Anger management

1. Introduction

Version followed: Novaco's stress inoculation approach to anger (Novaco 1975 book; 1976 ERIC paper; 1977 case report), as later developed into his formulation-based "anger treatment" (Taylor & Novaco 2005; Novaco 2011). For group delivery, the guide also follows the SAMHSA 12-session group manual (Reilly & Shopshire, 2002, updated 2019). Where the two differ, each item is labelled [Novaco SIT] or [SAMHSA group].

"Anger management" is a family of programmes, not one therapy. It covers brief psychoeducational courses through to individual cognitive-behavioural treatment. Raymond Novaco is credited as originator. In 1975 he adapted Meichenbaum's stress inoculation training, then used for anxiety and pain, to chronic anger. Most later programmes, including the widely used SAMHSA manual, combine the same ingredients: monitoring, arousal reduction, cognitive restructuring and behavioural (assertion and conflict) skills. [source: Novaco 1976 ERIC ED141673; Reilly & Shopshire 2019]

Core idea of change. Novaco defines anger as physiological arousal plus a cognitive label for that arousal. The label is shaped by environmental cues and by the person's appraisals and self-talk. Anger becomes a problem when it is dysregulated: too frequent, too intense, too long-lasting, too easily triggered or expressed through aggression. [source: Novaco 1976; Novaco 2011, p. 653]

Change comes from three things:

• Learning to see one's own anger pattern.
• Acquiring cognitive, arousal-reduction and behavioural coping skills.
• Rehearsing those skills under graded, controlled provocation, so that the client becomes "inoculated": able to be aroused but not overwhelmed, and to stay in control. [source: Novaco 1976, approx. pp. 9–13]

The SAMHSA programme frames anger as a learned habit that can be unlearned. It adds a social-learning account and Ellis's A-B-C-D model. [source: Reilly & Shopshire 2019]

2. Framework

2.1 Novaco stress inoculation: three phases [Novaco SIT]

Phase 1: Cognitive preparation

• Goal: educate the client about anger and its functions, map the client's personal anger pattern, give a shared language, and explain the rationale.
• Content: triggers (people and situations); the difference between anger and aggression; justified versus unnecessary anger; cognitive, bodily and behavioural determinants; how anger escalates within interaction sequences; anger control presented as coping with conflict and stress.
• Tools: an instructional handout and a self-monitoring diary. The diary entries become the material for discussion.
• [source: Novaco 1976, approx. pp. 9–10]

Phase 2: Skill acquisition and rehearsal

• Goal: teach cognitive, arousal (affective) and behavioural coping skills.
• Cognitive skills: cognitive restructuring and self-instructions.
• Arousal skills: relaxation; Novaco also lists encouraging humour and affection.
• Behavioural skills: impulse delay, communication and assertion.
• Method: the therapist models each skill, then the client rehearses it, first aloud and then silently (overt, then covert).
• [source: Novaco 1976, approx. pp. 10–12]

Phase 3: Application training (application practice)

• Goal: apply the skills under graded provocation.
• Method: the client and therapist build a hierarchy of provocations likely to occur in daily life. The client practises coping with each scene, first in imagination and then in role-play.
• [source: Novaco 1976, approx. pp. 12–13]
• Later protocols add in-vivo practice and progressive imaginal exposure that includes trauma triggers. [source: NCT02157779 protocol]

Session count and format by version

• Novaco 1976: [source: Novaco 1976, approx. pp. 13–14]
• Taylor & Novaco 2005: [source: Taylor & Novaco 2005 Preface, p. xii, via publisher sample]. Session frequency was not verified. [uncertain]
• VA trial: [source: NCT02157779 protocol]

Criteria for moving between phases [Novaco SIT]

What the sources state:

• Application training starts after skills have been modelled and rehearsed.
• Within application, the client rates their own competence against the hierarchy, and scenes are graded so that the client is challenged but not overwhelmed. [source: Novaco 1976, approx. pp. 12–13]
• Taylor & Novaco place readiness work in the preparatory phase, before skills training begins. [source: Novaco 2011, p. 659]

Practical criteria (my own synthesis, not stated in the sources) [synthesis]:

• Phase 1 to Phase 2: the client keeps the diary with at least some regularity; can name 2–3 personal triggers and bodily cues; and accepts at least one personal cost of their current anger.
• Phase 2 to Phase 3: the client can produce a relaxation response in session within a few minutes, and can generate alternative appraisals and coping statements for diary incidents.
• Moving up the hierarchy: the client reports peak anger on the current scene clearly below baseline across 2–3 trials, and uses coping statements spontaneously.

2.2 SAMHSA group manual [SAMHSA group]

Format: 12 weekly sessions of 90 minutes; ideal group size 8 (acceptable range 5–10). Written for adults with co-occurring substance use and mental health conditions, and intended as an adjunct to their main treatment. It can also be delivered individually. [source: Reilly & Shopshire 2019]

Session outline:

[source: Reilly & Shopshire 2019; Reilly et al. 2002 participant workbook]

Progression: the manual moves through the curriculum by session; it gives no clinical criteria for advancing. A certificate requires missing no more than 3 of the 12 sessions. [source: Reilly & Shopshire 2019; workbook]

