A research paper

O R I G I N A L P A P E R

Indigenous Adoption of Novaco’s Model of Anger Management Among Individuals with Psychiatric Problems in Pakistan

Sumara Naz • Muhammad Tahir Khalily

Published online: 11 February 2015 � Springer Science+Business Media New York 2015

Abstract The present study was designed to indigenously adopt Novaco’s model of anger management and examine its efficacy among individuals with psychiatric problems

in Pakistan. For the assessment of anger and psychiatric problems, Urdu-translated ver-

sions of Novaco Anger Inventory (NAI), Anger Self-Report Questionnaire (ASR) and

Depression Anxiety Stress Scale were used. A sample of 100 individuals was divided into

two groups: a treatment group (received the indigenously adopted model of anger man-

agement) and a control group (received general counseling). Results of mixed repeated-

measures ANOVA revealed that individuals in the treatment group significantly (p \ .01) scored lower on the NAI and ASR (at post-assessment) as compared to the control group.

Therefore, the indigenous model of anger management was shown to be more effective

than general counseling for anger management.

Keywords Indigenous model � Anger management � Psychiatric problems

Introduction

Mental health in Pakistan has remained a subject of debate over the last few years.

Although there is no national epidemiological study to provide precise statistics on mental

health problems in Pakistan, these problems alarmingly increase every day (Khalily 2011)

and according to a survey report, approximately 10–16 % of the general population in

Pakistan suffers from mental health disorders (Gadit 2007). In addition, there has been a

dire shortage of professionals in mental health care (Khalily 2011) and the problem be-

comes more deleterious when practitioners ignore uncontrolled anger as a co-morbid entity

S. Naz (&) � M. T. Khalily Psychology Department, Female Campus, International Islamic University, Islamabad, Pakistan e-mail: [email protected]

M. T. Khalily e-mail: [email protected]

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J Relig Health (2016) 55:439–447 DOI 10.1007/s10943-015-0012-y

of psychiatric illness (Posternak and Zimmerman 2002). A study carried out in Agha Khan

University and Hospital (AKUH) indicated that approximately 14 % of total patients in a

psychiatric unit showed violent behavior during their stay (Iqbal et al. 2006). Self-harming

or suicidal behavior, irritability, hostility, verbal and physical aggression are prominent

symptoms of depression (Khalily 2013; Wilkowski and Robinson 2008), generalized

anxiety disorder, social phobia (Deschenes et al. 2012) and PTSD (Orth and Wieland

2006). But unfortunately, in psychiatric patients, anger has not received much attention in

the literature to highlight its significance (DiGiuseppe 1999).

Anger is divided into four main components: cognitive (how an individual perceives an

event), affective (feelings associated with perceived thoughts), physiological (changes in

body, e.g., heart rate, blood pressure, sweating) and behavioral (response or action, e.g.,

screaming, physical or verbal attacks or withdrawal) (Novaco 2000). Anger is generated

and regulated by personal cognitive process (Kuppens et al. 2007) which can be influenced

by perspective taking skills, social learning and cultural norms (Schmitt 1996; Seligman

1998).

Cultural norms are important in defining how a particular structure of stimulation or

physiological change should be labeled a specific emotion (Hofstede 2001). Therefore,

knowledge about culture is important to differentiate the physiological responses as

emotion or reaction of physical activity. For example, one must know whether increased

heart rate is a symptom of excitement or fear (Fitness 2000). These cultural differences in

expression and regulation of emotions provide a strong basis for understanding inter-

cultural interactions (Hofstede 2001; Schwartz 2004). It is recommended that cultural and

social processes must be considered in treatment and interventions of anger (Bernal et al.

2003).

In some societies, religion is the center and an integral part of the culture. In fact,

religion and spirituality comprise a cultural and personal factor that has a prominent impact

on one’s behaviors, thoughts, values, health and illness patterns (Badri 2013; Rose et al.

2001). Ongoing quality research has begun to provide a scientific foundation for the

integration of religion and spirituality in psychotherapy (Hill and Pargament 2003; Koenig

2007; Plante and Sherman 2001), and some psychotherapists have successfully combined

religion and spirituality with cognitive behavioral therapy (CBT) for patients with symp-

toms of depression, anxiety and bereavement (Beitel et al. 2007; Razali et al. 1998).

