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Anger Management Group Treatment for Cocaine Dependence: Preliminary Outcomes

By Patrick Riley and Michael Shopshire

Anger precedes the use of cocaine for many cocaine-dependent individuals (1, 2); thus, cocaine-dependent individuals who experience frequent and intense episodes of anger may be more likely to relapse to cocaine use than individuals who can control their anger effectively. Several clinical trials have demonstrated that cognitive-behavioral interventions for the treatment of mood and anxiety disorders can be used to help individuals with anger control problems reduce the frequency and intensity with which they experience anger (3). Although studies have indirectly examined anger management group treatments in populations with a high prevalence of substance abuse (4, 5), few studies have directly examined the efficacy of an anger management treatment for cocaine-dependent individuals. Gerlock (5), for example, published a study demonstrating the effectiveness of an anger management treatment in a sample of participants who had a primary diagnosis of post-traumatic stress disorder. Although many participants had a history of drug or alcohol dependence, the sample was not selected based on inclusion criteria for a substance dependence disorder, such as cocaine dependence. Considering the possible mediating role of anger for substance abuse, a study examining the efficacy of anger management treatment in a sample of cocaine-dependent patients would be informative.

In the current study, we developed a cognitive-behavioral anger management group treatment for cocaine-dependent individuals who reported frequent and intense episodes of anger. The group treatment was developed as a stage I project funded by the National Institute on Drug Abuse under the Behavioral Therapies Development Program (6). The specific aims of the study were to write a manual to standardize treatment procedures, to determine the extent to which the frequency of anger episodes decreased, and whether decreased levels of anger were sustained at follow-up. Participants received separate treatment for cocaine dependence in addition to the anger management group treatment. Levels of anger and related negative affect were measured with self-report questionnaires at baseline, during treatment, at the end of treatment, and at 3 months post-treatment. We hypothesized that participants would increase their ability to control their anger and also reduce their levels of anger and related negative affect. We also examined survival time to dropout and relapse to cocaine and other substance use.

METHOD

Sample

Recruitment. An anger management group treatment was delivered in conjunction with two substance abuse treatment programs. Men received substance abuse treatment at the Substance Abuse Outpatient (SAOP) Clinic at San Francisco Veterans Affairs Medical Center. Women received substance abuse treatment at the Stimulant Treatment Outpatient Program (STOP) at San Francisco General Hospital. Potential participants were recruited for the study if they met the inclusion criteria of cocaine dependence according to the Diagnostic and Statistical Manual of Mental Disorders (7) and if they reported problems controlling their anger. Initial diagnoses were made by intake clinicians at the treatment programs and were verified by a clinical psychologist.

Participants were excluded if they had medical or psychiatric problems that were so severe that hospitalization was expected within the 6-month study period, were diagnosed by staff as having schizophrenia or organic brain dysfunction, planned to leave the San Francisco Bay Area within 6 months, or anticipated jail time within that period.

Study investigators recruited patients from early cocaine dependence treatment groups at the two study sites. Interested patients attended an orientation session at which the investigators explained study procedures, obtained informed consent, and determined eligibility for the study. Ninety-one patients consented and attended a 12-week anger management group treatment. Treatment groups began when at least 5 participants meeting the study criteria had been recruited. Participants waited between 1 and 6 weeks for their group to form. Seven cohorts of men and four cohorts of women were recruited. The mean size of the cohorts was 8.27 (SD = 2.83) participants.

Demographics. The sample consisted of 59 men and 32 women. Men and women did not differ on baseline levels of anger, negative affect, or drug use (all t values [is less than] 1.50). Men were significantly older than women, with a mean age of 44.3 (SD = 7.22) years versus a mean of 36.4 (SD = 5.31) years (p = .02). Of the 91 participants, 53 (58%) were African-American, 28 (31%) Caucasian, 5 (6%) Hispanic, 3 (3%) Asian, and 2 (2%) from other ethnic groups. There were 29 (32%) participants who reported taking medication for a psychiatric problem at baseline.

Drug use history. There were 67 (74%) participants who reported that they did not use any substance 30 days prior to baseline, which was expected considering that all participants were enrolled in substance abuse treatment programs. Also, 4 (4%) participants reported alcohol use only 30 days prior to baseline; 5 (6%) used cocaine only; 1 (1%) used heroin only; 3 (3%) used alcohol and marijuana; 3 (3%) used cocaine and alcohol; 2 (2%) used alcohol, cocaine, and marijuana; and 6 (7%) did not provide a response. Only 2 participants who used drugs or alcohol reported 7 or more days of drug or alcohol use during the 30 days prior to baseline.

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