Research on Social Work Practice

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Anger-Control Group Counseling for Women Recovering From Alcohol or Drug Addiction
A. Antonio González-Prendes
Research on Social Work Practice 2008 18: 616 originally published online 25 October 2007
DOI: 10.1177/1049731507308356

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 Anger-Control Group Counseling for Women
Recovering From Alcohol or Drug Addiction

A. Antonio González-Prendes
Wayne State University

Two experimental conditions, a manualized cognitive-behavioral anger-control treatment incorporating empower-

ment strategies and a relapse-prevention treatment without the anger-control component, were compared to assess
their impact on levels of trait anger and attributional styles of women recovering from alcohol and drug addiction.
Participants were predominantly African American, low-socioeconomic-level women living in a residential facility in
a major Midwestern city. Although significant changes were found for the anger-control group participants, sample
size (anger control n = 8, relapse prevention n = 5) and participant characteristics call for caution when interpret-
ing the results and limit the generalizability of the intervention. As a preliminary study, the findings are encouraging.
Recommendations for future research and implications for social work practice are discussed.

Keywords: women; anger; attributional styles; cognitive-behavioral treatment

It has been suggested that anger is a key emotional state
that contributes to the onset and maintenance of alcohol
and/or drug use and to the dynamics of the relapse
process (Daley & Marlatt, 1992; DeMoja & Spielberger,
1997; Gilbert, Gilbert, & Schultz, 1998; Larimer,
Palmer, & Marlatt, 1999). Beeder and Millman (1992)
suggested that alcohol and drug users may derive a self-
medicating effect from the use of substances to regulate
the noxious effect of negative affect such as anger.
DeMoja and Spielberger suggested that drug users expe-
rience anger more frequently than nonusers; are more
likely to feel less in control of their angry feelings; and
also are more apt to express such anger toward other
persons or objects in their environment. Tafrate, Kasinove,
and Dundin (2002) indicated that high trait anger partici-
pants tended to use alcohol and drugs when feeling
angry more than the low trait anger participants. The
postulated relationship between anger and substance
abuse presents a strong argument for the need to explore
and address anger issues within a comprehensive approach
to the treatment of addictions.
Author’s Note: This article was accepted under the guest editorship of Anne
E. (Ricky) Fortune. Portions of this article were previously presented at the
International Practice Research Symposium, June 1 to 2, 2005, sponsored by
the School of Social Welfare at the State University of New York at Albany.
Correspondence may be addressed to A. Antonio González-Prendes, Wayne’s
State University, School of Social Work, 4756 Cass Ave. #301, Detroit, MI
48202; e-mail: aa3232@wayne.edu.
Research on Social Work Practice, Vol. 18 No. 6, November 2008 616-625
DOI: 10.1177/1049731507308356
© 2008 Sage Publications
616
Although several meta-analytic reviews support the
effectiveness of cognitive-behavioral treatment (CBT)
on anger problems (R. Beck & Fernandez, 1998;
DelVecchio & O’Leary, 2004; DiGiuseppe & Tafrate,
2003; Edmondson & Conger, 1996), the need still exists
for further understanding the role played by client vari-
ables, such as attributional styles, as well as the theoret-
ical processes that influence the onset and maintenance
of anger and treatment outcomes with angry clients
(R. Beck & Fernandez, 1998; Deffenbacher, Dahlen,
Lynch, Morris, & Gowensmith, 2000). A review of the
aforementioned meta-analyses reveals a dearth of stud-
ies focusing on the application of CBT to treat anger in
women in general and women of color in particular.
Of a total of 148 studies only two unpublished disserta-
tions focused exclusively on anger treatment in women.
Wilson (as cited in Delvecchio & O’Leary, 2004) used
a CBT intervention with a mixed sample of 27 female
undergraduates and community members, and Wu (as
cited in R. Beck & Fernandez, 1998) focused on a sam-
ple of 26 divorced women. Neither of these two studies
appeared in the published literature. A number of stud-
ies included mixed samples of men and women with
heavy reliance on college undergraduate populations.
