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Natalie Winicov

Contemporary Social Issues

December 13th, 2017


A blind acceptance of anger management treatment

In the United States, approximately 9 million people are released from jail each year

(NRRC Facts & Trends, 2017). By the end of 2015, approximately 4.7 million people were on

probation or parole (Probation and Parole in the United States, 2015). If an individual has served

a prison sentence for a violent crime and is now under community supervision, there is a high

probability that they have been mandated to attend an "anger management" (AM) course as a

condition of their parole. However, while AM is widely accepted as one of the most commonly-

used interventions among offenders, its effectiveness is debatable. Among the studies that have

applied AM programs to offender populations, there is little evidence to validate claims that AM

courses reduce recidivism and reconviction, particularly among "violent" offenders. In their

comprehensive review of AM literature which involved five meta-analysis publications, Glancy

and Saini (2005) found no consensus in regard to the most effective AM treatment method.

If we can't agree on best practice or substantiate its implementation, this begs the

question: why do we still mandate it? While this paper does not argue that AM programs are

futile efforts, it does stress the need for further research, empirical evidence of effectiveness and

the establishment of research-based guidelines. Very few studies have examined its

effectiveness and those that do often evaluate outcomes such as program retention and self-

reported success rates rather than levels of anger or recidivism of violent offenses. Further,

studies that employ more meaningful measures report inconsistent results and point out the

minimal effect that a very short-term, educational program can have on ambivalent, mandated

clients.

In a time when the U.S. prison population is astronomical, it is imperative that we

establish empirically supported, research-based guidelines for recognizing, treating and


preventing future violence. Aside from anger’s close link to aggression, the health consequences

of anger include an increased risk of heart attack or stroke, weakened immune system, high

blood pressure, anxiety, depression, and even decreased life expectancy (Department of Health

& Human Services, 2014). Our current approach presents several issues, including 1) the limited

capacity of a treatment that is court-mandated, 2) the high complexity of programs that are very

short-term, and 3) an overemphasis on providing anger knowledge and psychoeducation rather

than practicing skill implementation. This paper will explore the impact of these factors on the

effectiveness of “anger management” treatment as we know it, and potential interventions that

may prove to be more suitable alternatives.

“Anger”

According to Howells (2005), incarcerated individuals present anger scores higher than

those of the general population, which has been linked to prison adjustment issues, disciplinary

issues, assault, and violence. To confound the issue, Zamble and Porporino (1990) found that

anger tends to increase in relation to time spent in prison- in other words, anger levels and time

incarcerated are positively correlated.

Saini (2009) claims that there is no agreed-upon definition of anger, a term that is often

and mistakenly used synonymously with aggression and violence. Mandated AM operates under

the assumption that anger is causally related to violence and that by managing anger, we can

manage violence. However, not all acts of aggression are anger-based, and anger certainly does

not always manifest itself as aggression. Violence is a learned coping strategy that often serves a

purpose for incarcerated individuals who are devoid of almost all control and constantly under

physical threat. AM further implies that someone who has committed a violent offense years ago
is going to violently re-offend, not taking situational influences or brain development into

consideration.

Treatment as a mandate

In order to successfully complete parole, the vast majority of people under parole

supervision are ordered to complete a set of mandates. This list may include substance abuse

treatment, mental health treatment, and domestic violence prevention courses. AM treatment is

yet another mandate applied to the overwhelming expectation that people under parole

supervision will obtain meaningful employment, abide by a curfew, find and maintain stable

housing and provide family support. This extensive list of obligations only increases the

likelihood that an individual will violate parole stipulations and consequently return to prison.

Half of all people under parole supervision are sent back to prison for a violation, 60% of whom

are violating terms of parole rather than criminally re-offending (Feldman, 2016). This constant

churn of prisoners has disproportionately affected people of color, devastating and destabilizing

the communities where many of the arrests are concentrated. Take Harlem, for instance:

according to the Justice Mapping Center, a one-mile area of East Harlem has "the highest

concentration of formerly incarcerate males in New York City" (one in twenty men) (Justice

Atlas of Sentencing and Corrections, 2017). Additionally, 75% of inmates in New York State

prisons come from seven neighborhoods in New York City, one of them being East Harlem (Our

Communities). Creating more and more stipulations for people under parole supervision only

perpetuates this cycle, setting individuals up to violate.

