Treating Alcohol Dependence
A Coping Skills Training Guide
By Peter M. Monti Ronald M. Kadden Damaris J. Rohsenow Ned L. Cooney David B. Abrams The Guilford Press
Copyright © 2002 The Guilford Press
All right reserved. ISBN: 1-57230-793-5
Chapter One
SESSION: ANGER MANAGEMENT Rationale
1. Anger or irritation is a normal human emotion. It occurs when:
a. Things seem out of our control.
b. We think our rights have been stepped on.
c. We are not getting what we want or what we think is right.
Many alcoholics don't like to use the word "anger" for lower levels of anger. Rather than insisting on the term, try "irritation" or another, similar term. Use the term they agree to throughout, instead of "anger."
2. There is a distinction between anger as a feeling (emotion) and some of the behavioral consequences of anger, such as aggression, impulsive actions, passivity, and passive-aggressive behavior. Some of these consequences increase the likelihood of drinking. Anger itself is neither good nor bad. It can be an intense feeling, and the reaction to that feeling may be constructive or destructive.
Destructive effects:
a. Anger causes mental confusion. It leads to impulsive actions and poor decision making, including drinking.
b. Aggressive reactions to anger decrease effective communication, create emotional distance, andtrigger hostility in others. Can you think of some examples in your life of how aggressive behavior has backfired?
c. Passive reactions to anger leave you feeling helpless or depressed, reduce self-esteem, mask real feelings with an appearance of indifference, are a barrier to communication, and build resentments that may spill out at the slightest provocation in a tantrum or drinking.
Constructive effects:
a. Feelings of anger let you know that there is a problematic situation and energize you to resolve it. Use anger as a signal that there is a problem that needs solving.
b. An assertive response to anger increases your personal power over unpleasant situations, helps you communicate your negative feelings and their intensity, can be used to change destructive aspects of a relationship, helps you avoid future misunderstandings, and may strengthen a relationship. An effective response with appropriate assertiveness helps you to increase the constructive effects and decrease the destructive effects of angry feelings.
3. Relationship between anger and problem drinking: Studies of people who relapsed after alcoholism treatment have revealed that many took their first drink when they were angry or upset. Anger seems to make people highly vulnerable to relapse. Therefore, it is particularly important to learn to cope with anger and irritation in a constructive way.
Skill Guidelines
Most emotions are best understood by using a behavior chain. Anger does not just happen. People often think that situations or events make them angry, but actually it is their thoughts or beliefs about the trigger situations or events that result in anger. Let's show what we mean by putting a behavior chain on the board to show how alternative thoughts affect feelings.
Trigger [arrow] Thoughts/beliefs [arrow] Feelings [arrow] Behavior Driver cuts in front "That S.O.B. How dare Fury Dangerous driving of you he!" Driver cuts in front "He must be in a hurry, Calm Safe driving of you maybe late to work."
The first step to managing your anger is to become more aware of your personal triggers and thoughts about those triggers. Increased awareness can help you to identify angry feelings early, before they grow and get out of hand, to change the thoughts that aggravate anger, and to change your behavior in response to the anger.
1. Become more aware of situations that trigger anger.
a. Direct triggers: a direct attack on you, whether verbal (e.g., insult) or nonverbal (e.g., physical attack, obscene gesture), or frustration resulting from inability to reach a goal (e.g., your ex-wife won't let you see the kids).
b. Indirect triggers: observing an attack on someone else, or your appraisal of a situation (e.g., feeling that you are being blamed, thinking that someone is disapproving of you, or feeling that too many demands are being made of you).
2. Become more aware of your automatic thoughts associated with anger.
This is the hardest step at first. Often, these thoughts occur so automatically and quickly that we are not aware of them. Sometimes you may notice the words that are running through your head, such as "That crazy loon, I'm not going to let him get away with that!" Other times, you can figure out what thoughts or beliefs you must be having in order to produce the emotion. For example, you say "Hi" to a friend and he just grunts and walks on:
Thoughts Feelings
"Uh oh, he must be annoyed with me about something. What Fear did I do to make him mad?" Guilt
"How dare he! After all I've done for him!" Irritation Anger "Poor guy. His boss must be ragging on him again." Sympathy Calm 3. Change your thoughts about the trigger.
a. The first thing to do is calm down. As long as you keep cool, you will be in control of the situation. Here are some phrases to help you cool off in a crisis:
"Slow down." "Chill out." "Take it easy." "Easy does it." "Take a deep breath." "Relax." "Cool it." "Count to 10." Decide on one or two phrases like these that you can say to yourself to help you cool your anger while in the situation.
b. After you've slowed yourself down, think about the situation: "What's getting me angry?" Question your interpretation of the situation. Think about whether your reaction was realistic: "Is it really that bad?", "Am I overreacting?", "Is it really worth getting stressed out over this little thing?"
c. Think about whether there might be another interpretation of the situation: "Maybe she's not trying to control me, she's just trying to help," "Maybe my son's not mad at me. He's scared that I might start drinking again," or "Is this really an attack or insult?"
d. Think about the negative consequences of getting angry: "If I blow up, I risk my sobriety," "If I yell, I'll just make things worse," or "If I stay cool, I'll handle this better."
e. Replace the negative thoughts with more positive thoughts: "There are a lot of jerks in the world but so what? I don't have to let them bother me," "Life's too short to sweat the small stuff," "This will be over soon. I can handle it," or "He's not trying to put me down, he's just upset about something I did that was wrong. Let me fix this."
4. Change what you do in response to the trigger.
a. Think about your options: "What is in my best interests here? My anger should be a signal that it's time to do some problem solving," or "What can I do? What is the best thing for me to do?" (Communications skills, or other coping skills might be used in this situation.)
b. Choose possible behaviors that will make you calmer or will solve the problem:
Leave the situation (useful with strangers, impersonal events).
