NPR recently ran a news story about Anger Management, a recent form of psychotherapy that has sprung up to offer a treatment-based alternative to jail for persons caught displaying overly aggressive behavior. That radio story took a skeptical tact towards the subject, pointing out that courts are increasingly viewing anger management programs as an alternative or adjunct to jail, and raising the important question of how such a practice could be justified when there is a lack of compelling evidence that such programs actually work. This is a good question I think, deserving of an answer. But it is also a loaded question that (in my mind at least) tries to reduce the issue to a yes or no answer ("Do Anger Management programs work or not?"). Answers to questions about treatments for human problems are never so simple.
There are lots of treatments in the world, but few of them are truly cures for particular human problems. Instead, most of the time, we judge the effectiveness of a treatment based on its probability of being helpful. Radiation and chemotherapy are quite useful interventions that physicians use to help kill off patient's cancers. Such interventions work much of the time, but sometimes they don't and people die. No one would suggest that radiation and chemotherapy should not be used in the fight against cancer simply because they do not always produce a positive result.
Treatments for out-of-control anger can be seen as analogous to treatments for cancer and should be held to basically the same standards. An effective treatment for anger problems should: 1) lessen anger problems in some reasonable percentage of cases and do this more consistently than other humane interventions, 2) not make anger problems worse, 3) be cost effective to deliver. In my experience, today's anger management programs meet these criteria fairly well. They certainly do not 'cure' people of anger problems, and they probably don't even reduce acting-out behavior in a good chunk of the people who participate in them. However, anger management's positive message that behavior change is possible and the detailed instructions it provides for how to achieve this change do get through to some participants and change their lives (and the lives of those around them) for the better. Regardless of the argument you prefer (that anger management is more humane; that it is less expensive to deliver than jail), it only makes sense to funnel 'angry' offenders through anger management programs a few times before finally jailing them (when that is ultimately necessary) in the hopes that some of them will see the light.
At the risk of setting up a 'straw-man' argument, anger management is more humane and less expensive than jail. Anger, basic emotion that it is, is largely provoked by social situations; it is often a reaction to feelings of powerlessness, feeling taken-advantage-of or feeling disrespected. Anger management programs provide a positive message to participants that behavior change is possible, and that further problems are avoidable. This message is provided in an inexpensive therapy setting; there is no need to provide for costly meals or housing or security as is the case when jail is involved. This positive intervention contrasts sharply with incarceration which basically suggests to people that they are bad-to-the-bone criminals from which society must be protected. Which message do you think is more likely to fuel feelings of powerlessness, being taken advantage of and being disrespected? Which message has a better chance of dissolving such feelings?
How Your Basic Anger Management Program Works
There is no fixed definition of what treatments an anger management program should contain. However, most anger management programs are built around well-understood cognitive-behavioral approaches to behavior change which are known based on scientific evidence to work well for helping people to deal with out-of-control emotions (e.g., anxiety, depression). While such approaches may not be thoroughly understood as they apply to anger just yet, their pedigree is impeccable.
The basic cognitive behavioral approach (whether applied to anger or anxiety or depression) goes like this.
- The therapist invites the patient to view their problem as a behavior somewhat separate from themselves. In this way, patients are freed from feeling bad about themselves as people and can focus on their behavior in a more dispassionate way.
- Over multiple sessions, the therapist teaches the patient to become increasingly conscious of how their problem behavior manifests.
- Thoughts and actions that lead up to the problem behavior are identified and mapped out so that the whole typical chain of events that leads up to their getting into trouble becomes visible.
- Thoughts and beliefs that trigger the problem behavior (e.g., "I must defend my honor at all costs") are identified and systematically challenged.
- Situations that are associated with problem behavior are identified (e.g., "You tend to get into fights while drunk - so work on getting sober or at least stay away from bars")
- Feelings that may have been 'unconscious' before are identified and systematically charted. It is not uncommon for angry people to be unaware of carrying around a lot of resentment and irritability.
- Also, the patient is encouraged to become increasingly conscious of the consequences of their acting out and to break through any 'denial' they may have as to their invulnerability. For example, that continued aggressiveness may result in jail time, and that no, jail time is not worth the brief rush of aggression-related pleasure.
- The patient's increased awareness of how they get themselves into trouble (assuming it grows) helps them to anticipate trouble earlier and earlier and enables them to take steps to avoid it. For example, it may dawn on the angry person that going out and getting drunk in a bar where they have been in fights before may be a bad idea, or that they don't have to become personally offended when someone cuts them off while driving.