The review of the available literature on the application
of CBT to anger problems reveals two significant limita-
tions. The first limitation is the lack of available clinical
research on the use of CBT to treat anger in women in
general and specifically in women of color. The second
limitation is the over-reliance of current studies on under-
graduate college populations (DelVecchio & O’Leary,

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 González-Prendes / ANGER-CONTROL GROUP COUNSELING 617
2004; DiGiuseppe & Tafrate, 2003; Tafrate et al.,
2002). Such limitations raise serious questions around
the generalizability of the available findings to clinical
populations such as the one in this study: inner-city,
low-income, women with extensive histories of alcohol
and drug addiction. Although a discussion of the reasons
for the lack of this research involving gender, racial and
ethnic minorities is beyond the scope of this article; the
fact remains that such research is needed to standardize,
validate, and assess the efficacy of treatment approaches
across diverse populations (Bernal & Scharron-Del-Rio,
2001). This study is an initial attempt to address the lim-
itations in the available research literature.
CBT has been suggested as a viable and effective
treatment approach with minority groups (Hays, 1995;
Organista & Muñoz, 1996). The available literature,
although limited, has shown positive results particularly
in the use of CBT with minorities to treat problems such as
depression (Kohn, Oden, Muñoz, Robinson, & Leavitt,
2002; Miranda et al., 2003; Organista, Muñoz, & González,
1994); panic disorders (Carter, Sbrocco, Gore, Marin, &
Lewis, 2003); stress (Webb, Beckstead, Meininger, &
Robinson, 2006); and affective and behavioral hostility
(Haugen, 2000). Yet, the need continues for assessing
the effectiveness of CBT across gender, ethnic, and racial
diverse populations (Harper & Iwamasa, 2000; Hays, 1995;
Iwamasa, 1996; Nagayama Hall, 2001), and specifically in
the treatment of anger with such groups.
PURPOSE OF THE STUDY
This study investigates the effects of a short-term,
8-session, manualized, cognitive-behavior anger-control
group program on a sample of predominantly African
American women recovering from alcohol and/or drug
addiction. More specifically, the study evaluated the
impact of treatment on participants’ level of trait anger
(Spielberger, 1988) and on attributional styles of partici-
pants relative to their perceived responsibility for the
causes of and solutions to their problems. Spielberger
(1988) defined trait anger as “a disposition to perceive a
wide range of situations as annoying or frustrating and
the tendency to respond to such situations with more fre-
quent elevations of state anger” (p. 1). Maladaptive or
toxic anger implies that such anger is a harmful, destruc-
tive, or deadly agent often expressed in various maladap-
tive ways that include: internalizing or “stuffing” of the
emotion; passive-aggressive or indirect means; aggres-
sion (verbal or physical with high levels of arousal); or by
redirecting the anger toward other pathologies. It is this
maladaptive or toxic anger that becomes the target of
anger treatment.
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THEORETICAL BACKGROUND
Cognitive-Behavioral Theory
The basic principles of CBT (A. T. Beck, 1976; Ellis,
1962; Meichenbaum, 1985) underscore the importance of
information processing and the products of such process-
ing in the form of appraisals, judgments, meanings, con-
clusions, and attributions, in determining one’s emotional
and/or behavioral responses to any given situation. Key
assumptions of the CBT approach (Dobson & Dozois,
2001) underscore the key role of rigid, biased, distorted,
and irrational cognitions in the etiology and treatment of
emotional disorders, and the notion that cognitive change
in a rational and realistic direction helps reduce emotional
symptoms and achieve clinical improvement.
Attributional Theory
To examine the relationship between anger and blame
and control attributions, the study was framed within a
theory developed by Brickman et al. (1982). This theory
accounts for the beliefs that individuals have regarding the
responsibility for the causes of their problems (blame attri-
butions), and responsibility for the solutions to their prob-
lems (control attributions). Brickman et al. proposed that
such attributions can be best understood within a four-
model paradigm representing four orientations that under-
score the level of responsibility that people accept for the
causes of and solutions to their problems (Table 1). In the
moral model, people ascribe a high level of responsibility
to themselves for both the causes of and solutions to their
problems. In the compensatory model, people do not see
themselves as being responsible for causing a problem,
but they do see themselves as being responsible for solv-
ing it. Individuals within the medical model do not see
themselves as being responsible for either the causes or
solutions to their problems. Finally, in the enlightenment
model people are deemed to be responsible for causing the
problem but not for the solution. The current study
focused on the moral and medical models as they repre-
sent opposite polarities of the orientation spectrum and as
such may provide a clearer notion of the attributional ori-
entations associated with anger.
