Anger Management Program Participants Gain Behavioral Changes in Interpersonal Relationships

Introduction

Wellness describes the entirety of one's physical, emotional, and social health; this includes all aspects of functioning in the world—physiological, intellectual, social, and spiritual—as well as subjective feelings of well-being (Murphey et al., 2014). Social and emotional health encompasses forming and maintaining satisfying and healthful relationships, taking another's perspective, resolving interpersonal conflict, feeling capable and whole, expressing emotions, navigating stress, and having supportive relationships (Centers for Disease Control and Prevention, 2013; Middlebrooks & Audage, 2008). To achieve well-being, individuals may need help learning how to become critically aware as they develop healthful relationships with their bodies, thoughts, and feelings and with others across their life-spans.

Many factors negatively affect social and emotional health, including ongoing and toxic stress, harmful coping behaviors, and relationship violence. People faced with unhealthful and abusive relationships, situations, and settings at points across their life-spans are at risk for a wide range of physical, psychological, social, emotional, cognitive, financial, and spiritual health challenges. The added dimensions of poverty and chronic economic stress compound these issues for people of all ages and can especially affect the healthful growth and development of children and youth (Middlebrooks & Audage, 2008).

Neurological research has shown that abuse and neglect can alter early brain development and result in childhood developmental delays, poor physical health, depression, lower academic achievement, social difficulties, and aggression (U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau, 2008) as well as longer-term health problems such as alcoholism, chronic disease, depression, and substance abuse (Middlebrooks & Audage, 2008). In addition to the substantial impacts on the children themselves, there are quantifiable financial costs to society. Nationally, the direct costs related to child abuse and neglect, such as costs associated with the child welfare system, are estimated at $33 billion annually (Wang & Holton, 2007). Annual indirect costs, such as costs for special education systems, are estimated at over $70 billion (Wang & Holton, 2007).

According to Fetsch & Schultz (2001), family experiences that increase the risk of involvement in subsequent interpersonal violence include experiencing or witnessing

• physical abuse and neglect,
• heavy use and harshness of physical punishment,
• parental permissiveness regarding aggression,
• active encouragement of the use of aggression outside the home,
• domestic partner or marital couple violence, and
• high levels of coercive family interaction.

Social experiences that have been found to foster violence can include

• experiencing or witnessing violence within the family,
• viewing violence in the media,
• having access to firearms,
• being involved with the use of alcohol and drugs, and
• experiencing other societal issues that foster violence, such as poverty, economic inequality, and discrimination.

Why Anger Management Programs Work

Considering the aforementioned research, educational programs that help people foster critical awareness around their own thoughts and feelings can empower them to make positive changes in their lives and ultimately improve their social-emotional health. One way to help people achieve social-emotional health and improve their interpersonal relationships is to teach communication and anger management skills (Jordaan, 2011).

Does teaching communication and anger management skills make a difference? Researchers agree that anger management training succeeds in promoting positive resolution of common, everyday anger issues experienced within families and by friends and coworkers (Thomas, 2001). In fact, healthful anger expression may even prevent aggression (Thomas, 2001). It is important to understand the difference between anger control and anger management. Anger management classes cannot be expected to modify severe aggression and violent behavior. Underlying assumptions of anger management education are that all anger expression does not necessarily lead to aggression and that healthful anger expression and management can be learned.

Another study showed that anger management training for parents and teens resulted in improved communication and problem-solving skills and reduced conflict at home (Stern, 1999). McCarthy-Tucker, Gold, and Garcia (1999) found that anger management training reduced aggressive behaviors of court-referred adolescent boys in a residential treatment facility. Their findings further suggested that anger management training may help reduce aggressiveness and provide coping skills to adolescent offenders with histories of violent crimes and aggressive behaviors (McCarthy-Tucker et al., 1999). The study suggested that routine use of anger management training could prove valuable in offender rehabilitation programs for all age groups (McCarthy-Tucker et al., 1999). However, community-based populations not involved with the legal system also can benefit from gaining anger management and communication skills. A meta-analytical study reporting on 74 anger programs confirmed that the majority of the people who participate in anger management benefit from the education (Kusmierska, 2011). The bulk of the programs compared were based on cognitive-behavioral theory.

