Research Article| Volume 41, P87-95, December 2022

Effects of a nonviolent communication-based anger management program on psychiatric inpatients


      • Anger expression and inhibition can be reduced by NVC in a psychiatric ward.
      • NVC can generate marginal positive changes in self-esteem and aggression.
      • NVC-based anger management programs are advised during mental health nursing care.
      • The NVC-based anger management is a one-to-one program that consists of six sessions that last 60 min each.
      • The program may be an accessible treatment option for psychiatric inpatients.


      This quasi-experimental study aimed to determine the effects of a nonviolent communication-based anger management program on self-esteem, anger expression, and aggression in 44 psychiatric inpatients (experimental group: n = 21; control group: n = 24). The program consisted of six sessions of 60 min each, using a non-equivalent control group pretest-posttest design, and thereafter analyzing the intervention effects. Results showed statistically significant differences between the experimental and control groups in anger expression and anger suppression. There were positive, though not statistically significant, changes in self-esteem and aggression. The findings indicated a decreasing effect of anger expression and anger suppression.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Psychiatric Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Akdemir D.
        • Çak T.
        • Aslan C.
        • Aydos B.S.
        • Nalbant K.
        • Çuhadaroğlu-Çetin F.
        Predictors of self-esteem in adolescents with a psychiatric referral.
        Turkish Journal of Pediatrics. 2016; 58: 69-78
        • Alia-Klein N.
        • Gan G.
        • Gilam G.
        • Bezek J.
        • Bruno A.
        • Denson T.F.
        • Hendler T.
        • Lowe L.
        • Mariotti V.
        • Muscatello M.
        • Palumbo S.
        • Pellegrini S.
        • Pietrini P.
        • Rizzo A.
        • Verona E.
        The feeling of anger: From brain networks to linguistic expressions.
        Neuroscience & Biobehavioral Reviews. 2020; 108: 480-497
        • Askari I.
        Core irrational beliefs and maladaptive schemas in cognitive behavioral therapy for anger and aggression (Order No. 27718888).
        (Available from ProQuest Dissertations & Theses Global. (2314809822). Retrieved from)
        • Averill J.R.
        Studies on anger and aggression. Implications for theories of emotion.
        The American Psychologist. 1983; 38: 1145-1160
        • Ayebami T.
        • Janet K.
        Efficacy of anger management strategies for effective living among adolescents and youths.
        IFE PsychologIA. 2017; 25: 47-58
        • Barlow K.
        • Grenyer B.
        • Ilkiw-Lavalle O.
        Prevalence and precipitants of aggression in psychiatric inpatient units.
        Australian and New Zealand Journal of Psychiatry. 2000; 34: 967-974
        • Bertsch K.
        • Florange J.
        • Herpertz S.C.
        Understanding brain mechanisms of reactive aggression.
        Current Psychiatry Reports. 2020; 22: 81
        • Bjørkly S.
        Psychotic symptoms and violence toward others - A literature review of some preliminary findings: Part 1. Delusions.
        Aggression and Violent Behavior. 2002; 7: 617-631
        • Blake S.M.
        A step toward violence prevention: “Non-violent communication” as part of a college curriculum (Order No. 1407883).
        (Available from ProQuest Dissertations & Theses Global. (230611695). Retrieved from)
        • Branden N.
        The six pillars of self-esteem.
        Bantam Books Inc., 1994
        • Buss A.H.
        • Perry M.
        The aggression questionnaire.
        Journal of Personality and Social Psychology. 1992; 63: 452-459
        • California State Dept. of Education
        Toward a state of esteem. The final report of the California task force to promote self-esteem and personal and social responsibility.
        Bureau of Publications, California State Department of Education, 1990
        • Chesney E.
        • Goodwin G.M.
        • Fazel S.
        Risks of all-cause and suicide mortality in mental disorders: A meta-review.
        World Psychiatry. 2014; 13: 153-160
        • Cho G.
        • Kim J.
        • Kim K.
        Cultural dispositions, control of anger, and empathy.
        The Korean Psychological Association. 2009; 23: 69-90
        • Chon B.
        Self-esteem: A test of its measurability.
        Yonsei Social Science Review. 1974; 11: 109-129
        • Chon K.K.
        • Hahn D.W.
        • Lee C.H.
        • Spielberger C.D.
        Korean adaptation of the state-trait anger expression inventory: Anger and blood pressure.
