21) | Convey a model of anger that involves different dimensions (cognitive, physiological, affective, and behavioral) that interact predictably (e.g. demanding expectations not being met leading to increased arousal and anger leading to aggression), and that can be understood and changed (see Anger Management by Kassinove & Tafrate; Overcoming Situational and General Anger by Deffenbacher & McKay). |
| | Process the client's list of anger triggers and other relevant journal information toward helping the client understand how cognitive, physiological, and affective factors interplay to produce anger and lead to increased risk of maladaptive behavioral consequences (e.g. verbal and/or physical aggression, unassertiveness and resentment, or passive aggression). |
| Verbalize an understanding of how the treatment is designed to prevent or manage anger, enhance functioning, and improve quality of life. (22) | Discuss the rationale for treatment, emphasizing how functioning can be improved through change in the various dimensions of anger; revisit relevant themes throughout therapy to help the client consolidate his/her/their understanding (see Overcoming Situational and General Anger: Therapist Protocol by Deffenbacher & McKay; Anger Management by Kassinove & Tafrate; Understanding Anger and Anger Disorders by DiGiuseppe & Tafrate). |
| Read a book or treatment manual that supplements the therapy by improving understanding of anger and anger control problems. (23) | Assign the client to read material that educates him/her/them about anger and its management (e.g. Overcoming Situational and General Anger: Client Manual by Deffenbacher & McKay, Of Course You're Angry by Rosselini & Worden, The Anger Control Workbook by McKay & Rogers, or Anger Management for Everyone by Kassinove & Tafrate); process and revisit relevant themes throughout therapy to help the client consolidate his/her/their understanding of relevant concepts. |
| Learn and implement calming and coping strategies as part of an overall approach to managing anger. (24) | As part of a larger personal and interpersonal skill set, teach the client tailored calming techniques (e.g. progressive muscle relaxation, breathing induced relaxation, calming imagery, cue-controlled relaxation, applied relaxation, mindful breathing) for reducing chronic and acute arousal that accompanies his/her/their anger expression (or supplement with “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Identify, challenge, and replace anger-inducing self-talk with self-talk that facilitates a more measured response. (25, 26, 27) | Use cognitive therapy techniques to explore the client's self-talk that mediates his/her/their angry feelings and actions (e.g. demanding expectations reflected in should, must, or have-to statements); identify, challenge, and change biased self-talk, assist him/her/them in generating appraisals that correct for the biases and facilitate a more flexible and temperate response to frustration; explore underlying assumptions and schema if needed. Combine new self-talk with calming skills as part of a coping skills set for managing anger. |
| | Assign the client a homework exercise in which he/she/they identify angry self-talk and generate alternatives that help regulate angry reactions; review; reinforce success, problem-solve obstacles toward sustained and effective implementation (or supplement with “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| | Role-play the use of calming and cognitive coping skills to visualized anger-provoking scenes, moving from low- to high-anger scenes. Assign the implementation of calming and cognitive techniques in his/her/their daily life and when facing anger-triggering situations; process the results, reinforcing success, and problem-solving obstacles. |
| Learn and implement thought-stopping as part of a new approach to managing angry feelings when they arise. (28) | As the initial part of a multicomponent coping strategy for controlling impulverbalsivity (e.g. “stop, calm, think, and act” approach), teach a thought-stopping technique in which the client silently “shouts” the word STOP upon recognizing the first signs of anger and then proceeds to the other management steps (i.e. calming, thinking) toward responding in an adaptive, effective manner (or supplement with “Making Use of the Thought-Stopping Technique” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); review implementation, reinforcing success, and problem-solving obstacles. |
| Learn and implement assertive communication skills for addressing frustration and anger in an honest, appropriate, respectful, and direct manner. (29) | Use skills-training interventions (e.g. instruction, modeling, role-playing, rehearsal, and practice) to help the client learn and implement assertive communication, highlighting its distinctive elements as well as the pros and cons of assertive, unassertive (passive), and aggressive communication (or supplement with Your Perfect Right by Alberti & Emmons or with “Assertive Communication of Anger” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Learn and implement problem-solving/solution-finding skills and/or conflict resolution skills to address personal and interpersonal problems. (30, 31, 32) | Use skills-training interventions (e.g. instruction, modeling, role-playing, rehearsal, and practice) to help the client learn and implement problem-solving/solution-finding skills (e.g., defining the problem clearly, brainstorming multiple solutions, listing the pros and cons of each solution, seeking input from others, selecting and implementing a plan of action, evaluating the outcome, and readjusting the plan as necessary), or supplement with “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce. |
| | Use skills-training interventions (e.g. instruction, modeling, role-playing, rehearsal, and practice) to help the client learn and implement conflict resolution skills (e.g., empathy, active listening, “I messages,” respectful communication, assertiveness without aggression, problem solving, compromise). |
