Anger Management In Substance Abuse Based On Cognitive .
Zarshenas et al. BMC Psychiatry (2017) 17:375DOI 10.1186/s12888-017-1511-zRESEARCH ARTICLEOpen AccessAnger management in substance abusebased on cognitive behavioral therapy: aninterventional studyLadan Zarshenas1, Mehdi Baneshi2, Farkhondeh Sharif3* and Ebrahim Moghimi Sarani4AbstractBackground: Anger and aggression have been developing notably in societies, especially among patients dependingon substance abuse. Therefore, this study aimed to investigate the effect of anger management based ongroup education among patients depending on substances according to Patrick Reilly’s cognitive behavioral approach.Methods: In a quasi- experimental study, all patients who met the inclusion criteria were evaluated regarding theiraggression level. The participants were assigned to 12 educational sessions based on group therapy and Patrick-Reilly’sanger management by focusing on using a combination of cognitive intervention, relaxation, and communicationskills. The data were analyzed using the SPSS statistical software, version 16.Results: The findings showed a significant difference between the two groups regarding aggression level afterthe intervention (p 0.001). No significant relationship was observed between aggression level and demographicvariables (p 0.05).Conclusion: The intervention of this study can be used for establishing self-management and decreasing angeramong patients depending on substances. They can also be used as a therapeutic program in addition to pharmacotherapy.Trial registration: IRCT2016102030398N1.Keywords: Aggression, Anger management, Cognitive behavioral therapy, Substances abuseBackgroundAnger arousal is often known as an adaptive response toaffective discomfort, which is represented by aggressivebehaviors [1] and can affect human relations. It is in facta feeling observed before aggressive behaviors. Studieshave shown that individuals with high levels of anger gotinvolved in verbal and physical aggression [2]. Thismight lead to aggressive behaviors towards familymembers and other individuals [3]. The prevalence ofaggression in a study by Nooripour et al., [4] wasreported to be 5% to 20%. Substance abuse and its consequences are among the most common health problems around the world [5]. Therapists often believe thatanger and aggression are associated with substance* Correspondence: farkhondeh Sharif@yahoo.com; fsharif@sums.ac.ir3Community Based Psychiatric Care Research Center, Shiraz University ofMedical Sciences, Shiraz, IranFull list of author information is available at the end of the articleabuse. Investigations have also shown that 40% of cocaine consumers suffered from different levels of aggression [6]. According to the World Health Organization,although law enforcement due to fear of punishmentcan have an impact on the behavior, change in beliefsthat reduce aggression and crime requires more timeand interventions [7]. Such methods led to reverse results in some cases compared to interventional programsbased on penalty and positive reinforcement among prisoners in a British camp. The results of that study indicated that the rate of crime recommitment wasincreased by focusing more on penalty [8]. Researchfound that anger management has a positive effect onthe prevention of offender behavior [9]. In fact, benefitting from anger management skills led to an increase inindividuals’ adjustment ability as well as psychologicalcapability [10]. Cognitive behavioral therapy is a methodused for treating a large number of mental disorders. Itbasically focuses on recognizing incorrect, negative, and The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Zarshenas et al. BMC Psychiatry (2017) 17:375illogical beliefs affecting patients’ affection, behaviors,and belief reconstruction [11]. The Patrick-Reilly approach is a cognitive behavioral approach based on acombination of cognitive interventions, relaxation, andcommunication skills. During therapeutic sessions basedon Patrick-Reilly’s approach, different strategies are provided for controlling anger initiation and its consistency.In addition, some tasks are given to participants in orderto guarantee learning. A number of these strategies includerelaxation through respiration, progressive muscle relaxation, thought blocking, and assertion skills [6]. Considering the importance of anger and aggression control amongpatients abusing substances, researcher’s experience aboutthe