The therapeutic effectiveness and ethics of court-mandated treatment often come into

question. In a study conducted by Sanderfer and Johnson (2015), 74.1% of participants agreed

that the use of legal force or coercion to enter treatment is not ethical, and 73.3% indicated that
court-mandated AM is a form of punishment. Level of motivation and readiness for treatment is

found to be a strong predictor of improvement in Howells et. al's (2005) study, but a mandate to

attend treatment is often met with resistance, jeopardizing client growth and retainment of

learned skills. Renwick et. al (1997) note that this frequent motivational issue is fueled by

participant confidentiality concerns and a general distrust of institutions that is fostered by

repeated institutional oppression and social rejection.

Notably, AM programs have greatly benefited from the use of treatment as a mandate.

Anger management fits under the umbrella of “group therapy”, and is therefore paid for by

Medicaid. Additionally, the Department of Corrections and Community Supervision (DOCCS),

multiple foundations and local governments delegate funding to programs that provide AM. This

calls into question the true motivation behind AM mandates; treatment programs stand to

financially benefit from providing to more clients, without being held accountable for providing

support for its effectiveness. For instance, In New York City, about 3,000 people a year are sent

to a one-day, $95 AM class run by a private, nonprofit agency, Education and Assistance

Corporation (Lewin, 2001). This ineffective, blanket mandate simply perpetuates the ongoing

cycle of parole and re-incarceration. Moreover, the funding that is funneled into the AM

industry and the clinicians involved in the programs are resources that could be directed towards

providing evidence-based interventions such as DBT.

Psychoeducation over skill implementation

Motivation could be improved by allowing more time during treatment to develop a

strong therapeutic alliance between the client and the practitioner and by placing less importance

on psychoeducation. AM programs have been criticized for their overemphasis on

psychoeducation while falling short on allowing participants to practice newly-learned emotional


regulation skills. Howell's et. al (2005) study results indicate that while AM participants

improved in anger knowledge scores compared to those not receiving treatment, these

individuals did not demonstrate a statistically significant change in state anger, anger control or

anger expression. Further, the difference in anger knowledge between the controls and the

treated group was marginal. It appears that knowledge attainment does not necessarily translate

to behavioral change.

Heseltine et. al (2010) found congruent results. In their study of 51 individuals on parole

participating in 20 hours of AM, the only statistically significant result was an increase in

offenders’ anger knowledge. Again, this illustrates an overestimation of the capacity of

psychoeducation and a need for greater balance in program content.

Absence of guidelines

Despite some evidence for treatment effectiveness in studies of AM, a glaring concern

among the literature is the huge variation in results and inconsistency in treatment delivery.

Interventions widely range in treatment length (from 20 hours to 330 hours), length and content

of clinician training and outcome measurement tools, and there is virtually no framework for

delivery or quality standards. In a New York Times article on the AM industry, the director of

the International Community Corrections Association is quoted: ''there are probably a hundred

curricula out there... what usually happens is the county probation department gets Beth, the

social worker down the road, to put together something for 10 guys on Tuesday nights, and her

friend takes another 10 on Thursdays'' (Lewin, 2001). Not only does this malpractice

compromise program integrity, but it this impedes researchers’ ability to make a direct

comparison of results. DiGiuseppe and Tafrate (2003) note that among the studies included in

their large analysis, “higher effect sizes on measures of aggression were significantly predicted
by the use of a treatment manual and an integrity check significantly predicted higher effect sizes

on measures of aggression. However, few researchers used integrity checks or treatment

manuals.” The absence of a treatment manual leaves it to the discretion of the program to decide

the length of treatment, causing an enormous variation, from treatments that are as few as 8

hours total to treatments adding up to 330 hours. The researchers claim that the implementation

of manuals and integrity checks in AM lower the results’ standard deviation.

Implications

Although the included studies on AM programs provide inconsistent and at best,

moderate effects, there are a number of proposals to improve treatment integrity.

First, all critics point to the need for an accepted definition of anger and guidelines to direct

treatment. The use of manuals and fidelity checks would ensure consistency and maintain

standards.

