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A description of anger-control therapy groups to helpvietnam veterans with posttraumatic stress disorderJ. Jeffries McWhirter a & Paulette C. Liebman ba Division of Psychology in Education , Arizona State University , Tempeb Psychiatry and Chemical Dependence Unit, Good Samaritan Medical Center , PhoenixPublished online: 31 Jan 2008.

To cite this article: J. Jeffries McWhirter & Paulette C. Liebman (1988) A description of anger-control therapy groupsto help vietnam veterans with posttraumatic stress disorder, The Journal for Specialists in Group Work, 13:1, 9-16, DOI:10.1080/01933928808411770

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Working with Groups

A Description of Anger- Control

Therapy Groups Vietnam Veterans

To Help

with Posttraumatic Stress Disorder

J. Jeffries McWhirter Paulette C. Liebman

The authors describe a group approach to anger control, using cognitive restructuring and structured experiential activities, for Vietnam veterans with posttraumatic stress disorder.

Anger is a common emotion experienced by most people in their daily lives, either personally or as the recipient from another person. In the mental health professions, contact with anger is usually increased be- cause of the frequency of anger in clients. It is difficult to deny the need for mental health professionals to understand better and deal productively with both their own anger and that of clients. The professional

J . Jeffries McWhirter is a professor in the Di- vision of Psychology in Education at Arizona Stare University. Tempe; Paulette C . Liebman is a clinical specialist in the Psychiatry and Chemical Dependence Unit, Good Samaritan Medical Center, Phoenix. Readers may contact the senior author regarding availability of the Anger Handbook.

literature does not reflect the importance of understanding and controlling anger, however (Novaco, 1977; Rothberg, 197 1).

The need for appropriate and productive anger control in the general population is obvious when the incidents of maladaptive styles for coping with anger are reviewed. The media provide multiple accounts of vi- olent anger, which results in assault and bat- tery, child abuse, spouse abuse, and murder. Conflict and anger in family relationships, sometimes leading to murder of one mem- ber, is not uncommon. Less violent anger between family members may be a contrib- uting factor in the increased incidence of divorce.

At the other end of the continuum from the violent coping style is the maladaptive

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passive style. This style may include be- haviors that specifically avoid dealing di- rectly with the anger. The passive approach, which is thought to contribute to depression, may also contribute to the incidence of chemical abuse in society as a way to numb the affect and decrease the pain of sup- pressed anger. This maladaptive style is also suggested as a possible cause of various so- matic complaints, which may include head- aches, gastric ulcer, hypertension, or ulcerative colitis.

An essential component of good mental health is the development of an adaptive style for coping with anger. Conflict in re- lationships is a normal and necessary fac- tor i n the progression of superficial interactions toward more meaningful re- lationships. Conflict is often a necessary process to increase intimacy in the rela- tionship (Paul & Paul, 1983). Therefore, an adaptive anger coping style is necessary for dealing with conflict in relationships because significant, flourishing relation- ships are an essential component of opti- mum mental health.

The purpose of this article is to describe a specific group therapy program of anger control designed for hospitalized Vietnam veterans with posttraumatic stress disorder (PTSD). The goal of the program is for the veterans to learn a more adaptive anger coping style to deal more appropriately with their anger in current interactions. The client population is composed of Vietnam vet- erans who have been diagnosed as having PTSD and accepted into the inpatient PTSD program at the Phoenix, Arizona Veteran’s Administration Medical Center.

The diagnostic criteria used for PTSD are described in the Diagnosric and Sta- tistical Manual of Mental Disorders (DSM- 111) (American Psychiatric Association [APA], 1980). The development of the dis- order follows a psychologically traumatic event that is not a usual stressful event in life and is stressful enough to cause symp- toms of reexperiencing the trauma and avoidance of similar situations or stimuli. The stressor is a catastrophic event that

results in massive psychological trauma, and for the Vietnam veteran is a man-made, unnatural catastrophe that creates a more powerful stress response. It is also less likely to be caused by one or two traumatic in- cidents but rather by a cumulative, chronic, recurring pattern of exposure to multiple events (Shatan, 1973).

Shatan (1973) identified the aftereffects of the war as an identifiable syndrome. He de- scribed it as the postVietnam syndrome and identified six common themes: (a) guilt feel- ings and self-punishment, (b) feelings of being made a scapegoat, (c) rage and other violent impulses against indiscriminate targets, (d) combat brutality and its resulting “psychic numbing,” (e) alienation from one’s own feel- ings and from other people, and (f) doubt about continued ability to love and trust oth- ers.