Hodge (2006) proposed that spiritually modified CBT helps clients to identify unpro-

ductive thoughts and underlying problems and assist them with substituting these thoughts

with more functional and productive self-statements by utilizing spiritual interventions.

Religious-based CBT has been shown to be more effective in counseling than general or

non-religious CBT (Johnson 2001; Nielsen et al. 2001). Researchers demonstrated sig-

nificant differences in religious and non-religious CBT; for example, Propst et al. (1992)

provided religion-based imagery procedures and religious arguments to replace irrational

thoughts and reported significant improvement in individuals with clinical depression.

Several studies have found that a form of religious psychotherapy was also effective

with Muslim clients who suffered from anxiety, depression and bereavement (Azhar and

Varma 1995a, b; Azhar et al. 1994; Badri 1979). Patients were encouraged to recognize

practical religious values and use these in their thoughts, actions and emotions. These

practical values have been seen as essential and a key factor for the success of therapy.

There have been many examples of CBT techniques adapted with Islamic teachings that

can be integrated into the counseling process with Muslim clients (Badri 2013).

In Pakistan, the majority of people identify themselves with Islam (Hackett and Grim

2012). However, most of the therapists in Pakistan practice a Western mode of therapy,

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which does not fit into the cultural context, and clients cannot relate to these techniques.

Therefore, there is a pressing need to develop or culturally adapt specific intervention plans

to manage uncontrolled anger effectively among psychiatric patients in Pakistan. However,

currently there is no literature available providing guidelines for framing anger manage-

ment in light of Islamic teaching (Khalily 2013). The current study is an attempt to

integrate religious (Islamic Teachings)-based techniques with Novaco’s model of anger

management to provide an effective model for practitioners to use for anger management.

The following is a summary of an indigenously adopted model of anger management.

Figure: Summary of indigenously adopted model of anger management

Relaxation training Breathe deeply, slowly repeat a calm word or phrase such as ‘‘Laa ilaaha ilallah (There is no God except Allah).’’ Recite the du’a: A‘oodhu billahi mina ash-shaytaani ar-rajeem (‘‘I seek refuge with Allah from Satan, the accursed’’)

Cognitive restructuring Instead of telling yourself, ‘this person is an absolute jerk,’ tell yourself, ‘Allah (God) likes those people who forgive others, so I need to give him or her some latitude.’ Think of Allah’s attributes. The first attribute of Allah, that we Muslims are reminded of, is Ar Rahman-Ar Rahim that is, Kind and Merciful

Thought stopping When angry, one should try to change his or her body position. Thus, if you’re standing up, sit down. Move away from the source of your anger, and refocus by thinking of your Creator

Make wudu (ablution) and ghusal (bath)

Time out techniques ‘‘If any of you becomes angry, let him keep silent.’’ If a person is trying to be silent, it will obviously restrict his or her ability to fight or utter obscenities and harsh words. ‘‘A strong man is the one who can control himself when he is angry.’’

Assertiveness technique When someone critiques you, do not react negatively. The Prophet (PBUH) is reported to have said: ‘‘Whoever can guarantee (the chastity of) what is between his two jaw-bones, I guarantee Paradise for him’’ (Al-Bukhari)

The objective of the study was to examine an indigenously adopted Novaco’s model of

anger management.

Hypotheses

1. An indigenously adopted anger management model will significantly reduce anger in

individuals experiencing psychiatric problems as compared to general counseling.

2. Individuals in the treatment group (at post-assessment) will have lower scores on the

Novaco Anger Inventory (NAI) compared to individuals in the control group.

3. Individuals in the treatment group (at post-assessment) will have lower scores on the

Depression Anxiety Stress Scale compared to individuals in the control group.

Methods

Sample

This study was a quasi-experimental study that included a pre-/post-test design for both the

treatment and control groups. The sample comprised 100 individuals (50 per group)

18–50 years old (M = 32, SD = .98) with psychiatric disorders from government and

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private hospitals of Islamabad, Rawalpindi and Wah Cantt. The subjects were selected for

the current study on the basis of the following inclusion and exclusion criteria given below.

Inclusion/Exclusion Criteria

Only those individuals who were assessed and diagnosed by qualified mental health pro-

fessionals for having psychiatric problems with uncontrolled anger were included. Indi-

viduals with schizophrenia, with a history of a brain injury, dementia, major risk of

committing suicide or who had a forensic history were excluded from the current study.