3. Guiding principles

• Anger is a normal emotion; the target is dysregulation. In practice, aim for anger that fits the situation and is regulated. Do not aim for no anger. [source: Taylor & Novaco 2005, pp. 1–4]
• Anger and aggression are distinct. In practice, teach early that anger is a feeling and aggression is a behaviour, and that the feeling does not dictate the act. [source: Novaco 1976; Reilly & Shopshire 2019 (anger / aggression / hostility)]
• Anger is cognitively mediated. In practice, appraisals (personal affront, threat, intent to harm) are the main targets for change. [source: Novaco 1976; Novaco 2011, pp. 651–653]
• Self-talk is the main tool for self-regulation. In practice, give the client concrete, rehearsed self-instructions for each stage of a provocation. [source: Novaco 1976, approx. p. 11]
• Arousal matters. Residual arousal from earlier events can amplify anger at a later minor provocation (excitation transfer). In practice, teach arousal reduction and ask about background stress. [source: Taylor & Novaco 2005, p. 8]
• Inoculate gradually. In practice, practise skills under provocation that is graded and controlled, keeping the client "aroused but not overwhelmed" (Novaco 1976, approx. p. 13). [source: Novaco 1976]
• Collaborate and build a shared language. In practice, use the client's own words, their diary data and a joint formulation. [source: Novaco 1976, approx. p. 10]
• Base treatment on assessment and case formulation. In practice, assess the client's specific control deficits before choosing which components to emphasise. [source: Novaco & Taylor 2015 BABCP workshop, reported by Hawkins]
• Treat resistance as readiness. In practice, expect ambivalence. Anger often serves "mastery-toned functions" (Novaco 2011, pp. 651–652), so work on readiness before pushing skills. [source: Novaco 2011, pp. 651–652, 659]
• Anger can be bound up with identity. In practice, do not frame the client as "an angry person"; separate the person from the pattern. [source: Taylor & Novaco 2005, p. 2; Novaco 2011, p. 662] The second half of this point is [synthesis].
• Apply the manual flexibly. In practice, follow the structure but adapt pace, examples and literacy demands to the person; the authors speak of having to "breathe life" into a manual (Taylor & Novaco 2005, p. 4). [source: Taylor & Novaco 2005, p. 4]
• Emphasise choice and responsibility. In practice, keep returning to the point where the client could have chosen differently; SAMHSA's anger meter carries the line "You have a choice!". [source: Reilly & Shopshire 2019]
• Venting is not treatment. In practice, correct the belief that "letting it out" reduces anger, and do not run cathartic exercises. [source: Reilly & Shopshire 2019 (myths)]
• Treat anger as a learned habit. In practice, expect change to need repetition, daily practice and homework. [source: Reilly & Shopshire 2019]
• Safety comes first and confidentiality has stated limits. In practice, set out the rules on threats and violence, timeouts, and duty-to-warn limits in session 1. [source: Reilly & Shopshire 2019]
• Anger work is adjunctive. In practice, coordinate with substance use, mental health or offence-focused treatment; do not replace them. [source: Reilly & Shopshire 2019; Taylor & Novaco 2005 Preface, p. xi]

4. Intervention inventory

All example language below is my own illustrative wording unless it is quoted and cited. Worksheets and rating scales are described, not reproduced.

4.1 Assessment and anger formulation [Novaco SIT]

• Purpose / when to use: before treatment and repeated at the end. Defines the person's specific deficits, guides which components to emphasise, and gives outcome data. [source: Novaco 1976; Novaco & Taylor 2015 BABCP workshop, reported by Hawkins]
• Steps:
  1. Take a history of anger and aggression: frequency, intensity, duration, typical mode of expression (verbal, physical, toward objects, inward), targets, settings, and substance involvement. Novaco's dysregulation dimensions are frequency, reactivity, intensity, duration and mode. [source: Novaco 2011, p. 653]
  2. Use a self-report anger measure and, in institutions, staff ratings. Novaco's instruments are the Novaco Anger Scale and Provocation Inventory (NAS-PI) and the brief Dimensions of Anger Reactions scales (DAR-5 and its revised form). They are licensed or published instruments; this guide does not reproduce their items. [source: Novaco publications page; Hawkins blog (DAR-7 handout)]
  3. Optionally run an imaginal provocation test before and after treatment: the client imagines standard provocation scenes, interleaved with neutral scenes, and rates anger and likely coping after each. The 1976 study used 12 scenes in random order and also measured blood pressure. [source: Novaco 1976, approx. pp. 14–15]
  4. Build a formulation across four elements: triggers (environment); appraisals and beliefs (cognition); bodily arousal; behaviour and its consequences. Also map the functions anger serves for the client. [source: Novaco 2011, pp. 651–653] Drawing this as a four-box formulation diagram is [synthesis].
  5. Screen for violence risk, suicide risk, substance use, psychosis or mania, trauma, cognitive impairment, and any current intimate-partner violence (see section 5).
• Example language (illustrative): "Let's take the last three times you got really angry and walk through them second by second: what happened, what went through your mind, what your body did, and what you did next."
• Watch for:
  • Clients may under-report anger if they think scores will be used against them (court, parole, staff). Say plainly how the information will be used. [source: Novaco 2011, pp. 651, 658]
  • Accounts of provocations are coloured by hostile attribution. Treat them as data about the client's appraisals, not as fact. [source: Novaco 2011, pp. 652–653]

4.2 Readiness and engagement work (preparatory phase) [Novaco SIT]

• Purpose / when to use: first, especially with mandated, institutionalised or ambivalent clients. Taylor & Novaco's preparatory phase is 6 sessions before skills training. [source: Taylor & Novaco 2005 Preface; Novaco 2011, p. 659] The detailed session content of that phase is not drawn on here. [uncertain] The steps below follow the stated aims: build trust, motivation and readiness.
• Steps [synthesis, informed by Novaco 2011]:
  1. Explain what the sessions are and are not. Clarify confidentiality and what (if anything) goes back to a court or staff.
  2. Elicit what anger does for the client (protection, respect, control, getting things done) before naming its costs. Novaco notes clients may not want to give up these functions. [source: Novaco 2011, pp. 651–652]
  3. Elicit costs across relationships, work, legal status, health and self-respect.
  4. Weigh the costs of staying the same against the costs of changing; change becomes likelier when the former outweigh the latter. [source: Novaco 2011, p. 659]
  5. Link anger control to the client's own valued goals. Novaco cites the Good Lives Model as one engagement route. [source: Novaco 2011, p. 659]
  6. Agree a personal goal stated as something the client wants (e.g., "keep my job", "my kids not scared of me"), not only as stopping aggression.
• Example language (illustrative): "I'm not here to take your anger away. It's probably kept you safe at times. The question is whether it's costing you more than it's giving you right now."
• Watch for:
  • It is working when the client starts bringing their own examples and talks about costs without being prompted.
  • It is not working if the client hears the programme as proof that they are dangerous. Novaco notes enrolment can carry that meaning for offenders. [source: Novaco 2011, p. 652]