Attributions of blame and control are thought to be
key factors in the onset and maintenance of anger
problems (A. T. Beck, 1999) and several studies have
suggested that such blaming process plays a significant
role in the formation of anger (Meier & Robinson,
2004; Ohbuchi et al., 2004; Weber, 2004). Kassinove
and Sukhodolsky (1995) summarized the relationship
between anger and blame by stating that “anger is an
accusatory response to some perceived misdeed. The
618 RESEARCH ON SOCIAL WORK PRACTICE
TABLE 1: Brickman et al.’s (1982) Attributional Models
Level of Responsibility for:
Attributional Model Causes
Solutions
Medical Low
Enlightenment High
Compensatory Low
Moral High
NOTE: Each model reflects an individual perception of personal
responsibility for the causes of or solutions to problems.
typical instigation to anger is some value judgment; it is
an attribution of blame” (p. 24). Averill (1982) sug-
gested that the ascribing of personal responsibility onto
an object for causing the adversity or setback is a key
aspect of the formation of blame and the onset of anger.
Hareli and Weiner (2002) have argued that “anger is
an accusation or a value judgment that another person
‘could and should have done otherwise’” (p. 188). This
assertion suggests that angry individuals believe control
over solutions to the problem rests with the other per-
son, the transgressor, and had this person acted differ-
ently the negative outcomes could have been prevented.
One also could argue that controllability implies power.
That is, if individuals believe they have appropriate con-
trol over the solutions to their problems, then they may
feel more empowered to take socially appropriate cor-
rective measures to resolve the problem, and conse-
quently may be less likely to feel exceedingly frustrated
and angry. Studies have suggested that feelings of pow-
erlessness or helplessness play a role in the formation of
anger and aggression (Farrow, 1989; Thomas, 1995).
While studying “anger attacks” in three single cases,
Fava, Anderson, and Rosenbaum (1990) suggested that
such attacks may occur in response to feelings of help-
lessness. Given these perspectives, if anger-control
treatment is to be effective it must also address partici-
pants’ external attributions of blame and control, and in
the process of doing so empower the clients to increase
their level of responsibility for their feelings and
actions, and to identify and implement socially appro-
priate solutions within their control.
Women and Anger
Gender-role socialization messages often discourage
women from the direct expression of anger, and instead
promote a view that such direct expression poses a
threat to the stability of relationships, thus encouraging
women to divert or reroute their anger (Cox, Van Velsor,
& Hulgus, 2004). Hatch and Forgays (2001) suggested
that early in life young girls begin receiving messages
that anger expression may lead to social rejection and
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internal emotional distress. As such, girls are then less
likely to learn to express anger effectively to achieve their
goals. Cox, Stabb, and Bruckner (1999) in their theory of
anger-diversion in women suggest that such anger diver-
sion is not a form of anger expression, but rather an
Low attempt on the part of women to reduce the internal dis-
Low
High
tress associated with the experience of anger and the threat
High that it may pose to their relationships. The authors suggest
that women diverting anger conversely experience higher
levels of anxiety and other symptoms, and require assis-
tance in developing and endorsing an assertive anger
expression style that allows for the direct and open com-
munication of angry feelings while respecting the rights of
the other person (Cox et al., 2004).
Munhall (1993) observed that for women anger is
often left in silence, or displaced, and transformed into
other more socially acceptable pathologies. Such
pathologies associated with women’s anger may include
self-cutting (AbuMadini & Rahim, 2001; Matsumoto
et al., 2004), bulimia (Meyer et al., 2005), and alcohol
and/or drug use (Brady & Sonne, 1999). Furthermore,
Hagan, Finnegan, and Nelson-Zlupko (1994) suggest
that because some women in our society are often
placed in repeated conditions of dependence on parents,
partners, and social services for their economic survival,
these conditions often leave these women feeling dis-
empowered, hopeless, with low self-esteem and lacking
self-confidence, thereby reducing their capacity to cope
effectively with stressful situations in their lives. Faced
with the lack or loss of material, personal, and social
resources, these women may be more susceptible to
forms of internal distress such as depression and anger
(Hobfoll, Johnson, Ennis, & Jackson, 2003).
