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Alcohol, Violence, and Aggression

Scientists and nonscientists alike have long recognized a two-way association between alcohol consumption and violent or aggressive behavior (1). Not only may alcohol consumption promote aggressiveness, but victimization may lead to excessive alcohol consumption. Violence may be defined as behavior that intentionally inflicts, or attempts to inflict, physical harm. Violence falls within the broader category of aggression, which also includes behaviors that are threatening, hostile, or damaging in a nonphysical way (2). This Alcohol Alert explores the association between alcohol consumption, violence, and aggression and the role of the brain in regulating these behaviors. Understanding the nature of these associations is essential to breaking the cycle of alcohol misuse and violence.

Extent of the Alcohol-Violence Association

Based on published studies, Roizen (3) summarized the percentages of violent offenders who were drinking at the time of the offense as follows: up to 86 percent of homicide offenders, 37 percent of assault offenders, 60 percent of sexual offenders, up to 57 percent of men and 27 percent of women involved in marital violence, and 13 percent of child abusers. These figures are the upper limits of a wide range of estimates. In a community-based study, Pernanen (4) found that 42 percent of violent crimes reported to the police involved alcohol, although 51 percent of the victims interviewed believed that their assailants had been drinking.

Alcohol-Violence Relationships

Several models have been proposed to explain the complex relationships between violence or aggression and alcohol consumption. To avoid exposing human or animal subjects to potentially serious injury, research results discussed below are largely based on experiments on nonphysical aggression. Other studies involving humans are based on epidemiological surveys or data obtained from archival or official sources.

Alcohol Misuse Preceding Violence

Direct Effects of Alcohol.

Alcohol may encourage aggression or violence by disrupting normal brain function. According to the disinhibition hypothesis, for example, alcohol weakens brain mechanisms that normally restrain impulsive behaviors, including inappropriate aggression (5). By impairing information processing, alcohol can also lead a person to misjudge social cues, thereby overreacting to a perceived threat (6). Simultaneously, a narrowing of attention may lead to an inaccurate assessment of the future risks of acting on an immediate violent impulse (7).

Many researchers have explored the relationship of alcohol to aggression using variations of an experimental approach developed more than 35 years ago (8,9). In a typical example, a subject administers electric shocks or other painful stimuli to an unseen "opponent," ostensibly as part of a competitive task involving learning and reaction time. Unknown to the subject, the reactions of the nonexistent opponent are simulated by a computer. Subjects perform both while sober and after consuming alcohol. In many studies, subjects exhibited increased aggressiveness (e.g., by administering stronger shocks) in proportion to increasing alcohol consumption (10).

These findings suggest that alcohol may facilitate aggressive behavior. However, subjects rarely increased their aggression unless they felt threatened or provoked. Moreover, neither intoxicated nor sober participants administered painful stimuli when nonaggressive means of communication (e.g., a signal lamp) were also available (5,9).

These results are consistent with the real-world observation that intoxication alone does not cause violence (4). The following subsections explore some mechanisms whereby alcohol's direct effects may interact with other factors to influence the expression of aggression.

Social and Cultural Expectancies.

Alcohol consumption may promote aggression because people expect it to (5). For example, research using real and mock alcoholic beverages shows that people who believe they have consumed alcohol begin to act more aggressively, regardless of which beverage they actually consumed (10). Alcohol-related expectancies that promote male aggressiveness, combined with the widespread perception of intoxicated women as sexually receptive and less able to defend themselves, could account for the association between drinking and date rape (11).

In addition, a person who intends to engage in a violent act may drink to bolster his or her courage or in hopes of evading punishment or censure (12,13). The motive of drinking to avoid censure is encouraged by the popular view of intoxication as a "time-out," during which one is not subject to the same rules of conduct as when sober (14,15).

Violence Preceding Alcohol Misuse

Childhood Victimization.

A history of childhood sexual abuse (16) or neglect (17) is more likely among women with alcohol problems than among women without alcohol problems. Widom and colleagues (17) found no relationship between childhood victimization and subsequent alcohol misuse in men. Even children who only witness family violence may learn to imitate the roles of aggressors or victims, setting the stage for alcohol abuse and violence to persist over generations (18). Finally, obstetric complications that damage the nervous system at birth, combined with subsequent parental neglect such as might occur in an alcoholic family, may predispose one to violence, crime, and other behavioral problems by age 18 (19,20).

Violent Lifestyles.

Violence may precede alcohol misuse in offenders as well as victims. For example, violent people may be more likely than nonviolent people to select or encounter social situations and subcultures that encourage heavy drinking (21). In summary, violence may contribute to alcohol consumption, which in turn may perpetuate violence.

Common Causes for Alcohol Misuse and Violence

In many cases, abuse of alcohol and a propensity to violence may stem from a common cause (22). This cause may be a temperamental trait, such as a risk-seeking personality, or a social environment (e.g., delinquent peers or lack of parental supervision) that encourages or contributes to deviant behavior (21).