4.3 Psychoeducation (cognitive preparation) [Novaco SIT / SAMHSA group]

• Purpose / when to use: sessions 1–2. Gives the rationale, a shared language, and correction of myths.
• Steps:
  1. Define three terms. Anger is an emotion; aggression is behaviour meant to harm; hostility is an attitude. [source: Reilly & Shopshire 2019]
  2. Explain that anger has functions. It can energise and mobilise action, signal that something matters, and protect. It also has costs when it is too frequent, too intense or expressed as aggression. [source: Novaco 1976, approx. pp. 5, 10] Novaco's fuller list of anger's functions appears in his 1976 American Journal of Psychiatry paper, which is not drawn on here. [uncertain]
  3. Distinguish justified anger from unnecessary anger. [source: Novaco 1976, approx. p. 10]
  4. Present the model: an event leads to an appraisal, which leads to arousal, which leads to behaviour, which produces consequences. Show how angry thinking and aggressive behaviour feed back to sustain anger. [source: Novaco 1976; Novaco 2011, p. 653]
  5. Go through the common myths and the facts behind each:
     • Anger and its expression are fixed. In fact, they are learned and can change.
     • Anger leads automatically to aggression. In fact, there are choices in between.
     • Aggression is needed to get what you want. In fact, it usually costs more than it gains over time.
     • Venting is always healthy. In fact, venting tends to rehearse anger rather than release it. [source: Reilly & Shopshire 2019]
  6. Explain stress inoculation by analogy with a vaccine: practise against small, controlled doses of provocation so that real ones are manageable. [source: Novaco 1976 (concept)] Using the vaccine analogy in session is [synthesis].
• Example language (illustrative): "Anger isn't the enemy. It's an alarm. The work is making sure the alarm goes off at the right volume and doesn't drive the car."
• Watch for: the client recognising their own pattern in the model, and fewer "they made me" statements over the following sessions.

4.4 Self-monitoring: anger diary, anger meter, check-in [Novaco SIT / SAMHSA group]

• Purpose / when to use: from session 1 throughout. Builds awareness and supplies the material for every session.
• Steps:
  1. [Novaco SIT] Give a simple diary. For each anger incident the client records: what happened, where and with whom, thoughts, anger intensity, what they did, and how well they coped. Diary entries are the basis for session discussion. [source: Novaco 1976, approx. p. 10] The diary fields listed here are [synthesis].
  2. [SAMHSA group] Introduce a 1–10 anger meter. 10 is reserved for losing control with negative consequences. Clients personalise what each level means for them and record their daily peak. [source: Reilly & Shopshire 2019]
  3. [SAMHSA group] Open every session with a check-in built on four questions: the event; the cues the client noticed; whether there were negative consequences; and which strategies were used and how they helped. [source: Reilly & Shopshire 2019]
  4. Review the records collaboratively. Praise the recording itself, whatever it shows. Pick one incident a session to analyse in detail.
• Example language (illustrative): "What was your highest number this week? Take me to that moment. What was the first sign you were climbing?"
• Watch for:
  • Diaries completed only in the waiting room. Simplify the format rather than drop monitoring. [synthesis]
  • It is working when peak ratings fall and clients notice cues earlier on the meter.

4.5 Identifying triggers and the four types of cues [SAMHSA group]

• Purpose / when to use: session 2. Builds early-warning detection.
• Steps:
  1. List triggering events: everyday hassles; "red flag" sensitivities rooted in past experience; online conflicts; even inanimate objects.
  2. Help the client separate the event (facts) from their interpretation.
  3. Map four kinds of cues:
     • Physical (heart rate, heat, tension).
     • Behavioural (pacing, raised voice, clenched fists).
     • Emotional: the primary feelings under the anger, such as hurt, fear, shame or rejection.
     • Cognitive: hostile self-talk, images, revenge fantasies.
  4. The client writes a personal list of their earliest cues. [source: Reilly & Shopshire 2019]
• Example language (illustrative): "Before you're at an 8, your body is already telling you something. What's the very first thing you notice?"
• Watch for: clients who notice only late cues. Use diary incidents to rewind to earlier ones.

4.6 Provocation hierarchy construction [Novaco SIT]

• Purpose / when to use: late in cognitive preparation or early in skill acquisition. Provides the graded scenes for application training. [source: Novaco 1976, approx. pp. 12–13; NCT02157779]
• Steps:
  1. From the diary and history, collect 10–15 real or likely provocation scenes that are specific (who, where, what was said).
  2. The client rates the anger each scene would provoke, for example on a 0–100 scale. [synthesis on scale]
  3. Order the scenes from mild to severe, with small steps between them.
  4. Write each scene as a short, vivid script in the present tense, including sensory detail and the specific provoking words or acts.
  5. Keep scenes realistic for the client's daily life. Include trauma-linked triggers only with explicit consent and the safety steps in 4.15. [source: NCT02157779]
• Example language (illustrative): "Let's build a ladder, from things that irritate you a bit up to the ones that would push you to the edge. We'll practise on the low rungs first."
• Watch for:
  • Scenes that are too vague to evoke anger.
  • A top rung that would be unsafe to rehearse. Leave those out, or defer them until skills are solid.