frequency of aggression and physical conflicts betweenpatients and nurses in psychiatric wards, and families’ concern about management of this misbehavior after their discharge, the present study aims to perform angermanagement group education based on Patrick Reilly’scognitive behavioral therapy approach. The aim of theintervention is to provide participants with education according to evidence-based and scientific findings in waysthat help them to gradually be able to control and managetheir anger through simple strategies and skills.MethodsStudy designThis study was a non-randomized trial with pretest/posttest evaluation on patients divided into an interventionand a control group.SamplingThe study population included all patients admitted inEbnesina Hospital, Shiraz, Iran. Considering α 0.05 andpower of 80% and using NCCS software, a 40-subjectsample size was determined for the study (20 subjects ineach group). The effect size based on the previous studywas calculated as about 1 (mean different 23, SD 14).The inclusion criteria of the study were depending onsubstances and not suffering from any psychiatric disorders affecting aggression (such as schizophrenia, bipolardisorder, PTSD and psychotic disorder that was diagnosedby the psychiatrist) On the other hand, the exclusion criteria were abusing substances and not participating ineducational sessions. “Depending on substances” vs.“abusing substances” was differentiated by the psychiatristaccording to the DSM-IV-TR criteria. In addition, theusers of amphetamines and stimulants who were sufferingfrom psychotic symptoms and could not participate ingroup therapy were excluded from the research sample.First, patients who were admitted in the EbnesinaHospital and met the inclusion criteria were selected(n 120). Then, Aggression Questionnaire (AGQ) wasused to measure their aggression levels. Those with ahigh aggression level were identified. Of these, 20 werePage 2 of 5non-randomly assigned to the intervention group and 20in the control group (Fig. 1). The members of the twogroups were not able to communicate with each otherduring the intervention. Although the staff were not awarewhich patients were in either of the groups, and also thepatients did not communicate with each other and shareinformation since they had been selected from differentparts, but complete blinding was not possible because ofthe intervention was performed by the researcher in theintervention group.It should be mentioned that of the 40participants, 2 patients in the intervention group refusedto attend the treatment sessions and also 2 patients in thecontrol group fled from the hospital. Since the doors ofpsychiatric hospitals are closed in Iran and the patientsare not able to leave the hospital freely, most of patientswith mental illness who are addicted to drug abuse arenot willing to stay in the hospital.Ethical considerationsThis study was approved by the Research Vicechancellor and Ethics Committee of Shiraz University ofMedical Sciences (95–10,537).ProcedureFirst, the study objectives and procedures were explainedto the participants and their informed consents were obtained. Then, the participants were non-random dividedinto an intervention and a control group. The first groupreceived an educational anger management course basedon Patrick Reilly’s cognitive behavioral therapy. The treatment sessions were held in the hospital ward. In doing so,they were classified into 10-group units and received 121.5 h educational sessions. The content of these sessionsconsisted of anger management, anger recognition, cognitive behavioral strategies for anger control, assistant techniques for anger control, and impact of pervious learningand practical tasks. Meanwhile, routine education wasprovided for the control group participants. One weekafter finishing the course, the rate of aggression was measured by AGQ in both study groups.Statistic methodsData analysis was performed using SPSS software(Version 16). To determine the participants’ demographic characteristics, descriptive statistics includingabsolute and relative frequency distribution, mean, andstandard deviation were used. In addition, intergroupcomparisons were performed using independent samplest-test. To evaluate the effectiveness of the treatment ineach group, paired samples t-test and chi-square testwere used. Finally, to compare the difference betweenthe two groups in terms of more than three variables,One-Way ANOVA was run.
