Editing Anger management (section)

== Types of treatment ==

Anger treatments' success rates can be difficult to estimate because excessive, severe anger is not a recognized disorder in the ''[[Diagnostic and Statistical Manual of Mental Disorders]]''. This manual is used as a reference for mental health professionals. Some research does exist on comparing various treatments for anger, but they also describe methodological difficulties in making accurate comparisons. The best practice for anger treatment is to use multiple techniques rather than a single technique.<ref>{{cite book |author=Kassinove, H. |title=Anger, Aggression, & Interventions for Interpersonal Violence |publisher=Lawrence Erlbaum Associates |year=2007 |editor1=T. A. Cavell |location=Mahwah, NJ |pages=77–94 |contribution=Finding a useful model for the treatment of anger and aggression |editor2=K. T. Malcolm}}</ref> The relaxation approach had the highest success rate as a standalone treatment.<ref>{{cite journal |author1=Mayne, J. T. |author2=Ambrose, K. T. |name-list-style=amp |year=2009 |title=Research review on anger in psychotherapy |journal=Psychotherapy in Practice |volume=55 |issue=3 |pages=353–363 |doi=10.1002/(SICI)1097-4679(199903)55:3<353::AID-JCLP7>3.0.CO;2-B |pmid=10321749}}</ref> The effectiveness of the CBT-based anger management therapies has been evaluated by a number of [[meta-analyses]]. In a 1998 meta-analysis with 50 studies and 1640 individuals, measures of anger and aggression were used to compare the effects of the anger management intervention with no treatment. A significant effect for anger management was found with a 67% chance of improvement for individuals having received the anger management as compared to the individuals without the therapy.<ref name="Beck" /> In addition, a 2009 meta-analysis compared psychological treatments for anger across 96 studies. After an average of 8 sessions, a significant improvement in anger reduction resulted.<ref>{{cite journal |author=Saini, M. |year=2009 |title=A meta-analysis of the psychological treatment of anger: Developing guidelines for evidence-based practice |url=http://jaapl.org/content/37/4/473.long |journal=Journal of the American Academy of Psychiatry and the Law |volume=37 |issue=4 |pages=473–88 |pmid=20018996}}</ref> Overall, the completion of an anger management program is likely to result in long-lasting positive changes in behavior. Successful interventions can result in not only a reduction of the outward display of [[aggression]], but also a decrease in the internal level of anger.<ref>{{cite journal |author1=DiGiuseppe, R. |author2=Tafrate, R. C. |name-list-style=amp |year=2003 |title=Anger Treatment for Adults: A Meta-Analytic Review |journal=Clinical Psychology: Science and Practice |volume=10 |issue=1 |pages=70–84 |doi=10.1093/clipsy.10.1.70}}</ref>

Some effective anger management techniques include relaxation techniques, monitored breathing exercises, [[cognitive restructuring]] and [[guided imagery|imagery]] (e.g. Stosny's '''H'''ealing imagery '''E'''xplain oneself emphatically what and why it makes you respond angrily '''A'''pply kindness and compassion to self '''L'''ove oneself '''S'''olving the co-morbid problems phases<ref>{{cite web|url=https://www.psychologytoday.com/articles/200506/the-lion-tamer|title=The Lion Tamer|work=Psychology Today|first=Cecilia Capuzzi|last=Simon|date=July 1, 2005}}</ref>), problem solving, improving communication strategies and interpersonal skills ('''DEAR MAN''' & '''GIVE''').<ref>APA, apa.org 2013. ''Controlling anger before it controls you, [http://www.apa.org/topics/anger/control.aspx?item=4 Strategies To Keep Anger At Bay]'', part 4. Washington, DC: APA's Office of Publications and Databases</ref><ref>{{cite journal|url=http://www.srmhp.org/0302/anger.html|title=Nonspecific Factors and the Efficacy of Psychosocial Treatments for Anger|publisher=srmhp.org|date=2005|volume=3|number=2|first1=Bunmi O.|last1=Olatunji|first2=Jeffery M.|last2=Lohr|s2cid=26577683|journal=The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work}}</ref> 

=== Decreasing arousal ===
A 2024 [[meta-analysis]] of 154 studies found that anger management treatments that focus on decreasing [[arousal]] are effective in decreasing anger and [[aggression]]. These include [[Breathwork (New Age)|breathwork]], [[mindfulness]] and [[meditation]].<ref name=":2">{{Cite journal |last=Kjærvik |first=Sophie L. |last2=Bushman |first2=Brad J. |date=2024 |title=A meta-analytic review of anger management activities that increase or decrease arousal: What fuels or douses rage? |url=http://dx.doi.org/10.1016/j.cpr.2024.102414 |journal=Clinical Psychology Review |volume=109 |pages=102414 |doi=10.1016/j.cpr.2024.102414 |issn=0272-7358|doi-access=free }}</ref>