4.7 Arousal reduction: breathing, progressive muscle relaxation, imagery [Novaco SIT / SAMHSA group]

• Purpose / when to use: skill acquisition phase. Taught early and practised daily. Lowers baseline arousal and gives an in-the-moment brake. [source: Novaco 1976 (relaxation training); Reilly & Shopshire 2019 (sessions 3–4); NCT02157779 (diaphragmatic breathing, guided imagery)]
• Steps:
  1. Rationale. Arousal amplifies anger, including arousal left over from unrelated stress. Relaxation is the counter-response. [source: Taylor & Novaco 2005, p. 8]
  2. Deep breathing. Teach slow abdominal breathing with a longer out-breath. Practise for several minutes in session. Then teach a short version (about three slow breaths) for use in real situations. [source: Reilly & Shopshire 2019]
  3. Progressive muscle relaxation. Work through muscle groups (hands, arms, shoulders, face, and on through the body), tensing each for about 5 seconds and then releasing it while attending to the contrast. [source: Reilly & Shopshire 2019] The timing is [synthesis].
  4. Guided imagery. The client builds a personal calming scene and practises entering it. [source: NCT02157779]
  5. Cue-controlled relaxation. Pair the relaxed state with a cue word ([synthesis]), so the client can relax quickly in real situations.
  6. Home practice. Assign daily practice and record pre- and post-practice tension ratings.
  7. For clients with cognitive impairment. The Managing Anger (2nd edn, 2006) manual uses a brief standing or sitting "On The Spot Arousal Reduction" routine (OTSAR) that can be used anywhere. [source: Wiley table of contents] Its steps are not drawn on here. [uncertain]
• Example language (illustrative): "Breathe in through your nose to a slow count of four... and out even slower... let your shoulders drop as you breathe out."
• Watch for:
  • Some trauma survivors feel unsafe when relaxing or closing their eyes. Offer eyes-open versions and grounding instead.
  • It is working when the client can reduce tension ratings within minutes and reports using the short breathing version during real incidents.

4.8 Cognitive restructuring of provocation appraisals [Novaco SIT]

• Purpose / when to use: skill acquisition phase, applied to diary incidents. Changes the appraisals that produce anger. [source: Novaco 1976, approx. pp. 10–11; NCT02157779]
• Steps: take one diary incident and work through Novaco's targets in turn.
  1. Personalisation. Identify where the client read the event as a personal affront or threat. Generate non-personal explanations. The aim is to "not take things personally" (Novaco 1976, approx. p. 10).
  2. Attentional focus / alternative viewing. Ask what else was going on. Help the client widen attention beyond the provoking cue.
  3. Exaggerated importance. Test how much this will matter in a week or a year. Novaco draws this target from Ellis.
  4. Justified versus unnecessary anger. Was a real wrong done? If so, what response fits it?
  5. Empathic role-taking. Rehearse the other person's point of view.
  6. Task orientation. Shift from "who is to blame" to "what outcome do I want, and what will get it".
  7. The client writes the alternative appraisal on the diary sheet and rates how believable it is.
• Example language (illustrative): "You read it as 'he's disrespecting me'. If a friend saw the same thing, what else might they think was going on? And what do you actually want to come out of this?"
• Watch for:
  • Do not argue that the client's anger is wrong. Validate the wrong when it is real, and work on the size and the response. [synthesis]
  • It is working when the client spontaneously offers alternative readings and focuses on outcomes in later diary entries.

4.9 A-B-C-D model [SAMHSA group]

• Purpose / when to use: session 5 and thereafter. A structured disputing method based on Ellis. [source: Reilly & Shopshire 2019]
• Steps:
  1. A, activating event: describe the facts only.
  2. B, beliefs: identify the beliefs and self-talk, especially "should" and "must" demands about how others or life must be.
  3. C, consequences: the emotional and behavioural results.
  4. D, dispute: challenge the belief and replace it with a realistic, flexible alternative. Then re-rate the anger.
  5. Practise on group members' check-in incidents.
• Example language (illustrative): "Where's the 'should' hiding in that? 'He should have called back.' Is there a law that says so, or is it 'I'd really prefer he had'?"
• Watch for:
  • Intellectual agreement without any change in feeling. Repeat the disputing on fresh, live incidents.
  • Disputes that turn into self-blame.

4.10 Self-instruction training across the four stages of provocation [Novaco SIT]

• Purpose / when to use: skill acquisition, then application. Gives rehearsed coping self-talk for each stage of an encounter. Novaco treats private speech as the central self-regulation tool. [source: Novaco 1976, approx. pp. 11–12]
• Steps:
  1. Explain the four stages:
     • Preparing for a provocation.
     • Impact and confrontation.
     • Coping with arousal.
     • Reflecting afterwards, which takes one of two forms: the conflict is unresolved, or the conflict is resolved. The third and fourth stages allow for the client losing control partly, and aim to stop rumination adding more arousal. [source: Novaco 1976, approx. pp. 11–12, Table 1]
  2. With the client, write 2–4 personal coping statements for each stage, in the client's own words. Use Novaco's sample statements only as prompts. An example of the arousal-stage style is "Relax and slow things down" (Novaco 1976, Table 1).
  3. The therapist models the statements aloud while imagining a scene. The client then rehearses them aloud, then in a whisper, then silently. [source: Novaco 1976 (overt then covert rehearsal)]
  4. Put the statements on a card or phone note for carrying. [synthesis]
  5. Use the statements during application training (4.15).
• Example language (illustrative):
  • Preparing: "This could get tense. I know what to do; I don't have to take the bait."
  • Impact: "Stay focused on what I want out of this."
  • Arousal: "My jaw's tight, time to breathe. Slow down."
  • Unresolved: "Shake it off; replaying it won't help."
  • Resolved: "I handled that better than I used to."
• Watch for:
  • Statements that sound like the therapist's words rather than the client's.
  • Self-talk that becomes suppression ("I'm not angry"). The aim is coping, not denial. [synthesis]

4.11 Thought stopping [SAMHSA group]

• Purpose / when to use: session 5. The SAMHSA manual includes it as an immediate way to interrupt a run of angry thoughts. [source: Reilly & Shopshire 2019]
• Steps:
  1. The client notices the start of an escalating angry thought chain.
  2. They give themselves a firm internal command to stop.
  3. They redirect attention to a coping statement, breathing, or the task in hand. The steps after the command are [synthesis].
• Example language (illustrative): "When you catch yourself replaying it, tell yourself 'Stop. Not helpful.' Then go straight to your breathing."
• Watch for: rebound rumination. Thought suppression can increase intrusive thoughts. If that happens, use the rumination work in 4.21 instead. [synthesis; this caution is not in the SAMHSA manual]