Hagan et al. (1994) suggest that these conditions are
more evident among poor, inner-city women who lack the
social and economic resources to remove themselves from
the situations of dependence that often coexist with abu-
sive and chaotic conditions, a representation that accu-
rately describes the women in this study. Mabry and
Kiecolt (2005) suggest that minorities, women, and people
of lower socioeconomic status experience less sense of
control than Whites, men, and those in the higher brackets
of income, education, and positions of prestige. They also
suggest that a sense of control (or lack of), the idea that
one is in control of one’s outcomes mediates the experi-
ence of anger more for African Americans than for
Whites. Thomas (2005) asserted that based on a review of
data collected between 1989 and 1991 on 531 women the
most prevalent theme of women’s anger, associated with
almost two thirds of anger-inducing situations, was pow-
erlessness. Fields et al. (1998) underscored the theme of
power or powerlessness as key in understanding the expe-
rience of anger in women in general and in African
 González-Prendes / ANGER-CONTROL GROUP COUNSELING 619
American women in particular. Given these perspectives
it would seem that to effectively treat anger in women
one must address the women’s sense of powerlessness,
and implement strategies to empower them to take
healthy control over their lives.
METHOD
This study used a pre- and post-treatment, two-group
design with participants randomly assigned to one of
two treatment options. One group received an 8-week,
manualized, cognitive-behavioral anger-control treatment,
and the other group received an 8-week relapse-prevention
treatment without the anger-control component. The study
included one independent variable with two modalities:
anger-control treatment and relapse prevention. Two
dependent variables were included; trait anger and attri-
butional style.
Outcome Measures
One outcome measure was the participants’ level of trait
anger as measured by the Trait Anger scale of the State-
Trait Anger Expression Inventory (STAXI; Spielberger,
1988). The Trait Anger scale consists of 10 items that mea-
sure individual differences in the disposition to experience
anger. Participants rate each item on a 4-point Likert-
type scale: 1 (not at all), 2 (somewhat), 3 (moderately
so), and 4 (very much so); the higher the rating the
higher the level of participant endorsement of that item.
Internal consistency for the Trait Anger scale has been
reported at .87 for both genders. Test–retest measures
following a 2-week interval were reported as .70 for
males and .77 for females (Spielberger, 1988).
The second outcome measure, the participants’ attri-
butional style, was measured by the Helping and Coping
Orientations Measures (HCOM; Michlitsch & Frankel,
1989). The HCOM has four subscales corresponding to
each of Brickman et al.’s (1982) attributional models:
medical, enlightenment, moral, and compensatory. The
HCOM is a 25-item scale that measures respondents’
attributions of responsibility for the causes of and solu-
tions to their problems. Respondents indicate their level
of agreement with each statement using a 5-point
Likert-type scale that ranges from 1 (strongly disagree)
to 5 (strongly agree). The responses indicate the
strength of the participants’ endorsement for either one
of the four attributional models. Participants were
instructed to complete the HCOM with regard to a spe-
cific problem that “caused” them to feel angry. Because
the study focused on the moral and medical models of
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attributions, only the scores in those models were used
in the analyses. Internal consistency measures for the
medical and moral subscales have been reported as α =
.84 (Medical) and α = .87 (Moral; McCracken, 1995).
Test–retest reliability measures for the HCOM over
2 weeks ranged from .66 to .83, and .68 to .92 over a
4-week period (Bailey & Hayes, 1998).
Participants
Residents living in a long-term residential treat-
ment community within the city of Detroit were
offered the opportunity to participate in the study
knowing that they would be randomly assigned to
either one of the two treatment conditions: anger-
management or relapse prevention. A total of women
volunteered to participate in the study. The women
reported low socio-economic backgrounds; long-term
histories of abuse of drugs and alcohol; and varying
degrees of involvement with the legal system. They
had experienced victimization and battering, estrange-
ment from families, and other healthy support sys-
tems, and loss of children to protective services agencies.
The goal of the residential program was to help and
empower the women to become independent and self-
supporting. Residence requirements included absti-
nence from drugs and alcohol; participation in support
groups such as Alcoholics and Narcotics Anonymous;
and participation in counseling. They also received
social services including support with job search,
attending school, and family reunification.
The participants ages ranged from 32 to 53, with a
mean age of 40.75 years (SD = 7.92). Of the 20 women,
17 were African American, 2 White, and 1 Latina.
Approximately 33% reported educational levels less
than high school, 58% reported high school completion,
and 8% reported some college. All the women indicated
that they had children although their children were nei-
ther living with them nor under their custody. Of these
women, 25% of the women described themselves as
single, 8% separated, 17% divorced, and 50% did not
indicate any current marital or relationship status.
Approximately 33% of the women indicated having
between 1 and 6 weeks of sobriety, 33% between 7 and
12 weeks, 17% between 13 and 18 weeks, and 17%
more than 18 weeks.
