Anger management/impulse control is a key issue in
substance abuse
Problems managing anger has always been a concern for
patients suffering from addictive disorders. Pioneering research in substance
abuse by my mentor, Dr. Sidney Cohen at the UCLA Neuropsychiatric Institute
demonstrated the relationship between, anger, violence and the use of alcohol
and or cocaine. One of the most popular articles written by Dr. Cohen, was
entitled, “Alcohol, the most dangerous drug known to man”. In this and other
publications, Dr. Cohen systematically demonstrated the causal relationship
between cocaine and alcohol abuse and aggression. Much of this research was
done in the 70s and 80s.
Anger has always been a factor in substance abuse
intervention. Unfortunately, until recently, it has been overlooked or treated
as an afterthought by substance abuse programs nationwide. Substance use and
abuse often coexist with anger, aggressive behavior and person-directed
violence. Data from the Substance Abuse and Mental Health Administration’s
National Household Survey on Drug Abuse indicated that 40 % of frequent cocaine
users reported engaging in some form of violence or aggressive behavior. Anger
and aggression often can have a causal role in the initiation of drug and
alcohol use and can also be a consequence associated with substance abuse.
Persons who experience traumatic events, for example, often experience anger
and act violently, as well as abuse drugs or alcohol. This is currently
occurring with recently returned combat veterans from Iraq who are experiencing
PTSD.
Anger and substance abuse treatment
Substance abuse and dependence has grown beyond even
the bleakest predictions of the past. In the United States alone, there are an
estimated 23 million people who are struggling (on a daily basis) with some
form of substance abuse or dependence. The toll it is having on our society is
dramatically increased when we factor in the number of families who suffer the
consequences of living with a person with an addiction, such as:
• Job loss
• Incarceration
• Loss of child Custody
• DUI’s
• Domestic Violence/Aggression
• Marital problems/divorce
• Accidents/injuries
• Financial problems
• Depression/anxiety/chronic anger
Unfortunately, most substance abusers may not even be
aware that they have an underlying anger problem and do not “connect” their
anger problem to their alcoholism, drug addiction and substance abuse.
Therefore, they do not seek (or get) help for their anger problem. But more
often than not, their anger is the underlying source of their disorder.
Anger
often precedes the use of cocaine and alcohol for many alcohol and cocaine
dependent individuals. Anger is an emotional and mental form of “suffering”
that occurs whenever our desires and expectations of life, others or self are
thwarted or unfulfilled. Addictive behavior and substance abuse is an addict’s
way of relieving themselves of the agony of their anger by “numbing” themselves
with drugs, alcohol and so on. This is not “managing their anger”, but
self-medication.
When we do not know how to manage our anger
appropriately, we try to keep the anger inside ourselves. Over time, it festers
and often gives rise to even more painful emotions, such as depression and
anxiety. Thus, the individual has now created an additional problem for
themselves besides their substance abuse, and must be treated for an additional
disorder. Several clinical studies have demonstrated that structured anger
management intervention based on emotional intelligence for individuals with
substance abuse problems is very effective in reducing or altogether
eliminating a relapse.
Medical research has found that alcohol, cocaine and
methamphetamine dependence are medical diseases associated with biochemical
changes in the brain. Traditional treatment approaches for drug and alcohol
dependency focus mainly on group therapy and cognitive behavior modification,
which very often does not deal with either the anger or the “physiological”
components underlying the addictive behavior. Therefore, individual coaching
for skill enhancement in emotional intelligence has far more promise for
success.
Anger precedes the use of cocaine for many
cocaine-dependent individuals; thus, cocaine-dependent individuals who
experience frequent and intense episodes of anger may be more likely to relapse
to cocaine use than individuals who can control their anger effectively.
Several clinical trials have demonstrated that cognitive-behavioral
interventions for the treatment of mood and anxiety disorders can be used to
help individuals with anger control problems reduce the frequency and intensity
with which they experience anger.
Although studies have indirectly examined anger
management group treatments in populations with a high prevalence of substance
abuse, few studies have directly examined the efficacy of anger management
treatment for cocaine-dependent individuals.
Although many participants in these studies had a
history of drug or alcohol dependence, the sample was not selected based on
inclusion criteria for a substance dependence disorder, such as cocaine
dependence. Considering the possible mediating role of anger for substance
abuse, a study examining the efficacy of anger management treatment in a sample
of cocaine-dependent patients would be informative.