Operational Definition

For the purpose of this study, anger was defined as a state of arousal involving facial and

body changes and tendencies toward action, as reported by practitioners with a high score

on the Novaco Anger Inventory.

Instruments

Demographic Sheet

Each participant’s personal details (e.g., age, gender, education, occupation) were

collected.

Novaco Anger Inventory (Short Version)

An Urdu-translated version (Naz 2014) of the NAI was used to assess the degree of anger.

NAI is a short form of the original 90-item Novaco Provocation Inventory (Novaco 1975).

It has 25 items with a five-point Likert-type scale ranging from ‘‘very little’’ to ‘‘very

much.’’ The alpha coefficient reliability of the inventory for the current study was 0.71.

Anger Self-Report Questionnaire (ASR)

Reynolds et al. (1994) developed the ASR, which is a 30-item single-scale questionnaire to

measure anger, derived from an original 89-item scale. For the current study, an Urdu-

translated version (Naz 2014) was used. Answered on a six-point Likert-type scale ranging

from 1 (strongly disagree) to 6 (strongly agree), it had an alpha coefficient of 0.71 for the

current study.

Depression Anxiety Stress Scale (DASS)

The DASS is a 42-item questionnaire developed by Lovibond and Lovibond (1995). An

Urdu-translated (Aslam 2007) version of the scale was used in the present study with a

four-point scale ranging from 0 (does not apply) to 3 (applies to me most of the time)

where higher scores represented higher levels of disorder. The alpha coefficient of the scale

was 0.62 for the current study.

The following three steps were considered when developing the religious-based

indigenous model of anger management. These steps of CBT have been successfully used

by Novaco for anger management.

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Cognitive Preparation

Clients were familiarized with anger provocation, maladaptive anger by self monitoring,

intensity and knowing the type of anger.

Skill Acquisition

In this step, clients were taught to cope with maladaptive anger by restructuring their

thoughts, thought stopping exercise, communication and social skills.

Application Training (Rehearsal Phase)

Clients were exposed to an anger-provoking situation using imagery, story narration and

role playing.

These three steps were covered in 12 sessions. Every session comprised 30–35 min.

The indigenous model of anger management was approved by the committee of clinical

psychologists headed by a senior faculty member trained in the Novaco model and who

attended Novaco accredited workshops. After approval of the model, it was implemented

with two clients who were diagnosed with depression and scored high on NAI. After a

successful trial of the model, it was finalized for use in the main study.

Procedure

The sample was divided into two groups: treatment group (received indigenous model of

anger management) and control group (received general counseling). Twelve sessions of

the intervention plan were completed in 9 weeks. The first six sessions were conducted in

3 weeks, two sessions a week, while the remaining were six weekly sessions. For the

treatment group, 50 individuals were approached, informed consent was obtained from

each participant planning on attending all the sessions of the treatment plan, but only 37

individuals attended all 12 sessions. There were six individuals who attended nine sessions

and provided mid-assessment and four individuals attended less than nine sessions. There

were three individuals who did not come back after the first or second session. Similarly,

50 individuals for the control group were approached who received general counseling.

There were 39 individuals who attended general counseling during the 9 weeks. Indi-

viduals who participated in the current study were assessed on NAI, ASR and DASS prior

to starting the intervention plan, again at the middle of the plan (after session 6), and then,

post-assessment was taken to compare the scores.

Data Analysis

Statistical Package for Social Sciences (SPSS 20) was used to analyze the data.

Results

Table 1 shows there was a significant main effect of the treatment to reduce anger across

the assessments over three time points (F[1, 74] = 49.91, p \ .01). The between-group result shows that there was a significant interaction between the time and group type (F[1,

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74] = 36.14, p \ .01). Thus, the psychiatric patients who received the indigenous inter- vention plan showed significantly lower scores on the NAI when compared to those who

received general counseling.

Table 2 shows that there was a significant main effect of the indigenous intervention

plan to reduce anger (F[1, 74] = 24.17, p \ .01). Result reveals that anger decreased proportionately across the three-point assessment. The comparison of the control and

treatment groups shows that there was a significant interaction among the ASR scores and

group type (F[1, 74] = 15.44, p \ .01). Thus, the psychiatric patients who received the indigenous intervention plan showed significantly lower scores on the ASR when com-

pared with those who receive general counseling.

