Anger Management And PTSD: Engaging Substance Abuse Patients In Long-Term Treatment
By Patrick M. Reilly, Ph.D., H. Westley Clark, M.D., J. D., M.P.H., & Michael S. Shopshire, Ph.D.
NCP Clinical Quarterly 6(3): Summer 1996
John witnessed many atrocities during combat in Vietnam. His most terrifying moment, however, occurred when his best friend was killed by a land mine just a few feet away. Upon returning home, John often felt depressed and fearful; he was continuously agitated and always searching for the slightest sign of harm. He turned to heroin to shut out the pain.
As with many Vietnam-combat veterans, John avoided addressing a traumatic incident by using drugs and alcohol. According to the National Vietnam Veterans Readjustment Study, Vietnam veterans with PTSD are six times more likely to abuse drugs compared to Vietnam veterans without PTSD (1). Because patients with a dual diagnosis of PTSD and substance abuse are quick to avoid emotional trauma with the use of substances, treatment of PTSD is especially complicated. The agitation, hypervigalence, and hostility symptomatic of PTSD further complicates treatment. Treatment staff are often reluctant to interact with angry patients for fear of violence. In addition, anger is a significant relapse cue for substance abuse, increasing the probability that patients will leave treatment and return to a lifestyle of substance abuse.
The Substance Use PTSD Team (SUPT), at the San Francisco Department of Veterans Affairs Medical Center focuses on treating patients with concurrent diagnoses of substance abuse and PTSD. As with many treatment programs for PTSD, SUPT focuses on helping patients develop a new understanding of their trauma. The Vietnam veteran with combat-related PTSD tells his story, explores the intrusive occurrences of the event running through his mind, and eventually reintegrates the trauma into existing cognitive schemas or newly established ones (2). For the veteran with PTSD and substance abuse, however, these final objectives are at the end of a long term treatment program.
Engaging the veteran in long-term treatment is the first barrier to overcome before issues regarding the trauma can be addressed. Many Vietnam combat veterans diagnosed with PTSD view the VA hospital as an extension of the military, an institution for which they hold contempt. The anger-provoking events patients typically encounter while seeking treatment at the VA hospital intensifies this disdain. Patients frequently complain about the cumbersome appointment procedures and discourteous clerks who process a seemingly endless flow of paperwork. These events are interpreted as signs of disrespect, which in turn serve as triggers for anger. When anger is triggered, it not only complicates treatment, but it increases the likelihood that substance abuse patients will relapse to drugs and leave the treatment program. Helping patients cope with various anger provoking situations will improve treatment outcome.
Engaging the patient in long-term treatment is an important first step in the longer-term treatment of PTSD. Patrick M. Reilly, Ph.D. and H. Westley Clark, M.D. have developed a cognitive-behavioral anger management treatment specifically for patients with diagnoses of PTSD and substance abuse (3). The anger management treatment is not a panacea; it merely complements standard substance abuse treatment and PTSD treatment offered by the SUPT program.
The treatment consists of 12 weekly 90 minute group sessions that are a mix of insight-oriented exercises about anger, such as discussing anger in the family of origin or reevaluating a past violent incident, and didactic sessions covering basic cognitive-behavioral strategies, such as time-out, relaxation training, assertive behavior, and conflict resolution. Offering a variety of different sessions holds the patients’ interest and encourages them to continue attending the anger management group sessions. The primary objective is to teach patients to monitor their anger and to develop a specific plan for controlling their anger.
Monitoring anger is an important component of treatment. In our research with cocaine abuse patients without combat-related PTSD, we have discovered that significant decreases in anger expression can be achieved if patients learn to monitor anger-provoking events and break the events down into specific component processes (4). It seems reasonable to extend these findings to substance abuse patients with combat-related PTSD. Patients with anger control problems often report that anger occurs spontaneously, without warning, and beyond their control. Patients are taught that anger may occur automatically, but it is far from uncontrollable. Self-monitoring consists of two basic techniques. In the first technique, patients are asked to monitor their anger on the "anger meter." The anger meter is a 1 to 10 point thermometer scale in which "10" represents anger of such extreme intensity that the patients’ expression of anger led to, or potentially could lead to, negative consequences, such as arrest, jail time, or expulsion from a drug treatment program. Patients are taught to use other points along the anger meter to represent intermediate levels of anger.
