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Journal of Psychoactive Drugs

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Anger Management and Temper Control: Critical

Components of Posttraumatic Stress Disorder and
Substance Abuse Treatment
a a b a
Patrick M. Reilly , H. Westley Clark , Michael S. Shopshire , Ervin W. Lewis &
c
Donna J. Sorensen
a
San Francisco Veterans Affairs Medical Center and Department of Psychiatry ,
University of California , San Francisco
b
Department of Psychiatry , University of California , San Francisco
c
San Francisco Veterans Affairs Medical Center, Substance Abuse Programs
Published online: 23 Jan 2012.

To cite this article: Patrick M. Reilly , H. Westley Clark , Michael S. Shopshire , Ervin W. Lewis & Donna J. Sorensen
(1994) Anger Management and Temper Control: Critical Components of Posttraumatic Stress Disorder and Substance
Abuse Treatment, Journal of Psychoactive Drugs, 26:4, 401-407, DOI: 10.1080/02791072.1994.10472460

To link to this article: http://dx.doi.org/10.1080/02791072.1994.10472460

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 Anger Management and Temper
Control: Critical Components of
Posttraumatic Stress Disorder
and Substance Abuse Treatment'

Patri ck M. Reilly, Ph.D.*; H. Westley Clark, M.D., J.D ., M.P.H.*;

Downloaded by [ECU Libraries] at 13:54 21 April 2015

Michael S. Shopshire, Ph.D. **; Ervin W. Lewis, M.D.* & Donna J. Sorensen , Ph.D.***

Abstract-Recent stud ies have show n associations among co mba t expe rie nce . PTSD . a nger and
hostility, and involve me nt in viole nce. Clinical obse rvatio ns of vetera ns enrolled in the S ubsta nce
Use / Posttra umatic Stress Disord er Team (S UPT) program at the Sa n Fra ncisco Vetera ns Affai rs
Medi cal Ce nter revealed relati vely high levels of anger and aggress ive behavior. includi ng ph ysical
assaults and property damage. In response to th is ange r and aggressive behavior. an anger mana gem ent
treatment was add ed to the SU PT prog ra m's treatm ent of substa nce ab use and PTSD, A nger
mana gement co nsisted of a 12-week cognitive- behavioral grou p treatm ent. Session topics include d
ide ntifying the ph ysical , em otional. and situatio nal cues to anger . de velop ing indiv idua lized ange r-
co ntrol plans. recognizing and altering des tructi ve "el f-ta lk. utili zin g time-out , pract icing confl ict
resoluti on techniques. a nd using the group to discuss and eva luate high-risk a nger s ituations . S pec ial
attention was given to sel f-monitoring anger-escalatin g behav ior (using an anger meter) and avo iding
nega tive co nsequences . Th is article descr ibes the compo nen ts of the anger managem ent treat men t.
A cl inica l vignette is also present ed to illustrate the ben efi ts of anger managem en t treatm en t.

Keywords- anger management . pos ttraumatic stress diso rde r. substance abuse. treatm ent

Posttraumatic stress disorder (PTSD) requires compre -
hensiv e and intensive treatment. The recurrent and intrusive
distressing recollections that are a central feature of PTSD
may require behavioral therapy or long-term psychotherapy.
PTSD in Vietnam combat veterans poses particular prob-
lems that may complicate these treatm ents. Accordin g to
the National Vietnam Veteran s Readju stment Study
(NVVRS), 22.2% of male Vietnam veterans with a current
PTSD diagnosis suffered from alcohol abuse and depen-
dence, in contrast with 9.2% of mal e Vietnam veteran s
tThis article was su pported in part by Natio na l Institut e on Drug
Abus e grant I R 180A06097.
·San Fran cisco Vet erans Aff airs Med ical Center and Department
of Psy chiatry, U niversi ty of California. San Francisco .
··Oepartment o f Ps ychi atry, Un i ve rs ity o f C a lifo rn ia . San
Fran cisco.
···San Francisco Veterans Affairs Medical Cent er, Substance Abuse
Programs.
Please addre ss reprint requests to Patrick M. Reilly, Ph.D., Su bstance
Abuse Programs, San Fran cisc o Veterans Affairs Medical Ce nter (116E).