Table 3 shows a significant main effect of the indigenous intervention plan to reduce

illness (F[1, 74] = 48.36, p \ .01), which means that there was a significant difference across the three times of assessments for DASS. The comparison of the control and

treatment groups revealed no significant difference in the interaction among DASS scores

and group type (F[1, 74] = 2.66, p [ .05). Thus, the indigenous intervention plan and general counseling did not differ on psychological problems.

Table 1 Mixed repeated-mea- sures analysis of variance (ANOVA) to compare three assessments of the treatment and control groups for the NAI (N = 76)

G.type = group type (treatment and control group)

Group type Time point assessment M SD

Treatment group 1 91.35 6.73

2 87.41 7.15

3 85.62 6.64

Control group 1 79.43 10.25

2 79.01 10.45

3 78.97 10.37

Source SS MS df F p

Time 363.90 363.90 1 49.91 .00

G.type 4,576.69 4,576.90 1 20.46 .00

Time 9 G.type 263.47 263.47 1 36.14 .00

Error 539.49 7.29 74

Table 2 Mixed repeated-mea- sures analysis of variance (ANOVA) to compare three assessments of the treatment and control groups for the ASR Questionnaire (N = 76)

G.type = group type (treatment and control group)

Group type Time point assessment M SD

Control 1 109.46 14.69

2 105.41 17.14

3 96.03 12.71

Treatment 1 113.03 7.91

2 112.77 8.10

3 112.51 7.89

Source SS MS df F p

Time 1,846.18 1,846.18 1 24.17 .00

G.type 4,757 4,757 1 15.44 .00

Time 9 G.type 1,584.61 1,584.61 1 20.74 .00

Error 7,596.65 102.65 74

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Discussion

The current study examined an integrated Novaco’s model of anger management with the

cultural and religious values of Pakistani society. Pakistani culture is a part of the con-

temporary Islamic civilization, which draws its values and traditions from a rich Islamic

history. Within this culture, a distinctive understanding of uncontrolled anger and man-

agement strategies exist that could be implemented at the cognitive and behavioral stages

(Khalily 2013). It was hypothesized that a religion-based indigenous model of anger

management would reduce anger among psychiatric patients. The results of our study

suggested, with a certain degree of confidence, that there was a change in the overall NAI

score across three times of assessments as compared to general counseling. Similar results

were observed for the three assessments of the ASR Questionnaire. These findings sup-

ported the hypotheses as well as corroborating previous research indicating that clients

receiving counseling with an element of religiosity showed successful progress toward their

goals of overcoming problems (Morrison et al. 2009). Christian religious cognitive therapy

was compared with non-religious cognitive therapy in counseling, and the former was much

more effective in managing the psychiatric problems of the clients (Koenig 2007). Similar

results can be found in the study by Razali et al. (1998), who utilized cognitive techniques

guided by the Qur’an and hadith for the treatment of anxiety and depression and reported

that it was more effective for Muslim clients as compared to conventional therapy.

Conclusion

The current study focused on a distinctive strategy which included consideration of cultural

and religious norms in an integrated anger management strategy. Therefore, Novaco’s

model of anger management was adopted by integrating the strategies extracted from the

Qur’an and Sunnah. Individuals who obtained indigenous treatment scored lower on anger

measurement at post-assessment as compared to individuals who received general coun-

seling. Furthermore, the individuals in the treatment group also scored lower on DASS as

compared to the control group, although it was not significant but indicated that anger

could hinder the progress of treatment for psychiatric disorders.

Table 3 Mixed repeated-mea- sures analysis of variance (ANOVA) to compare three assessments of the treatment and control groups for the Depression Anxiety Stress Scale (DASS) (N = 76)

G.type = group type (treatment and control group)

Group type Time point assessment M SD

Control 1 87.51 5.05

2 86.54 4.93

3 83.54 5.73

Treatment 1 86.49 6.34

2 85.85 6.32

3 84.03 6.26

Source SS MS df F p

Time 393.05 393.05 1 48.36 .00

G.type 9.66 9.66 1 .10 .74

Time 9 G.type 21.68 21.68 1 2.66 .10

Error 2,257.5 30.51 74

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