Another example of a common cause relates to the frequent co-occurrence of antisocial personality disorder (ASPD) and early-onset (i.e., type II) alcoholism (23). ASPD is a psychiatric disorder characterized by a disregard for the rights of others, often manifested as a violent or criminal lifestyle. Type II alcoholism is characterized by high heritability from father to son; early onset of alcoholism (often during adolescence); and antisocial, sometimes violent, behavioral traits (24). Type II alcoholics and persons with ASPD overlap in their tendency to violence and excessive alcohol consumption and may share a genetic basis (23).

Spurious Associations

Spurious associations between alcohol consumption and violence may arise by chance or coincidence, with no direct or common cause. For example, drinking is a common social activity for many adult Americans, especially those most likely to commit violent acts. Therefore, drinking and violence may occur together by chance (5). In addition, violent criminals who drink heavily are more likely than less intoxicated offenders to be caught and consequently are over represented in samples of convicts or arrestees (7). Spurious associations may sometimes be difficult to distinguish from common-cause associations.

Physiology of Violence

Although individual behavior is shaped in part by the environment, it is also influenced by biological factors (e.g., hormones) and ultimately planned and directed by the brain. Individual differences in brain chemistry may explain the observation that excessive alcohol consumption may consistently promote aggression in some persons, but not in others (25). The following subsections highlight some areas of intensive study.

Serotonin

Serotonin, a chemical messenger in the brain, is thought to function as a behavioral inhibitor. Thus, decreased serotonin activity is associated with increased impulsivity and aggressiveness (26) as well as with early-onset alcoholism among men (27).

Researchers have developed an animal model that simulates many of the characteristics of alcoholism in humans. Rhesus macaque monkeys sometimes consume alcohol in sufficient quantities to become intoxicated. Macaques with low serotonin activity consume alcohol at elevated rates (25); these monkeys also demonstrate impaired impulse control, resulting in excessive and inappropriate aggression (25,27). This behavior and brain chemistry closely resemble that of type II alcoholics. Interestingly, among both macaques and humans, parental neglect leads to early-onset aggression and excessive alcohol consumption in the offspring, again correlated with decreased serotonin activity (27).

Although data are inconclusive, the alcohol-violence link may be mediated by chemical messengers in addition to serotonin, such as dopamine and norepinephrine (28). There is also considerable overlap among nerve cell pathways in the brain that regulate aspects of aggression (29), sexual behavior, and alcohol consumption (30). These observations suggest a biological basis for the frequent co-occurrence of alcohol intoxication and sexual violence.

Testosterone

The steroid hormone testosterone is responsible for the development of male primary and secondary sexual characteristics. High testosterone concentrations in criminals have been associated with violence, suspiciousness, and hostility (31,32). In animal experiments, alcohol administration increased aggressive behavior in socially dominant squirrel monkeys, who already exhibited high levels of aggression and testosterone (33). Alcohol did not, however, increase aggression in subordinate monkeys, which exhibited low levels of aggression and testosterone (6).

These findings may shed some light on the life cycle of violence in humans. In humans, violence occurs largely among adolescent and young adult males, who tend to have high levels of testosterone compared with the general population. Young men who exhibit antisocial behaviors often "burn out" with age, becoming less aggressive when they reach their forties (34). By that age, testosterone concentrations are decreasing, while serotonin concentrations are increasing, both factors that tend to restrain violent behavior (35).

Conclusion

No one model can account for all individuals or types of violence. Alcohol apparently may increase the risk of violent behavior only for certain individuals or sub-populations and only under some situations and social/cultural influences (4,36).

Although much remains to be learned, research suggests that some violent behavior may be amenable to treatment and some may be preventable. One study found decreased levels of marital violence in couples who completed behavioral marital therapy for alcoholism and remained sober during followup (37). Results of another study (7) suggest that a 10-percent increase in the beer tax could reduce murder by 0.3 percent, rape by 1.32 percent, and robbery by 0.9 percent. Although these results are modest, they indicate a direction for future research. In addition, preliminary experiments have identified medications that have the potential to reduce violent behavior. Such medications include certain anticonvulsants (e.g., carbamazepine) (38); mood stabilizers (e.g., lithium) (39); and antidepressants, especially those that increase serotonin activity (e.g., fluoxetine) (40,41). However, these studies either did not differentiate alcoholic from nonalcoholic subjects or excluded alcoholics from participation.

References

(1)Reiss, A.J., Jr., & Roth, J.A., eds. Understanding and Preventing Violence. Vol. 3. Washington, DC: National Academy Press, 1994.

(2)Moss, H.B., & Tarter, R.E. Substance abuse, aggression, and violence. Am J Addict 2(2):149-160, 1993.

(3)Roizen, J. Epidemiological issues in alcohol-related violence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 7-40.

(4)Pernanen, K. Alcohol in Human Violence. New York: Guilford Press, 1991.

(5)Gustafson, R. Alcohol and aggression. J Offender Rehabil 21(3/4):41-80, 1994.

(6)Miczek, K.A., et al. Alcohol, GABAA-benzodiazepine receptor complex, and aggression. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 139-171.

(7)Cook, P.J., & Moore, M.J. Economic perspectives on reducing alcohol-related violence. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 193-212.

(8)Buss, A.H. The Psychology of Aggression. New York: Wiley, 1961.