The reexperience and avoidance criteria represent two main aspects of the stress response: an intrusive-repetitive tendency and a denial-numbing tendency, both of which are attempts to adapt to the stressful event. The purpose of the intrusive ideas and feelings is to reintegrate the mental information, whereas the purpose of the ideational denial and emotional numbing is a defensive function that intermittently interrupts the intolerable ideas and emo- tions to decrease the emotional respon- siveness (Horowitz et a l . , 1980). The vacillation between recollections and numbing is an attempt to provide a healthy coping response, so that the person can eventually master his emotional responses and search for personal meaning from the experience. The attempted adaptation re- sponses occur mostly on the unconscious level. Dysfunctional consequences are ex- hibited, however, when the emotional numbing is excessively generalized to other areas in the veteran’s life, which may in- clude impaired capacity for intimacy and may result in isolation, alienation, and chemical abuse (Williams, 1983). Dys- functional consequences of the intrusive ideas and feelings may at times be asso- ciated with violent behavior. Vietnam vet-

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erans with PTSD are three times more likely to be violent than are Vietnam veterans without the disorder (Boulanger, Ka- dushin, & Rindskopf, 1985).

The affective stress response is another important aspect of the disorder. The trau- matic experiences create an affective re- sponse that usually consists of grief, guilt, or terror; such responses will continue until the impact of the trauma is resolved and integrated (Arnold, 1985). The associated features of PTSD include depression, anx- iety, increased vulnerability, unpredictable explosions of aggressive behavior, and im- pulsive behavior (APA, 1980). Depression may actually be a manifestation of impacted grief related to the numbed apathy that pre- vents bereavement for the loss of their com- rades (Shatan, 1973). Depression may also be a manifestation of guilt related to wit- nessing or participating in events that are considered atrocities according to the vet- eran's precombat values. The inability to mourn may exhibit itself as continuous sad- ness, inability to enjoy, or vengeful rage (Arnold, 1985).

There are understandable reasons for Vietnam veterans to express anger and rage as a result of their experiences in the war. Although the tragedy and cruelty of war is self-evident, the following factors contribute to the unique experiences of the Vietnam war veteran. Figley (cited in Walker & Cav- enar, 1982) identified five major differ- ences between the Vietnam War and other wars: (a) entering and leaving the war alone rather than with the support of peers in a unit; (b) significant opposition to the war at home; (c) nature of the warfare, which included frequent winning and losing of same territory, guerilla-type fighting, and having women and children involved in the violence; (d) the role of military psychiatry in a war that claimed a low incidence of psychiatric casualties, which in fact may have been masked by the high incidence of chemical abuse; and (e) the brief tran- sition period to home from the battlefield, which often was only 24 hours and pro- vided no debriefing time.

RELATIONSHIP TO THE INPATIENT PROGRAM The anger-group program is one aspect of the multigroup, 120-day inpatient PTSD program at the Phoenix Veterans Admin- istration Medical Center. Phase 1 of the program is based on the intensive, abreac- tive, therapeutic group process through which the traumatic events are revivified and relived to uncover and work through the appropriate affects. This phase is not intended to teach new skills and coping behaviors. Phase 2, however, is focused on learning a broader repertoire of skills and fills in the developmental stages that were arrested as a result of the trauma. Group psychotherapy in this stage is con- cerned with improving the level of func- tioning, teaching new skills, and raising the level of awareness. The anger-group program discussed in this article makes up Phase 2 . This phase of the program is fo- cused on the transition back into society and the community.

CONCEPTUAL FRAMEWORK OF THE ANGER PROCESS The conceptual framework of the anger pro- cess is based on a continuum of styles for coping with anger and a model that describes the relationship of the cognitive and affec- tive components in the anger process.

Anger coping styles are represented on the continuum with extremes considered as mal- adaptive and the middle as adaptive (see Ta- ble 1). The maladaptive extreme on the left is represented as active-violent behavior and the extreme on the right as maladaptive pas- sive-avoidance behavior. The center adap- tive coping style is essentially assertive. A large percentage of the Vietnam veterans in the program have high scores on the Passive- Aggressive scale of the Millon Clinical Mul- tiaxial Inventory (MCMI) (Millon, 1983). The veterans' behavior (by self-report and observed by staff) often occurs on the ex- treme ends of the continuum of violent or avoidant behaviors.

