1. The programme at a glance
Indication. Problematic anger in adults — disproportionate, frequent or destructive outbursts that damage relationships, work or safety —, whether it meets the criteria for intermittent explosive disorder or accompanies another disorder, in a person whose family and partner are not exposed to controlling violence, that is, to coercive control (section 3).
Reference model. The cognitive behavioural therapy of anger as described by Novaco and then by Deffenbacher: applied relaxation (section 31), cognitive work on hostile readings and on demands (section 6), skills training, and rehearsal of those skills under arousal, that is, while the anger and the body are wound up, through imaginal exposure to provocations (section 33). It is this format, extended to twelve weeks, that has been evaluated in intermittent explosive disorder.
Format. Twelve weekly individual sessions of fifty to sixty minutes. A separate interview with the partner, when that is possible and safe, between the first and the second session. Two booster sessions, at one month and at three months.
Mechanism targeted. Not suppressing anger, which is a normal emotion, but four changes: spotting it at 3 out of 10 instead of 8 (on the personal scale built at session 4), bringing the body down instead of discharging it, reading situations as something other than attacks, and having available, under arousal, a course of action other than aggression.
| Session |
Focus |
Session output |
| 1 |
Assess, look for violence, set the frame |
Violence looked for, limits of confidentiality stated |
| 2 |
What anger costs, and the emergency time-out |
Cost written down, commitment, provisional time-out |
| 3 |
The model of anger |
Two episodes broken down into six steps |
| 4 |
Triggers and early signs |
Personal scale, signs at 3 out of 10 |
| 5 |
Bringing the body down |
Relaxation learnt, time-out negotiated |
| 6 |
Hostile thoughts |
Three hostile readings re-examined |
| 7 |
Injustice, demands and rumination |
Two demands softened, rumination measured |
| 8 |
Settling what keeps coming back |
One recurring problem handled in six steps |
| 9 |
Asking instead of attacking |
One request and one refusal rehearsed in role play |
| 10 |
Resentment, forgiveness and repair |
One repair prepared, one resentment examined |
| 11 |
Imaginal exposure to provocations |
Three high scenes gone through under arousal |
| 12 |
Review and relapse prevention |
Written plan, measures repeated |
In this table, the time-out is an agreed pause: at the first sign of rising anger, the person announces that they are leaving, leaves the room and comes back at a stated time (section 31). The "high scenes" are the situations on the training list rated 7 or 8 out of 10 (section 33).
What the person takes away. Ten printable worksheets, listed in section 38: my anger record, what my anger costs me, my scale and my signs, my time-out and my relaxation, the thoughts that light the fuse, settling what keeps coming back, "asking, refusing, repairing", my training scenes, my plan for what comes next, and a worksheet for those close to them, which is handed to them directly.
What distinguishes this programme from the other manuals on this site. Three things. Section 3, placed before all the others, which organises the detection of violence in the couple and in the family and which can suspend or redirect the programme. The explicit refusal of venting, replaced by bringing arousal down. And imaginal exposure to provocations, which turns skills that are known into skills that are available.
2. Before you begin
The four preliminary decisions
Is anyone afraid of this person? That is section 3, and it is the only question that can stop the programme.
Is the anger the problem, or the symptom of another one? A manic episode, a psychosis, a brain injury, intoxication or withdrawal are treated first. Section 9.
Is there an immediate risk to the person themselves? Look for suicidal thoughts, dangerous driving and alcohol (sections 10 and 11).
And who is asking? Someone who comes of their own accord, someone sent by their partner, by their employer or by the courts are not treated in the same way. Motivation is worked on, and it is worked on first. Session 2.
What this programme does not treat
Controlling violence within a couple. It is not a programme for perpetrators of domestic violence, it does not replace a judicial response, and it must never serve as an argument for a victim to stay. Section 3.
Instrumental aggression, premeditated, used to obtain something. See Antisocial personality: a therapist's manual.
Severe alcohol use disorder, which is treated first or alongside. See Alcohol use disorder: a therapist's manual.
Children and adolescents, whose outbursts call for work with the parents. See Treating oppositional defiant disorder in children: a therapist's manual.
And the meltdowns of an autistic person, which are not treated as fits of anger. See Autism in adults: a therapist's manual.