(9)Gustafson, R. What do experimental paradigms tell us about alcohol-related aggressive responding? J Stud Alcohol 11(suppl):20-29, 1993.

(10)Bushman, B.J. Effects of alcohol on human aggression: Validity of proposed explanations. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 227-243.

(11)Lang, A.R. Alcohol-related violence: Psychological perspectives. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 121-148.

(12)Collins, J.J. Alcohol and interpersonal violence: Less than meets the eye. In: Wolfgang, M.E., eds. Pathways to Criminal Violence. Newbury Park, CA: Sage Publications, 1989. pp. 49-67.

(13)Fagan, J. Intoxication and aggression. In: Tonry, M., & Wilson, J.Q., eds. Crime and Justice. Vol. 13. Chicago: Univ. of Chicago Press, 1990. pp. 241-320.

(14)MacAndrew, C., & Edgerton, R.B. Drunken Comportment. Chicago: Aldine Publishing, 1969.

(15)Zack, M., & Vogel-Sprott, M. Drunk or sober? Learned conformity to a behavioral standard. J Stud Alcohol 58(5):495-501, 1997.

(16)Miller, B.A. Investigating links between childhood victimization and alcohol problems. In: Martin, S.E., ed. Alcohol and Interpersonal Violence. NIAAA Research Monograph No. 24. NIH Pub. No. 93-3496. Rockville, MD: NIAAA, 1993. pp. 315-323.

(17)Widom, C.S., et al. Alcohol abuse in abused and neglected children followed-up: Are they at increased risk? J Stud Alcohol 56(2):207-217, 1995.

(18)Brookoff, D., et al. Characteristics of participants in domestic violence: Assessment at the scene of domestic assault. JAMA 277(17):1369-1373, 1997.

(19)Raine, A., et al. Birth complications combined with early maternal rejection at age 1 year predispose to violent crime at age 18 years. Arch Gen Psychiatry 51(12):984-988, 1994.

(20)Raine, A., et al. High rates of violence, crime, academic problems, and behavioral problems in males with both early neuromotor deficits and unstable family environments. Arch Gen Psychiatry 53(6):544-549, 1996.

(21)White, H.R. Longitudinal perspective on alcohol use and aggression during adolescence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 81-103.

(22)Jessor, R., & Jessor, S.L. Problem Behavior and Psychosocial Development. New York: Academic Press, 1977.

(23)Virkkunen, M., et al. Serotonin in alcoholic violent offenders. Ciba Foundation Symposium 194:168-182, 1995.

(24)Cloninger, C.R., et al. Inheritance of alcohol abuse: Cross-fostering analysis of adopted men. Arch Gen Ps ychiatry 38:861-868, 1981.

(25)Higley, J.D., et al. A nonhuman primate model of type II excessive alcohol consumption? Part 1. Low cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations and diminished social competence correlate with excessive alcohol consumption. Alcohol Clin Exp Res 20(4):629-642, 1996.

(26)Virkkunen, M., & Linnoila, M. Serotonin and glucose metabolism in impulsively violent alcoholic offenders. In: Stoff, D.M., & Cairns, R.B., eds. Aggression and Violence. Mahwah, NJ: Lawrence Erlbaum, 1996. pp. 87-100.

(27)Higley, J.D., & Linnoila, M. A nonhuman primate model of excessive alcohol intake: Personality and neurobiological parallels of type I- and type II-like alcoholism. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 192-219.

(28)Coccaro, E.F., & Kavoussi, R.J. Neurotransmitter correlates of impulsive aggression. In: Stoff, D.M., & Cairns, R.B., eds. Aggression and Violence. Mahwah, NJ: Lawrence Erlbaum, 1996. pp. 67-86.

(29)Alexander, G., et al. Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annu Rev Neurosci 9:357-381, 1986.

(30)Modell, J.G., et al. Basal ganglia/limbic striatal and thalamocortical involvement in craving and loss of control in alcoholism. J Neuropsychiatry Clin Neurosci 2(2):123-144, 1990.

(31)Dabbs, J.M., Jr., et al. Salivary testosterone and cortisol among late adolescent male offenders. J Abnorm Child Psychol 19(4):469-478, 1991.

(32)Virkkunen, M., et al. CSF biochemistries, glucose metabolism, and diurnal activity rhythms in alcoholic, violent offenders, fire setters, and healthy volunteers. Arch Gen Psychiatry 51:20-27, 1994.

(33)Miczek, K.A., et al. Alcohol, drugs of abuse, aggression, and violence. In: Reiss, A.J., & Roth, J.A., eds. Understanding and Preventing Violence. Vol. 3. Washington, DC: National Academy Press, 1994. pp. 377-570.

(34)Robins, L.N. Deviant Children Grown Up. Baltimore: Williams & Wilkins, 1996.

(35)Brown, G.L., & Linnoila, M.I. CSF serotonin metabolite (5-HIAA) studies in depression, impulsivity, and violence. J Clin Psychiatry 51(4)(suppl):31-43, 1990.