Zarshenas et al. BMC Psychiatry (2017) 17:375Page 3 of 5Fig. 1 Flow chart of study designInstrumentsThe study data were collected using a demographic information form and AGQ. The demographic information form included age, education level, marital status,and type and duration of substance abuse. Indeed, AGQassessed the patients’ level of aggression. This questionnaire was invented by Buss and Perry in 1992 [12]. InIran, the psychometric characteristics of AGQ were determined by Najarian. Accordingly, its test-retest reliability coefficients were reported to be 64 and 74% [13].ResultsThis study was conducted on 36 participants. Most of theparticipants were between 20 and 40 years old and a fewof them were less than 20 years old. The mean age of theparticipants was 33 and 31 years in the intervention andcontrol groups, respectively. Besides, 66% of the participants were single and 33% were married. Additionally, 50,38, and 11% of the participants had below diploma degrees, diplomas, and B.Sc. degrees, respectively. Moreover,52, 22 and 25% of the participants abused opium, heroin,and methadone, respectively (Tables 1 and 2).The intervention group’s mean level of aggression was54.11 before the intervention and 47.72 after that. Thesemeasures were respectively 59.17 and 63.72 in thecontrol group. Based on the results of paired t-test, thelevel of aggression changed significantly in both groupsafter the intervention.According to Table 3, the mean of aggression level decreased by seven scores in the intervention group, butincreased by four scores in the control group, whichwere both statistically significant. In the interventiongroup, the mean of aggression level decreased by at leastone score and at most 11 scores. On the other hand, thismeasure increased by at least one score and at mosteight scores in the control group.DiscussionAnger and aggression are not only socially unacceptable,but they are also considered to be the risk factors forhealth problems. Moreover, the risk of showing aggressive and dangerous behaviors was higher among individuals with mental illnesses [14]. The present study aimedto assess the impact of group education based on angermanagement on aggression level among patients suffering from substance abuse. This is one of rather few studies of anger management with adults, though. In thecurrent study, 50, 38, and 11% of the participants hadbelow diploma degrees, diplomas, and B.Sc. degrees, respectively. Therefore, most of the participants had below
Zarshenas et al. BMC Psychiatry (2017) 17:375Page 4 of 5Table 1 Comparison of qualitative demographic characteristics among participants in control and experiment groupPvaluetwo groupscontrol group% Of 1Single33.227.7538.87Married49.955.51044.48High school 24.927.7522.24Methadone0.280.87Experiment groupdiploma degrees, which is in agreement with the results ofsome studies [15, 16], but inconsistent with some others[17]. Low level of education is a predisposing factor fordependency on substances. However, few studies havebeen conducted on the prevalence of substance abuseamong individuals with below diploma degrees. Thus, it isnot clear whether the large number of dependent cases isrelated to the higher availability of substances or theopenness of this group in expressing their dependencycompared to those with high education levels.In the current study, the results of data analysis indicated that the level of aggression was higher thanthe average level before the intervention. This is compatible with the results of some studies [3, 18], butnot consistent with some others [19]. Increase of aggression among patients and other society memberscan be attributed to high levels of stress in urban andindustrial communities. Yet, our study findings revealed that interventions on anger management skillscould significantly decrease the level of aggressionamong patients dependent on opioid materials. Whilethe control group did not receive the training, thelevel of aggression was higher suggesting that physicaland recreational environments in mental hospitalsmay be vital to reduce the influence of the environment on patients’ aggression.Table 2 Comparison of quantitative demographic characteristicsof participants in the experiment and control groupsPvaluecontrol groupExperiment 1150920 to 40 years22.2427.75Above 40 yearsLess than 20 years31.5633.22mean99Standard deviationVariableAgeVariableMarriage statusEducationOpioid typeHaving the skill of anger management will increaseone’s adaptive and psychological capacity. Lack of awareness about the right ways to live and absence of necessary skills, provide the context for mental illness andsocial dilemmas, which are mainly the result of poor education. Anger management training can raise people’sawareness about the concept of anger, the factors causingviolence and ways to control it. Moreover, it can promotehealthy and useful social behaviors