4150 D ement Stre et. San Francisco, Califo rnia 94 12 1.
without a curr ent PTSD diagnosis (Kulka et al . 1990 ). The
NVVRS data also show that 6.1 % of Vietnam veteran s with
a current PTSD diagnosis suffered from drug abu se and
dependence (other than alcoh ol) , in contras t with 1.0% of
male Vietnam veterans without a current PTSD dia gnosis.
Many explanations have been offered for these ele vated
prevalence rates of substance abuse. One plau sible expla-
nation that has attracted attention is the self-medication
hypothesis (Khantzian 1985) . According to this hypoth esis,
combat veteran s use alcohol or other drug s to modul ate
either the physiological hypcrarousal or the numbing and
avoidance common with PTSD.
Self-medicati on is not a sufficient explanation for
alcohol or other drug use among Vietnam veteran s with
PTSD ; howev er, it is a primary contributor. Alcohol and
other drug s may be poor regulators of negati ve affect-
such as anger, mood lability, irritability, and temper-but
they do offer some relief to the combat veteran who suffers
from PTSD . Anecd otally, combat veteran s in treatm ent for

Journal of Psychoactive Drugs 401 Vol. 26(4), Oct · Dec 1994

 Reilly et al.
P'I'Sl) and suhs ta nce ahuse commonly descrihc having used
psychoactive subs ta nces during the Vietnam War to toler-
ate stress of combat, fear of death, a nd boredom as soci ated
with forei gn military dut y. Alc ohol and oth er dru gs were
readil y av ailable and, for man y combat vetera ns, alcoh ol
and oth er dru g use wa s view ed as a viable coping strateg y;
however, thi s coping stra tegy offered only short-term ben-
e fi ts. In the long term, alcohol and other dru g usc result ed
in many disadvantages. First, alcohol and other drug addic-
tion s may have contributed to the onset of PTSD by allowing
veterans to avoid addressing unpleasant emotions e licited
during combat.. Second, the cyclical effects of the drug s anel
the lifestyle associated with drug use may maintain the
symptoms associated with PTSD. Third, substance abu se
and PTSD int er act to such a great ext ent that treatment is
es pecially complica ted. PTSD, for exam ple, is associ ated
with incre ased sym ptoms of irritability, ang er, and mood
lahility, which may in tum lead to a slip or a relapse.
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Because this subpopula tion of veterans has prohlems
with ange r contro l (Chcm tob et al. 1994 ), adjunctive treat-
ments for PTSD arc ne eded to address these secondary
problem s. This article describes a 12-week ange r-manage -
ment gro up int ervention for indi viduals with PTSD wh o
abu se dru g s a nd have anger control probl em s. A case
vi gn ett e is a lso presented to help clarify the procedures.
PTSD AND SUBSTANCE AB USE
P'l'Sl) consists of a complex and heterogeneous set of
symptoms. The es sential feature of the syndrome is me devel-
opme nt of sympto ms following exposure to an extreme
traumatic stressor. According to DSM-IV (American Psy -
chiatric Association 1994), the response to the stress or mu st
he a direct personal experi ence of an e vent and involve
actual or thre atened death o r serio us injury, or a threat to
phy sical integrity of se lf or others. Th e respon se to the e vent
C<Ul tak e many form s, such as recurrent and intru sive dis-
tre ssin g recollections or dr eams of the event, ac ting o r
feeling as if the traumatic event wer e recurring, and inten se
psychological di stress or phy siological reacti vity on expo-
sure to int ernal or e xternal cu es sy mbo lizing the traumatic
event. Individuals with IYTSD tend to avoid stimuli ass oc i-
ated with the event and to sho w a numbing of general
responsiveness. Persist ent symptoms of increased arousal
arc al so present; they include irritability or outbursts of
anger, difficulty concentrating, and hypervigilance.
