Complete psychological testing or objective questionnaires for assessing anger expression. (4)
Administer to the client psychometric instruments designed to objectively assess anger expression (e.g. Anger, Irritability, and Assault Questionnaire, Buss-Durkee Hostility Inventory; State-Trait Anger Expression Inventory); give the client feedback regarding the results of the assessment; readminister as indicated to assess treatment response.
Cooperate with a complete medical evaluation. (5)
Arrange for a medical evaluation to rule out nonpsychiatric medical and substance-induced etiologies for poorly controlled anger (e.g. brain injury, tumor, elevated testosterone levels, stimulant use).
Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (6, 7, 8, 9)
Assess the client's level of insight (syntonic versus dystonic) toward the presenting problems (e.g. demonstrates good insight into the problematic nature of the described behavior, agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the problem described and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the problem described, is not concerned, and has no motivation to change).
Assess the client for evidence of research-based correlated disorders (e.g. oppositional defiant behavior with attention-deficit/hyperactivity disorder [ADHD], depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g. increased suicide risk when comorbid depression is evident).
Assess for any issues of age, gender, or culture that could help explain the client's currently defined problem behavior and factors that could offer a better understanding of the client's behavior.
Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g. the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g. the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
Explore the consequences of anger, motivation and willingness to participate in treatment, and agree to participate to learn new ways to think about and manage anger. (10, 11, 12)
As part of exploring the client's decisional balance to engage in treatment, assist the client in identifying the positive consequences of managing anger (e.g. respect from others and self, cooperation from others, improved physical health, etc.) or supplement with “Alternatives to Destructive Anger” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce.
As part of exploring the client's decisional balance to engage in treatment, ask the client to list and discuss ways anger has negatively affected his/her/their daily life (e.g. hurting others or self, legal conflicts, loss of respect from self and others, destruction of property); process this list.
Use motivational interviewing techniques toward clarify the client stage of change, moving the client toward the action stage in which he/she/they agree to take specific actions to more effectively conceptualize and manage anger (see Motivational Interviewing by Miller & Rollnick).
Verbalize an understanding of how angry thoughts and feelings can lead to increased risk of addiction. (13, 14)
Use guided discovery (e.g. Socratic questioning) to educate the client about his/her/their tendency to engage in addictive behavior as a means of relieving uncomfortable feelings; develop a list of several instances of occurrence.
Teach the client about high-risk triggers of substance use including strong negative emotions, social pressure, interpersonal conflict, strong positive emotions, and other stressors; discuss examples of how triggers can lead to substance use, the consequences of this pattern, and the availability of alternatives in preventing and managing the risk.
Agree to learn new alternative ways to recognize and manage anger. (15)
Confirm with the client that he/she/they agree to try to learn new ways to recognize and manage anger.
Cooperate with a medication evaluation for possible treatment with psychotropic medications to assist in anger control; take medications consistently, if prescribed. (16, 17)
Assess the client for the need and willingness to take psychotropic medication to assist in control of anger; refer him/her/them to a prescriber for an evaluation and prescription of medication, if needed.
Monitor the client's psychotropic medication adherence, side effects, and effectiveness; confer as indicated with the prescriber.
Keep a daily journal of persons, situations, and other triggers of anger; record thoughts, feelings, and actions taken or not. (18, 19)
Ask the client to self-monitor, keeping a daily journal in which he/she/they document persons, situations, thoughts, feelings, and actions associated with moments of anger, irritation, or disappointment (or supplement with “Anger Journal” in the Adult Psychotherapy Homework Planner by Jongsma & Bruce); routinely process the journal toward helping the client understand his/her/their contributions to generating his/her/their
anger responses.