and how to deal withpsychological stress in order to enable people not to useaggressive behaviors in their interactions with others.This is compatible with the results of some previousinvestigations [20, 21]. However, several studies assessingthe effect of cognitive behavioral approach on anger management came to contradictory results. For instance,Ozabaci conducted a meta-analysis in 2011 and found thatthis approach was not as effective as expected in aggressionamong children and adolescents [22]. Farajzadeh alsoemployed the same approach in group education for angermanagement. They evaluated the effect of this approachon aggression and social qualification of adolescents livingin Welfare Organization’s dormitories in Tabriz, Iran. Theyfound that the intervention was not effective in changingadolescents’ social skills and aggression levels [23]. The difference among the results might be due to differences incontents and durations of educational interventions. Alsothis difference may also be due to the difference in contextand nurture of the dormitories’ welfare organization.ConclusionsThe results of this study showed that anger managementeducation could decrease the level of aggression anddevelop health promotion among patients abusingsubstances. Considering the importance of anger management and aggression control, anger managementeducation performed by nurses and other healthcaremembers is highly crucial. Moreover, the level of
Zarshenas et al. BMC Psychiatry (2017) 17:375Page 5 of 5Table 3 Comparison of the mean aggression level before and after the intervention between the experiment and control groupspvalueControl groupStandard deviationMeanExperiment groupStandard deviationMean0.1881259.1710.5854.11Before intervention0.0011163.7210.0047.72After intervention–0.0130.015aggression was closely related to substance abuse. Thus,it is a main barrier against quitting addiction. Therefore,it is essential to encourage nurses to establish permanenteducational programs, especially in psychiatric wards,for controlling patients’ anger through anger management using group education.3.AcknowledgementsThe present article was extracted from the M.Sc. thesis written by MehdiBaneshi. Hereby, the authors would like to thank Ms. A. Keivanshekouh at theResearch Improvement Center of Shiraz University of medical Sciences forimproving the use of English in the manuscript. They are also grateful for thepatients for contributing their time to the study.7.8.4.5.6.9.10.FundingNot applicable.Availability of data and materialsData will not be shared because of the confidentiality of patient data.11.12.13.Authors’ contributionsLZ, FS, and EM participated in study design, data collection, and data analysis.MB participated in data collection and data analysis. All authors read andapproved the final manuscript.Ethics approval and consent to participateInformed consent obtained from participants was written. The study wasapproved by the Ethics Committee of Shiraz University of Medical Sciences(IR.SUMS.REC.1395.18).14.15.16.17.Consent for publicationNot applicable.18.Competing interestsThe authors declare that they have no competing interest.19.Publisher’s Note20.Springer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.21.Author details1Department of Mental Health and Psychiatric Nursing, Community BasedNursing and Midwifery Research Center, School of Nursing and Midwifery,Shiraz University of Medical Sciences, Shiraz, Iran. 2Department of Nursing,School of Nursing and Midwifery, Student Research Committee, ShirazUniversity of Medical Sciences, Shiraz, Iran. 3Community Based PsychiatricCare Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.4Department of Psychiatry, Research Center for Psychiatry and BehaviouralScience, Shiraz University of Medical Sciences, Shiraz, Iran.Received: 10 April 2017 Accepted: 16 October 2017References1. Novaco RW, Ramm M, Black L. Anger treatment with offenders, Theessential handbook of offender assessment and treatment; 2005. p. 129.2. Kassinove H. Anger disorders: Definition, diagnosis, and treatment: Taylor &Francis; 1995; p. 109.22.23.P-valueDiGiuseppe R, Tafrate RC. Anger treatment for adults: a meta-analyticreview. Clin Psychol Sci Pract. 2003;10(1):70–84.Nooripour R, et al. Effectiveness of psychodrama on aggression of femaleaddicts with bipolar personality. J Addiction Prevention. 2016;4(1):4.Lowinson JH. Substance abuse: a comprehensive textbook. Philadelphia:Lippincott Williams & Wilkins; 2005. p.1260.Reilly PM, Shopshire MS. Anger management for substance abuse andmental health clients: A cognitive behavioral therapy manual. J Drug AddictEduc Erad. 2014;10(1-2):198–238.Butchart, A. and C. Mikton, Global status report on violence prevention, 2014.McDougall C, et al. Evaluation of HM prison service enhanced thinking skillsProgramme. Minist Justice Res Ser. 2009;3(9):1–60.Henwood KS, Chou S, Browne KD. A systematic review and meta-analysison the effectiveness of CBT informed anger management. Aggress ViolentBehav. 