Treatment Groups
Anger treatment. Anger treatment was offered in
eight 90-minute group sessions that followed a struc-
tured CBT format (J. Beck, 1995) Treatment evolved
620 RESEARCH ON SOCIAL WORK PRACTICE
through three stages: (a) developing a conceptual under-
standing of the problem, (b) skills acquisition and rehearsal,
and (c) application and follow through (Meichenbaum, 1985,
1993). Each session focused on specific themes that included:
recognition of the influence of thoughts on emotions and
behaviors; identification of the clients’ own particular cogni-
tive distortions and idiosyncratic beliefs that contributed to
the onset and maintenance of anger; learning to assess the
validity and functionality of anger-inducing messages,
with special focus on evaluation of evidence for or against
their beliefs, and recognition of other plausible, alternative
explanations to interpret situations (other than their anger-
inducing conclusions); recognizing physical, emotional,
and mental (thoughts and images) cues to anger; increasing
responsibility for one’s emotions and behaviors by aug-
menting the capacity to self-monitor; relaxation strategies;
and assertive communication and conflict-resolution skills.
Role-play and a here-and-now orientation were used to
keep the group focused on present experiences and to prac-
tice and reinforce cognitive and behavioral skills. Group
interaction and feedback provided opportunities to rein-
force successes and troubleshoot setbacks.
Empowerment was an integral and recurrent theme
throughout the treatment program aimed to help the women
increase their level of self-determination, self-efficacy, and
expand their opportunities (Zastrow & Kirst-Ashman,
2004). This process of empowerment revolved around five
key themes: (a) awareness of realistic boundaries of control
and responsibility, (b) appropriately assertive communica-
tion and conflict resolution, (c) identification of individual
and collective strengths as women, and the functionality of
such strengths in coping with challenges and overcoming
societal obstacles, (d) recognition of positive contributions
of women to our society, and (e) identification of reasonable
immediate and long-term steps, within their control, to
access resources, expand opportunities, and achieve per-
sonal goals (e.g., family reunification, education, employ-
ment, improved finances, etc.).
Relapse prevention. The relapse-prevention treatment
met for eight 90-minute, weekly sessions and followed
a cognitive-behavioral approach based on Daley and
Marlatt’s (1992) nine key themes of relapse prevention:
Understand relapse as a process and not a discrete event;
identify high risk relapse triggers and discuss strategies
to avoid these; identify cognitive and behavioral cues
that increase the risk of relapse and actual cravings;
identify and practice cognitive strategies to reframe irra-
tional beliefs or cognitive distortions that fuel cravings
or negative emotional states; identify and discuss the
role of social and peer pressure to use substances; iden-
tify elements of a supportive relapse-prevention network
and begin its implementation; identify cognitive and
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behavioral mechanisms to cope with negative emotional
states without using alcohol or drugs; develop a relapse-
prevention plan with emphasis on how to interrupt a
relapse episode should one take place; and identify and
discuss elements of a balanced lifestyle (i.e., nutrition,
exercise, recreation and healthy social interaction, work,
and spirituality).
Research Hypotheses
The study hypothesized that the CBT anger-control
approach would reduce levels of trait anger and increase
levels of endorsement of the moral model of attributions
from pre- to post-treatment. It was also hypothesized that
the difference between the scores in the Trait Anger scale
of the STAXI (Spielberger, 1988) and the endorsement of
the moral model of the HCOM (Michlitsch & Frankel,
1989), from pre- to post-treatment, would be significantly
greater in the anger-control group when compared to the
differences in the relapse-prevention group.
Data Analysis
A total of 20 participants started the study (10 in each
group) and 13 completed the treatment. Of 10 women, 8
completed the anger-control treatment and 5 of 10 com-
pleted the relapse-prevention treatment. The Mann-
Whitney U test for independent samples was used to
establish pre-treatment equivalency between the groups,
and to compare the change scores between the two
groups on measures yielded by the Trait Anger scale of
the STAXI (Spielberger, 1988), and the moral and med-
ical models of the HCOM (Michlitsch & Frankel, 1989).
Wilcoxon-signed rank tests were used to compare
changes in STAXI and HCOM scores from pre- to post-
treatment for participants in both groups separately.
Finally, effect size was used to evaluate the practical
meaning of score changes at post-test when compared to
pretest, and the differences between the two groups. The
effect size was calculated using Cohen’s d by dividing
the difference between two means (treatment–control)
over a pooled standard deviation. An effect size ≥ .08 is
considered to represent a large magnitude of treatment
effect (Cohen, 1988). All decisions on the inferential
analyses were made using a .05 level of significance.