Th e etiology of Pf 'Sl) is still unclear, but a con sen sus
is hc ginning to form regarding the necessary phases of treat-
ment (Kiyuna, Kopriva & Farr 1993). M lUlY treatments arc
psychodynamic and consist of helping clients reevaluate
their past trauma and con struct a more appropriate inner
repre sentation of th eir tr aumatic experiences (Emery,
Emery & Berry 1993 ). Horowitz and colleagues (Mann ar
& Horowitz 1988 ; Horowitz 1986 , 1979), for example, have
outlined the healing process oflYTSD as a four-stage sequence .
Journal of Psych oactive Dru gs
Anger Management, PTSD, and Substance Abuse
In the first stage of treatment, emphas is is placed on estab-
lishin g rapport with the client and crea ting an a tmosphere
of sa fety and suppo rt. Once psy chologi cal and emotional
sta bilization is achi eved , the se co nd stage co ns ists of en-
ge ndering a se nse of hope with in the cli ent. In the third
stage, the client de velops a new und erstanding of me trauma
hy reexperi encing the event: the client " te lls his story" and
is helped to explore the intru siv e oc currences in affective
and cog nitive processes. Co m pletion of treatment is sig-
nal ed hy a fun ctional reintegration of the traumatic
e xperience, either within the clie nt's e xisting co gnitive
schem as or through newly es ta blished one s.This four-stage
sequence is characteristic of many treatments o f PI'Sl) in
that the initi al stages co nce ro forming an a lliance with the
therapist, while subseq uent stages con cern reexperiencing
or unco vering a traumat ic e xperie nce that ha s not yet been
resolv ed.
Es ta blishing rapport with the clie nt and creating an
atm osph ere of sa fety and suppo rt. is an esse ntial as pec t of
ear ly treatm ent of IYfSD . U nfortunate ly, building rapport.
and crea ting a suppo rtive en vironment is ofte n complica ted
in Vietn am comba t ve terans with P'I'Sl) by substance abuse
(McFall , Ma ckay & Don o van 19 92 ; lIyer e t a l. 1991;
Keane, Cadde ll & Ta ylor 1988) a nd an ger and vio lence
prohl ems (Kulka ct al. 1990; lIy er ct a l. 1986; Ca rro ll et
al. 1985 ; Esco bar et a l. 1983). IY/,SD c lients who di splay
ange r and vio lence problems, for exam ple, arc mor e likel y
to co ntinue usin g alco ho l an d o the r dru gs, or relapse to
these substances. In addition , treatment programs arc of -
ten reluctant 10 e nro ll these c lie nts; or if e nro lled, they arc
more likely to be di scharged from treatment for di sc iplin-
ary reason s.
The Substan ce Usc/ Pos ttra uma tic Stre ss Di sorder
Team (SU JYl") at the San Franci sco Vet eran s Affair s Medi-
c al Ce nter, a treatment program for Vietnam co m ba t
veteran s, developed a multistage treatm ent model consis-
tent with Horowitzs four- stage model of treatment. In
phase one of the SU l" f program , cli ents atte nd a struc-
tured open group designed to engage, stabilize, and further
assess the cl ient. Th e focu s of thi s phase is on add ress ing
substance abu se prohlems and anger managem ent . Absti -
nence is encouraged, hut is not required . 'Ib is more tolerant
approach ha s been taken based on the beli ef that the inde-
pendent complications of subs ta nce abuse and PTSD
interact to suc h a great e xtent that they hinder engage-
ment.. In phase one of treatment, clients ar c encouraged
to addres s the difficulty of changing their situa tio n, th e
extent PTSD contributes to their substa nce abuse, and their
attitudes toward in stitutional se ttings , e specially those
operated hy the go vernment.
In ph ase two , psychocducational issue s and co ntin-
ued anger management arc emphas ized. Psychoeducational
issue s include the way s that PTSD and substa nce abuse
interact, distortions of thinking associated with substance
abuse and PI'SD, and models of relapse prevention .
402 Vol. 26(4), Oct -Dec 1994
 Reilly et al,
Consistent with the Horowitz model, treatment staff
establish rapport with clients and provide a safe and sup-
portive environment in phases one and two of treaunent.
Once these conditions are established, the focus of treat-
ment shifts in phase three to combat trauma.