(36)Lipsey, M.W., et al. Is there a causal relationship between alcohol use and violence? A synthesis of evidence. In: Galanter, M., ed. Recent Developments in Alcoholism. Vol. 13. New York: Plenum Press, 1997. pp. 245-282.

(37)O'Farrell, T.J., & Murphy, C.M. Marital violence before and after alcoholism treatment. J Consult Clin Psychol 63:256-262, 1995.

(38)Gardner, D.L., & Cowdry, R.W. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psychiatry 143(4):519-522, 1986.

(39)Sheard, M.H., et al. The effect of lithium on impulsive behavior in man. Am J Psychiatry 133:1409-1413, 1976.

(40)Coccaro, E.F., et al. Fluoxetine treatment of compulsive aggression in DSM-III-R personality disorder patients. J Clin Psychopharm 10:373-375, 1990.

(41)Salzman, C., et al. Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. J Clin Psychopharm 15(1):23-19, 1995.

National Institute on Alcohol Abuse and Alcoholism
Alcohol Alert No. 38, Updated October 2000

Page last modified or reviewed by athealth on January 29, 2014

What are alternative approaches to mental health care?

An alternative approach to mental health care is one that emphasizes the interrelationship between mind, body, and spirit. Although some alternative approaches have a long history, many remain controversial. The National Center for Complementary and Alternative Medicine at the National Institutes of Health was created in 1992 to help evaluate alternative methods of treatment and to integrate those that are effective into mainstream health care practice. It is crucial, however, to consult with your health care providers about the approaches you are using to achieve mental wellness.

Self-help

Many people with mental illnesses find that self-help groups are an invaluable resource for recovery and for empowerment. Self-help generally refers to groups or meetings that:

• Involve people who have similar needs
• Are facilitated by a consumer, survivor, or other layperson;
• Assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident, addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative;
• Are operated on an informal, free-of-charge, and nonprofit basis;
• Provide support and education; and
• Are voluntary, anonymous, and confidential.

Diet and Nutrition

Adjusting both diet and nutrition may help some people with mental illnesses manage their symptoms and promote recovery. For example, research suggests that eliminating milk and wheat products can reduce the severity of symptoms for some people who have schizophrenia and some children with autism. Similarly, some holistic/natural physicians use herbal treatments, B-complex vitamins, riboflavin, magnesium, and thiamine to treat anxiety, autism, depression, drug-induced psychoses, and hyperactivity.

Pastoral Counseling

Some people prefer to seek help for mental health problems from their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community. Counselors working within traditional faith communities increasingly are recognizing the need to incorporate psychotherapy and/or medication, along with prayer and spirituality, to effectively help some people with mental disorders.

Animal Assisted Therapies

Working with an animal (or animals) under the guidance of a health care professional may benefit some people with mental illness by facilitating positive changes, such as increased empathy and enhanced socialization skills. Animals can be used as part of group therapy programs to encourage communication and increase the ability to focus. Developing self-esteem and reducing loneliness and anxiety are just some potential benefits of individual-animal therapy (Delta Society, 2002).

Expressive Therapies

Art Therapy: Drawing, painting, and sculpting help many people to reconcile inner conflicts, release deeply repressed emotions, and foster self-awareness, as well as personal growth. Some mental health providers use art therapy as both a diagnostic tool and as a way to help treat disorders such as depression, abuse-related trauma, and schizophrenia. You may be able to find a therapist in your area who has received special training and certification in art therapy.

Dance/Movement Therapy: Some people find that their spirits soar when they let their feet fly. Others-particularly those who prefer more structure or who feel they have "two left feet"-gain the same sense of release and inner peace from the Eastern martial arts, such as Aikido and Tai Chi. Those who are recovering from physical, sexual, or emotional abuse may find these techniques especially helpful for gaining a sense of ease with their own bodies. The underlying premise to dance/movement therapy is that it can help a person integrate the emotional, physical, and cognitive facets of "self."

Music/Sound Therapy: It is no coincidence that many people turn on soothing music to relax or snazzy tunes to help feel upbeat. Research suggests that music stimulates the body's natural "feel good" chemicals (opiates and endorphins). This stimulation results in improved blood flow, blood pressure, pulse rate, breathing, and posture changes. Music or sound therapy has been used to treat disorders such as stress, grief, depression, schizophrenia, and autism in children, and to diagnose mental health needs.

Culturally Based Healing Arts

Traditional Oriental medicine (such as acupuncture, shiatsu, and reiki), Indian systems of health care (such as Ayurveda and yoga), and Native American healing practices (such as the Sweat Lodge and Talking Circles) all incorporate the beliefs that:

• Wellness is a state of balance between the spiritual, physical, and mental/emotional "selves."
• An imbalance of forces within the body is the cause of illness.
• Herbal/natural remedies, combined with sound nutrition, exercise, and meditation/prayer, will correct this imbalance.

Acupuncture: The Chinese practice of inserting needles into the body at specific points manipulates the body's flow of energy to balance the endocrine system. This manipulation regulates functions such as heart rate, body temperature, and respiration, as well as sleep patterns and emotional changes. Acupuncture has been used in clinics to assist people with substance abuse disorders through detoxification; to relieve stress and anxiety; to treat attention deficit and hyperactivity disorder in children; to reduce symptoms of depression; and to help people with physical ailments.