4.12 Timeout and strategic withdrawal [SAMHSA group / Novaco-based VA protocol]

• Purpose / when to use: from session 1 or 3. An immediate strategy to leave a situation before reaching 10 on the meter. [source: Reilly & Shopshire 2019; NCT02157779 ("strategic withdrawal")]
• Forms:
  • Informal timeout: the client leaves the situation or conversation, calms down, and returns.
  • Formal timeout: a policy agreed in advance with family or friends.
  • Leader-called timeout: in group, the leader can call one at any time, and members comply, stepping out for 5–10 minutes if needed. [source: Reilly & Shopshire 2019]
• Steps (formal timeout; details are [synthesis] unless marked):
  1. Agree a signal word or gesture with the other person when both are calm.
  2. The person taking the timeout says they are taking one and when they will return.
  3. During the timeout, do no driving, drinking or ruminating. Use breathing or a walk instead.
  4. Return at the agreed time and resume the topic calmly, or set another time to discuss it. The agreed family policy itself is from [source: Reilly & Shopshire 2019].
• Example language (illustrative): "I'm getting too heated. I'm taking 20 minutes and I'll come back so we can finish this."
• Watch for:
  • A timeout used as stonewalling, punishment or exit from every difficult talk. The return is non-negotiable.
  • Coercive partners using the timeout policy to control the other person (see section 5).

4.13 Anger control plan [SAMHSA group]

• Purpose / when to use: session 3, then revised in each session. A personal toolbox of immediate and preventive strategies. [source: Reilly & Shopshire 2019]
• Steps:
  1. List immediate strategies: timeout, breathing, coping statements, thought stopping.
  2. List preventive strategies: exercise, talking to a supportive person, recovery or 12-Step meetings, exploring the primary feelings under the anger, the Conflict Resolution Model.
  3. Link each strategy to a point on the anger meter.
  4. Add a social support plan: who to call for which kind of support, and how to ask.
  5. Review the plan at every check-in: which tools were used, and what worked. [source: Reilly & Shopshire 2019]
• Example language (illustrative): "At a 4, what's your move? At a 7? If you get to 8, what's the one thing you'll do no matter what?"
• Watch for: plans that are too long to remember when aroused. Keep 2–3 tools per level.

4.14 The aggression cycle [SAMHSA group]

• Purpose / when to use: session 4. Ties the meter, cues and control plan together. [source: Reilly & Shopshire 2019]
• Steps:
  1. Teach the three phases:
     • Escalation (buildup): cues rising, below 10.
     • Explosion: verbal or physical aggression, equal to 10 on the meter.
     • Post-explosion (aftermath): the negative consequences.
  2. Each client maps one recent episode onto the cycle and marks their individual speed and intensity.
  3. Identify the earliest point where the control plan could have interrupted the cycle.
• Example language (illustrative): "Everyone goes through the same three phases. Some of you go from 2 to 10 in seconds, some over days. Where in your buildup could you have stepped off?"
• Watch for: clients who see only the explosion. Keep pulling attention back to the buildup phase.

4.15 Application training: graded imaginal and role-play provocation (inoculation) [Novaco SIT]

• Purpose / when to use: phase 3, once skills have been rehearsed. The client practises the full coping package under controlled provocation, moving up the hierarchy. [source: Novaco 1976, approx. pp. 12–13; NCT02157779]
• Before starting (consent and safety):
  • Explain the purpose of the exercise and that the client controls the pace.
  • Agree a stop signal.
  • Agree how intense role-play may get: no touching, a set distance, and an agreed limit on volume.
  • Do not use this with clients who are currently acutely suicidal or homicidal, psychotic, manic or intoxicated. Those exclusions were used in the VA trial. [source: NCT02157779]
  • With trauma triggers, proceed only with explicit consent, after stabilisation, and with grounding available. [synthesis, consistent with NCT02157779]
  • In secure settings, follow local safety protocols for staff presence and the room. [source: Managing Anger 2nd edn table of contents (safety precautions)] The details of those precautions are not drawn on here. [uncertain]
• Steps:
  1. Relax the client briefly and take a baseline anger rating.
  2. Present the lowest scene. Either the therapist narrates it in present tense, or the client imagines it with eyes open or closed.
  3. The client signals when the anger is noticeable and applies the coping skills (self-instructions, breathing, reappraisal) while holding the scene. The therapist may prompt coping statements at first and then fade the prompts.
  4. Take ratings of anger (0–100) and of coping. Discuss what helped.
  5. Repeat the scene until anger is clearly lower and coping is fluent. Then move up a step. Novaco's application practice has the client calibrate their competence against the hierarchy. [source: Novaco 1976]
  6. Role-play. Re-run the same scenes with the therapist, or a group member, playing the provoker at matched intensity, starting mild. The client practises self-instructions plus a behavioural response (assertion, timeout).
  7. In vivo. Assign real-world practice with selected low-to-moderate situations, and debrief it in the next session. [source: NCT02157779 (in-session and in-vivo practice)]
  8. Close each exposure session with relaxation and a check that the client has de-escalated before leaving.
• Example language (illustrative): "You're in the queue, and the man behind you pushes past and says 'Move it.' Notice your body... What's your first coping thought? Say it out loud... Now breathe... Where's your anger now, out of 100?"
• Watch for:
  • Under-arousal (the scene is too weak or the client is avoiding it). Add specific detail.
  • Over-arousal: shouting, standing up, or fixation on revenge. Stop, relax, drop a step. The target zone is "aroused but not overwhelmed" (Novaco 1976, approx. p. 13).
  • Signs it is working: peak anger falls within and across trials, recovery is faster, and coping statements appear spontaneously.

4.16 Modelling and behavioural rehearsal [Novaco SIT]

• Purpose / when to use: whenever a new skill is introduced. [source: Novaco 1976 (modelling, then overt and covert rehearsal); NCT02157779 (modelling and rehearsal of coping skills)]
• Steps:
  1. The therapist demonstrates the skill, including some fumbling and recovery (coping rather than mastery modelling). Coping modelling is [synthesis] here, though it follows Meichenbaum's tradition.
  2. The client performs it aloud.
  3. The therapist gives specific feedback.
  4. The client repeats it.
  5. The client practises it covertly.
• Example language (illustrative): "Watch me do it first; I'll show you where I nearly lose it and how I pull back. Then it's your turn."
• Watch for: rehearsal that is flat and scripted. Raise the realism step by step.