THEORETICAL MODEL
The objectives of anger management treatment are
(1) to teach clients to identify the specific cues and trig-
gers to anger, and (2) to help clients develop strategies for
controlling their anger in the form of individualized con-
trol plans. The treatment also has the secondary objectives
of examining the associations among substance abuse,
anger, and violence, as well as the way substance abuse
escalates anger and violence.
The treaunent approach is a form of self-instructional
training (Meichenbaum 1985) based, in part, on the early
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work of Novaco (1975). The approach also borrows from a
treatment model that has been used successfully by the
Domestic Abuse Project in Minneapolis (Edelson &
Grusznski 1988; Reilly & Grusznski 1984).
Anger control problems are conceptualized from a
cognitive-behavioral perspective. A fundamental assump-
tion of this approach is that it is not specific persons or
events that produce emotional and behavioral responses,
hut the cognitive appraisal of these events . Anger can be
described rather easily within this cognitive framework:
anger results from the belief that we, or our friends, have
been unfairly slighted, which causes us both painful feel-
ings and a desire or impulse for revenge (Lazarus 1991).
Anger is an adaptive emotion that signals threat or harm,
quickly energizes behavior, and mobilizes resources, direct-
ing a behavioral response to reduce the threat (Novaco
1976). For some individuals, however, anger is experienced
frequently and with intense arousal. When experienced in
this extreme form, anger can lead to health problems, ver-
bal abuse, or violence.
Various approaches have been used for the treatment
of anger, but the SUPT program decided to base its treat-
ment model on Meichenbaum's (1985) self-instructional
training. According to Meichenbaum, responses such as
anger and violence are socially learned , reinforced, and
practiced to the extent that these responses soon become
automatic . Individuals display these responses without
deliberate thought and without thinking of the consequences
of their actions. Responses that are learned, however, can
be unlearned . Mcichenbaum's approach can be used to teach
clients to think and plan before they act: to stop, look, and
listen before behaving impulsively (Liebert & Spiegler
1994).
The anger management treaunent is organized around
Meichcnbaum's three phases of treaunent: conceptual, skill
acquisition and rehearsal, and application and follow-
Journal oj Psychoactive Drugs
Anger Management, PTSD, and Substance Abuse
through. The conceptual phase consists of creating a work-
ing relationship with clients, and helping them better
understand the nature of their anger. Clients are taught a
basic conceptual framework for understanding anger. Ini-
tially, the focus is on reconceptualizing anger in terms of
the persons, situations, and events that elicit anger, as well
as the thoughts, images, and physical cues that indicate an
escalation of anger. The focus is also on the role that cog-
nitions and other emotions, such as shame and guilt, play
in eliciting and escalating anger.
In the skill-acquisition and rehearsal phase, clients are
provided with a variety of behavioral and cognitive coping
techniques, which they can then use to control their anger.
Clients dilTerregarding their ability to use these techniques,
so they are encouraged to consider what works best for
them and to consolidate these strategies into a specific and
individualized anger-control plan.
The application and follow-through phase in
Meichenbaum's approach consists of arranging for trans-
fer and maintenance of change from the therapeutic
situation to the real world. Transfer is encouraged through-
out the 12 weeks of treaunent. At the start of each session,
for example, clients "check in" by describing an event dur-
ing the past week that had produced an escalation of anger.
Clients are encouraged to describe how they managed their
anger by using one of the specific cognitive-behavioral strat-
egies outlined in group.
DESCRIPTION OF TREATMENT
Sessions 1 and 2: Cues to Anger and the Anger Meter
The first two sessions consist of a set of didactic pre-
sentations in which clients are presented with a basic
conceptual framework for understanding their anger. Cli-
ents are taught to examine the cues indicating an escalation
of anger. Cues are presented as belonging to four cue cat-
egories: physical, emotional, fantasies and images, and
red-flag words and situations.
