• Ex-serving ADF members report significantly greater levels of anger than serving ADF members (DVA, 2018).
• A useful tool for assessing the presence and severity of anger in veterans is the Dimensions of Anger Reactions 5 scale (DAR5).
• Interventions addressing anger should be based on a cognitive behavioural therapy (CBT) model.

Key characteristics

Problematic anger and aggression are common problems for veterans. Anger presents a potential risk to others, yet there is limited evidence-based information available for practitioners.

Anger may improve with interventions targeted at other disorders, such as PTSD or depression, however there may be benefit in using interventions specifically designed to address anger. The evidence-based interventions presented are suitable for veterans and the general population (e.g., Moreland et al., 2012).

Prevalence

Problematic anger is not in itself an accepted diagnosable condition. However, it is commonly reported as a presenting problem for veterans from Australia and the United States. For example, just over 10% of US veterans of Iraq and Afghanistan report having problems controlling violent behaviour (Elbogen et al., 2010).

Screening and assessment

There are a range of key questions that GPs and mental health care practitioners can ask to:

1. identify the severity of problematic anger in veterans
2. screen for risk of aggression and harm to others

Practitioners should be mindful to consider the possibility of violence to loved ones and others. Some useful screening questions for problematic anger include:

• Do you find that you are often bothered by feelings of anger?
• Does your anger interfere with your mood, relationships, work or physical health?
• Are there times when you feel so angry that you have thoughts of harming someone?

If the veteran answers ‘yes’ to the final question, screen for risk of harm to others with questions such as:

• What is it you have thoughts of doing and to whom?
• Do you have access to ... (check means and opportunity to use guns or other potentially lethal implements)?
• Have there been times in the past when you have become so angry that you have harmed someone? If so, what happened?

A useful tool for assessing the presence and severity of anger in veterans is the Dimensions of Anger Reactions 5 scale (DAR5). In a more complete assessment of anger, practitioners should:

• identify key triggers and cues to anger and the extent of the veteran’s anger responses
• investigate the chronicity and pattern of poorly controlled anger
• identify vulnerabilities to anger, including:
  • intoxication and withdrawal from alcohol and/or drugs
  • acquired head injury from physical trauma
  • alcohol dependence or overdose
• identify key people related to anger (i.e., who is the anger directed towards, or who is present when anger occurs)
• assess a veteran’s social network to help identify people who are likely to play an important role in treatment
• take a history of all forms of violence, including injuries to others and road rage, and make an appraisal of the veteran's potential to engage in violence
• explore the veteran’s legal position, including existing orders and charges pending
• assess the veteran’s ability to keep his or her partner and family safe from physical violence
• seek the veteran’s agreement to ongoing monitoring of progress and practitioner contact with family members

The assessment of anger needs to be part of a broader assessment of mental health problems. Identification of any untreated mental health disorder may not preclude participation in anger-specific treatment. However, treatment of these primary mental health disorders may address the anger problem.

Include partners and family in assessment

Partners and other family members should be included in the assessment process where appropriate. Wherever possible, the veteran’s consent to family members participating should be obtained. However, at least one assessment with family members should occur without the veteran present (with or without consent). This ensures that the safety concerns of family members are identified.

It may be necessary to negotiate that family members are seen by another practitioner or service. Particularly if the veteran does not wish his or her own practitioner to see them. This also enables the practitioner to maintain responsibility to address the family’s safety needs and risk of harm. The family assessment may act as another source of information about:

• the veteran's current and past levels of violence
• readiness to change
• violence potential

Joint sessions with the family and the veteran should only be conducted where the partner and children feel safe in both:

1. the counselling session
2. at home following the session

Practitioners may consider combined sessions after separate assessments, provided the following criteria are met:

• the couple is choosing to remain together
• the veteran’s partner expresses a wish to participate
• there is no history of severe violence
• violence is not severe enough to elicit substantial fear in the partner
• both members of the couple acknowledge aggression or violence is a problem (where aggression or violence is present)
• the partner’s mental or emotional state is sufficiently stable
• the partner possesses adequate support resources
• a safety plan for partners and family has been established

The interventions below are not suitable for veterans engaging in violence where anger is not a significant feature. These cases should be managed according to the current principles for the prevention of family violence. Anger management does not address power and control issues that feature in most family violence presentations. Referral options for practitioners not experienced in family violence are provided at the end of this section.