Take time out to cool.
Use assertiveness to request a change.
Analyze how to solve or cope with the problem.
Talk to the person about it in a calm, rational way.
c. After trying to resolve the problem, you may find that you cannot resolve the conflict, and you still feel angry. Remember that you can't fix everything. Thinking about it over and over again only makes you more upset. Try to shake it off-it may not be so serious. Don't let it interfere with your life. Some actions you can take include the following:
Call a sober friend to help you calm down. Plan something fun to counteract the lousy feelings.
Modeling (Optional)
The therapists present the clients with the following scenario:
Your spouse (or friend, or teenage child) is helping you to wash and wax your car. In the middle of the job, he/she suddenly walks away, goes inside, and turns on the TV. You find yourself increasingly angry as you look at the work that remains and the mess that has to be cleaned up. You decide to confront your work partner.
The therapists should demonstrate an appropriate response to this situation, articulating their self-statements for anger management aloud:
Cool-down phrases ("OK, chill down and think a minute."). Thoughts about the situation ("What's getting me angry? Is this a personal attack? Am I expecting too much?"). Thoughts about options ("What is in my best interest here? What can I do?").
Behavior Rehearsal Role Plays
Have clients each list a trigger situation and the thoughts or beliefs they each had in the situation that led to anger. Guide the group in generating positive, alternative thoughts and behaviors in each situation. Then, have clients discuss what they think the consequences of these alternatives would be.
Introducing the Practice Exercise
This assignment asks clients to practice using these skills in an anger-provoking situation. Clients describe the situation, calming phrases, anger-increasing thoughts, alternative anger-reducing thoughts, and behaviors to solve the problem or to calm themselves.
Therapist Tip Sheet: Anger Management
POINTS FOR RATIONALE
1. Anger is a normal emotion when we feel out of control, rights violated, don't get what we want. 2. Distinction between feeling (emotion) and some behavioral consequences:
Anger or irritation as a feeling is neither good nor bad.
Behavioral reaction can be constructive or destructive.
3. Some consequences (aggression, impulsive actions, passivity, passive-aggression) increase likelihood of drinking.
4. Destructive effects:
Anger causes mental confusion, can lead to poor decisions, impulsive acts, drinking.
Aggressive reactions: poor communication, emotional distance, hostile response.
Passive reactions: feeling helpless, lower self-esteem, poor communication, resentments. Constructive effects:
Anger is a signal that there is a problem that needs solving.
Anger provides energy to act. Assertive response: more power, better communication, improve relationships, resolve problem, avoid future misunderstandings.
POINTS FOR BLACKBOARD (IN CAPITALS)
BEHAVIOR CHAIN to show how thoughts/beliefs about triggers result in anger.
TRIGGER [arrow] THOUGHTS/BELIEFS [arrow] FEELINGS [arrow] BEHAVIOR
SKILL GUIDELINES
1. BECOME AWARE OF TRIGGERS-situations that trigger anger:
DIRECT TRIGGERS: attack, insult, stopped from reaching goal.
INDIRECT TRIGGERS: observation, appraisal, thoughts.
2. BECOME AWARE OF AUTOMATIC THOUGHTS associated with anger.
3. CHANGE YOUR THOUGHTS ABOUT THE TRIGGER: CALM DOWN before reacting.
THINK ABOUT SITUATION. QUESTION YOUR REACTION.
ANOTHER INTERPRETATION?
THINK ABOUT NEGATIVE CONSEQUENCES of acting angry.
REPLACE NEGATIVE THOUGHTS WITH POSITIVE THOUGHTS.
4. CHANGE WHAT YOU DO:
THINK ABOUT OPTIONS.
CHOOSE EFFECTIVE BEHAVIOR: makes you calmer or solves problem.
AFTERWARDS, LET GO OF THOUGHTS.
PLAN ACTIVITY TO COUNTERACT BAD FEELINGS:
Call a sober friend to calm down or ask advice about a problem.
Do something fun.
Reminder Sheet: Anger Management
Anger often results from the way we think about things: Trigger Events [arrow] Thoughts [arrow] Anger [arrow] Behavior
Become more aware of the events and thoughts that trigger your anger.
Use phrases like these first, to help you calm down in a crisis:
Slow down. Chill out. Take it easy. Easy does it. Take a deep breath. Relax. Cool it. Count to 10.
Next, think about what's getting you so angry: What's getting me angry? What event? What thoughts?
Is there another way to interpret the situation? Is this really a personal attack or insult? Am I overreacting? Is it really that bad?
Think about the negative consequences of getting angry and the positive consequences of staying cool.
Replace the negative thoughts with more positive thoughts: I don't have to let jerks bother me. Life's too short to sweat the small stuff. It's not worth risking my sobriety.
Think about your options: What can I do? What is in my best interests here? Anger should be a signal to start problem solving.
Do something to make yourself calmer or to solve the problem: Leave the situation or take time out. Make an assertive request for change. Analyze how to deal with the problem. Talk to the person in a calm, rational way.
If the problem won't go away or if you still feel angry: Remember that you can't fix everything. Try to shake it off. Don't let it interfere with your sobriety. Plan something fun to make yourself feel better. Call a sober friend to help you calm down.
PRACTICE EXERCISE
Until the next session, pay attention to your response to anger-provoking situations. Try to identify and change your thoughts in those situations.
Continues...
Excerpted from Treating Alcohol Dependence by Peter M. Monti Ronald M. Kadden Damaris J. Rohsenow Ned L. Cooney David B. Abrams Copyright © 2002 by The Guilford Press. Excerpted by permission.
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