4.17 Assertiveness training [SAMHSA group / Novaco SIT]

• Purpose / when to use: SAMHSA sessions 7–8; also part of Novaco's behavioural component. Replaces both aggression and passive build-up of resentment. [source: Reilly & Shopshire 2019; Novaco 1976; NCT02157779]
• Steps:
  1. Define three styles:
     • Aggressive: aims to harm or dominate.
     • Passive: lets one's own rights be violated, often storing anger that explodes later.
     • Assertive: stands up for one's rights while respecting the other person's. [source: Reilly et al. 2002 workbook]
  2. Show that these styles are learned, not fixed. [source: workbook]
  3. Teach a simple assertive statement: describe the behaviour, state your feeling and its impact, then make a specific request. [synthesis]
  4. Role-play using the client's real situations, with feedback on voice, posture and words.
• Example language (illustrative, for the client to use): "When you cancel at the last minute, I feel let down, because I've arranged my day around it. Can you give me more notice next time?"
• Watch for: "assertive" statements that carry hostility, such as sarcasm or accusations in disguise. Coach tone as well as words.

4.18 Conflict Resolution Model [SAMHSA group]

• Purpose / when to use: sessions 7–8. A structured way to raise a grievance. [source: Reilly et al. 2002 workbook; Reilly & Shopshire 2019]
• Steps:
  1. Identify the problem.
  2. Identify the feelings it causes.
  3. Identify its specific impact.
  4. Decide whether to resolve it or let it go: is it important enough to raise?
  5. If raising it, address and resolve it: arrange a time, describe your view, express your feelings, and discuss solutions together. [source: workbook]
• Example language (illustrative): "Before you raise it, run the five steps. What's the problem, how does it make you feel, what's the actual impact, and is this worth raising, or one to let go?"
• Watch for: step 4 matters. Letting go is a legitimate, skilled choice, not defeat.

4.19 Problem-solving, impulse delay and humour [Novaco SIT / Managing Anger manual]

• Purpose / when to use: for recurrent practical stressors that feed anger, and for impulsive responding. Novaco lists impulse delay, communication skills, and encouraging humour and affection among the affective and behavioural components, but says they are described elsewhere. [source: Novaco 1976, approx. p. 12] The Managing Anger manual includes a problem-solving routine worksheet. [source: Wiley table of contents]
• Steps [synthesis]:
  1. Problem-solving: define the problem concretely; brainstorm options without judging them; weigh likely consequences; choose and plan; try it; review.
  2. Impulse delay: build a fixed pause before responding (count, three breaths, or "sleep on it" for messages and emails).
  3. Humour: practise gentle, non-sarcastic humour that deflates the importance of the provocation, never aimed at the other person.
• Example language (illustrative): "Before you send that text, what's your rule? Save it as a draft and look again in an hour."
• Watch for: sarcasm posing as humour. That is hostility, not coping.

4.20 Exploring family-of-origin learning [SAMHSA group]

• Purpose / when to use: sessions 9–10. Shows how anger patterns were modelled and learned, which supports the idea that they can be changed. [source: Reilly et al. 2002 workbook; Reilly & Shopshire 2019]
• Steps:
  1. The client reflects on the family they grew up in: its structure; how each parent expressed anger; any threatened or actual violence or abuse; whether other emotions were shown; how discipline worked; the client's role in the family; and the messages they received about men and women.
  2. Identify which of these patterns show up in the client's current relationships, and what purpose they serve.
  3. Consider what would happen if the client gave them up. [source: workbook]
• Example language (illustrative): "When your dad got angry, what did the house feel like? Which of his moves do you catch yourself doing?"
• Watch for:
  • The material can stir up painful feelings and trauma. The manual suggests discussing these with the leader or a counsellor, and deeper work belongs in individual therapy. [source: Reilly & Shopshire 2019]
  • Using family history to justify aggression. Keep the focus on choice now.

4.21 Working with rumination and grudges [Novaco SIT]

• Purpose / when to use: when anger persists through replaying grievances or planning revenge. Novaco identifies rumination as a "viable treatment target" (Novaco 2011, p. 660), and his recent work examines anger rumination and revenge planning. [source: Novaco 2011, p. 660; Novaco publications page] The Managing Anger manual has a session on "carrying a grudge". [source: Wiley table of contents]
• Steps [synthesis]:
  1. Map the rumination: its triggers, how long it lasts, the content of revenge fantasies, and what it does to the client's arousal.
  2. Use Novaco's reflection-stage self-statements for unresolved conflict to disengage.
  3. Schedule a short daily "worry/grievance time" to contain the rumination. [synthesis]
  4. Shift attention to valued activity.
  5. Where relevant, explore letting go or forgiveness as the client's own choice, never as a demand.
  6. Assess revenge planning as a risk factor (see section 5).
• Example language (illustrative): "Each replay is another dose of the provocation, given by you to yourself. What would it take to put this one down?"
• Watch for: specific, rehearsed revenge plans against an identifiable person. Move to risk assessment.

4.22 Involving partners or family [Novaco SIT / VA protocol / SAMHSA group]

• Purpose / when to use: when anger is mainly expressed at home and it is safe to involve others. Novaco's 1976 inpatient programme added couples' group sessions with husbands before discharge. The VA protocol offers an optional psychoeducation session with a spouse or family member. SAMHSA's formal timeout is agreed with family. [source: Novaco 1976; NCT02157779; Reilly & Shopshire 2019]
• Steps [synthesis]:
  1. Screen individually and privately for intimate-partner violence and coercive control before any joint session.
  2. If it is safe, hold a joint psychoeducation session: the anger model, the client's cues, the control plan, and the timeout agreement.
  3. Agree how the partner can support the plan without becoming responsible for the client's anger.
• Example language (illustrative): "Your job tonight isn't to manage his anger. It's to understand the plan he's using and agree how timeouts will work in your house."
• Watch for: fear, deference or minimising by the partner. If any appear, stop joint work and follow your domestic abuse safeguarding procedures.