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TABLE 1 Continuum of Anger Coping Styles

Maladaotive AdaDtive MaladaDtive

Active Passive Violent Aggressive Assertive Withdrawn Avoidant Indirect Direct Indirect Nonverbal Verbal Nonverbal

Note. The extremes of the continuum are maladaptive (i.e., poor coping styles) and the middle of the continuum is adaptive (i.e., effective coping style). The combat veteran often tends to function at the extremes of the continuum. The goal of achieving an effective coping style is to function in the middle of the continuum. The most adaptive coping style is direct, verbal, and assertive behavior.

The anger process model represents the progression from the situation to anger or rage. Vietnam veterans often state that they immediately advance from a specific sit- uation to immediate anger or rage, thereby eliminating any possible hope for change because of total lack of control. The model identifies the cognitive and affective com- ponents that occur before the resulting an- ger. Many of the group experiences are focused on teaching the veterans how to increase their awareness of these compo- nents and to assume control and personal responsibility. The intent is to alter the sudden and immediate progression to an- ger or rage.

The first event is the cognitive component described as the belief system. It includes attitudes, beliefs, expectations, values, “shoulds,” and an individualized concept of the ideal self. The clients interpret the situation based on their own belief systems. Based on this interpretation and resulting self-talk, each client experiences the affec- tive component.

Like the cognitive component, the affec- tive component frequently occurs without conscious awareness. The affective com- ponent is described as primary feelings that include hurt, disappointment, confusion, in- adequacy, helplessness, fear, guilt, rejec- tion, sadness, grief, and shame. Because primary feelings such as these are usually painful to experience, they are often blocked out of awareness. Blocking out primary feel-

ings is particularly common with veterans, because these feelings decrease survival chances if experienced in the combat situ- ation. Anger, however, would probably tend to increase survival chances. Novaco de- scribes eight functions of anger: energizing, disruptive, expressive, self-promotional, defensive, potentiating, instigative, and dis- criminative (Novaco, 1975). Only the dis- ruptive function would be a negative function in the combat situation, but the remaining functions are potentially related to survival and, therefore, positively reinforcing to the anger.

Often veterans ask, “What can I do to change? I don’t know what I can do dif- ferently.” The model includes areas in which change can occur throughout the progression from the situation to the actual anger. The areas to be changed in the sit- uation include perceptive and communi- cation skills. In the belief system, the areas of change include attitudes, beliefs, ex- pectations, values, “shoulds,” the indi- vidualized concept of the ideal self, and self-talk. In the affective component, the areas of change include increased self- awareness, personal responsibility, and self- disclosure of primary feelings. In the anger component, the area of change is an in- crease in direct, honest, appropriate ver- balizations and a decrease i n usually nonproductive, alternative choices for dealing with anger; these may include psy- chological or physical withdrawal, dis-

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placement, and physical responses directed at persons or inanimate objects.

CONCEPTUAL FRAMEWORK OFANGERCONTROL Meichenbaum, Novaco, and others have described in the literature the importance of the cognitive components in anger con- trol and other stress inoculation training procedures (Hazaleus & Deffenbacher, 1986; Meichenbaum & Novaco, 1985; No- vaco, 1977). The anger process model de- scribed above provides the conceptual framework for the client to understand the process of anger cognitively. Meichen- baum and Novaco described the first phase of their stress inoculation training as ed- ucational to provide cognitive preparation (Meichenbaum & Novaco, 1985; Novaco, 1977). This anger-management strategy is based on the assumption that because arousal of anger is significantly determined by cognitive factors, the strategy is di- rected toward the mastery of cognitive self- control skills. The techniques are depen- dent on the clients’ knowledge of those internal and external factors that affect be- havior. The clients must become skilled as observers of the cues in the external en- vironment, as well as of their individual thoughts, feelings, and actions. Therefore, the client needs a conceptual framework to organize observations.

In addition to the cognitive component in the anger model, the affective component has been emphasized. The PTSD population demonstrates a significant denial-numbing tendency. Anger is one of the most frequent affective responses experienced by veterans while the primary feelings are blocked from awareness. Anger becomes the outlet used to relieve the tension from the blocked pri- mary feelings. Thus, the affective compo- nent is especially important in the conceptual framework for this population. After the client has come to a cognitive understanding of the affective response, the strategy includes in- creasing self-awareness and self-disclosure of primary feelings.