The results of the pretreatment analyses using the
Mann-Whitney U test indicated no statistically signifi-
cant difference between the two groups on measures
of trait anger (z = –0.87, p < .05), and endorsement of
the medical model of attributions (z = –0.60, p ≤ .05), or
the moral model (z = –0.69, p < .05). Results of the
Wilcoxon signed-rank test revealed statistically signifi-
cant decreases from pre- to post-treatment levels of trait
 González-Prendes / ANGER-CONTROL GROUP COUNSELING 621

TABLE 2: Anger-Control Group Wilcoxon Signed Rank Tests TABLE 4: Wilcoxon Signed Rank: Anger-Control Group Pre
and Post Attributional Change
Trait Anger n M SD z Value Sig. of z Effec
Size Attributional Model n M SD z Value Sig. of z Effec
Size
Pre 10 23.3 2.67 –2.53* .011 2.17
Post 8 16.13 1.73 Moral
Pre 10 3.20 0.60 –2.54* .011 2.88
*p < .05. Post 8 3.95 0.37
Medical
TABLE 3: Mann-Whitney Test: Anger-Control and Relapse-
Pre 10 3.56 0.67 –2.37* .018 1.79
Prevention Groups’ Trait Anger Change
Post 8 2.79 0.64
Trait Anger n M SD M Rank z Value Sig. of z Effec
*p < .05.
Size

Anger control 8 –7.50 2.82 4.81 –2.51* .011 2.31 TABLE 5: Mann-Whitney: Between-Groups Comparison of
Relapse 5 –3.00 1.87 10.50 Attributional Style Change
prevention
Model or M z Sig. Effect
*p < .05. Group n M SD Rank Value of z Size
anger for the anger-control group (z = –2.53, p < .05; see
Moral
Table 2). Results for the relapse-prevention group were not Anger control 8 0.75 0.49 8.13 –2.23* .026 4.15
significant (z = –1.60, p < .05). Comparisons of the change Relapse 5 –0.04 0.32 3.25
scores from pre- to post-treatment between the two groups prevention
were conducted using the Mann-Whitney U test for two Medical
Anger control 8 –0.77 0.53 6.63 –0.17 .864 0.27
independent samples. Change scores were calculated by Relapse 5 –0.58 1.24 6.25
subtracting pretreatment scores from post-treatment. The prevention
results of this analysis revealed statistically significant dif- *p < .05.
ferences between the two groups (z = –2.53, p < .05). As it
was hypothesized, the mean rank for the anger-control
group, 4.81 was statistically lower than the mean rank for Limitations
the relapse-prevention group, 10.50 (see Table 3).
Wilcoxon signed-rank test were also used to deter- A number of limitations have to be considered when
mine whether there were any significant changes from interpreting the results and attempting to make causal
pre- to post-treatment in the levels of endorsement of the inferences about the effects of the intervention. The small
medical and moral orientations for both groups. As sample size dictated the use of nonparametric statistics to
hypothesized, the anger-control group showed a statisti- test the hypotheses. The use of nonparametric tests, how-
cal significant increase in their endorsement of the ever, limits generalizations and presents a drawback in that
moral model (z = –2.54, p < .05) and a significant they lack the statistical power of their parametric counter-
decrease in their endorsement of the medical model (z = parts, and thus increases the risk of a Type II error (i.e.,
–2.37, p < .05; see Table 4). Theoretically, according to accepting a false null hypothesis when it should be
Brickman et al. (1982), the medical model presents an rejected) (Runyon & Haber, 1991). The absence of a con-
opposite orientation to that of the moral model. Like trol (no treatment) group creates another limitation. As
opposite ends of a scale, it was expected that an increase such, one cannot tell whether possible therapeutic gains
in one would lead to a decrease in the other one. experienced by the relapse-prevention group might have
The relapse-prevention group showed no statistical sig- been generalized in ways that affected the magnitude of
nificant changes in their level of endorsement of either the differences between the two groups. Although the magni-
moral model (z = –0.37, p < .05), or the medical model tude of change measured by effect sizes were in the large
(z = –0.092, p < .05). When changes from pre- to post- range, the small sample and the absence of a control group
treatment scores were compared between the two groups, preclude any definitive statements about the effectiveness
statistical significant differences were found for the level of and generalizability of the intervention.