[[Relaxation therapy]] can reduce cognition and motivations to act out, and through relaxation, clients gain coping skills to better manage their anger. This therapy addresses various aspects of anger such as physiological, cognitive, behavioral, and social. These aspects combined are what make relaxation an effective treatment for anger.<ref name="Deffenbacher, L. J. 1999" /> [[Mindfulness-based stress reduction|Mindfulness]] attempts to teach clients acceptance of bodily sensations and emotions. Mindfulness originated in Eastern spiritual traditions that are practiced through meditation. A two-prong component of mindfulness includes: self-regulation and orientation toward the present moment. The center of this therapy technique is experiencing the present moment in a non-judgmental manner that is reflective of meditation. In practice, clients observe breathing, sitting and walking during meditations. The goal is for clients to understand that his or her thoughts of anger are merely thoughts rather than reality. Mindfulness is also a technique used in the relaxation approach because the technique halts physiological arousal.<ref name=":0" /> An example of this is ''Meditation on the Soles of the Feet (SoF)'' which has been shown to help persons with mild intellectual disability decrease aggressive behavior by mindfully focusing on the soles of their feet.<ref>Singh NN. (2020). "Implementation Science of Mindfulness in Intellectual and Developmental Disabilities." Am J Intellect Dev Disabil. 125 (5): 345–348. https://doi.org/10.1352/1944-7558-125.5.345</ref><ref>Singh NN, et al. (2013). "Mindfulness-Based Treatment of Aggression in Individuals with Mild Intellectual Disabilities: A Waiting List Control Study." Mindfulness volume 4, pages158–167. https://doi.org/10.1007/s12671-012-0180-8</ref><ref>Singh, N. N., Singh, J., Singh, A. D. A., Singh, A. N. A., & Winton, A. S. W. (2011). Meditation on the Soles of the Feet for anger management: A trainer's manual. Raleigh: Fernleaf. http://www.fernleafpub.com/Products.html</ref>

=== Catharsis ===
Following [[psychoanalytic theory]], there is a belief that expressing anger can reduce it through [[catharsis]]. A 2024 meta-analysis found no evidence for this hypothesis. Anger management interventions that increased arousal (such as hitting a bag, jogging or cycling) had no effect on anger and aggression.<ref name=":2" /> 

=== Prevention and Relationship Enhancement Program ===

The Prevention and Relationship Enhancement Program (PREP) is a program that was used in a study consisting of [[United States Air Force|Air Force]] families. The families were assigned to either a traditional multi-couple group format or a self-directed book version focusing on relationship satisfaction and anger management skills. There was a significant main effect for time related to both relationship satisfaction (pretest M = 49.8, SD = 17.6; post-test M = 53.8, SD = 17.6, F(1, 76) = 6.91, p < .01), and anger management skills, (pretest M = 32.2, SD = 4.2; post-test M = 34.6, SD = 4.0, F(1, 74) = 31.79, p < .001).<ref>{{Cite journal|author1=Anderson, J. R.|author2=Stith, S. M.|author3=Johnson, M. D.|author4=Strachman-Miller, M. M.|author5=Amanor-Boadu, Y.|author6=Linkh, D. J.|name-list-style=amp|year=2013|title=Multi-couple group and self-directed PREP formats enhance relationship satisfaction and improve anger management skills in Air Force couples|journal=American Journal of Family Therapy|volume=41|issue=2|pages=121–133|doi=10.1080/01926187.2012.671104|hdl=2097/15494|s2cid=56032423|hdl-access=free}}</ref>

The self-directed book version did not show as positive of results. Improving a couple's anger management skills can be a vital step in ensuring there are no violent outbreaks throughout the relationship.

=== Cognitive behavioral therapy ===

The use of [[cognitive behavioral therapy]] (CBT) is frequent in anger management treatment. By trying to get patients to open up about their emotions and feelings and being driven to accomplish a specific task (in this case controlling anger), a person is cognitively motivated to use positive skills towards their behavior.

