User:PseudoPsych/sandbox

History
The negative effects of anger have been observed throughout history. Advice for countering seemingly uncontrollable rage has been offered by ancient philosophers, pious men, and modern psychologists. Seneca The Younger (4 BC- 65 AD) advised for pre-emptively guarding against confrontational situations, perspective taking, and not inciting anger in anger-prone individuals. Other philosophers echoed Seneca with Galen recommending seeking out a mentor for aid in anger reduction. In the middle ages, saints would serve as both examples of self-control and mediators of anger-induced disputes. Examples of intercession for the common people from the wrath of local rulers abound in hagiographies. The story of St. Francis of Assisi and the metaphorical Wolf of Gubbio is one famous instance.

In modern times, the concept of controlling anger has translated into anger management programs based on the research of psychologists. Classical psychotherapy based anger management interventions originated in the 1970's. Success in treating anxiety with Cognitive behavioral therapy (CBT) interventions developed by Meichebaum inspired Novaco to modify the stress inoculation training to be suitable for anger management. Stress and anger are sufficiently similar that such a modification was able to create a successful branch of treatment. Both stress and anger are caused by external stimuli, mediated by internal processing, and expressed in either adaptive or maladaptive forms. Meichebaum, and later Novaco, used each aspect of experiencing the relevant emotion as an opportunity for improvement to the patient’s overall wellbeing.

Targeted Populations
Empirically supported programs exist for a variety of people seeking anger management.

Adults
Anger management interventions are based in cognitive behavioral techniques and follow in a three step process. First, the client learns to identify situations that can potentially trigger the feeling of anger. If a potential trigger can be avoided, the individual can not only avoid unwanted outbursts, but also avoid internal conflict. Second, relaxation techniques are taught as appropriate responses to the identified situations. Common techniques include regulating breathing and physically removing yourself from the situation. Finally, role-play is used to practice the application of the learned techniques for future encounters with anger-inducing situations in the individual’s life. The end result of repetition is an automatic response of learned beneficial techniques. Modifications of each general step result in distinctive programs. Additionally, different fields of psychology will change aspects of the above three step process, which is primarily based in cognitive-behavioral therapy. Group, family, and relaxation only therapies each contribute to the wider range of available anger management programs. Successful interventions can result in not only a reduction of the outward display of aggression, but also a decrease in the internal level of anger.

The effectiveness of the CBT-based anger management therapies has been evaluated by a number of meta-analyses. In a 1998 meta-analysis with 50 studies and 1640 individuals, measures of anger and aggression were used to compare the effects of the anger management intervention with no treatment. A significant effect for anger management was found with a 67% chance of improvement for individuals having received the anger management as compared to the individuals without the therapy. In addition, a 2009 META-analysis compared psychological treatments for anger across 96 studies. After an average of 8 sessions, a significant improvement in anger reduction resulted. Overall, the completion of an anger management program is likely to result in long lasting positive changes in behavior.

Professionals
One motivation for seeking anger management can be career related. As both a preventative and corrective tool, anger management is available to help individuals cope with potentially anger-inducing aspects of their jobs. One such situation applies to caretakers of individuals with mental illness. The daily stress combined with slow or no progress with the people under their care can create a high level of frustration. Skills training for caretakers of relatives with dementia has been developed to help cope with these feelings of frustration in a positive manner.

Anger management is also beneficial in law enforcement. The role of police officers is to protect civilians, however conflicts between the police and the general public can develop. The goal of anger management would be to reduce such occurrences like police brutality from negatively impacting the relation between law enforcement and citizens. Anger management programs tailored towards this goal could orient themselves towards these means by focusing on conflict resolution and including specific law enforcement scenarios in the training. This need was noticed by Novaco, who originally designed an intervention for anger management based on cognitive behavioral therapy, resulting in a specialized skills training program for law enforcement.

Children and Adolescents
Anger management programs with a cognitive-behavioral basis have been modified for children and adolescents. There are three common types of CBT aimed at the youth. First, skills development (Communication, negotiation, rationalization, etc.) uses modeling to teach appropriate reactions to anger. Second, effective education focuses on identifying the feelings of anger and relaxation. Finally, problem solving conveys a view of cause and effect for situations as an alternative to anger. A wide range of methods can be used to convey these three components, with both age and severity being important factors. For younger children, involvement can be increased by presenting anger management in more of a fun format with educational games and activities being available. For adolescents, group therapy can be an effective form given the resemblance to the individual's natural social environment. The severity of expressed anger issues often relates to the intensity of the subsequent anger management program. A few violent outbursts in a classroom setting could result in several sessions with the school's counselor. However, more severe juvenile delinquency could result in court mandated anger management sessions in a juvenile correctional facility.