| | Conduct conjoint sessions to help the client implement new personal and interpersonal skills (e.g. assertion, problem solving, and/or conflict resolution skills) with his/her/their significant other (or supplement with “Applying Problem Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce). |
| Combine learned anger management skills into a new approach to handling frustration. (33). | Assist the client in adopting a client-tailored strategy for managing anger that combines any of the somatic, cognitive, communication, problem-solving, and/or conflict resolution skills relevant to their needs. |
| Practice using new anger management skills in session with the therapist and during homework exercises. (34, 35). | Select situations in which the client will be increasingly challenged to apply his/her/their new strategies for managing anger; create a hierarchy to guide practice of these situations. |
| | Use any of several techniques, including relaxation, imagery, behavioral rehearsal, modeling, role-playing, or in vivo exposure/behavioral experiments to help the client consolidate and generalize the use of his/her/their new anger management skills into daily life. |
| Decrease the number, intensity, and duration of angry outbursts, while increasing the use of new skills for preventing or managing anger. (36) | Monitor the client's reports of anger episodes toward the goal of decreasing their frequency and increasing adaptive management through the client's use of new anger management skills (or supplement with “Alternatives to Destructive Anger” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); review progress, reinforcing success, and providing supportive corrective feedback toward sustained improvement. |
| Learn and implement relapse prevention strategies. (37, 38, 39, 40, 41) | Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible angry outburst and relapse with the choice to return routinely to his/her/their old pattern of anger. |
| | Identify and rehearse with the client the management of future situations or circumstances in which lapses back into maladaptive anger could occur. |
| | Instruct the client to routinely use new anger management strategies learned in therapy (e.g. calming, adaptive self-talk, assertion, and/or conflict resolution) to prevent or respond to frustrations. |
| | Develop a “coping card” or other reminder on which new anger management skills and other important information (e.g. “Recognize moments to stop, think, and act,” “Calm yourself,” “Be flexible in your expectations,” “Voice your opinion calmly,” “Respect others' points of view”) are recorded for the client's later use. |
| | Schedule periodic “maintenance sessions” to help the client maintain therapeutic gains. |
| Identify social supports that will help facilitate the implementation of anger management skills. (42) | Encourage the client to discuss his/her/their anger management goals with trusted persons who are likely to support his/her/their change. |
| Participate in Acceptance and Commitment Therapy (ACT) for learning a new approach to anger and anger management. (43, 44, 45, 46) | Use an ACT approach to help the client experience and accept the presence of anger-invoking thoughts and images without allowing them to change the client's commitment to value-driven action; reinforce the client's efforts toward engaging in activities that are consistent with identified, personally meaningful values (see Acceptance and Commitment Therapy by Hayes, Strosahl, & Wilson). |
| | Teach mindfulness meditation to help the client recognize the negative thought processes associated with anger and change his/her/their relationship with these thoughts by accepting thoughts, images, and impulses that are reality-based while noticing but not reacting to non-reality-based mental phenomena (see Guided Mindfulness Meditation [Audio CD] by Kabat-Zinn). |
| | Assign the client homework in which he/she/they practice lessons from mindfulness meditation and ACT in order to consolidate the approach into everyday life. |
| | Assign the client reading consistent with the mindfulness and ACT approach to supplement work done in session (see Get out of Your Mind and into Your Life: The New Acceptance and Commitment Therapy by Hayes). |
| Gain insight into the origins of current anger control problems by discussing experiences that may be involved in their development. (47, 48) | Assist the client in identifying past relationship dynamics (e.g. with father, mother, others) that may have influenced the development of current anger control problems; discuss how these experiences have positively or negatively influenced the way he/she/they handle anger. |
| Verbalize an understanding of how anger has been reinforced as a coping mechanism for stress. (48) | Teach the client how anger blocks the awareness of pain, discharges uncomfortable feelings, erases guilt, and places the blame for problems on others. |
| Verbalize an understanding of the need for and process of forgiving others to reduce anger. (49) | Assist the client in identifying whom he/she/they need to forgive, and educate him/her/them as to the long-term process that is involved in forgiveness versus a magical single event; recommend reading books on forgiveness (e.g. Forgive and Forget by Smedes); review the client's progress, reinforce success, and assess its impact on anger reduction. |
| Verbalize an understanding of the concept of a higher power and the benefits of acceptance of such a concept. (50) | Teach the client about the 12-step recovery program concept of a higher power, and how to turn over perpetrators of pain to his/her/their higher power for judgment. |
| Implement regular physical exercise to reduce tension. (51) | Teach the client the benefits of regular physical exercise; assign a program of implementation. |
| Attend 12-step recovery group meetings regularly and share feelings with others there. (52) | Teach the client the importance of actively attending 12-step recovery meetings, getting a sponsor, reinforcing people around him/her/them, and sharing feelings. |
| Develop a long-term plan to recover from substance abuse and anger. (53) | Assist the client in developing a five-year personal recovery plan. |