Physical cues to anger escalation can be either inter-
nal or external. Internal cues include rapid heartbeat,
tightness in the chest, and feeling hot or flushed . External
cues include clenched fists, a glaring stare or agitated pac-
ing back and forth . Emotional cues are the other emotions
that coincide with anger and further increase the escalation
of anger. For many clients, anger is a reaction to feeling
hurt, shamed, or powerless. In these instances, anger is used
to increase feelings of power and control. Other emotions
indicating this loss of control may include fear, jealously,
hurt, and humiliation. Fantasies and images can also indi-
cate anger, and may include elicitors of anger, such as
imagining that one's spouse is having an affair, or behav-
ioral reactions following anger, such as mental rehearsals
and fantasies of committing a violent assault. Red-flag
words and situations are the specific issues and events from
403 Vol. 26(4) , Oct -Dec 1994
 Reilly et al.
an individual's past that may continue to elicit anger. For
example, cli ents may react with anger when called a par-
ticular nam e the y wer e teased with duri ng their childhood .
Specifi c criti cism s, such as " yo u' ll never be any good," can
al so elici t ang er. Oth er ex a m ples are thou ght s about
ex-spo uses, refe re nces to Vietnam, or the frustrations as-
so cia te d with having un stable living and financial
ci rcumstances . Clients arc taught that these c ues may differ
across individual s, and emphasis is placed on the speci fic
cu es that they usc to monitor their escalation phase.
Teaching cli ents to se lf-monitor their anger is a second
important goal of treatment. As de scribed by Meichenbaum
(1985), responses such as ang er have been learned to the
extent that they appear to occur spo nta neo us ly, without
deliberate thou ght or control. Self-monitoring allows cli -
ents to understand the events and situations that elicit anger,
the cues that indicate an escal ation of anger, and the thought s
and cognition s that maintain and further escalate an ger.
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To help cli ent s monitor their anger more objectivel y,
they are asked to rate their anger on the ang er meter (see
Figure 1)-a 1-10 thermometer-type scale in which I rep -
resent s a slate of complete ca lm and 10 repre sents a complete
loss o f co ntro l, which usually result s in aggress ion, such as
verbal abuse or violence, and co nse q uences , such as a loss
of int imacy, fre edom, a job, or a bene fit. Le vels of an ger
aro usal be tween these two anchors are as signed intermcdi-
ate valu es on the anger meter. In the fourth sess ion, the anger
meter is link ed to a cycle of violence or aggression (Walker
197 9). During the first two sessions, how evcr, the ange r
met er is presented in its simples t term s.
Sessions 2 and 3: Anger-Control Plans and
Anger as a Secondary Emotion
In sessio ns 2 and 3, the co nce pt o f an an ger-control
plan is presented. Each c1icnt is asked to begin formulatin g
a plan for controlling anger. Dev eloping the anger-control
plan co rres po nds to Mei chenbaum's skill-acquisition and
rehearsal phases. During group sess ions , speci fic cognitive
and beh avi oral strateg ies are presented and discussed. Cli -
ents are encouraged to use a combination of traditional
cognitive-be ha viora l regulation strategies and individual
stra teg ies they develop themselves. Exam ples of traditional
cognitive-behavioral strategies presented in subseq ue nt ses-
s io ns include time-out, relaxation training , exerci se,
monitoring negative self-ta lk, and conflict resolution mod -
e ls. Individual strategies developed by clients include
att ending l2-Step me etings, and talking abo ut an anger-
provoking situation with a friend or relative. Regardless of
the strategies used, the individual nature of these stra tegies
is em phas ized and clients are encouraged to use the strate-
gie s that work best for them . A specific example is presented
in Figure 2.
After the concept of an anger-control plan is introduced,
other emotions are discussed that may coincide with , or
Journal ofPsychoactive Drugs
Anger Management, I'TSD, and Substance Abuse
FIGURE 1
ANGER METER USED
TO MONITOR ANGER
10* " Explosion, violence .
loss of control, ne gati ve
co nsc q ucnccs -i-You lose!
9
8
7
6
5
4
3
2
1 You have a c ho ice !
o lise yo ur ange r co ntro l plan
L- ~ _~
,_U_ld_,_'lVOid hittin g
e licit, anger, Group mem ber s co m ple te a struc tured exer-
c ise where they a rc asked to identi fy the und e rl yin g
emotio ns coi ncid ing with 111Ci r o utbursts of a nge r. Th e
man ner in which anger can be a reacti o n to fear . insec u-
rity, jealou sly, or humiliati on is discu ssed .