endorsement of the moral model (z = –2.23, p < .05), and Another limitation relates to the study’s population that
nonsignificant results were found for the medical model consisted predominantly of African American women
(z = –0.17, p < .05). For the moral model of attributions, the (85%) recovering from alcohol and drug addiction living in
anger-control group had a mean rank of 8.13 that, as hypoth- a residential facility in a major Midwestern city. Such char-
esized, was significantly higher than the mean rank of 3.25 acteristics limit the generalizability of the findings and as
obtained for the relapse-prevention group (see Table 5). such, generalizations should not be made beyond the

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622 RESEARCH ON SOCIAL WORK PRACTICE
sample of the study. When considering the findings of the
study, one must also consider possible across-groups conta-
mination that might have occurred from the participants liv-
ing and interacting in the same residential setting. Although
it is not clear how that process might have actually affected
the study outcomes, one could surmise that everyday inter-
action between members of both groups in the residential
facility might have resulted in some exchange of informa-
tion that could have influenced attitudes and behaviors that
might have affected the findings in the study.
Although it was neither possible nor feasible to physically
separate both groups in the residential facility, future studies
in similar settings would want to consider the option of offer-
ing the interventions sequentially rather than simultaneously.
Doing so would reduce the probability of contamination
between the groups and help determine how the two groups
may differ when the possibility of interaction and contami-
nation between treatment conditions is removed from the
study. Finally, the use of self-report instruments raises the
possibility that some clients might have provided responses
that they deemed to be socially desirable. Nonetheless,
despite these limitations, the magnitude of change appears to
be clinically meaningful and the study offers an overview
that highlights interesting theoretical and practical concerns
for social workers and future researchers to consider when
working with populations of women with anger problems
similar to the ones in this study.
Last, the attrition rate is also an issue that needs to be
considered. Of the participants, 29% in the anger-control
group and 50% in the relapse prevention did not complete
treatment. The two participants in the anger-control group
that did not complete treatment had come to the end of
their stay at the residential facility and as such had to move
out and were not able to continue in treatment. The reasons
given by participants for dropping out of the relapse-
prevention group were relapse into drug and alcohol use
(2), conflict with work schedule (1), and no specific reason
(2). One could argue that the emphasis and focus on
empowerment for the anger-control group helped instill a
higher level of hope in those participants thus contributing
to their ability to remain in treatment. As participants in the
anger-control group began to feel a heightened sense of
empowerment, they might have felt more hopeful and as
such more inclined to stay with the treatment than the par-
ticipants in the relapse-prevention group.
DISCUSSION AND APPLICATION TO
SOCIAL WORK PRACTICE
Studies (Fields et al., 1998; Thomas, 2005) have
underscored the current limitations of anger research on
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women, and have called for more focus and attention to
anger in working-class women and vulnerable women
groups whether such vulnerability is related to culture, dis-
ability, sexual orientation, or other factors. This study was a
preliminary attempt to apply a structured 8-week cognitive-
behavioral anger treatment approach to women of low
socioeconomic levels recovering from alcohol and/or drug
addiction. The main purpose of the study was to investigate
the effects of a cognitive-behavioral anger-control group
counseling on participants’ levels of trait anger and on the
attributions of responsibility for the causes of (blame attri-
butions), and solutions to their problems.
The data indicate that the participants in the anger-
control group appeared to have significantly reduced
scores of trait anger from pre- to post-treatment. They
also experienced significant reduction in trait anger when
compared to the relapse-prevention group. These results
appear to lend support to prior research (Deffenbacher
et al., 2000; Reilly & Shopshire, 2000) and meta-analyses
(R. Beck & Fernandez, 1998; DelVecchio & O’Leary,
2004; DiGiuseppe & Tafrate, 2003; Edmondson & Conger,
1996; Tafrate et al., 2002) that suggest that CBT is an effec-
tive approach to reduce levels of trait anger.
Regarding the attributional orientations of the partic-
ipants, the anger-control group appeared to have made
significant changes from pre- to post-treatment by
increasing their level of endorsement of the moral
model of attributions and reducing their endorsement of
the medical model. Although the study’s small sample
did not lend itself to the use of correlation analysis to
evaluate the relationship between attributional orienta-
tions and trait anger, the general implications and direc-
tion of the findings conform to the notion discussed earlier
in this article, suggesting a negative relationship between
higher levels of internal responsibility and trait anger. By
increasing their endorsement of the moral model and
decreasing the endorsement of the medical model, the
anger-control group participants (who showed significant
decreases in trait anger from pre- to post-treatment)
appeared to be embracing a higher level of responsibility
for the causes of and solutions to their problems. Although
statistically this study did not link participants’ attribu-
tional changes with decreases in the levels of trait anger,
prior research has suggested that external attributions of
blame (Epps & Kendall, 1995; Gotner, Golan, &
Jacobson, 1997; Trachtenberg & Viken, 1994) and con-
trol (DeMoja, 1997; DeMoja & Spielberger, 1997) are
characteristic of anger reactions.