History of the Program

In 1995, Colorado State University (CSU) Extension researchers searched the literature for an effective parenting and child abuse prevention program. They were specifically looking for a program that dealt with parent skill development and addressed anger management. The program they identified was The RETHINK Method: Anger Management for Parents (Institute for Mental Health Initiatives, 1991). The program teaches parents and caregivers developmentally appropriate information about infants, toddlers, preschoolers, school-aged children, and teens. The curriculum demonstrates how to identify anger triggers at each of the stages and offers tips to help parents effectively manage anger when these triggers occur (Fetsch, Schultz, & Wahler, 1999).

In 1996, CSU Extension extended an invitation to other state Extension systems to attend training on the Institute for Mental Health Initiatives. Three Michigan State University Extension staff members attended the training and became involved with a national study conducted by CSU Extension on the effectiveness of the training. The results of that study indicated that parents who completed the RETHINK workshops made statistically significant improvements in managing their anger (Fetsch, Yang, & Pettit, 2008). Parents reported controlling and managing their anger better, improving their anger management skills overall, and reducing their family conflict levels (Fetsch et al., 2008).

In 2001, CSU Extension specialist Robert Fetsch and staff traveled to Michigan and offered training on the curriculum for all interested Extension staff and community partners. As a result of Extension staff's receiving this training, widespread program implementation occurred across the state, and since that time, the program has become an effective and popular parenting education program. Extension educators started to receive requests from participants and service agencies to open the class to anyone interested in anger management, not just those interested for parenting purposes. As a result, in 2004, a team of family and consumer science educators adapted RETHINK to create the new program RELAX: Alternatives to Anger (also referred to herein as RELAX).

RETHINK Method: Anger Management for Parents addresses stressors of parenting at each of the developmental stages of child development and involves a cognitive-behavioral, preventive curriculum. It is offered in six 2-hr weekly sessions that use the video Anger Management for Parents: The RETHINK Method Videotape. The RELAX: Alternatives to Anger curriculum is also based on cognitive-behavioral theory. The RELAX program targets individuals 18 years and older, with the goal of teaching participants to manage anger constructively when they encounter stress triggers of everyday life, such as stressors related to relationships, finances, work, and road rage.

In 2011, a team of experts in the human development field peer reviewed the RELAX program. Reviewers were PhD-awarded scholars in their fields of study hailing from different institutions across the country, including University of Minnesota, University of Wisconsin, Oklahoma State University, and California State University–Monterey Bay.

Program Description

RELAX: Alternatives to Anger is designed to actively engage adult learners in a group setting to increase knowledge and skills around anger management and provide constructive ways to deal with anger. Aspects of achieving social-emotional health are woven throughout the training and include expressing emotions, navigating stress, resolving interpersonal conflict, taking another's perspective, feeling capable and whole, and building skills for forming and maintaining satisfying, healthful, and supportive relationships.

The core concepts of RELAX: Alternatives to Anger are as follows:

• R = Recognize your anger signals.
• E = Empathize by seeing the other person's point of view.
• L = Listen and really hear what the person is saying.
• A = Accept that the other person's anger is not about you.
• X = X out the past, and keep it in the present.

RELAX is a community-based program that is open to anyone in a community and is marketed in a variety of ways. The target audience for RELAX is adults 18 years and older. Parents and caregivers of children remain a targeted primary audience. Some participants are mandated or highly encouraged to attend the course as a result of court contact either from domestic violence or assault charges. RELAX is promoted through websites, workplace wellness initiatives, child-care provider networks, courts, and human service agencies.

RELAX: Alternatives to Anger program sessions are 60–120 min in length per class for 4 weeks and work well in group settings from small groups (8–10 people) to large groups (20–30 people). The group format provides participants with opportunities to share their feelings and allows for social interaction and getting to know one another. The RELAX format is based on adult learning principles. The curriculum uses a combination of the following teaching strategies to ensure the greatest impact: visuals, lectures, problem-based learning, case studies, educational games, role playing, and discussion (Ota, DiCarlo, Burts, Laird, & Gioe, 2006). Each lesson includes at least three of these techniques to engage the adult participants. Table 1 provides more information about the program.