Ayurveda: Ayurvedic medicine is described as "knowledge of how to live." It incorporates an individualized regimen - such as diet, meditation, herbal preparations, or other techniques - to treat a variety of conditions, including depression, to facilitate lifestyle changes, and to teach people how to release stress and tension through yoga or transcendental meditation.

Yoga/meditation: Practitioners of this ancient Indian system of health care use breathing exercises, posture, stretches, and meditation to balance the body's energy centers. Yoga is used in combination with other treatment for depression, anxiety, and stress-related disorders.

Native American traditional practices: Ceremonial dances, chants, and cleansing rituals are part of Indian Health Service programs to heal depression, stress, trauma (including those related to physical and sexual abuse), and substance abuse.

Cuentos: Based on folktales, this form of therapy originated in Puerto Rico. The stories used contain healing themes and models of behavior such as self-transformation and endurance through adversity. Cuentos is used primarily to help Hispanic children recover from depression and other mental health problems related to leaving one's homeland and living in a foreign culture.

Relaxation and Stress Reduction Techniques

Biofeedback: Learning to control muscle tension and "involuntary" body functioning, such as heart rate and skin temperature, can be a path to mastering one's fears. It is used in combination with, or as an alternative to, medication to treat disorders such as anxiety, panic, and phobias. For example, a person can learn to "retrain" his or her breathing habits in stressful situations to induce relaxation and decrease hyperventilation. Some preliminary research indicates it may offer an additional tool for treating schizophrenia and depression.

Guided Imagery or Visualization: This process involves going into a state of deep relaxation and creating a mental image of recovery and wellness. Physicians, nurses, and mental health providers occasionally use this approach to treat alcohol and drug addictions, depression, panic disorders, phobias, and stress.

Massage therapy: The underlying principle of this approach is that rubbing, kneading, brushing, and tapping a person's muscles can help release tension and pent emotions. It has been used to treat trauma-related depression and stress. A highly unregulated industry, certification for massage therapy varies widely from State to State. Some States have strict guidelines, while others have none.

Technology-Based Applications

The boom in electronic tools at home and in the office makes access to mental health information just a telephone call or a "mouse click" away. Technology is also making treatment more widely available in once-isolated areas.

Telemedicine: Plugging into video and computer technology is a relatively new innovation in health care. It allows both consumers and providers in remote or rural areas to gain access to mental health or specialty expertise. Telemedicine can enable consulting providers to speak to and observe patients directly. It also can be used in education and training programs for generalist clinicians.

Telephone counseling: Active listening skills are a hallmark of telephone counselors. These also provide information and referral to interested callers. For many people telephone counseling often is a first step to receiving in-depth mental health care. Research shows that such counseling from specially trained mental health providers reaches many people who otherwise might not get the help they need. Before calling, be sure to check the telephone number for service fees; a 900 area code means you will be billed for the call, an 800 or 888 area code means the call is toll-free.

Electronic communications: Technologies such as the Internet, bulletin boards, and electronic mail lists provide access directly to consumers and the public on a wide range of information. On-line consumer groups can exchange information, experiences, and views on mental health, treatment systems, alternative medicine, and other related topics.

Radio psychiatry: Another relative newcomer to therapy, radio psychiatry was first introduced in the United States in 1976. Radio psychiatrists and psychologists provide advice, information, and referrals in response to a variety of mental health questions from callers. The American Psychiatric Association and the American Psychological Association have issued ethical guidelines for the role of psychiatrists and psychologists on radio shows.

This fact sheet does not cover every alternative approach to mental health. A range of other alternative approaches - psychodrama, hypnotherapy, recreational, and Outward Bound-type nature programs - offer opportunities to explore mental wellness. Before jumping into any alternative therapy, learn as much as you can about it. In addition to talking with your health care practitioner, you may want to visit your local library, book store, health food store, or holistic health care clinic for more information. Also, before receiving services, check to be sure the provider is properly certified by an appropriate accrediting agency.

Note: Inclusion of an alternative approach or resource in this fact sheet does not imply endorsement by the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.
SAMHSA'S National Mental Health Information Center
KEN98-0044
04/03

Page last modified or reviewed by athealth on January 29, 2014

Anger. Everybody experiences it and everybody expresses it. It is a natural and healthy human emotion when managed effectively. But it can be a source of various physical, mental, emotional, social, or legal problems when not managed effectively. It is often a problem in one of these areas that brings a client in for counseling, either on a voluntary or a mandated basis. As a counselor, there are numerous and varied options for intervention. And there are numerous and varied aspects to consider before selecting an appropriate intervention.

Defining Anger

There are many different views from which to consider the construct of anger. Dahlen and Deffenbacher (2001) identify three main ingredients to anger. First, there is an anger-eliciting stimulus, typically an easily-identifiable external source (e.g., somebody did something to me) or internal source (e.g., emotional wounds). Second, there is a pre-anger state, which includes one's cognitive, emotional, and physical state at the time of provocation; one's enduring psychological characteristics; and one's cultural messages about anger and about expressing anger. Third, there is one's appraisal of the anger-eliciting stimulus and one's ability to cope with the stimulus. All three of these ingredients interact to create a state of being angry.

