IRAQ WAR CLINICIAN GUIDE

Iraq War Clinician Guide
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72 Assessment and Treatment of Anger
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anger expression style is learned, and the skills required to alter anger patterns will take time to
master.
Several psychiatric problems tend to be highly comorbid with PTSD, such as depression and
substance abuse. These problems also pose potential barriers for effective treatment of anger
problems among those with PTSD. In addition, veterans with PTSD are more likely to suffer from
physical health problems, and often suffer from severe social and occupational impairments. These
factors serve to increase stress and ameliorate emotional and tangible resources for the veteran,
placing him or her at additional risk for anger dysregulation and violence perpetration. Further,
these factors may lead to a reduced ability to make use of treatment for anger problems. The
veteran's capacity to marshal the cognitive resources to do the work of therapy (e.g., participate in
self-monitoring exercises or practice communication skills) and to comply with the demands of
treatment may be compromised. The treatment provider, therefore, must fully assess for comorbid
problems and their impact on both the veteran's anger and his or her compliance with therapy,
and should ensure that the veteran receives appropriate treatment for comorbid problems. For
example, substance abuse must be addressed due to its disinhibiting effects with respect to anger
and aggression.
Anger Management Intervention
Most PTSD treatment programs recommend and offer varied modalities and formats for the
treatment of anger problems among veterans. Programs typically offer individual and group
therapies, and cognitive-behavioral treatments for anger appear to be the most common.
Increasingly, PTSD programs are utilizing manualized or standardized group treatments for anger
treatment, and there is some research evidence for the effectiveness of such treatments (Chemtob,
Novaco, Hamada, & Gross, 1997). Below, we briefly outline session content derived from a 12-
week standardized cognitive behavioral group treatment for anger among veterans with PTSD.
Although this material derives from a group treatment approach, the issues raised are relevant for
other therapy formats and modalities.
Overview of the treatment. The goal of our anger management group is for veterans to learn to
understand and to better regulate their anger responses through greater awareness of their anger
triggers and an application of constructive anger management strategies. Additionally, veteran's
appraisals of threat in their environment and daily experience of anger are targeted as they learn to
prepare back-up responses (e.g., timeouts, relaxation, cognitive restructuring, ventilation, and
positive distraction). Each session consists of group discussions and skills-building exercises. We
have found that each group of veterans will present with special needs and the sessions should be
adapted accordingly. Group leaders vary their coverage of the material to best complement the
unique needs of their group, and make efforts to encourage group cohesion and a safe and
supportive group atmosphere.
The first two sessions of group are devoted to orienting the veterans to treatment, discussing
treatment goals and expectations of therapy, enhancing motivation to work on anger management,
and providing psychoeducation on the anger response and the impact of PTSD on anger. Sessions
3 through 7 are devoted to self-monitoring exercises so that the veteran may better understand his
or her anger response, developing an understanding of the distinction between different forms of
anger expression, learning to use relaxation strategies for managing anger, and exploring
motivational issues that may be impeding progress. The remaining sessions focus on
DEPARTMENT OF VETERANS AFFAIRS
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NATIONAL CENTER FOR PTSD