Table 1.
Description of RELAX: Alternatives to Anger Program

Session number and title	Program content	Delivery method
Session 1: What Is Anger?	Overview of the program; defining anger and recognizing anger signals	Lecture and group hands-on activities and discussion
Session 2: Calming Down and De-Stressing	Learning how to RELAX when angry or stressed	Lecture and group hands-on activities and discussion
Session 3: Four Principles of Problem Solving	Learning to empathize with and listen to others; accepting that anger is not about oneself	Lecture and group hands-on activities
Session 4: Forgiving and Letting Go of the Past	"X-ing" out the past; staying in the present and putting the concept of "R E L A X" into practice; retrospective survey	Lecture and group hands-on activities; 10-question self-reporting tool

The RELAX program has universal application. It has been applied within the Extension system as a workplace wellness program and as a professional development program. For example, staff involved with Supplemental Nutrition Assistance Program Education and the Expanded Food and Nutrition Education Program have gone through the program as a workplace wellness initiative. 4-H staff have been trained to use the information both personally and professionally to improve volunteer management. Moreover, during the major drought of 2012, many farm families felt the stress of the economic and environmental situation. Agricultural educators used the RELAX information with their farm families to address the anger and stress of potential financial impacts.

The RELAX: Alternatives to Anger logic model framed the overall programmatic goals for what participants should achieve as a result of the education. These include short-term, medium-term, and long-term goals:

• Short-term
• Increase knowledge and improve anger management.
• Medium-term
• Make positive behavioral changes.
• Increase or sustain anger control.
• Long-term
• Decrease family and interpersonal conflict.
• Decrease anger and violence.

Evaluation Method and Results

Survey Instrument

A 10-question survey instrument was used to measure the effectiveness of the RELAX: Alternatives to Anger program. The items were based on the Family Problem Solving Communication Index (FPSC) (McCubbin, Thompson, & McCubbin, 1996), which was designed to measure communication and problem solving within a family system. The FPSC, in general, is based on the premise that family communication determines how individuals will manage tension and stress, be resilient, and come back to normal family functioning after a stressful hardship (McCubbin et al., 1996). The original FPSC instrument comprised statements beginning with "we" to reflect the family unit; the tool adapted for the purpose of evaluating the RELAX: Alternatives to Anger curriculum comprised statements using the pronoun "I" to reflect personal actions relative to participation in the education. The FPSC provided a good conceptual foundation of communication items; other items focused on program objectives specific to anger management skills were added. Also, the FPSC used a 4-point Likert agreement scale (0 = false, 1 = mostly false, 2 = mostly true, 3 = true) for response choices, whereas the tool adapted for use in evaluating RELAX involved 5-point Likert response options for indicating amount of engagement in a healthful skill (1 = very little, 2 = little, 3 = average, 4 = some, 5 = a lot).

Retrospective Pretest Design

The evaluation of the RELAX program involved a retrospective pretest design. Retrospective pretest methodology is widely used in Extension program evaluation and has proved to be a simple, convenient, and reliable method of collecting program outcomes (Pratt, McGuigan, & Katzev, 2000). Participants self-rate what their amount of engagement in a behavior was before the program and after the program. Retrospective pretest methodology produces a legitimate assessment of program outcomes because it allows the program participant to reflect on his or her preprogram and postprogram behaviors after participating in the program intervention or educational lessons (Pratt et al., 2000). Retrospective evaluation designs reduce response-shift bias, participants' overestimation or inflation of their own understanding of a topic when taking a pretest before educational content has been provided (Moore & Tananis, 2009). Designs that reduce response-shift bias improve the overall validity of the measured outcomes.

To check reliability of the evaluation instrument, the 10 survey items were assessed together as a measurement scale. An internal consistency reliability test for the 10 preprogram rankings (α = .82) and 10 postprogram rankings (α = .79) established internal reliability for the scale. The alpha coefficients show that reliable scales can be made from a composite mean of the 10 indicators. The latent construct represents anger management skills and positive communication behaviors. The construct reflects the intended program outcomes and indicators. Composite mean variables were constructed for each individual on the basis of his or her average preprogram and postprogram ratings. Using composite means allows each item to be equally weighted and addresses the presence of missing data better than using a summed scale does.