How to use it
Read the whole text before the first session, in particular sections 3, 7, 17, 31 and 33: violence in the couple and in the family, the model, the frame, relaxation and the time-out, and imaginal exposure. Each session is described along the same lines: the aim, the steps, what you say, the common mistakes, and the criterion for moving on.
Three warnings specific to this presenting problem.
The patient minimises, and that is the rule. "We argue like everybody else", "I did not hit her, I just pushed her". This is not necessarily lying: shame and the memory of the angry state distort. That is why you ask about precise acts rather than about labels, and why you offer a separate interview with the partner (section 3).
The therapist is tempted to take sides, for the patient whose wounds one hears, or against him whose acts one hears. Both positions make the work fail. You can acknowledge the injustice suffered and hold firmly that violence is not an acceptable response.
And your own safety is involved too. Section 11.
3. First of all: violence in the couple and in the family
Why this section is placed here
Because it is the only one that can suspend the programme, because it is regularly skipped, and because domestic violence can present for care under this precise heading: "I have an anger problem". Meta-analyses find, among men who perpetrate domestic violence, moderately higher levels of anger and hostility than among non-violent men, including in distressed couples (Norlander and Eckhardt, 2005), and this association holds for perpetrators of both sexes (Birkley and Eckhardt, 2015). Anger is therefore often present. It does not explain everything, and that is the whole problem.
What this manual is not
It is not a programme for perpetrators of domestic violence. Those programmes work on responsibility, control and respect, they often form part of a judicial response, and even they obtain modest effects on reoffending (Babcock et al., 2004 and 2024). An individual anger regulation programme was not designed for that.
"Anger management" is not the right answer to coercive control. Controlling violence — what sociology calls coercive control (Stark, 2007) — is not an emotion that overflows. It is a system: isolating, monitoring, belittling, controlling the money, threatening, frightening, with or without blows. It is often exercised in cold blood, and it chooses its target: rarely the line manager, almost always the partner. Learning to breathe does not touch the system. The work of Johnson (2008) distinguishes this controlling violence, which tends to become more frequent and more severe over time, from a situational violence, made of conflicts that escalate without either partner seeking to control the other, and which can also be severe. What separates them is neither the intensity of the anger nor the existence of arguments: it is control, with the fear and the loss of freedom that it imposes on the other person.
And work on anger can make the situation worse. It can wrongly reassure the victim ("he is getting treatment"), supply an argument before a judge, give the perpetrator a vocabulary for shifting responsibility ("you know perfectly well that you set me off"), and turn the time-out into a weapon, for example to close down all discussion (section 31). These distortions are known, and they justify the screening that follows.
How you detect it
You ask the questions directly, at the first session, of everyone. Not "are you violent?", which always gets "no", but behavioural questions: "When you are angry with your partner, have you ever pushed her, held her back, shaken her? Thrown an object in her direction? Punched a wall next to her? Stopped her leaving a room? Squeezed her neck, even briefly?"
You ask what happens outside the outbursts. "Do you look at her phone? Do you decide what she spends? Can she see her friends without telling you?" These are the questions that bring out control, which does not show up in the account of the anger outbursts.
You ask the question about fear. "Has anyone at home ever been afraid of you?" It is the most useful question, and it is the one that settles the matter.
You look for the history — police call-outs, complaints, protection orders, proceedings, recent or planned separation —, for weapons, and for the whole family: elderly parents, siblings, flatmates.
You look for the children: their age, whether they are present during the outbursts, any violence they have suffered directly, and their fear. A child exposed to violence between their parents is affected even when they are not the target: a meta-analysis of one hundred and eighteen studies finds, among child witnesses, difficulties more marked than among non-exposed children, and not significantly different from those of physically abused children (Kitzmann et al., 2003).
The separate interview
Why. The patient's account, even when sincere, is incomplete. The person who lives with him knows whether she is afraid, and she will never say so in front of him.
How. It is offered at the first session as an ordinary part of the programme. You see the partner alone, at a time they have chosen, without the patient waiting in the waiting room. You never see the couple together first.
What you say to the person you see. What the programme can and cannot do, and that it does not guarantee their safety. That nothing they confide will be reported back to the patient. And the resources that exist for them, independently of him: specialist helplines, voluntary organisations, emergency services.