GROUP STRUCTURE The group we describe here is a time-lim- ited one for clients in the inpatient PTSD program. It is scheduled for six sessions of 1% hours each, twice a week, for 3 weeks. The group usually consists of eight participants. The treatment procedures can be classified according to Meichenbaum and Novaco’s phases of stress-inoculation training (1985): cognitive preparation, skill acquisition and rehearsal, and application and practice.

The cognitive preparation phase includes didactic presentation of the two anger mod- els previously described in the conceptual framework; these are given to the clients in an Anger Handbook. In addition, concepts related to Novaco’s functions of anger and self-statements are presented: the Johari Window (Luft, 1984), a model of self-es- teem, and the areas for change in the anger process.

The skill acquisition and rehearsal phase is based on structured experiential activi- ties developed for clients to gain insight into their individual patterns of response. The Affective Inventory is a structured ex- periential activity to help the veterans gain insight into levels of self-awareness and patterns of self-disclosure of their affective states. A second structured experience is the Anger List. This activity is adapted from a values clarification activity devel- oped by Simon (1 974) called the Love List. During the application and practice phase, role playing may be used to practice al- ternative responses to anger.

The following information provides a ses- sion by session description of the anger group. The guidelines for each session are approx- imate, because the time required for each activity may vary.

Session 1

During Session 1 , two didactic concepts are presented. The Johari Window (Luft, 1984) is presented as a model of interper- sonal relationships. Discussion is focused

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on the veteran’s ability to accept feedback and to self-disclose. The importance of both to successful treatment and adaptive cop- ing with conflict in interpersonal relation- ships is discussed.

Novaco’s (1976) eight functions of anger are also presented. The positively reinforc- ing aspects of anger, which would tend to make the veteran want to repeat the behav- ior, are highlighted. Interestingly, seven of the functions are positively reinforcing in the combat situation and six are reinforcing in the noncombat situation. This information provides some rationale for the persistence of anger.

The Affective Inventory is a written ac- tivity. The veterans are provided with a list of affective states and asked individually to circle those they are aware of having ex- perienced in the past year and to check the ones they have disclosed verbally to another person. They are allowed time in the group to complete the activity before the entire group processes the information.

It is important to assist the veterans in identifying their own patterns of behavior; these may include:

Level of awareness of affective states versus a denial-numbing tendency Changes of awareness level since en- tering the program Level of self-disclosure compared to level of awareness Types of affective states with higher versus lower level of awareness Types of affective states that are self- disclosed Present affective response to the ex- perience

Session 2

A model of self-esteem is presented that represents self-concept as composed of the ideal self, the perceived self, and the real self. High congruence of the three com- ponents increases self-esteem. Discussion includes the relationship of decreased awareness of affective states when incon-

gruent with the ideal self. Participants dis- cuss and define their own self-esteem based on the model.

The model of anger coping styles is pre- sented. The discussion focuses on common patterns of functioning of the combat veteran on the extreme maladaptive end of the con- tinuum. The goal of learning an adaptive coping style is emphasized.

The cognitive component of the anger model and its effect on self-talk is also presented. Cognitive restructuring is dis- cussed and Novaco’s (1977) handout, ti- tled Productive Self-Talk fo r Anger Management, is given. Discussion in- cludes the components of the belief system and the resulting self-talk that follows. Volunteers role-play selected self-talk used in past or present situations.

Session 3

The third session focuses on the written Anger List. All veterans individually re- cord specific anger situations. Specific sit- uations rather than general situations are emphasized to identify patterns of behav- ior. Each situation is then coded based on 26 codes. Examples of the codes include verbal expression of anger, physical acting out of anger, spontaneous versus delayed awareness of anger, unmet expectations, negative self-talk, and separate codes for 11 different primary feelings.

Members process the experience as a group. Participants are encouraged to share individual patterns of response for each code without focusing on the specific anger sit- uation. The relationships of codes with one another may also be significant. The pro- cessing includes:

The pattern of self-disclosure versus no self-disclosure The relationship of no self-disclosure to the number of other people verbally told about the anger pattern of physi- cally acting out The pattern of physically acting out

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The relationship of unresolved anger and date of occurrence The pattern of anger that is directed at large groups of people versus individ- uals The pattern of spontaneous or delayed responding The pattern of physical or psycholog- ical withdrawal The pattern of negative versus positive self-talk The pattern of unmet and possibly un- realistic expectations The pattern of occurrence of the pri- mary feelings

Session 4

Frequently, the processing of the Anger List overlaps into this session. After pro- cessing is finished, the complete anger model is presented. This provides the op- portunity for the veteran to integrate the new experiential learning with the total conceptual framework.