Sample

A total sample of 1,168 program evaluation surveys were collected from RELAX: Alternatives to Anger participants over 3 program years (2013–2015). Data collection was statewide, and participants were residents in 51 of Michigan's 83 counties. The average age of participants was 38 years, with a range of 18 to 73 years. According to voluntary self-reported race and ethnicity information, 61% of the participants were White/Caucasian, 22% were Black/African American, 7% were Hispanic/Latino, 2% were American Indian/Alaskan, 3% were multiracial, less than 1% were Asian, and less than 1% were Native Hawaiian/Pacific Islander. Some of the participants preferred not to answer the race and ethnicity question or otherwise omitted answers. Sixty-four percent of the respondents were women. For those reporting educational levels, 33% were high school graduates, 27% were college graduates, 25% had attended some college, and 15% had not completed high school.

Program Outcomes

The 10 questions on the evaluation instrument used for the RELAX program were aligned with program logic model outcomes and associated indicators. These program outcomes were included as part of the state's Extension Plan of Work and Report of Accomplishment. The program outcomes and associated indicators are listed below.

• Outcome: Participants demonstrate skills and strategies for healthful relationships.
• Indicator: Improved ability to respond to one's own social-emotional needs and the social-emotional needs of others
• Indicator: Decreased involvement with unhealthful, abusive behaviors and/or relationships
• Outcome: Participants improve their knowledge about strategies to address aggression and violence.
• Indicator: Increased knowledge about the impacts of healthful and unhealthful relationships on individuals and setting
• Indicator: Increased knowledge about ways to foster safe and fair relationships and settings

Analysis

To measure individual-level change, change scores were calculated for each participant for each of the 10 survey items. To assess group-level change at a program level, composite mean scores for preprogram and postprogram ratings were created for means testing through the use of a dependent t-test.

Change scores were created for each individual by subtracting the preprogram rating from the postprogram rating for each item. Because the evaluation instrument had 10 items, there were 20 variables relative to preprogram and postprogram rating scores. Change scores in the direction of intended improvement were recorded in a category titled "changed." Change scores that did not move in the direction of the change anticipated or intended or showed no change were coded as "unchanged." For example, if a participant self-rated on a survey item as a 4 before the program and a 4 after the program, this result was coded as unchanged.

Table 2 shows the numbers and percentages of individuals whose change scores indicate positive change relative to the survey items, indicators, and program outcomes. In general, most participants improved relative to each program outcome.

Table 2.
RELAX: Alternatives to Anger Program Participants' Self-Reports of Change Relative to Program Outcomes

Outcome	Indicator	Survey item	No. assesseda	No. of individuals with self-reported changes in skillsb	% of individuals with self-reported changes in skills
Participants demonstrate skills and strategies for healthful relationships.	Improved ability to respond to one's own social-emotional needs and the social-emotional needs of others	I work hard to be calm and talk things through.	1,113	694	62%
		I get upset, but try to end on a positive note.	1,114	688	62%
	Decreased involvement with unhealthful, abusive behaviors and/or relationships	I am respectful of others' feelings.	1,110	505	46%
		I work hard to make sure that those close to me are not hurt emotionally or physically.	1,115	569	51%
		I take time to understand how others feel.	1,114	674	61%
Participants improve their knowledge about strategies to address aggression and violence.	Knowledge about the impacts of healthy and unhealthy relationships on individuals and setting	I (don't) yell and scream.	1,118	677	61%
		I know what triggers my anger at others.	1,110	642	58%
		I walk away from conflict without being satisfied.	1,104	289	26%
		I (don't) make matters worse by bringing up old issues.	1,102	635	58%
	Knowledge about ways to foster safe and fair relationships and settings	I talk things through until I reach a solution.	1,110	673	61%
aNumber assessed differs by question because preprogram and postprogram ratings were needed in calculation, and missing data were present and varied by item. bReflects self-reports of improvement in communication and anger management skills associated with the survey item.