Treatment length

Anger management programs can range from 8 to 330 hours (Henwood et. al, 2015), but

more often fall in the shorter, less intensive range. Howells et. al (2005) recommend that if AM

treatment is to occur, mental health professionals should conduct at least eight sessions of

treatment. Poor follow-up outcomes in several studies imply a need for lengthier, more intensive

treatment that allows participants the opportunity to apply their newly-learned skills. Heseltine

et. al (2010) argue that “it is expecting too much of a program of this brevity to expect it to

produce a change in actual experience or behavior in prisoners, who typically have long-term

and multiple psychological difficulties". The authors suggest that the disparities in length-of-

treatment may set successful programs apart from ineffective programs.

Individualized approach
Current AM programs have been further criticized for their “one-size-fits-all” approach.

Each act of anger-related violence involves a unique set of preceding events, complex

relationships, personal histories of trauma exposure and coping skills. DiGiuseppe and Tafrate

(2003) classify three different subtypes of anger that require improved “symptom-and-treatment

modality matching”. For instance, for individuals that primarily experience anger as a physical

sensation, relaxation techniques may be more impactful, while individuals who experience anger

largely as emotional distress may benefit from cognitive restructuring. Individuals who have

been referred to AM as a result of a domestic violence offense may be better suited for classes on

creating and maintaining healthy relationships. One amorphous “anger management treatment”

that is completely lacking programmatic research and validity should not be the agreed-upon

blanket treatment for all violent offenders.

Given the many possible catalysts for violence and the lack of evidence to demonstrate a

relationship between anger and violence, the treatment of anger is not always appropriate for

violent offenders. Violence is often elicited for reasons unrelated to anger, for example, to

secure money, being under the influence of drugs or alcohol, exercising self-defense, appealing

to gang authority, or supporting a friend. Mandating clients to AM for the sole reason that their

crime was violent, despite being non-anger-related, is a recipe for resentful, ambivalent clients

who will likely perceive treatment as punishment. Further, convictions do not always accurately

reflect the behavior and it is common for convicted individuals to take a plea bargain despite

their innocence to reduce charges, avoid costs of going to trial, get out of custody, etc.

Alternatives

There is no shortage of studies that find absolute efficacy of AM treatments, meaning that

AM is more effective in reducing anger in comparison to no treatment at all. However,


DiGiuseppe and Tafrate (2003), in their analysis of 57 anger treatment studies, find very little

studies that illustrate relative efficacy- efficacy of AM in relation to other interventions. One

such intervention alternative is music therapy. A program conducted in the Netherlands applied

AM to forensic patients in a music therapy context under the reasoning that music is easily

accessible to most people. Music also has the ability to evoke strong emotions and cause critical

memories to surface. Haakvort (2002) claims that "music therapy helps patients to musically 1)

become aware of the causes of their anger, 2) discern the first symptoms of anger and 3) acquire

one or two new coping strategies."

In this intervention, patients first practice recognizing physical symptoms of anger while

listening to or creating music. This prompts the individual to identify anger triggers and

experience anger in a safe, therapeutic setting, and then use music as a tool to cope with anger as

it emerges. The therapist will intentionally provoke a patient by playing anger-inducing music or

by imposing on their piano keyboard space. This set-up allows the client to experience anger or

frustration in real-time with the therapist, and employ music to communicate that feeling while

learning to tolerate it (Haakvort, 2002). A more recent exploratory study conducted by Haakvort

et. al (2013) randomly assigned “forensic patients” to TAU or an AM music therapy. Results

indicated that music therapy participants had a greater improvement in positive coping skills,

compared to the control group.

While this variation of treatment for AM requires further research with greater sample

sizes, the behavioral outcomes are encouraging and this intervention can be easily applied in

forensic settings.
Conclusion

Anger is a pertinent social issue and at a clinical level, can have serious mental and

physical health consequences and subsequent health care costs. However, it is unacceptable for

our system to require anger management program participation under the assumption that all

“violent offenders” suffers from an anger “disorder”, and further, that no standards exist for these

mandated programs. As AM curriculum creator, Dr. Barry Glick, states in an interview, ''The

problem is that we're usually looking for a quick fix...if it took years to get a person where he is

now, you can't expect to change it in six hours of class” (Lewin, 2001). In a country that is

“home” to the world’s largest prison population, the anger management industry should be

working towards reducing the prison number rather than contributing to its growth.
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