During the World War II, researchers observed high levels of anger associated with exposure to traumatic events among soldiers presenting with what was then called “combat neurosis” (Grinker & Spielgel, 1945 in Morland et al., 2012). More recently, numerous studies have continued to show a close relationship between posttraumatic stress disorder (PTSD) and both anger and hostility among veterans (Chemtob et al. 1997; Jakupcak et al., 2007; Morland et al., 2012; van Voorhees et al., 2019). Some authors believe deficits in emotional regulation associated with PTSD could explain these reactions. These deficits can occur in all three domains of anger regulation (I.e., cognitive, emotional, behavioral) leading to anger dysregulation (Chemtob et al. 1997). Indeed, among veterans, significant correlations have been found between aggressive impulses/tendencies, difficulties managing anger leading to violent behavior, and arousal symptoms linked to PTSD (Elbogen et al., 2010).
A 2006 meta-analysis (Orth & Wieland, 2006) evaluated the relationship between forms of anger and PTSD in adults exposed to traumatic events. This meta-analysis included 39 studies with almost 9,000 participants. The authors identified 19 studies dealing exclusively with military samples. The results indicate positive correlations between different forms of anger and PTSD. In addition, this meta-analysis showed that these correlations were greater in military samples than in civilian samples. The authors went further by demonstrating that this link (anger/PTSD) worsened as the length of exposure to the traumatic event increased; this finding is consistent with the theories on associative networks involved in memory formation. These theories postulate that over time, a reinforcement of the association between fear and anger structures is created by the simultaneous and repeated activation of these two specific brain regions during memory formation (Bower, 1981 in Orth and Wieland, 2006). Among veterans, the re-experiencing of traumatic events during combat is associated with chronic and excessive vigilance to threats and a tendency to react with hostility to those threats (Chemtob et al., 1997). This hostile reaction among veterans can be understood by considering the influence of military training. During their training, military personnel are taught that aggressive behavior neutralizes fear thus increasing their chances of survival (Faucher & Iucci, 2010). In contrast, among civilians, it is more frequently the fear reaction that predominates, rather than hostility.
Most studies on anger among veterans focus on veterans with PTSD. Other operational stress disorders (e.g., anxiety, depression, substance use) are more often overlooked. One notable exception is a study by Gonzalez and colleagues (2016), who demonstrated among 2,077 veterans that anger among veterans suffering from PTSD worsens if patients are also depressed. Another study found that the risk of violence directed towards oneself increased among anger-afflicted veterans who had developed addictions. Specifically, veterans who suffered from addiction used more violent means to commit suicide than those who had not been diagnosed with a substance abuse problem (Ilgen et al., 2010). On a different note, veterans may experience many losses with the end of military life. Today most veterans are young and may have families to support. Upon discharge, they often find themselves unemployed, sometimes with a physical disability or even a serious mental illness. Veterans sometimes mourn the loss of a sense of belonging, a sense of pride, a life routine, support from the armed forces, camaraderie, the safety of the military uniform and weapons, adrenaline or direction in life (Faucher and Iucci, 2010). In addition to these losses, veterans often have a pessimistic and unfavorable view of civilian life: without excitement and in need of major adjustments. Many veterans have an exacerbated sensitivity to anything that may seem unjust, unfair, and undeserved, or to anything that limits their rights; threatens their security; or confirms a negative perception of themselves, life, and others (Faucher and Iucci, 2010, p. 18). This may explain why they are more likely to express their anger, whether defensively or offensively, when a situation seems unfair to them. This reaction may be adaptive in some contexts (such as combat) but becomes dysfunctional in others (civilian life). Excessive and overwhelming anger can thus lead to many negative consequences in the lives of veterans. Interpersonal problems may arise whether with spouses, friends or coworkers. Difficulties in keeping one's job and explosions of anger while driving or in public places have also been reported as examples. This may extend to problems with the law (e.g., domestic violence, child abuse, physical assault). At an intrapersonal level, anger is often associated with low self-esteem, feelings of shame, and guilt, as well as self-mutilation, including suicide (Faucher & Iucci, 2010). More broadly, a study of more than 3,500 returning soldiers indicated that the presence of anger was positively associated with mental and physical health impairments and psychosocial dysfunctions (Novaco et al., 2012). The consequences are numerous and can be severe, which is why it is essential to help these individuals identify their difficulties and offer them the most appropriate psychotherapeutic treatments possible.
It is important to assess anger when planning psychotherapeutic treatment in this population. This assessment can help therapists determine whether anger should be treated as a priority over the rest of the disorders, as some individuals may not be able to engage in further treatment until this overriding issue is addressed. It is believed that anger could interfere with treatment in several ways, such as by weakening the therapeutic alliance, reducing the client's commitment or limiting the client's capacity for introspection. Also, avoiding traumatic memories for fear of associated emotions (such as anger) may prevent veterans from becoming fully engaged in the treatment of their operational stress injuries (Morland et al., 2012). Further research is needed to compare the effectiveness of anger management therapies to usual PTSD psychotherapies, although there are already some indicators that veterans with PTSD may benefit from anger management treatment (Forbes et al., 2008; Morland et al., 2012). For example, a study evaluating anger management group therapy with veterans showed significant reductions in anger and PTSD symptoms in post-treatment (Morland et al., 2010).
Research on effective treatments for anger among veterans, whether in the context of PTSD or not, remains limited. However, several meta-analyses exist on the effectiveness of anger treatments. DiGiuseppe and Tafrate's meta-analysis (2003) suggests that training, relaxation, cognitive restructuring, practice of new anger management and conflict resolution strategies are the most effective treatments for anger. In 2006, Deffenbacker discussed three meta-analyses and controlled trials on the effectiveness of psychotherapies to treat anger. He concluded that cognitive-behavioral guidance interventions emerged as effective in treating anger, with a moderate to high effect size that was sustained over time. Moreover, multi-component interventions appear to be as effective as single-component interventions. Saini (2009) conducted a meta-analysis to examine the effects of anger therapies using a variety of theoretical approaches. Results suggested that psychological treatments are generally effective in treating anger. However, multi-component therapies appear to have superior efficacy. Research on effective psychotherapies for anger treatment is still in its infancy as it relates to identifying best practices for specific populations, especially when integrated with other psychological disorders (such as PTSD). However, current meta-analyses on anger indicate that anger-focused treatments show some effectiveness. In conclusion, investigating the role anger plays in the lives of veterans appears to be a promising avenue for developing more effective treatments and improving life outcomes.
About the Authors
Josianne Lamothe, MSW, is a doctoral student in criminology at Université de Montréal. She works as a clinician in mental health. Her research focuses on the experiences of youth protection workers with client violence.
Marine Tessier, PhD.c., MPs, is pursuing her doctorate in clinical psychology at the Universitéde Montréal. She holds a master degree in clinical psychology from France and has significant clinical experience with various populations including victims of crime and detainees. Her doctoral research project deals with posttraumatic stress injuries among paramedics and emergency dispatchers.