Session 5

During this session, the Anger Handbook is provided; it includes the anger model and the previously discussed specific areas for change to achieve an adaptive coping style. Discussion is focused on the process of changing behavior in the specific areas iden- tified in the anger model.

Session 6

The last session is focused on the application and practice phase, in which the clients may use role-plays, group discussion, or both to process past or present anger situations. Vol- unteers present an anger situation and the group describes or role-plays a more adap- tive coping style for the specific situation. Discussion also includes changes made by individuals since the beginning of the group.

RECOMMENDATIONS FOR OTHER POPULATIONS

This specific group therapy program for an- ger control is effective with other popula- tions. The anger program has been used with nonpsychotic, general psychiatric inpa- tients. These patients frequently report con- siderable problems with anger control and respond enthusiastically to the experience. It also seems to be useful with outpatient psychiatric patients. The Anger List exper- iential activity is useful in training experi- ences with hospital personnel, including professional and nonprofessional staff. There are many groups in the general population that could benefit from the experience.

REFERENCES

Arnold, A.L. (1985). Diagnosis of posttraumatic stress disorder in Vietnam veterans. In S.M. Sonnenberg, A.S. Blank, Jr., & J.A. Talbot (Eds.), The trauma of war: Stress and recovery in Vietnam veterans (pp. 101-123). Washing- ton DC: American Psychiatric Press.

Boulanger, G., Kadushin, C., & Rindskopf, D. (1985). Posttraumatic stress disorder: A valid diagnosis? In G. Boulanger & C. Kadushin (Eds.), Vietnam veterans: Facts andfiction of their psychological adjustment. Hillsdale, NJ: Erlbaum.

American Psychiatric Association. (1980). Di- agnostic and statistical manual of mental dis- orders (3rd ed.). Washington, DC: Author.

Hazaleus, S.L., & Deffenbacher, J.L. (1986). Relaxation and cognitive treatments of anger. Journal of Consulting and Clinical Psychol-

Horowitz, M.J., Wilner, N., Kaltreider, N. , & Alvarez, W. (1980). Signs and symptoms of posttraumatic stress disorder. Archives of Gen- eral Psychiatry, 37, 85-92.

Luft, J . (1984). Group process: An introduction to group dynamics. Palo Alto, CA: Mayfield Publishing Co.

Meichenbaum, D., & Novaco, R. (1985). Stress inoculation: A preventative approach. Issues in Mental Healrh Nursing, 7 , 419-435.

Millon, T. (1983). The Millon ClinicalMultiaxial Inventory manual (3rd ed.). Minneapolis, MN: National Computer Systems, Inc.

ogy. 5 4 , 222-226.

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Novaco, R.W. (1975). Anger control: The de- velopment and evaluation of an experimental treatment. Lexington, MA: Lexington Books.

Novaco, R.W. (1976). The functions and regu- lation of the arousal of anger. American Jour- nal offsychiarry, 133, 1124-1128.

Novaco, R.W. (1977). A stress inoculation ap- proach to anger management in the training of law enforcement officers. American Journal of Community Psychology. 5 , 327-346.

Paul, J . , & Paul, M. (1983). Do I have to give up me to be loved by you? Minneapolis: CompCare Publications.

Rothberg, A. (1971). On anger. American Jour- nal of Psychiatry, 128, 454-460.

Simon, S . (1974). Meeting yourselfhalfway. Niles, IL: Argus Communications.

Shatan, C. (1973). The grief of soldiers: Vietnam combat veterans’ self-help movement. Ameri- can Journal of Orthopsychiatry, 43, 640-653.

Walker, J.I., & Cavenar, J.O. (1982). Vietnam veterans: Their problems continue. The Jour- nal of Nervous and Menlal Disease, 170, 174- 180.

Williams, C.C. (1983). The mental foxhole: The Vietnam veteran’s search for meaning. Amer- ican Journal of Orthopsychiatry, 53, 4- 17.

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