What you ask them. Whether they are afraid, and of what. What happens during the outbursts. Whether they can go out, spend money, see whom they wish. Whether the children are afraid. Whether there have been physical acts, threats, a weapon, strangulation.
What you do not do. Report back to the patient what has been said. Ask them to monitor the patient or to judge his progress. Make them responsible for the success of the programme. Offer couple therapy.
If the patient refuses, you note it, you do not make it an absolute condition, and you return to the question of fear in greater detail: a repeated refusal, accompanied by anxiety about what the partner might say, is clinical information. If the person does not wish to come, you pass on to them, by a safe channel and not through the patient, the details of a helpline and worksheet 10, which is intended for those close to the patient (section 38).
What you decide next
No violence, no fear, no control. The programme runs as it is described.
Isolated violent acts, in a context of conflict, without control and without settled fear in the other person. The programme is possible, on four conditions: the act is named as violence, and not as anger; an explicit commitment is made — no physical violence, no threat, no destruction during the programme; the time-out is negotiated with the other person, not imposed; and the situation is checked again at sessions 6 and 12.
Coercive control, settled fear, repeated violence. This is not the programme. You refer to a specialist programme for perpetrators of domestic violence, where one exists, you make sure that the person exposed has been given the details of support services, and you tell the patient why. Individual work on anger may come in addition, never instead, and only in coordination with that service.
Signs of high danger. Strangulation, even once, death threats, an accessible weapon or threats with a weapon, violence that is getting worse, recent or planned separation, obsessive jealousy, stalking, violence during a pregnancy, imposed sexual intercourse, threats of suicide by the perpetrator. Several of these features are associated with a markedly increased risk of homicide (Campbell et al., 2003; Glass et al., 2008). What follows becomes an emergency response: protection of the people exposed, specialist services, and, depending on the situation and the law of your country, emergency services or the authorities.
Protection obligations
They vary from one country to another, and you must know them before the first session: what the law obliges or allows you to report, and to whom.
For adult victims, the World Health Organization does not recommend mandatory reporting of domestic violence to the police by health professionals, and recommends offering this reporting to the person if she wishes it (World Health Organization, 2013). Some legislations provide for exceptions, in particular in cases of immediate danger.
For children, most countries provide a procedure for informing child protection services when a child is in danger, and exposure to domestic violence is often part of it.
In every case, the limits of confidentiality are stated to the patient before the questions about violence, what is observed is recorded precisely, and a decision to report is taken after seeking advice, for example from your supervisor, never alone if that can be avoided.
What you say to the patient
"I am going to ask you precise questions about what happens when you are angry, including about physical acts. I ask them of everyone I see for this reason, because the answer changes what I can offer you."
"What you are describing to me is not badly managed anger. It is violence, and it is a problem of a different nature. I am not dropping you: I am referring you to what was designed for it."
All configurations
Controlling violence is most often exercised by men against women, and the most severe forms affect women above all. It exists in every configuration, including in same-sex couples. The screening questions and what follows are the same.
4. Four pictures not to confuse
1. Ordinary anger, even intense
Occasional, proportionate outbursts that subside, without physical acts or threats. The person finds themselves "too short-tempered" without anything in their life really suffering from it. What points to it: the absence of consequences. What it implies: information, and possibly Anger: understanding it and regulating it. Not this protocol.
2. Problematic anger
Frequent, intense or long outbursts — shouting, insults, sarcasm, punitive silence, lasting resentment — that damage relationships, work or health, often associated with another disorder. What points to it: the impact, without the thresholds for intermittent explosive disorder necessarily being reached. What it implies: this programme, once what must be treated first has been treated.
3. Intermittent explosive disorder
Brief, sudden outbursts, out of all proportion to what sets them off, verbal or physical, not premeditated, followed most often by regret or shame, in a person who is sometimes calm between the outbursts. What points to it: the explosive quality and the repetition. Section 8. What it implies: this programme, in its full format.
4. Controlling violence
A person presented as "short-tempered", but whose outbursts always target the same person, never occur at work or in front of witnesses, and are accompanied by monitoring, jealousy, control of the money or of who they see. The other person is afraid. What points to it: the selectivity of the target, the fear, the other person's loss of freedom. What it implies: section 3, not this programme.