        The Korean Journal of Health Psychology. 1997; 2: 60-78
        • Coid J.
        • Kallis C.
        • Doyle M.
        • Shaw J.
        • Ullrich S.
        Shifts in positive and negative psychotic symptoms and anger: Effects on violence.
        Psychological Medicine. 2018; 48: 2428-2438
        • Constantinou E.
        • Van Den Houte M.
        • Bogaerts K.
        • Van Diest I.
        • Van den Bergh O.
        Can words heal? Using affect labeling to reduce the effects of unpleasant cues on symptom reporting.
        Frontiers in Psychology. 2014; 5: 807
        • Cox E.
        • Dannahy P.
        The value of openness in e-relationships: Using NVC to guide online coaching and mentoring.
        International Journal of Evidence Based Coaching and Mentoring. 2005; 3: 39-51
        • Creemers D.H.M.
        • Scholte R.H.J.
        • Engels R.C.M.E.
        • Prinstein M.J.
        • Wiers R.W.
        Implicit and explicit self-esteem as concurrent predictors of suicidal ideation, depressive symptoms, and loneliness.
        Journal of Behavior Therapy and Experimental Psychiatry. 2012; 43: 638-646
        • Daffern M.
        • Simpson K.
        • Ainslie H.
        • Chu S.
        The impact of an intensive inpatient violent offender treatment programme on intermediary treatment targets, violence risk and aggressive behaviour in a sample of mentally disordered offenders.
        The Journal of Forensic Psychiatry & Psychology. 2018; 29: 163-188
        • Davidson R.J.
        • McEwen B.S.
        Social influences on neuroplasticity: Stress and interventions to promote well-being.
        Nature Neuroscience. 2012; 15: 689-695
        • DiGiuseppe R.
        End piece: Reflections on the treatment of anger.
        Journal of Clinical Psychology. 1999; 55: 365-379<365::AID-JCLP8>3.0.CO;2-3
        • Dirmaier J.
        • Harfst T.
        • Koch U.
        • Schulz H.
        Therapy goals in inpatient psychotherapy: Differences between diagnostic groups and psychotherapeutic orientations.
        Clinical Psychology and Psychotherapy. 2006; 13: 34-46
        • Ekman P.
        Emotions revealed: Recognizing faces and feelings to improve communication and emotional life.
        New York Times Books, New York2003
        • Ferri J.
        • Schmidt J.
        • Hajcak G.
        • Canli T.
        Emotion regulation and amygdala-precuneus connectivity: Focusing on attentional deployment.
        Cognitive, Affective and Behavioral Neuroscience. 2016; 16: 991-1002
        • Fritz M.
        • Shenar R.
        • Cardenas-Morales L.
        • Jäger M.
        • Streb J.
        • Dudeck M.
        • Franke I.
        Aggressive and disruptive behavior among psychiatric patients with major depressive disorder, schizophrenia, or alcohol dependency and the effect of depression and self-esteem on aggression.
        Front Psychiatry. 2020; 11599828
        • Garofalo C.
        • Holden C.J.
        • Zeigler-Hill V.
        • Velotti P.
        Understanding the connection between self-esteem and aggression: The mediating role of emotion dysregulation.
        Aggressive Behavior. 2016; 42: 3-15
        • Gooding P.
        • Tarrier N.
        • Dunn G.
        • Shaw J.
        • Awenat Y.
        • Ulph F.
        • Pratt D.
        The moderating effects of coping and self-esteem on the relationship between defeat, entrapment and suicidality in a sample of prisoners at high risk of suicide.
        European Psychiatry. 2015; 30: 988-994
        • Haddock G.
        • Barrowclough C.
        • Shaw J.J.
        • Dunn G.
        • Novaco R.W.
        • Tarrier N.
        Cognitive–behavioural therapy v. social activity therapy for people with psychosis and a history of violence: Randomised controlled trial.
        The British Journal of Psychiatry. 2009; 194: 152-157
        • Horsselenberg E.M.A.
        • van Busschbach J.T.
        • Aleman A.
        • Pijnenborg G.H.M.
        Self-stigma and its relationship with victimization, psychotic symptoms and self-esteem among people with schizophrenia spectrum disorders.
        PLOS ONE. 2016; 11e0149763
        • Hubbard J.A.
        • Smithmyer C.M.
        • Ramsden S.R.
        • Parker E.H.
        • Flanagan K.D.
        • Dearing K.F.
        • Simons R.F.