Anger management/impulse control is often an after
thought
In spite of the information available to all
professional substance abuse treatment providers, anger management /impulse
control has not received the attention that is deserved and needed for
successful substance abuse treatment. Many if not most substance abuse programs
claim to offer anger management as one of the topics in its treatment yet few
substance abuse treatment programs include Anger Management Facilitator
Certification for the counselors who are providing this intervention.
Typically, new substance abuse counselors are simply
told that they will need to teach a certain numbers of hours or sessions on anger
management and then left to find their own anger management information and
teaching material. These counselors tend to piece together whatever they can
find and present it as anger management.
Despite the connection of anger and violence to
substance abuse, few substance abuse providers have attempted to either connect
the two or provide intervention for both. In the Los Angeles area, a number of
primarily upscale residential rehab programs for drug and alcohol treatment
have contracted with Certified Anger Management Providers to offer anger
management either in groups on an individual basis for inpatient substance
abuse clients. Malibu based Promises (which caters to the stars) have
contracted with Certified Providers to offer anger management on an individual
coaching bases.
It may also be of interest to note that SAMSHA has
published an excellent client workbook along with teacher’s manual entitled,
Anger Management for Substance Abuse and Mental Health Clients: A Cognitive
Behavioral Therapy Manual [and] Participant Workbook. This publication is free
and any program can order as many copies as needed without cost. There is
simply no excuse for shortchanging substance abuse clients by not providing
real anger management classes.
Limited anger management research
What has been offered as anger management in substance
abuse programs has lacked integrity. The Canadian Bureau of Prisons has
conducted a 15-year longitudinal study on the effectiveness of anger management
classes for incarcerated defendants whose original crime included substance
abuse, aggression and violence. One of the first findings was that in order to
be useful, the anger management model used must have integrity. Integrity is
defined as using a client workbook containing all of the material needed for an
anger management class, consistency among trainers in terms of how the material
is taught and a pre and post assessment to document change made by clients who
complete the class.
It is not possible to determine the effective of anger management
which is fragmented and not based on any particular structure or theoretical
base.
Anger management training is rarely integrated into
substance abuse treatment
. At the present time, anger
management is rarely integrated into any model of substance abuse intervention.
Rather, it is simply tacked on to a standard twelve-step or dual diagnoses
model.
Trends in substance abuse treatment
Several years ago, the California state legislature
established statewide guidelines for all substance abuse programs. This
legislation is included in what is commonly referred to as proposition 36. As a
result of this legislation, all substance abuse counselors must have documented
training in anger management facilitator certification. This training requires
40 hours of core training plus 16 hours of continuing anger management
education of a yearly basis.
What is Anger Management?
Anger management is rapidly becoming the most
requested intervention in human services. It may be worthwhile to define what
anger management is and is not. According to the American Psychiatric
Association, anger is a normal human emotion. It is not a pathological
condition therefore; it is not listed as a defined illness in the Diagnostic
and Statistical Manual of Nervous and Mental Disorders. Rather, anger is
considered a lifestyle issue. This means that psychotherapy or psychotropic
medication is not an appropriate intervention for teaching skills for managing
anger/impulse control.
The American Association of Anger Management Providers
defines anger management as an emotional intelligence skill enhancement course
that teaches skills in recognizing and managing anger, stress, assertive
communication and emotional intelligence. Anger is seen a normal human emotion
that is a problem when it occurs too frequently, lasts too long, is too
intense, is harmful to self or others or leads to person or property directed
aggression.
The Anderson & Anderson anger management
curriculum is currently the most widely used model of anger management in the world.
This model includes a Pre Emotional Intelligence assessment at intake that is
designed to determine the client’s level of functioning in 15 scales emotional
intelligence. The coaching/classes teach skills in the scales in which the
client’s scores fall in the low range. A Post assessment is administered after
course completion to determine the success or lack thereof of the program. The
most common EQ Assessment used in the EQ-i-2.0.
In Summary
All anger management programs should conduct an
assessment at intake for substance abuse and psychopathology and all substance
abuse programs should assess all participants for the current level of
functioning in recognizing and managing anger, stress, assertive communication
and emotional intelligence.
All substance abuse programs should have their
intervention staff certified in anger management facilitation. At least one
person at each site should also be certified in the administration and
interpretation of the EQ-i-2.0 Emotional Intelligence Assessment.
Guidelines should be established to determine the
number of hours/sessions that each client will receive in skill enhancement in
the core emotional intelligence competencies.
Anderson & Anderson is the largest and oldest
provider of Emotional Intelligence Coaching, Anger Management Facilitator
Certification as well as Organizational Development in Anger Management.
George Anderson, www.andersonservices.com
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