The participants in the relapse-prevention group also
showed reductions in their scores on trait anger from
pre- to post-treatment; however these results were not
statistically significant. One may surmise that these
 González-Prendes / ANGER-CONTROL GROUP COUNSELING 623
changes may have been the result of the passage of time;
possible effects of also participating in community-
based support groups; across groups’ contamination; or
generalizations of treatment effects from the relapse-
prevention program itself. Reilly and Shopshire (2000)
suggest that substance abuse treatment has been shown
to reduce anger even when such anger is not directly tar-
geted. The relapse-prevention group did not reveal any
significant changes in their levels of endorsement of the
moral or medical models of attributions.
As previously stated, the findings of this study should be
interpreted with caution and inferences regarding the effect
of the intervention should not be made beyond the sample
presented here. Nonetheless, the results suggest that social
workers working with angry clients may want to explore
and assess the role that attributions of blame and control
may play in the onset and maintenance of their clients’
anger. One could surmise that such external attributions of
blame and control reflect the angry individuals’ own sense
of powerlessness and helplessness to change life conditions.
Therefore, social workers working with angry clients may
want to explore such issues of perceived powerlessness par-
ticularly when working with historically vulnerable and
oppressed populations such as the women in this study.
The focus on empowerment throughout this group chal-
lenged the women to take socially appropriate action that
would serve them not only to maintain their sobriety, but
also to set the path for improving their overall life condi-
tions, and to attain some of their own stated goals (e.g.,
reunification with their families and children, freedom
from the legal system, economic independence, gainful
employment and school involvement among others). As far
as the women in the anger group were concerned, at the
end of treatment they appeared to have gained a heightened
sense of responsibility for their emotions and behavior, and
an increased sense of control over the solutions to their
problems in the form of increased awareness of the short-
term immediate steps that they needed to take to reach their
long-term goals.
Hays (1995) suggested that CBT lends itself to be
particularly useful with cultural diversity because of its
focus on client empowerment. In CBT clients are helped
to recognize that they have control over their thoughts
and consequently over their emotions and behaviors. This
realization in itself was empowering to the women in treat-
ment. The participants seemed to respond positively to the
structured CBT approach; the focus on the here-and-now;
and the use of in-session role-play to address specific real-
life situations and practice the cognitive and behavioral
skills discussed in groups. Although powerlessness or
empowerment were not measured variables in this study,
the women’s stories at the end of treatment reflected
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a heightened sense of awareness of their own capabilities,
potential, and sense of self-efficacy. Although more
research is needed to assess the direct impact of empower-
ment on anger reduction, the findings in this study suggest
that social workers may want to consider empowerment
strategies as part of a comprehensive approach to treat
anger problems particularly with individuals who repre-
sent a gender, racial, or ethnic minority.
FUTURE DIRECTIONS
Although this project presents several limitations, it
may also serve as a pilot study to generate further
research in the use of CBT to treat anger in vulnerable
and marginalized women’s groups. The results of the
research suggest that CBT may be a viable alternative
when working with angry individuals similar to the par-
ticipants in this study. This is particularly meaningful
given that the overwhelming majority of participants in
this project were women of color, a population under-
represented in studies using CBT in anger treatment.
The study also raises a number of issues for social work-
ers to consider when conducting future research on the
subject of anger with similar populations. First, addi-
tional research with larger samples is needed to further
ascertain the effectiveness of the intervention and to
develop further empirical support, and culturally sensi-
tive approaches for the treatment of anger with CBT that
specifically targets gender, racial, and ethnic minorities.
Second, additional research could shed more light that
the role of empowerment plays on the treatment of
anger when working with oppressed and vulnerable
populations, and provide insight into the actual cogni-
tive mechanisms that lead to the development of a sense
of empowerment. Third, future studies may want to
include a follow-up component that would allow the
investigators to assess how well treatment gains were
maintained over time. Finally, additional research with
larger samples in the form of randomized controlled
studies may help to further evaluate the relationship
between trait anger and the attributions of responsibility
that people make for the causes of and solutions to their
problems, and the contributions of such attributions to
the onset and maintenance of anger problems.
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