Session 4: Time-out and the Aggression Cycle
'li me-o ut can be used formally or informally. Formally,
time-out is associated with establi shed relation ships with
famil y members a nd friend s. A form al arrange ment is made
betw een the client and a friend or family member. Spe-
cific rules of the interac tion are se t forth, an d both parti es
agree to follow the se rul es . Either party can call a time-
out. Th e person calling the time-out leav es the s ituation
for a specific peri od , and thus pre vent s the furth er es ca la-
tion of anger. Th e per son then returns to the situation and
checks in with the oth er party. Tog eth er, the y can decide to
finish the transaction or postpone the issue for a time when
both parti es believe they can resolve the conflict s uccess -
fully.
Many group members have used time-out more infor-
mally , meaning to take a few deep breaths and think before
reacting. Time-out may al so refer to leaving a
noninterpersonal situation that is producing an escalation
of ang er. For exam ple, riding a crowded bus e lic its an ger
in many clients. An example of a time-out strategy in this
situation is gelling off the bus and boarding a less crowded
bus.
The aggress ion cycle is based on Walker 's ( 1979) cycle
of violence. The SUPT pro gram modification of the cycle
consi sts of three phases : escalation, explo sion . and
postexplosion . Anger arousal increases during the esca la-
404 Vol. 26(4), Oct- Dec 1994
 Reilly et aI.
tion phase, in which individuals may deny or minimize the
importance of tension or conflictual situations. They may
increase hostile self-talk or attempts to intimidate olhers
through body language. If arousal is left unchecked, an
individual may display aggression or violence during the
explosion phase. Clients are taught that lhese outbursts
usually involve a destructive and uncontrollable discharge
of anger. Both verbal abuse and physical aggression are
considered to be destructive and uncontrollable behavior
becau se in many instances the consequences to the indi-
vidual may be equally severe. The postexplosion phase
involves the consequences of the explosion phase, which
may include jail, termination from treatment or a service
program, financial costs , or loss of family or loved ones.
Other consequences include feeling s of regr et. remorse. or
guilt.
Clients are taught that the escalation phase is the criti -
cal point in the aggression cycle where the intervention is
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most effective. During the escalation phase, clients can
choose alternatives to violent behaviors and prevent fur-
ther escalation. Many clients believe that their anger and
violence is sudden, spontaneous, and wilhout warning . They
also believe, however, they would be less violent or ag-
gressive if they had advance warning . By using the
aggression cycle, and by identifying the cues that indicate
an escalation of anger, clients learn that their anger and
violence are never sudden and unpredictable, and that they
can control their anger by monitoring their cues and using
appropriate cognitive-behavioral strategies.
Session 5: Self-Talk Model
Self-monitoring of verbal statements that escalate and
maintain anger is central to self-instructional training. As
with other cognitive theori sts, Meichenbaum (1985) con-
tends that individuals respond to events with an inner dialog
or "self-talk." Ellis (1973) takes a similar approach, con-
tending that the beliefs and expectations of an event produce
emotional responses. Thus, from the perspective of anger
management, a core set of beliefs underlies an escalation
of anger. Ellis developed a straightforward A (activating
event), B (belief), C (consequence) model of cognitive ap-
praisal. Beliefs or expectations are lhought to mediate the
emotional response (C) to the activating event (A). Stated
simply, changing beliefs and expectations is the mo st
direct way of changing emotional respon ses. This model is
presented to SUPT clients and some of the possible beliefs
they may use during the escalation phase of the aggression
cycle are di scussed.
Session 6: Relaxation Training
Relaxation training is anolher specific behavioral tech-
nique available to clients. In this session the basic rationale
for relaxation training is examined, and clients practice
deep-breathing exercises and other basic techniques. They
are encouraged to set aside time to practice these exercises.
Journal oj Psychoactive Drugs
Anger Management, PTSD, and Substance Abuse
FIGURE 2
JOHN'S ANGER CONTROL PLAN
Specific Cognitive-Behavioral Strategies
I. Take a time-out.
2. Take a 20 -minute walk.
3. Slow down and take a few deep breath s .
4. Use the conflict-resolution model.
5 . Talk about stre ssful events with Bill. Tom . or Fred.