2015;25:280–92.Van Vugt E, et al. Evaluation of a group-based social skills training forchildren with problem behavior. Child Youth Serv Rev. 2013;35(1):162–7.Shafiabadi A, Naseri GR. Theories of counseling and psychotherapy. Tehran:Center for Academic Publication; 2007:115–34.Buss AH, Perry M. The aggression questionnaire. J Pers Soc Psychol.1992;63(3):452.ZahediFar S, Najarian B, ShokrKon H. Construction and validity formeasuring aggression troubleshooting. J Psychol Educ Sci. 1998;1–2:73–102.Torrey EF. Stigma and violence: Isn’t it time to connect the dots? SchizophrBull. 2011;37(5):892–6.Rasouliazad M, Hashemabadi BAG, Tabatabaei SM. Effects of cognitivebehavioral group therapy in male opiod dependent patients comorbid withmajor depressive disorder. Q J Fundam Ment Health. 2009;11(3(43)):195–204.Manning V, et al. An exploration of quality of life and its predictors inpatients with addictive disorders: gambling, alcohol and drugs. Int J MentHeal Addict. 2012;10(4):551–62.Okunna NC, et al. An evaluation of substance abuse, mental healthdisorders, and gambling correlations: an opportunity for early public healthinterventions. Int J Ment Heal Addict. 2016;14(4):618–33.Mackintosh M-A, et al. Peeking into the black box: mechanisms of action foranger management treatment. J Anxiety Disord. 2014;28(7):687–95.Shorey RC, et al. The relationship between spirituality and aggression in asample of men in residential substance use treatment. Int J Ment HealAddict. 2016;14(1):23–30.Malekpour M, Zangeneh S, and Aghbabaei S. A study of the psychometricproperties of novaco anger questionnaire (short form) in Isfahan. 2012.Hutchinson G, et al. CBT in a Caribbean context: a controlled trial of angerManagement in Trinidadian Prisons. Behav Cogn Psychother. 2017;45(1):1–15.Özabacı N. Cognitive behavioural therapy for violent behaviour in childrenand adolescents: a meta-analysis. Child Youth Serv Rev. 2011;33(10):1989–93.Farajzadeh R, et al. Learning to control anger in a group - cognitive andanger to altering the effect of a teenage boy in dormitories Bdsrprst wellbeing of the city of Tabriz. New Thoughts on Education. 2012;8(3):51–66.
to assess the impact of group education based on anger management on aggression level among patients suffer-ing from substance abuse. This is one of rather few stud-ies of anger management with adults, though. In the current study, 50, 38, and 11% of the participants had below dip
worksheets to complete homework assignments, and space to take notes for each of the ses . about anger, anger as a habitual response, and the introduction of the anger meter used to monitor anger. I. Purpose of the Group . 1) Learn to manage anger effectively. 2) Stop violence or the threat of violence.
Recognise whether you may be experiencing anger problems. Understand what anger is, what causes it and what keeps it going. Find ways to understand, manage or overcome your anger. Contents of this self help guide . Strategies that you could use to overcome your anger problems: 1. Understanding more about anger
Muay Thai Championship between universities volunteered for the study. “The Trait Anger and Anger Expression Scales” by Spielberger was used to determine the trait anger and anger expression styles of participants. Kruskal Wallis H and Mann Whitney U tests were
ANGER MANAGEMENT. for Substance Use Disorder and Mental Health Clients Overview of Group Anger Management Treatment. Definitions . In the most general sense, anger is a feeling or emotion that ranges from mild irritation to intense fury and rage. Many people often confuse anger with aggression. Aggression is behavior
III. Statewide Trends in Substance Abuse Part 1: Demographics of People in Substance Abuse Treatment In fiscal year 2012, there were 105,189 total admissions to substance abuse treatment 81.2% of people in substance abuse treatment were white, and 7.1% were black, approximately reflecting the relative proportions of these races in the population.
Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual. DHHS Pub. No. (SMA) 08-4213. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2002, reprinted 2003, 2005, 2006, 2007, and 2008.
In the anger management studies using this manual, the majority of patients were from ethnic minority groups. Consistent reductions in anger and aggressive behavior occurred in these groups, indicating that anger management group treatment is effective. The treatment model is flexible and can accommodate racial, cultural, and gender issues.
The new 2nd grade Reading Standard 6 has been created by merging two separate reading standards: “Identify examples of how illustrations and details support the point of view or purpose of the text. (RI&RL)” Previous standards: 2011 Grade 2 Reading Standard 6 (Literature): “Acknowledge differences in the