Another way the data were examined involved calculating a composite change score for each individual across all items. These data offer a measure of program effectiveness. In the calculation of the composite change score for an individual, the individual's average rating across all items was used, resulting in a total average score of 0 to 5. The average composite score on the preprogram ratings for the group was 3.10 (SD = .77). The average composite score on the postprogram ratings for the group was 3.89 (SD = .64). A dependent t-test was performed on the preprogram and postprogram composite scores. The participants' self-reported ratings on communication and behavioral skills were significantly higher as a result of the RELAX: Alternatives to Anger program's educational lessons (t [1,124] = −33.08, p < .001***). This sample of participants gained communication and anger management skills, showing program effectiveness for RELAX: Alternatives to Anger.

Discussion

The RELAX: Alternatives to Anger program was found to be effective in producing individual change and change on a group level. Participants ended the program with improved skills. The retrospective surveys indicated that after completing the program, participants were more aware of when they become angry because of the skills they learned by participating in the program. As a result of the RELAX: Alternatives to Anger program, participants were managing their anger in more positive and constructive ways. Results of the evaluations indicated that improved communication skills are a large part of this encouraging change. Many of the participants shared through open-ended questions on the retrospective surveys that they had never learned communication skill such as using "I" messages or expressing feelings in an appropriate way. By practicing and using healthful communication skills, they were experiencing a positive change in how they managed anger.

Given that the RELAX: Alternatives to Anger program has been successful in meeting program outcomes for participants, educational efforts will continue and expand within the state. The need for educational and anger management programs is supported by statistics on violence and child abuse and neglect every year the data are published. Research has identified effective violence prevention and intervention programs and approaches relevant to the multiple settings where people live, learn, and grow. These include programs designed to help parents and caregivers learn to deal with anger in healthful ways that, in turn, strengthen the safety and health of other family members, such as children and youths.

The RELAX: Alternatives to Anger program is offered as a 4-week series of classes and has been adapted as an online self-paced course through the national eXtension website so that others across the United States, as well as in other countries, have access to the content. Additionally, the program is offered as a train-the-trainer program for others interested in teaching anger management as part of their work or volunteer positions. A special 2-hr version of RELAX called RELAX for Parents and Caregivers has been created and targets parents and caregivers of children up to 5 years old.

Implications for Findings

There are few anger management programs available to the general adult population, as demonstrated through the literature review. As indicated by Kusmierska (2011), most anger treatment programs have been clinical interventions, whereas RELAX is an educational prevention program targeting individuals who experience everyday anger and stress. The program has had success in assisting adult participants in building skills to constructively manage anger through improved communication strategies. There is an opportunity for the Extension system to reach a new audience with this type of educational outreach and make similar impacts. For example, 4-H staff can use the RELAX curriculum to assist in volunteer management. Also, additional future plans are to adapt the curriculum for developmentally delayed adults, nonreaders, and the Spanish-speaking population. Indeed, there have been many requests for a Spanish version of the curriculum. To be mindful of how or whether the RELAX: Alternatives to Anger program was culturally competent for a Spanish-speaking audience, Extension staff gathered feedback through focus group research around the state, particularly in areas where there are the fastest growing Spanish-speaking communities. The goals are to have the RELAX program translated into Spanish and to enhance and embrace the cultural richness this process may inspire and then to share the experience with others as a model for cultural competency.

The original intent behind the creation of the RELAX: Alternatives to Anger program was to produce an evidence-based curriculum. With more federal and state funders requiring evidence-based programs that show effectiveness and accountability, RELAX: Alternatives to Anger could add to the repertoire of evidence-based programs specifically because it is cost effective, easily distributed, and simple to replicate and has demonstrated effective positive behavior outcomes. Steps are being taken to show alignment with standards created by The Society for Prevention Research (Fetsch, MacPhee, & Boyer, 2012) relative to evidence-based programming.

Conclusion

The findings of the study reported here indicate the importance of teaching adults how to communicate appropriately and manage their anger constructively. Dealing with toxic stress and anger is universal and ongoing. Individuals can greatly benefit from learning productive social-emotional skills and strategies for healthful relationships. Extension professionals are in an ideal position to provide education to a wide and diverse audience, resulting in a far-reaching positive impact.

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