6. Try to understand my red-nag si tuatio ns by talking
about them to the anger management suppor t group.
7. Accept o thers rather than expecting them to live up to
my expectation s.
8. Listen to mu sic.
9. Attend the 42nd Street AI'. me eting .
10. Work o ut three time s a week at the YM CA.
Session 7: Conflict Resolution Model
The conflict resolution model is introduced as a strat-
egy to resolve conflicts and to solve problems, The model
con sists of four step s: (I) identify the event producing the
conflict, (2) explore the feelings associated with the con-
flict, (3) examine the conseq uences of the conflict , and
(4) develop a solution or compromise to resolve the con -
flict.
Sessions 8 and 9: Analysis of Most Violent Incident
The "Analysis of Mo st Violent Incident" is a struc-
tured exerci se in which each group member an aly zes his
most aggre ssive or violent incident from his past . At this
point in treatment, clients are aware of their own specific
cues indicating an escal ation of anger and have begun to
develop spec ific anger-control plans. The purpose of this
exercise is to help clients reevaluate an epi sode where they
were extremely violent. Cli ent s review the epi sode and
explore how they might have controlled their anger had
they used the ang er management strategies they have
learned in group. The exercise con sist s of describin g where
the incident occurred, the events leading up to it. the client's
expectations regarding violence, the type of violence dis-
played, if alcohol or other drug s were invol ved, or whelhcr
memories of combat experience played a role during the
incident. Clients then discuss the advantages and disad-
vantages of using violence to cope with thi s incident.
Identifying the advantages and payoffs of using violence
is important becau se this assists clients in understanding
the motivation driving their behavior.
Sessions 9 and 10: Anger in Family of Origin
..Anger in Family of Origin" is an exercise con sisting
of a series of questions designed to help clients explore
how they were influenced by the expressi on of anger
and other emotions in lheir familie s. Cli ents are asked
405 Vol. 26 (4 ). O ct -()~ c 1994
 Reilly et al.
to describe how anger wa s expressed in their families; how
other emotio ns w ere e xpressed ; how they were di sciplined ,
how they responded to th e di scipline; the rol e they pla yed ;
th e most fr equent phrase they heard; th e me ssages they
received a bo ut th eir parents a nd me n and women in gen -
eral ; the thoughts, behaviors, and attitudes that carry o ver
into th eir adult lives and relationships; and the current pur-
pose the se behaviors serve . Final ly, clients arc asked to di scu ss
the difficulty of changing the se behaviors. The Anger in
Fa m ily of Origin exercise is meant to help cli ents under-
s tand the manner in which pa st behavior may influence
current behavior.
Session 11: Assertiveness Training
Th e assertiveness ski lls pre sentation is provided to teach
g ro up m embers the definition s and difference s between
a ssertive , aggressive, nonassertive, and passiv e-aggressi ve
behaviors. Group members ar c tau ght that the se behaviors
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arc learned, and arc not rigid unchangeable predi spositions.
C lie nts arc enco uraged to practi ce as sertive beh aviors; the y
arc a sked to co ns id e r how a g gre s siv e or non a sserti vc
behaviors can he e xp ressed as se rtive ly.
Session 12: Final Session
In the final sessio n, gro up members re vie w the ir anger-
co ntro l plans and di scu ss thc specific ways they ha ve learn ed
to manage their an ger.
CASE VIGNETTE
A male vet eran di agnosed with IYI"SD and subs tance
abu se was enrolled in the SUIYI" program and received anger
management treatment . He be gan att ending the an ger man-
agemcnt groups in May 199 2 and continues to attend a
drop-in anger management s uppo rt group regularl y.
John is a 45-year-old , divorced, Hispanic, Vietnam
ve te ra n, with a 25-y ea r history of alcohol and heroin dcpcn-
dence. I Ie gr ew up in Texas, graduated from hi gh sc hoo l,
and served in the Navy from July 1969 to April 1971. Dur-
in g hi s tour in Vietnam , John sa w s ig nific a nt combat ,
including friendly and ho stile incoming fire . He took part
in amphibiou s invasions and engaged the enemy in fire
fight s. John sa w many of his co m rades killed, including his
best friend who died several fcct away from him from an
e xploding land mine . lie al so witnes sed many atrocities,
including the killing of Vietnamese ci vilians.