The effectiveness of anger management has been studied in children and adolescents for the purpose of evaluating existing programs and designing more effective programs. In a meta-analyses of 40 studies, an overall effect size of 0.67 was found for CBT anger management treatment, suggesting anger management as a legitimate approach to problematic levels of anger. Skills development (0.79) and problem solving (0.67) both had a higher impact than affective education (0.36). This was believed to be due to behavioral aspects being more easily conveyed than cognitive for children. The true value from early interventions aimed at youths comes from the preventative aspect. Curbing negative behaviors early in life could lead to a more positive outlook as an adult.

Individuals with Intellectual Disabilities
Individuals with intellectual disabilities can struggle with managing anger. When faced with aggression from individuals with an intellectual disability, caretakers often employ a combination of four different strategies. Depending on both the setting and individual, the following strategies for aggression minimization present in different ways.

1. Reactive Strategies - Aim to minimize impact of overtly aggressive behavior by using established protocols. Ex. Enforced isolation after the start of a violent outburst.

2. Ecological Interventions - Attempt to reduce aggression level by changing an aspect of the environment for a more calming effect. Ex. Reducing ambient noise to lower irritation.

3. Contingency Management - Focuses on modifying behavior through a combination of reinforcement and punishment. Ex. Using a token economy to enforce rules concerning behavior.

4. Positive Programming - Teaches life skills as an alternative to aggression. Ex. Anger management with a CBT background.

The need for anger management is also evident in situations where individuals with intellectual disabilities are prescribed psychotropic medication as the result of aggressive and/or self-injurious behavior. The medication’s role as a chemical restraint does not help modify the underlying cause of aggression. Sedation is best used as an emergency measure with skills training as a long term solution to decreasing the overall rate of violent incidents. In a meta-analysis reviewing 80 studies, behavioral based interventions were found to be generally effective in modifying behavior. Additionally, cognitive behavioral therapy as administered by lay therapists was found to be effective, which supports the feasibility of such anger management programs.

Impediments
There are a number of factors that can lower the probability of a successful anger management intervention. One such obstacle is the level of the individual's motivation. Overall low readiness is an impediment to the effectiveness of anger management due to the lower attendance rates and negative effect on the therapeutic alliance. Involuntary assignment to an anger management program, for example court mandated sessions, will result in a lower average motivation level than voluntary admission. In one study with incarcerated inmates, there was a correlation found between individual readiness and improvement.

Additionally, given the component of anger as a social construct, difficulty with communication between cultures can serve as another impediment. What is deemed an appropriate expression of anger is culturally dependent. Therefore, a mismatch between client and therapist could result in a misunderstanding as to the end goal of the program. For example, a client could only wish to decrease physical violence, while the therapist aims to decrease both verbal and physical outbursts. Gender dependent expectations of anger expression can contribute as well to societal standards. The same violent outburst for a man and woman is subject to different interpretations due to anger being seen as more permissible in males.

The cost of taking anger management could also be a significant obstacle. The time required for anger management depends on the program. Weekly one hour sessions with 8-12 sessions per program are common, but a single intensive all day session variety exists as well. The monetary cost can amount to $30-$50 per session for general therapy, or much higher fees for specialized coaching. The availability of anger management programs locally can be problematic for more isolated areas, creating an additional cost for travel. However, online options can follow the same structure as an in person intervention with similar outcomes.

Benefits
The benefits of undergoing anger management center around the successful reduction in anger and violent outbursts. Personal relationships that have been previously strained by a high level of aggression are likely to undergo improvement. Professionally, workplace relationships have a similar outcome that are beneficial to an individual's career and personal sense of satisfaction. Legally, continued attendance to anger management programs, mandated or not, can be seen as a sign of good faith. For incarcerated individuals, an earlier parole time can be the result of good behavior learned from anger management classes. From an emotional standpoint, reducing the internal level of anger results in a decrease in stress and an increase in overall happiness as a result.

From a medical standpoint, physical illnesses also improve from positive emotional and behavioral changes. Anger management style and overall level of anger has been associated with both acute and chronic pain sensitivity. Blood pressure is another physiological aspect effected by anger, with increased levels of anger being correlated with higher blood pressure. The implications of an effect on blood pressure for overall health is made evident by the link between high blood pressure and the increased risk of cardiovascular disease. An increase in the immune system's efficacy has also been observed as a result of the increased level of relaxation. Successful anger management could also lead to an overall longer life span due to the decrease in reckless behavior and violent altercations.