4.23 Trauma-adapted psychoeducation (military / combat) [VA protocol]

• Purpose / when to use: veterans, or others whose anger was adaptive in a dangerous environment. [source: NCT02157779]
• Steps:
  1. Frame anger and high alertness as responses that were adaptive in the war zone but are maladaptive at home. The VA trial used the Army's "Battlemind" materials for this. [source: NCT02157779]
  2. Give extra emphasis to relaxation and arousal reduction. [source: NCT02157779]
  3. Include trauma triggers in the provocation hierarchy only with consent (see 4.15). [source: NCT02157779]
  • Chemtob, Novaco et al. (1997) is the original Novaco-model trial for severe anger in PTSD. Its session details are not reported here. [uncertain]
• Example language (illustrative): "Over there, going from zero to a hundred in a second kept you alive. Here, the same switch is costing you. We're not removing it; we're putting a dimmer on it."
• Watch for: re-experiencing symptoms during exposure. Ground the client, and coordinate with PTSD treatment.

4.24 Practice and review sessions [SAMHSA group / Managing Anger]

• Purpose / when to use: SAMHSA sessions 6 and 11; recap sessions in Managing Anger. They consolidate learning and re-teach whatever has not landed. [source: Reilly & Shopshire 2019; workbook; Wiley table of contents]
• Steps:
  1. Run the extended check-in.
  2. Review each concept briefly: meter, cues, control plan, cycle, relaxation, A-B-C-D, thought stopping.
  3. Rehearse on live member incidents.
  4. Balance cognitive, behavioural, immediate and preventive strategies.
• Example language (illustrative): "Which tool did you actually use this week, and which one keeps slipping your mind?"
• Watch for: members who drift from the material into storytelling. Redirect to the skill.

4.25 Maintenance and relapse prevention: personal action plan, closing exercise [SAMHSA group / Managing Anger]

• Purpose / when to use: final sessions. Secures generalisation and plans for setbacks. [source: workbook (session 12); Wiley table of contents (personal action plan, "blueprint" summary); Reilly & Shopshire 2019 (aftercare strongly recommended)]
• Steps:
  1. The client rates how useful each treatment component was.
  2. The client writes a summary of what they learned, their control-plan strategies and how to use them, and specific areas they still need to work on.
  3. Build a written action plan: high-risk situations ahead, early cues, the tools for each meter level, and support contacts.
  4. Plan for lapses, treating an outburst as information rather than failure. [synthesis]
  5. Graduation or certificate (SAMHSA requires attendance at 9 or more of the 12 sessions).
  6. Arrange aftercare, booster sessions or follow-up.
• Example language (illustrative): "Imagine six months from now you've had a bad blow-up. What's the first thing you'll do the next morning?"
• Watch for: overconfidence ("I'm cured"). Name the specific situations still likely to be hard.

5. Handling problems

Court-mandated or reluctant clients.

• Treat this as a matter of readiness, not as resistance. [source: Novaco 2011, p. 659, citing Howells & Day]
• Be transparent about what gets reported and to whom.
• Elicit the functions anger serves for the client before its costs (4.2).
• Tie the work to the client's goals (job, children, freedom), not only to the court's goals.
• Accept clients at their current level of readiness. [source: Reilly & Shopshire 2019]
• Do not argue about whether the client "has an anger problem". Ask instead what the anger has cost them. [synthesis]

Blame and externalising ("they made me").

• Do not confront head-on. Validate the provocation, then separate the event from the appraisal and from the response (4.5, 4.8).
• Novaco notes that hostile attribution bias colours clients' accounts; work with those accounts as data. [source: Novaco 2011, p. 652]
• Repeatedly locate the choice points. [synthesis]

Anger tied to identity or status ("if I back down I'm weak").

• Reframe control as strength and as staying in charge, so that provocation does not "pull your strings".
• Separate respect from intimidation.
• Novaco links this entrenchment to resistance to therapy. [source: Novaco 2011, p. 662] The responses here are [synthesis].

Stuck: diary shows no change after several sessions. [synthesis]

• Re-check the formulation. Is arousal driven by something untreated, such as sleep loss, pain, intoxication, depression or PTSD? Is the environment still provoking (high-conflict housing, work)?
• Novaco notes that recurrent anger can reflect choices such as staying in high-conflict settings; address the setting as well as the person. [source: Novaco 2011, p. 653]
• Increase rehearsal under provocation (4.15). Insight alone is rarely enough.

Non-adherence: diaries, relaxation practice. [synthesis]

• Simplify the task (a phone note or a single daily meter rating).
• Do the homework together in session.
• Link practice to one valued outcome.
• Review whatever the client did bring, without criticism.
• With low literacy or cognitive impairment, use pictorial versions (thermometers, traffic lights). [source: Wiley table of contents, Managing Anger (traffic-light routine, anger thermometer)]

Overwhelm during exposure or role-play.

• Stop the scene. Use the agreed stop signal, breathing and grounding.
• Drop a step on the hierarchy. Keep the client "aroused but not overwhelmed" (Novaco 1976, approx. p. 13).
• Do not let the client leave until they have de-escalated. In the VA protocol, a distressed participant stays until the distress is manageable. [source: NCT02157779]

In-session escalation, or anger directed at the therapist (rupture).

• In group, call a timeout; a member may be asked to step out. Repeated non-compliance can lead to discharge. [source: Reilly & Shopshire 2019]
• In individual work [synthesis]:
  • Lower your voice and slow down.
  • Keep a non-threatening position and a clear exit for both of you.
  • Name the anger without judging it.
  • Validate whatever is legitimate in the complaint.
• Once calm, treat the rupture as a live practice incident: run the four stages together and repair openly. [synthesis]
• Managing Anger includes de-escalation techniques and listening to a person describing their anger as part of the therapeutic relationship. [source: Wiley table of contents] Their content is not drawn on here. [uncertain]

Violence risk, threats, revenge planning.