The three other things to have ruled out
An organic cause — brain injury, early dementia, neurological illness —, especially when the character changed in adulthood. A substance — alcohol, stimulants, certain medicines, withdrawal states. And a mood episode: recent irritability, with a reduced need for sleep or acceleration, prompts a search for a manic or hypomanic episode.
The three sorting questions
"Against whom, and where?" Anger that erupts everywhere is a regulation problem; anger that targets only one person, at home, first raises the question of power.
"Is anyone afraid of you?" It isolates violence.
"Always, or since a particular moment?" It points towards a long-standing disorder, a mood disorder, a trauma, a lesion or a substance.
5. The dimensions of problematic anger
Five parameters
Frequency, intensity — how far, and how fast —, duration — a few minutes or several days of resentment —, expression — shouting, insults, threats, destruction, physical acts, dangerous driving, sarcasm, punitive silence, anger turned against oneself —, and consequences, which decide the treatment.
Anger, hostility, aggression
Anger is an emotion: an arousal triggered by a perceived harm, which pushes towards action. Hostility is an attitude: a lasting disposition to see others as malicious or contemptible. Aggression is a behaviour: the act that aims to harm. One can be very angry without being aggressive, and be aggressive without being angry. The programme targets all three, and measures them separately.
Two forms of aggression
Reactive, or impulsive, aggression responds to a perceived provocation, is not planned, and is often regretted: it is the aggression of intermittent explosive disorder, and the one this programme targets. Instrumental aggression is planned and serves a goal; it is not a matter of anger regulation. The two coexist in some people, and it is their proportion that guides what follows.
Swallowed anger
Some patients never shout: they accumulate, they ruminate, they keep quiet, then they explode over a detail or turn the anger against themselves. They tend to consult for its effects — tension, insomnia, depression, a sudden break-up. The programme applies to them, with an emphasis on assertiveness. Session 9.
Frequently asked questions
The patient says that it is his partner who provokes him.
This is very frequent. You can acknowledge that the situation is difficult and hold that what he does belongs to him. Above all, ask the questions in section 3: an anger that targets only one person, at home, should prompt a search for control.
Can this programme be run with someone who has already hit his partner?
Not as a response to that violence. An isolated act, without control and without settled fear, may allow the programme under strict conditions. Repeated violence, control or fear call for a specialist programme for perpetrators of domestic violence and for making the person exposed safe. Section 3.
Should the couple be seen together?
Not at the start, and never as long as there is violence, control or fear. The partner is seen alone, and what they say is never reported back. Sections 3 and 35.
The patient is referred by the courts and asks me for a certificate.
You can attest to his attendance and to the nature of the programme, not that he is no longer dangerous or that he has changed. Make that clear in writing from the first session. Section 17.
Should the person be allowed to "let it all out" in the session?
No. Letting someone recount an offence at length while going up, without doing anything with it, is a guided rumination. You gather the facts, you stop the rise, and you work.
Does sport not provide an outlet?
A regular physical activity improves sleep and background mood. But as a technique for bringing an anger down, the activities that increase arousal are not effective on average, and those that lower it are. During a time-out, one walks in order to get away, not to empty oneself out.
The patient becomes angry with me.
That is expected, and it is useful. Name it calmly, ask where he is on his scale, and use it as an exposure. If it becomes threatening, end the session, announcing that you are doing so. Section 17.
He says that he feels nothing coming before he explodes.
That is almost always untrue, and it is not a lie. Go back over an episode second by second: the signs exist, they have never been noticed. Session 4.
His anger is justified: he has suffered a real injustice.
That is often the case. The work bears on what it costs and on the way of expressing it, not on its legitimacy. Acknowledge the injustice early, and explicitly. Section 32.
Can a medication help?
There is no medication for anger. In intermittent explosive disorder, an antidepressant reduced impulsive aggression in a placebo-controlled trial, with remission, complete or partial, in fewer than half of the patients treated. Treating an associated disorder often helps. The decision belongs to the doctor. Section 15.
How many sessions?
Twelve, as in the trials conducted in intermittent explosive disorder, with two boosters, and thirteen or fourteen when session 2, session 9 or both are spread over two sessions (section 34). More in the presence of a personality disorder, a brain injury or a fragile motivation.
And if the patient is a woman, and her partner is afraid of her?
The approach is the same. Controlling violence exists in every configuration, and the screening, the separate interview and what follows do not change. Section 3.