Studies show using a mix of CBT as well as other therapies on the participants/clients increased the effective usage of the anger management techniques and that they also felt more in control of their own anger. Personal changes like these can lead to less aggression and fewer violent acts. The use of play therapy with this is also found efficient in tackling anger issues among children.<ref>{{cite web|url=http://www.lianalowenstein.com/anger_frey_edited.pdf|title=Creative Strategies for the Treatment of Anger|first=Diane E|last=Frey}}</ref>

[[Rational emotive behavior therapy]] explains anger through the client's beliefs and emotion, rather than the event itself. The concept involves clients interpreting events in a rational manner in order to avoid irrational thoughts that lead to anger. Delayed reaction technique is when clients attempt to uncover what is making them angry before acting out on their anger. This allows them to have time to change what is making them angry and increase time before their response; this encourages thought on a more rational level. In addition, clients are also encouraged to avoid demands in an [[Anti-oppressive practice|anti-oppressive]] order to avoid anger.<ref name=":1">{{cite book |author=Potts, L. |title=Anger management |publisher=Greenhaven Press |year=2008 |editor=L. Krueger |location=Farmington Hills, MI}}</ref> An example of a demand placed on a client may be that, "I have to have this done by my standards". Research is starting to show that the better individuals understand what anger management is and how it can help them personally and in relationships, aggressive actions are less likely to occur.<ref>{{cite web |title=Free Anger |url=http://freeanger.blogspot.com/ |publisher=Free Anger}}</ref>

=== Positive mentalization and personal development ===

This is a style that is commonly used in elementary schools for students expressing anger outbursts. Researchers who have looked into the reason for young student anger have found that one common reason could be the inability to adjust socially. Students that were selected for this study received a daily one-hour session throughout one week of school. The researchers of the [[mentalization]] program educated children through group therapy in [[positive psychology]] and tried to do activities that put the child in a happy mood while interacting. At the end of the week, research showed that there was a negative correlation between anger and social adjustment. This process lowered the overall anger levels of the students involved in social adjustment deficits.<ref>{{cite journal|author1=Rohini, N. S.|author2=Devi, R.|name-list-style=amp|year=2011|title=Management of anger and enhancement of social adjustment among school students with the application of positive therapy|journal=Indian Journal of Community Psychology|volume=7|issue=2|pages=249–255}}</ref>

Use of [[personal development]] (PD) led to higher views of themselves and more positive [[self-esteem]]. Aggression has been shown to be a result of poor self-worth as well as thinking that those around us do not care or support us, so this PD is vital in helping change a person's [[self-perception]].<ref>{{cite journal|author1=Down, R.|author2=Willner, P.|author3=Watts, L.|author4=Griffiths, J.|name-list-style=amp|year=2011|title=Anger management groups for adolescents: A mixed-methods study of efficacy and treatment preferences|journal=Clinical Child Psychology and Psychiatry|volume=16|issue=1|pages=33–52|doi=10.1177/1359104509341448|pmid=20223794|s2cid=27909142}}</ref>

=== Anger journaling ===
{{See also|Journal therapy|Writing therapy}}
Understanding one's own emotions can be a crucial piece of learning how to deal with anger. Children who wrote down their negative emotions in an "anger diary" actually ended up improving their emotional understanding, which in turn led to less aggression. When it comes to dealing with their emotions, children show the ability to learn best by seeing direct examples of instances that led to certain levels of anger. By seeing the reasons why they got angry, they can in the future try to avoid those actions or be prepared for the feeling they experience if they do find themselves doing something that typically results in them being angry.<ref>{{cite journal|author1=Renati, R.|author2=Cavioni, V.|author3=Zanetti, M.|name-list-style=amp|year=2011|title='Miss, I got mad today!' The Anger Diary, a tool to promote emotion regulation|journal=The International Journal of Emotional Education|volume=3|issue=1|pages=48–69|url=https://www.researchgate.net/publication/303913674}}</ref>

Simply logging episodes of anger could also be beneficial. Middle school students with emotional disorders who completed regular “anger logs” showed pronounced improvement of anger management. According to Keller, Bry and Salvador, students who used anger logs “were observed to exhibit significantly more prosocial behaviors toward their teachers and showed a trend toward exhibiting fewer negative behaviors toward peers”.<ref>{{Cite journal |last1=Kellner |first1=Millicent H. |last2=Bry |first2=Brenna H. |last3=Salvador |first3=Diana S. |date=2008-09-05 |title=Anger Management Effects on Middle School Students with Emotional/Behavioral Disorders: Anger Log Use, Aggressive and Prosocial Behavior |url=http://dx.doi.org/10.1080/07317100802275520 |journal=Child & Family Behavior Therapy |volume=30 |issue=3 |pages=215–230 |doi=10.1080/07317100802275520 |s2cid=146684597 |issn=0731-7107|url-access=subscription }}</ref>