Dahlen and Deffenbacher (2001) also identify four related domains in which anger exists. First, in the emotional and experiential domain, anger is a feeling state ranging in intensity from mild annoyance to rage and fury. Second, in the physiological domain, anger is associated with adrenal release, increased muscle tension, and activation of the sympathetic nervous system.

Third, in the cognitive domain, anger is associated with biased information processing. Fourth, in the behavior domain, anger can be either functional (e.g., being assertive, setting limits) or dysfunctional (e.g., being aggressive, withdrawing, using alcohol and drugs, etc.).

Rhoades (n.d.) provides additional ways to understand anger. What is the source and expression of the anger? Is it intense and situation-specific or chronic and generalized? What is the extent of the anger? Does it easily and quickly evolve into deep feelings of resentment? Is it coupled with intense aggression or explosiveness? Has it become uncontrollable? What is the anger hiding? Is it a cover-up for fear, being used as a shield to keep other people at a distance so they are unable to see one's insecurities and weaknesses?

Expressing Anger

The expression of anger can take many forms. Some common means of expressing anger include venting, resisting, seeking revenge, expressing dislike, avoiding the source of anger, and seeking help (Marion, 1997). However, in many cultures, people are taught that while expressing anxiety, depression or other emotions is acceptable, expressing anger is not (Controlling anger before it controls you, n.d.). As a result, many people never learn how to handle their own or others' anger effectively or to channel it constructively.

Gorkin (2000) distinguishes between the intention and the usefulness of anger expressions. In terms of intention, the expression of anger can be purposeful or spontaneous. The purposeful expression of anger is intentional, has a significant degree of consideration or calculation, and yields a high degree of self-control. The spontaneous expression of anger is immediate, has little premeditation, and yields little to moderate self-control.

In terms of usefulness, the expression of anger can be constructive or destructive. Constructive expression of anger affirms and acknowledges one's integrity and boundaries without intention to threaten another person. Destructive expression of anger defensively projects and rigidly fortifies one's vulnerable identity and boundaries. These distinctions provide for four basic expressions of anger. Purposeful and constructive expression leads to assertion. Purposeful and destructive expression leads to hostility. Spontaneous and constructive expression leads to passion and suffering. And spontaneous and destructive expression leads to rage, violence, screaming, and hitting. With respect to rage, one can be outraged, by a seemingly clear and external (sometimes criminal) target, or one can be "in-raged" (Gorkin, 2000), by a reaction to still unresolved internal hurts and humiliations (vs. actual, immediate stimulus-and-response provocation).

Although much of the work in anger management focuses on helping people understand what triggers their anger and on learning a healthier response, or expression, of that anger, the debate continues regarding the healthiest ways to express anger. Interestingly, some sources (e.g., Schwartz, 1990) indicate that repressing anger can be adaptive for coping with certain emotions. Other sources (e.g., Controlling anger before it controls you, n.d.) document that suppressing anger can lead to headaches, hypertension, high blood pressure, depression, emotional disturbances, gastrointestinal disorders, respiratory disorders, skin disorders, genitourinary disorders, arthritis, disabilities of the nervous system, circulatory disorders, and even suicide. It is important to learn to identify whether or not a client's reactions to and expressions of anger are a problem.

Assessing Anger

How does a client know when his or her anger is more of a problem than a help? Few formal assessments exist to quantifiably measure the level of one's anger. However, there are numerous qualitative indicators to review with clients to understand the extent of their concerns about their anger and anger management strategies.

• Is the anger chronic, long-lasting, too intense, or too frequent (Rhoades, n.d.)?
• Does the anger disrupt the client's thinking, affect the client's relationships (Rhoades, n.d.), or affect the client's school or work performance?
• Does the client exhibit frequent loss of temper at slight provocations, passive-aggressive behavior, a cynical or hostile personality, chronic irritability and grumpiness?
• Has the client begun to display low self-esteem, sulking, or brooding?
• Is the client withdrawing socially from family and friends?
• Is the client getting physically sick or doing damage to one's own or others' bodies or property?
• Is the client experiencing physical symptoms such as increased heart rate, increased blood pressure, or increased adrenaline flow (Controlling anger before it controls you, n.d.)?

Although some of these symptoms may be indicative of other issues, they are also often related to unresolved anger. The bottom line is that when a person becomes a victim to his or her anger, the anger is a problem.

Managing Anger

According to Wellness Reproductions (1991), there are three main methods of dealing with anger. First, there is "stuffing" one's anger, a process in which a person may or may not admit his or her anger to self or others and in which one avoids direct confrontations. A person may stuff his or her anger out of fear of hurting someone, fear of rejection, fear of damaging relationships or fear of losing control. Often, a person who stuffs anger is unable to cope with strong, intense emotions and thinks that anger is inappropriate or unacceptable. Stuffing one's anger typically results in impaired relationships and compromised physical and mental health.