John began using alcohol and heroin while in Vietnam .
Following hi s di scharge, he e xpe rie nced s ymp to ms of
depression, fearfulness, hypervi gilance , and isolation. John
be gan to increase hi s alcohol and heroin usc in an attempt
to decrease the se feeling s. Although trained as a welder,
John wa s unable to hold stead y employment. Prior to hi s
entry into treatment for JYrSD, he was hospitalized on se v-
eral oc casions for depression and two s uic ide attempts. John
Journal of Psychoactive Dru gs
Anger Management, PTSD, and Substance Abuse
wa s arrested mor e than 30 times for assault and di sorderly
conduct.
In 1991 , John began outpatient treatment in the Po st-
traumati c Stre ss Di sorder C linic at th e San Fra nc isco
veterans Affair s Medi cal Ce nter. I Ie engaged in gro up psy -
c ho the ra p y a n d receiv ed p sy chopharmacotherapy;
however, he continued to abuse alcohol a nd heroin and
di splay ed s ig nificant behavioral difficulti es , including
occasional assaults . In December 1991, John wa s hospi -
tali zed in th e inpatient PTSD program following an
es ca la tio n of angry outburst s, including an incident in
whi ch, a ppare nt ly without provocation, he swung a stick
a t a man he e nco unte re d on a walk .
At thc time of hi s adm iss io n to both the S LJJYr pro-
gram and thc anger managem ent gro up in May 1992, John
reported that he had no t used alcohol or o the r drugs for
o ne month . He co mplai ned, howe ver, o f intru siv e thoughts
and memories, ni ghtmares, fla shbacks, sleep di sturbance,
poor co nce ntra tio n, and frequent o ut burst" o f a ng er.
Duri ng his init ial sessio ns in th e an ger man agem ent
gro up, John reported hi gh level s of irritability and anger,
and very lo w fr ustration tolera nce . O n o ne occas io n, he
destroyed person al pro pert y during an e pisode of rage. O ver
thc course of seve ra l week s in th e g ro up , th ou gh , John
became s killed a t m on ito rin g his a ng e r by usin g the an ge r
me te r a nd identify ing the ph ysical , e mo tional, a nd si tu-
a tiona l c ues th at led to hi s esca latio n of an ger. li e al so
became a wa re of his hostile se lf-ta lk, a nd be gan changing
these negati ve thou ghts to mor e positive thou ghts. Soon ,
he reported ex pe rie nc ing Icss an ger; John began to usc
a nge r m an agem e nt s tra tegies, s uc h a s tim e- out and an
ex erc ise program, to control his anger e ffec tive ly, By the
eighth week of treatment, John wa s regularl y practicing
asserti ven ess techniques, s uc h as co nfl ic t re solution . I lis
improvement is ex e m plified by an incident that occurred
during his tenth week of treatment. John reported that he
had become a nge re d when he learned th at hi s landlord had
let his ex-wife int o his a pa rtme nt without his permi ssion .
Rather Hum acting o ut aggr es sively ag a ins t the landlord or
destroying property, John spo ke directl y to his landlord,
resolving the incident ass ertively.
John has co ntinued to make sig nifica nt progress . I Ie
completed the 12-week group and continues to attend a n
anger management support group for SLJPT clients. lIe has
maintained hi s ab stinence throughout his treatment in the
SLJlyr program. He ha s become sig nifica ntly less isolated,
having formed fri endships with group members, and has
enrolled in a work training program . He has progressed
from angry outbursts and vio lent ly acting out to taking brief
time-outs and assertively resolving conflicts. John is now
more confident in his ability to negotiate difficult s itua-
tion s, can id entify anger-provoking sit ua tio ns , and can
manage his anger effectively with spec ific cognitive and
behavioral techniques,
406 Vol. 26(4 ). Oct-Dec 1994
 Reilly et aI.
CONCLUSION
John exemplifies the complications associated with the
treatment of PTSD and subslance abuse . Many of these
clients display outbursts of anger that may complicate treat-
ment. In respon se to these problems, a cognitive-behavioral
group treatment for anger management was developed. The
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