My own experiences helping to deliver a cognitive behaviorally informed anger management therapy suggest to me that this type of therapy, designed as it is to help open up a space in the patient where self-regulation can occur, does indeed help some people even as it goes in "one ear and out the other" for some others. I recall one man (incarcerated several times previously and looking to avoid that fate again) who listened attentively to our presentations, even as I recall another man in the same group who stuck to a macho posture and rejected most everything we said. I don't know that we helped either of these men for sure, but I suspect we helped the first guy move along just a bit in his path towards a less aggressive life.
Letting Go Of Anger And Aggression Is Difficult
I respect the idea of anger management and definitely think it is what we should be offering angry people, even as I myself don't hold out hope for it being a perfect therapy that helps all participants. This is because it is really hard to get even motivated people to change how they handle anger. There are multiple reasons for why this is so.
- Anger is a seductively attractive emotion to have. In many cases it feels good to be angry. It involves a positive "rush". When you're rushing, you aren't much aware; you're too full of yourself to be aware at that moment. This rush, this lack of awareness (certainly lack of awareness of the larger implications of your angry outburst) is what needs to be overcome when treating the angry patient. Because these feelings are intoxicating, and because some people lean on anger as a crutch so that they don't have to feel shame, it is particularly hard to get people to let go of their angry displays.
- Anger often involves a feeling of righteousness; of being more powerful than your opponants by virtue of your being more right. Many aggressively angry people know when they are behaving badly but don't care too much about it because they believe they have a right to act that way because they are more right than the people they are aggressive towards. Anger management protocols ask angry people to give up that rush of righteousness for sober rationality that says to them, "give up your aggressive displays so that your life will become less contentious over the long haul". This is essentially an argument for delaying gratification in the service of a better life. But a lot of angry people don't want to delay gratification. They want gratification now and they think they have a right to it.
- Anger is a social emotion deeply bound up with identity and therefore with power relationships between people. Anger can be sparked in relatively powerless people as an alternative to feeling powerless. In this sense anger becomes a life-raft for self-esteem. And if some people take anger too far into aggression to the point where they becomes a threat to society, this doesn't change the fact that the angry person will work to hold on to their anger so long as they see anger as the best prop available to hold up their self-esteem and shield them from uncomfortable emotions like shame.
- There is also an epidemic of people out there who don't know how to be angry without being aggressive at the same time. In my experience, many people learn from their social environments that one is either passive or aggressive, either acted upon, or an actor. Given such stark alternatives, it is little wonder that some people opt to become aggressive. It's a lot to expect that an anger management treatment can be effective when one is working with someone who cannot even conceive of a non-passive (e.g., assertive) alternative to aggression.
Motivation Is Key To Change
So there are a lot of reasons why people cling to anger even when it doesn't work for them. Any therapy that is going to tackle such a stubborn problem needs to be understood as something that will work best when patients are motivated to change, and will work worst when they aren't. Therapy isn't like dog training or jail. When training a dog or dealing with a prisoner, you can impose fairly tight outside control over rewards and punishments. Reasonably smart dogs and prisoners learn the rules and figure out how to behave in order to gain reward and avoid punishment. In therapies like anger management, however, the only real control over behavior is owned by the patients themselves. Patients are horses that are led to water; only their own hunger will determine if they will 'drink'.
My sense is that anger management will turn out to be about as effective as are programs for helping drug and alcohol addicts to kick their habits. People going through a drug rehab program aren't really expected to become clean and sober their first time through. It is pretty much expected that they will relapse. But when they do relapse they can get back to rehab, and in the process of repetition more and more of the wisdom of 'sobriety' tends to become apparent. Some people don't see why they should give up drinking or druging until they have sustained major losses and are facing jail time. Others never see. As is the case in drug rehab, many angry patients probably won't 'get it' the first time through an anger management program. However, this doesn't mean that such people can't be helped. Experience with consequences will help their motivation, as will the availability of second chances and repetition of therapy.
I'm sounding negative on anger management's ability to be helpful and I don't mean to be perceived that way. I think anger management is a great thing and that the principles (at least those taken from cognitive behavioral therapy) will prove to be sound. No treatment is perfect. I'm confident that anger management programs will undergo an evolutionary process so that they will become more effective therapies. But to expect them to be cures for inappropriate anger and aggression, now or at any time in the future, would be unrealistic.