Second, there is escalating one's anger, a process in which a person provokes blame and shame. The purpose is to demonstrate power and strength while avoiding the expression of underlying emotions. A person who escalates his or her anger is often afraid of getting close to other people and lacks effective communication skills. Escalating one's anger typically yields short-term results, impaired relationships, and compromised physical and mental health. Sometimes, escalating one's anger also leads to physical destruction of property or to abusive situations, thus adding the potential for legal ramifications.

Third, there is managing one's anger, a process in which a person is open, honest, and direct and in which one mobilizes oneself in a positive direction. The focus is on the specific behavior that triggered the anger and on the present (past issues are not brought into the current issue). A person who manages his or her anger avoids black and white thinking (e.g., never, always, etc.), uses effective communication skills to share feelings and needs, checks for possible compromises, and assesses what is at stake by choosing to stay angry versus dealing with the anger. Managing one's anger results in an increased energy level, effective communication skills, strengthened relationships, improved physical and mental health, and boosted self-esteem.

Summary

It is this process of managing one's anger that is the primary goal of counseling people to effectively deal with anger. The goal is not to eliminate anger. Anger is a natural and healthy emotion. After a client acknowledges he or she is angry, a counselor can help the client learn how to reduce the emotional and physiological arousal that anger causes and learn to control its effects on people and the environment. To be more effective, practitioners should attempt to understand the extent and expression of the anger, the specific problems resulting from the anger, the function the anger serves, the underlying source of the anger, and the domain the problems occur in (e.g. emotional, physiological, or cognitive) before choosing interventions for the client.

Specific strategies and skills as well as some additional considerations in helping clients manage anger are reviewed in Anger Management 2: Counseling Strategies and Skills.

References

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J.

V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Gorkin, M. (2000, August 17). The four faces of anger. Retrieved July 23, 2003

Marion, M. (1997). Guiding young children's understanding and management of anger. Young Children, 52(7), p. 62-67.

Rhoades, G. F. (n.d.) Anger management online conference transcript. Retrieved July 23, 2003

Schwartz, G. E. (1990). Psychobiology of repression and health: A systems approach. In J. L. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health. Chicago: University of Chicago Press.

Wellness Reproductions. (1991). Anger management. Retrieved July 23, 2003

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482766
2003-12-00
Author: Eileen K. Hogan

Page last modified or reviewed by athealth on January 29, 2014

Many different strategies and skills for anger management intervention have been tried and tested. Some of the most empirically supported interventions are cognitive-behavioral interventions including relaxation coping skills, cognitive interventions, behavioral coping and social skills training, and problem-solving skills training.

According to Dahlen and Deffenbacher (2001), relaxation coping skills target both the emotional and physiological arousal associated with anger with the intent being to lower the anger arousal. In contrast to targeting arousal, cognitive interventions target biases in information processing and cognitive appraisals. They help to identify distorted patterns of thinking, develop more reality-based and less anger-engendering cognitions, and free up problem-solving and coping resources.

Behavioral coping and social skills training target the actual expression of anger (vs. reducing anger arousal). Specific skills training that has been empirically supported includes direct coping skills (e.g., interpersonal communication, negotiation, feedback), related coping skills (e.g., parenting, budgeting and financial planning, assertive communication), and inductive social skills training (e.g., clients identify and explore effective behaviors for coping with anger) (Dahlen and Deffenbacher, 2001).

Problem-solving skills training is useful when there are no behavioral skill deficits (e.g., poor social skills) but there is a lack of general problem-solving skills with which to assess situations and to choose various coping skills. A basic problem-solving methodology is to identify the problem, generate alternative solutions, consider theconsequences of each solution, select an effective and appropriate response, and evaluate the outcomes of implementing the specific response (Skiba & McKelvey, 2000).

Additional strategies that have been found to be useful in managing anger effectively include avoiding situations that make one angry, changing environments, focusing on something positive, engaging in substitute positive activities, and improving communication and social skills. Humor has also been found to be helpful when it is used constructively to help face problems; sarcastic humor is just another form of unhealthy anger expression (Controlling anger before it controls you, n.d.).

Structured Programs

In addition to the strategies and skills highlighted above, there are numerous structured and pre-packaged programs for helping people learn to manage their anger more effectively. These programs vary in intended audience, theoretical basis, teaching method, and actual skills and techniques used. A summary of several programs can be found in Anger Management 3: Structured Interventions.

Additional Considerations in Anger Management Interventions

Cultural Impact of Client's Natural Environment

Howells and Day (2002) highlight the importance of understanding the culture a client returns to upon leaving a counseling or training session. Will the culture support the behavior changes and thinking processes that the client has been learning? In some cases (e.g., the gang a client hangs out with, incarcerated clients, institutionalized clients), the culture the client lives in day-to-day will not necessarily support the kinds of changes a client may be trying to make.

Indeed, daily survival may be based on vastly different modes of operation than a client may be practicing in counseling. It is important to clarify which culture is in charge of the client's daily life (e.g., the family and its subcultures? the street corner and friends? the neighborhood? the school and teachers?) and how it may affect a client's success in learning to manage anger more effectively.