Reflecting on feelings of anger in writing can be a type of Cognitive Behavioral Intervention (CBI), or a self-strategy used to combat negative thoughts.<ref>{{Cite journal |last=Okamoto |first=Scott K. |date=February 2004 |title=Book Review: HELPING SCHOOLCHILDREN COPE WITH ANGER: A COGNITIVE BEHAVIORAL INTERVENTION, by Jim Larson and John E. Lochman. New York: Guilford (The Guilford School Practitioner Series), 2002. 190 pp. $30.00 (hardbound) |url=http://dx.doi.org/10.1023/b:comh.0000015511.77944.89 |journal=Community Mental Health Journal |volume=40 |issue=1 |pages=91–92 |doi=10.1023/b:comh.0000015511.77944.89 |s2cid=34710252 |issn=0010-3853|url-access=subscription }}</ref>

=== Other evidence-based approaches ===

Anger management interventions are based in cognitive behavioral techniques and follow in a three-step process.<ref name="Beck">{{cite journal|author1=Beck, R.|author2=Fernandez, E.|name-list-style=amp|year=1998|title=Cognitive-behavioral therapy in the treatment of anger: A meta-analysis|journal=Cognitive Therapy and Research|volume=22|issue=1|pages=63–74|doi=10.1023/A:1018763902991|s2cid=5209157}}</ref> First, the client learns to identify situations that can potentially trigger the feeling of anger. A situation that elicits anger is often referred to as an anger cue.<ref name="Deffenbacher, L. J. 1999">{{cite journal|author1=Deffenbacher, L. J.|year=1999|title=Cognitive-behavioral conceptualization and treatment of anger|journal=Psychotherapy in Practice|volume=55|issue=3|pages=295–309|doi=10.1002/(SICI)1097-4679(199903)55:3<295::AID-JCLP3>3.0.CO;2-A|pmid=10321745}}</ref> If a potential trigger can be avoided, the individual can not only avoid unwanted outbursts, but also avoid internal conflict. Often anger occurs through automatic thought and irrational beliefs, these pose a problem for treatment because the patient may respond too quickly to change the thought or behavior. Wright, Day, & Howells referred to this phenomenon as the "hijacking of the cognitive system by the emotional system".<ref name=":0">{{cite journal|author1=Wright, S.|author2=Day, A.|author3=Howells, K.|name-list-style=amp|year=2009|title=Mindfulness and the treatment of anger problems|journal=Aggression and Violent Behavior|volume=14|issue=5|pages=396–401|doi=10.1016/j.avb.2009.06.008}}</ref>  Second, relaxation techniques are taught as appropriate responses to the identified situations. Common techniques include regulating breathing and physically removing themselves from the situation. Finally, [[role-play]] is used to practice the application of the learned techniques for future encounters with anger-inducing situations in the individual's life. The result of repetition is an automatic response of learned beneficial techniques.<ref name="Beck" /> Modifications of each general step result in distinctive programs. Additionally, different fields of psychology will change aspects of the above three-step process, which is primarily based in cognitive-behavioral therapy. Group, family, and relaxation only therapies each contribute to the wider range of available anger management programs.

=== Medication ===
As anger is a psychological concern, treating with medication is a secondary line of approach. However, if there is a medical reason for an anger response certain psychotropic medications are prescribed by doctors to complement the psychotherapy intervention. Medications include antidepressants, anti-psychotics, anti-seizure medications, and beta blockers. These drugs specifically do not target anger directly, but they have a calming outcome that can support control of rage and negative feeling.<ref>{{cite book|first1=Charles H.|last1=Elliott|first2=Laura L.|last2=Smith|first3=W. Doyle|last3=Gentry|title=Anger Management For Dummies|url=https://books.google.com/books?id=idplCQAAQBAJ&pg=PA289|year=2015|publisher=John Wiley & Sons|isbn=978-1-119-03000-3|page=289}}</ref>

Antidepressants may have a particular role when anger is a manifestation of depression. Anger attacks are found in 40% of those with [[major depressive disorder]] with 64–71% of cases responding to an [[SSRI]] such as [[fluoxetine]].<ref>{{cite journal |last1=Fava|display-authors=et al |first1=M |title=Fluoxetine treatment of anger attacks: a replication study |journal=Annals of Clinical Psychiatry |date=1996 |volume=8 |issue=1 |pages=7–10|doi=10.3109/10401239609149084 |pmid=8743642 }}</ref>