In a second technique, patients break down episodes of anger into specific components. Patients are taught to identify the specific events that elicited the anger. Identifying the events is a skill that takes time to learn, so patients are first instructed to look for the cues that indicate an escalation of anger. They are taught to review an episode in terms of a conceptual framework in which cues are classified as physiological reactions, behavioral manifestations, feelings coinciding with anger, e.g., disrespect or shame, and specific thoughts and images that maintain and escalate anger. Teaching patients to monitor anger-provoking situations and to break episodes down into component parts is a key element of our treatment. Again, preliminary data from our research program suggests that merely monitoring the anger-provoking situations and analyzing the situations in term of our conceptual framework significantly reduces anger levels.
A second important component of treatment concerns helping patients formulate a specific repertoire of cognitive-behavioral anger management strategies: the anger control plan. The degree of sophistication of these plans vary from patient to patient. Some patients enroll in treatment with ineffective anger management skills, such ignoring anger, while others use strategies that are similar to cognitive-behavioral techniques. In our research program, however, we have discovered that certain strategies are more effective than others (5). Merely ignoring anger and pretending that it will go away is less effective than using a specific cognitive-behavioral strategy, such as cognitive restructuring or confronting a person who elicited anger in an assertive manner rather than in an aggressive one. Thus, it appears that when possible, patients should be encouraged to use established cognitive-behavioral strategies for their control plans.
Patients with PTSD and substance abuse are often able to monitor their anger and use specific anger reduction strategies. The key to successful anger reduction is to help patients develop a specific control plan and make sure that they use it. Also, patients should be reminded that learning to manage their anger may take some time and a great deal of practice. Finally, it is important to keep in mind the patients' limitations. Some patients may be ready to learn sophisticated strategies such as cognitive restructuring and using assertive behavior, whereas other patients must first attain the more modest goal of learning to monitor their anger and to break down the anger-provoking situation into its component parts.
References
1. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough R. L; Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). The National Vietnam Veterans Readjustment Study: Tables of findings and technical appendices. New York: Raven.
2. Marmar, C. R., & Horowitz, M. J. (1988). Diagnosis and phase-oriented treatment of posttraumatic stress disorder. In J.P. Wilson, Z Harel & B. Kahana (Eds.), Human adaptation to extreme stress: From Holocaust to Vietnam. New York: Raven.
3. Reilly, P. M., Clark, H. W., Shopshire, M. S., Lewis, E. W., Sorensen, D. J. (1994). Anger management and temper control: Critical components of Posttraumatic Stress Disorder and substance abuse treatment. Journal of Psychoactive Drugs, 26, 401-407.
4. Reilly, P. M, Shopshire, M. S., Clark, H. W., Campbell, T., Ouaou, R., Llanes, S. (in press). Substance use associated with decreased levels of anger. In L. Harris (Ed.), Problems of drug dependence; 1996: Proceedings of the 58th annual scientific meeting of the College on Problems of Drug Dependence, Inc. Washington D. C.: U. S. Government Printing Office.
5. Shopshire, M. S., & Reilly, P. M. (1996, April). Appraisal themes and coping strategies associated with anger. Paper presented at the annual meeting of the Western Psychological Association Conference. San Jose, CA.
Patrick M. Reilly is Assistant Clinical Professor, Department of Psychiatry, UCSF; Chief, Substance Abuse Outpatient Clinic, San Francisco Department of Veterans Affairs Medical Center. H. Westley Clark, M.D., J.D. is Associate Clinical Professor, Department of Psychiatry, UCSF; Chief, Substance Use PTSD Team, San Francisco Department of Veterans Affairs Medical Center. Michael S. Shopshire, Ph.D. is Assistant Research Psychologist, Department of Psychiatry, UCSF.
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