• Set the limits of confidentiality in session 1, including mandated reporting and Tarasoff-type duties. [source: Reilly & Shopshire 2019]
• When a client describes a specific target, plan, means or intent, carry out a structured violence risk assessment, consult, and follow your local duty-to-warn and protect procedures. [synthesis]
• Lethal-means counselling: if the client has access to firearms or other weapons, discuss safe storage or temporary removal (for example with a trusted person), especially during high-conflict periods. [synthesis]

Suicide and self-harm.

• Anger, especially when directed inward or after a loss of control, can co-occur with suicidality. Screen at intake and whenever risk indicators appear.
• Use your service's standard risk-assessment and safety-planning procedure, including lethal-means counselling (storage and removal).
• Clients with suicidal or homicidal ideation requiring hospitalisation were excluded from the VA trial. [source: NCT02157779] The remaining guidance is [synthesis].

Intimate-partner violence. [synthesis]

• Do not treat general anger management as a substitute for specialist perpetrator programmes where coercive control or partner violence is present.
• Screen each partner separately and prioritise the victim's safety.
• Make sure timeout agreements cannot be used to control the partner (4.12).
• None of the sources address this directly; this is synthesis, based on general practice. [uncertain]

Substance use.

• SAMHSA recommends at least 2 weeks of abstinence before joining, with clinical discretion.
• A single slip does not lead to discharge. Repeated use leads to referral to a more intensive level of care and restarting the programme.
• Intoxication in session means the client cannot take part in exposure work. [source: Reilly & Shopshire 2019; NCT02157779 (severe substance use disorder excluded)]

Severe mental illness and medication non-adherence.

• Coordinate with the psychiatric team.
• Refer clients who cannot process the material or who are non-adherent and unstable. [source: Reilly & Shopshire 2019]
• Exclude current psychosis or mania from exposure work. [source: NCT02157779]

Intellectual or cognitive impairment.

• Use the Taylor & Novaco protocol: a longer preparatory phase and individual delivery. [source: Taylor & Novaco 2005]
• Check suitability: self-monitoring ability, memory, language, and recognition of emotions. [source: Managing Anger table of contents (suitability checklist)]
• Use visual tools, brief arousal-reduction routines and frequent recaps.
• Clients with intellectual disabilities can report their own anger accurately. [source: Novaco 2011, p. 662]

Hidden anger surfacing during treatment.

• Novaco reports one patient in whom treatment uncovered severe anger that had not been recognised before. [source: Novaco 1976]
• Expect anger ratings to rise early as awareness improves. Explain this in advance so the client does not read it as getting worse. [synthesis]

Group problems. [synthesis unless marked]

• War stories that glamorise aggression: limit storytelling and redirect members to the skill. [source: Reilly & Shopshire 2019 (leader may limit responses and redirect)]
• Members validating each other's hostility: ask the group what the cost was.
• Absences: members notify the leader in advance; missing more than 3 sessions means no certificate, though they may continue attending. [source: Reilly & Shopshire 2019]
• Family-of-origin disclosures: refer deeper trauma work to individual therapy. [source: Reilly & Shopshire 2019]

Measurement problems.

• Self-report may be suppressed in forensic settings. [source: Novaco 2011, pp. 651, 658]
• Triangulate with staff or partner reports and behavioural incidents, and rely on the diary rather than questionnaires alone. [synthesis]

Relapse after treatment.

• Arrange booster sessions and aftercare (SAMHSA strongly recommends aftercare). [source: Reilly & Shopshire 2019]
• Review the personal action plan (4.25).
• Analyse the lapse using the aggression cycle and update the plan. [synthesis]

Sources

Sources

• Raymond W. Novaco – Publications (UC Irvine faculty site)
• Novaco, R. W. (1976). Cognitive regulation and skills training in the management of anger: A stress inoculation approach. ERIC ED141673, full text
• Reilly, P. M., & Shopshire, M. S. (2019 update). Anger Management for Substance Use Disorder and Mental Health Clients: A Cognitive-Behavioral Therapy Manual. SAMHSA PEP19-02-01-001
• Reilly, Shopshire, Durazzo & Campbell (2002). Anger Management for Substance Abuse and Mental Health Clients: Participant Workbook (govdocs copy)
• Novaco, R. W. (2011). Anger dysregulation: Driver of violent offending. Journal of Forensic Psychiatry & Psychology (author copy)
• Treatment of Trauma-Related Anger in OEF/OIF/OND Veterans – study protocol (NCT02157779), adapted from Novaco
• Taylor & Novaco (2005) – publisher sample: front matter and Chapter 1
• Taylor & Novaco (2005) – Wiley table of contents
• Managing Anger, 2nd edn (2006) – Wiley table of contents (the authors are not named on the page [uncertain])
• Hawkins, J. – Report of Novaco & Taylor BABCP 2015 pre-conference workshop on anger

Further reading (not drawn on)

• Novaco, R. W. (1975). Anger Control: The Development and Evaluation of an Experimental Treatment. Lexington Books.
• Novaco, R. W. (1977). Stress inoculation: A cognitive therapy for anger and its application to a case of depression. Journal of Consulting and Clinical Psychology.
• Meichenbaum, D. (1985). Stress Inoculation Training. Pergamon.
• Taylor, J. L., & Novaco, R. W. (2005). Anger Treatment for People with Developmental Disabilities: A Theory, Evidence and Manual Based Approach. Wiley.
• Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D. M. (1997). Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder. Journal of Consulting and Clinical Psychology.
• Novaco, R. W. (2007). Anger dysregulation. In T. A. Cavell & K. T. Malcolm (Eds.), Anger, Aggression, and Interventions for Interpersonal Violence.

Further reading (not drawn on): PubMed, including a key meta-analysis (PMID 20018996), Europe PMC and Semantic Scholar, and several archive.org items. Session-level content of Taylor & Novaco's preparatory and treatment phases, and of Managing Anger, therefore remains [uncertain].