Psychoeducation and self-management strategies

The education phase of the treatment is critical for establishing a therapeutic alliance. Achieved through: 

• personal validation
• empathy
• addressing motivation for change

Adopting a collaborative approach based on mutual respect when working with veterans with problematic anger is important. Essential components of education include:

• monitoring of anger frequency, intensity or duration, preferably recorded in a diary
• identification of anger cues and triggers
• identification of contextual factors that influence anger
• discussion of the individual's anger response in terms of physiological arousal, cognitive and behavioural components

Education may also address the following:

• costs of anger - help the veteran to see the problems caused by
  1. dysfunctional anger, and
  2. likely benefits of anger management, both in the short and long term
• potential impact of military training on development of the anger response
• other causes of anger. e.g. ‘survivor mode’ of functioning. That is, anger in posttraumatic presentations is:
  1. intrinsically linked to perception of threat and survival needs, and
  2. threat perception and anger are reciprocally influenced (Novaco & Chemtob, 2002)
• potential impact of community attitudes towards a given conflict. Particularly for veterans of Vietnam, Iraq, and Afghanistan

Psychological interventions

Interventions addressing anger should be based on a cognitive behavioural therapy (CBT) model.

Cognitive behavioural therapy (CBT)

CBT typically includes the following elements:

• Arousal management - this includes: breathing techniques, progressive muscle relaxation, and distraction techniques. This helps the veteran to recognise and manage the physiological arousal associated with anger.
• Cognitive therapy - people with anger problems often
  1. process information inaccurately, and
  2. appraise relatively benign situations as threatening.
  Treatment needs to address faulty attribution and evaluation styles, and assist the veteran to develop ways of challenging those thinking styles. Cognitive interventions for anger and anger-related aggression should also identify and address core beliefs about gender, and explore where and how these beliefs are related to the presence of abuse and violence.
• Self-instruction training - this helps the veteran to identify the stages of their anger reaction. The veteran learns a series of statements that act to control the negative affect in the situation. These can be rehearsed to:
  1. prepare to enter an anger-provoking situation
  2. cope with encountering the situation, and
  3. evaluate the aftermath of the situation.
• Imaginal exposure - in anxiety disorders, exposure is maintained with the expectation that:
  1. habituation will occur, and
  2. the level of anxiety be reduced over time as the person learns that the situation or image is not dangerous.
  In anger, maintaining exposure can sometimes exacerbate the problem. Exposure in anger should include:
  1. assisting the veteran to imagine anger-triggering events, and
  2. practicing skills of anger management in response.
  As the anger reaction emerges, techniques of relaxation and breathing retraining are used as well as self-instructions to defuse the anger. Situations are re-evoked until the veteran is able to imagine manage each situation effectively. Influential people or aspects of each situation are also identified to assist the veteran to manage the imaginal exposure.
• Behavioural techniques - people with anger problems often have difficulties identifying strategies to solve problems without aggressive behaviour, especially interpersonal problems. Therefore, skills need to be incorporated to enhance:
  • problem solving
  • social skills
  • communication skills
  • assertion techniques
  • negotiation and conflict resolution.

‘Short circuit’ techniques, such as time-out and time management, should also be discussed. These interventions can be introduced later in the treatment program after the veteran has developed more effective anger management skills.

Therapeutic alliance

Therapeutic alliance is a significant factor contributing to beneficial treatment outcomes. This is particularly pertinent here as veterans with anger problems often have difficulty forming a working alliance with therapists. For example, therapists and veterans may fail to agree on the goals of therapy as:

• therapists may want to address a veteran’s anger
• veterans may want to focus on changing the behaviour of the targets of their anger or getting revenge

In posttraumatic presentations, the information processing bias towards threat detection may:

• result in the therapist being perceived as a threat
• lead to the veteran’s attendance at treatment prematurely terminated

Discussion of the ‘survivor mode’ model of bias toward threat detection may be helpful in pre-empting threats to the alliance.

Problematic anger differs somewhat from other mental health problems in that a veteran may be:

• slower to recognise the problem
• less receptive to treatment

Veterans with problematic anger are more likely to present to treatment at the behest of others. As opposed to self-recognition of their own distress and difficulties. Therefore, there is a greater emphasis on education for problematic anger as it helps to build the case to the veteran on the need for treatment. In this way, the veteran is more likely to recognise the problem and its impact, and be motivated to address it.

Psychological treatment setting and duration

Problematic anger can usually be treated in an outpatient setting. There is currently insufficient evidence to recommend an optimal duration of psychological treatment.

Pharmacological interventions

Anger and resulting aggression can present as primary problems or they can be seen as symptomatic of other conditions. It is important to assess the situation carefully in order to guide effective use of psychotropic medications that may be beneficial. Anger and aggression can occur in the context of:

• mood disorders
• anxiety disorders
• PTSD
• chronic pain
• psychosis
• brain injury and/or cognitive impairment

It follows that effective medical treatment of these conditions will reduce the severity of abnormal anger and associated aggression. Impulsive aggression has been shown to improve with treatments including lithium and various anticonvulsant medicines. Dysregulation of the serotonin system has been demonstrated in some studies. Possibly explaining the role of selective serotonin reuptake inhibitor (SSRI) antidepressants in improving anger symptoms. Even when anger occurs in the absence of other common mental health problems (Kamarck et al., 2009).

See also