Transferring Skills to the Classroom, Workplace, and Home

Another consideration is the adequate transfer of skills learned in counseling to one's natural environment. This could be the classroom, the workplace, or even one's home. Besley (1999) conducted an experiment on transferring skills to the classroom environment of a student client.

According to Besley (1999), change begins at a teachable moment, and four conditions are necessary for change:

• the person is in an environment where he or she feels safe,
• the person is supported and encouraged during the change process,
• the environment is relevant to the person, and
• the person is involved and has some degree of control in the change process.

In a school setting, when a counselor has been working with a student individually to develop more effective anger management skills, there still remains the issue of encouraging the student to use the new skills outside the counseling sessions (e.g., in the classroom, in the cafeteria, on the playground). One proven way to do this is to have the counselor sit in the classroom (or cafeteria or playground) with the student and be available to coach the student right at the moment(s) he or she becomes angry (Besley, 1999). The counselor can then coach the student's cognitive processes and help the student cope with impulsivity and, at the same time, model effective and useful skills for the other students and even the teacher.

Readiness for Anger Management Intervention

The best anger management training delivered by the most qualified counselor will be ineffective if the client is not ready for anger management training. According to Howells & Day (2003), there are several different things that can impact readiness for anger management.

Sometimes there are a complex array of factors presenting with the anger problem. People with certain mental and personality disorders may also have an anger management problem. Or anger management and control may be a symptom of a serious mental or personality disorder.

Existing client inferences about their anger "problem" can impact their readiness. Some clients may view anger as an appropriate response to many situations. Some clients may believe that catharsis is the best approach (expressing anger is considered better than controlling it) or that angry responses get results (in reality, although angry outbursts sometimes generate desired short- term results, they rarely result in long-term change). Attitudes of self-righteousness, low personal responsibility, blaming others, and condemning others also reduce readiness. For some clients, anger may not even be considered a problem. In fact, anger may be adaptive in certain settings for the client: it may bring with it many social benefits such as perceptions of higher status, strength, and competence. Unfortunately, these types of beliefs and perceptions can be difficult to uncover and assess.

The client's skill level also impacts readiness for effective treatment. People need certain cognitive processes with which to think about consequences and choices in order to improve anger management skills. Sometimes a person's impulsive nature will interfere with the application of such cognitive processes. Other issues that impact a client's readiness are difficulty judging the intent of others, underestimating one's own reaction to anger-provoking situations, wanting to blame conflict on others, an inability to distinguish one's feelings, and poor social and problem-solving skills.

Finally, the client's beliefs about treatment impact readiness. Even in coerced or mandatory treatment, if the client concurs with the need for treatment and perceives the treatment as likely to be helpful in meeting his or her goals, then coercion is not as big an issue. However, if the client believes the treatment is not likely to fulfill his or her personal goals, then coercion could definitely impact readiness.

How does a counselor positively influence the readiness variables? Counselors can explore the personal goals of the client and help the client become aware of any discrepancies between the actual social consequences of their anger expression and the pursuit of their personal goals. Counselors can work to incorporate the client's goals and treatment plan into the values and goals of the existing informal culture of the client.

Counselors can also help clients build appropriate interpersonal and cognitive skills and develop an appropriate vocabulary for communicating triggers, thoughts, emotions, and behaviors.

Variables that Influence Effective Treatment

In studies on the effect of anger management interventions with student populations, Skiba and McKelvey (2000) found three variables to have the most influence. First, the length of treatment: typically, more sessions yield stronger initial outcomes and booster sessions (e.g., annually) improve long-term outcomes. Second, proper framing: the more the training is made relevant to the student and the environments in which he or she lives on a daily basis, the stronger the initial outcomes. Finally, supplemental interventions (e.g., utilizing weekly goals, utilizing components of Aggression Replacement Training) help improve initial outcomes. Although these factors were studied specifically in reference to student populations, they are likely applicable to other client bases as well.

Summary

Anger. Everybody experiences it and everybody expresses it. Some people manage their anger in healthy ways. Other people are managed by their anger in unhealthy ways. Although there are many skills, strategies, and structured programs (see Anger Management 3: Structured Interventions) known to help people improve how they deal with anger, there are many factors to consider when selecting an effective intervention. In addition to understanding the expression, function, source, and resulting problems of a client's anger (see Anger Management 1: An Overview for Counselors), practitioners can also attempt to understand the client's cultural needs with respect to dealing with the problem, the ability of the client to transfer new skills to their daily environments, and the client's readiness and skill level for dealing with the problem. Only then can the practitioner choose an intervention that will be truly effective for the client.

For more information please see: Anger Management 1: An Overview for Counselors

References

Besley, K. R. (1999). Anger management: Immediate intervention by counselor coach. Professional School Counseling, 3(2), pp. 81-90.

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association.

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J. V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Howells, K. & Day, A. (2003). Readiness for anger management: clinical and theoretical issues. Clinical Psychology Review, 23. pp. 319-337.

Skiba, R. & McKelvey, J. (2000). What works in preventing school violence: The safe and responsive fact sheet series - Anger management. Retrieved July 23, 2003 from What works in preventing school violence

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482767
2003-12-00
Author: Eileen K. Hogan

Page last modified or reviewed by athealth on August 27, 2018