        Observational, physiological, and self-report measures of children’s anger: Relations to reactive versus proactive aggression.
        Child Development. 2002; 73: 1101-1118
        • Joung J.
        • Jang M.
        • Shin H.
        The mediating effect of internalized stigma on the relationship between hospitalization stress and quality of life among patients with mental illness in a closed ward.
        Journal of East-West Nursing Research. 2018; 23: 70-80
        • Joung J.
        • Kim S.
        Effects of a relapse prevention program on insight, empowerment and treatment adherence in patients with schizophrenia.
        Journal of Korean Academy of Nursing. 2017; 47: 188-198
        • Kay S.R.
        • Wolkenfeld F.
        • Murrill L.M.
        Profiles of aggression among psychiatric patients.
        The Journal of Nervous and Mental Disease. 1988; 176: 539-546
        • Kim G.N.
        • Lee S.
        • Kim J.M.
        The application of mindfulness meditation program for psychotic disorder in closed ward.
        The Journal of Humanities. 2017; 43: 217-242
        • Kim S.
        • Hwang Y.
        The effect of nonviolent communication training program on shame-proneness high school student’s self-esteem and their empathy ability.
        Psychology and Behavior. 2012; 4: 91-111
        • Kim S.H.
        • Kim H.S.
        The meta analysis of the effects of self-esteem and depression programs of the elderly.
        Journal of Social Science. 2014; 40: 77-97
        • Krakowski M.
        • Czobor P.
        Executive function predicts response to anti-aggression treatment in schizophrenia: A randomized controlled trial.
        The Journal of Clinical Psychiatry. 2012; 73: 74-80
        • Lee A.H.
        • DiGiuseppe R.
        Anger and aggression treatments: A review of meta-analyses.
        Current Opinion in Psychology. 2018; 19: 65-74
        • Lee H.
        Effects of nonviolent communication program for schizophrenia patients.
        Kwangju University, Kwangju, South Korea2018 ([Unpublished master’s thesis])
        • Lee H.J.
        • Kim S.O.
        The development and verification of an experiential couple group therapy program -integration of the satir growth model and non-violent communication.
        Korea Journal of Counseling. 2010; 11: 831-854
        • Lerner J.S.
        • Keltner D.
        Fear, anger, and risk.
        Journal of Personality and Social Psychology. 2001; 81: 146-159
        • Luo C.
        • Chen H.
        • Zhong S.
        • Guo H.
        • Li Q.
        • Cai W.
        • Wang X.
        Manic episode, aggressive behavior and poor insight are significantly associated with involuntary admission in patients with bipolar disorders.
        PeerJ. 2019; 7E7339
        • Malarchick E.P.
        The buffering effects of positive self-verbalizations on anger induced from film (Order No. 9930411). Available from ProQuest Dissertations & Theses Global. (304547782).
        (Retrieved from)
        • Marlow E.
        • Nyamathi A.
        • Grajeda W.T.
        • Bailey N.
        • Weber A.
        • Younger J.
        Nonviolent communication training and empathy in male parolees.
        Journal of Correctional Health Care. 2012; 18: 8-19
        • Ministry of Health and Welfare
        The 2016 epidemiological survey of mental disorder in Korea.
        • Mun J.H.
        • Hong S.M.
        The effects of group art therapy on self-esteem and aggression of a probation office juvenile.
        Korean Journal of Arts Therapy. 2015; 15: 73-88
        • National Center for Mental Health
        National mental health statistics 2019.
        • Nosek M.
        • Durán M.
        Enhancing empathy & conflict resolution skills through nonviolent communication (NVC) training in Latino adults and youth.
        Progress in Community Health Partnerships: Research, Education, and Action. 2017; 11: 275-283
        • Nosek M.
        • Gifford L.
        • Kober B.
        Nonviolent Communication training increases empathy in baccalaureate nursing students: A mixed method study.
        Journal of Nursing Education & Practice. 2014; 4: 1-15
        • Novaco R.W.
        • Whittington R.
        Anger regulation for psychotic patients.
        in: Fernandez E. Treatments for anger in specific populations: Theory, application, and outcome. Oxford University Press, 2013: 114-137
        • Nugteren W.
        • van der Zalm Y.
        • Hafsteinsdóttir T.B.
        • van der Venne C.
        • Kool N.
        • van Meijel B.
        Experiences of patients in acute and closed psychiatric wards: A systematic review.
        Perspectives in Psychiatric Care. 2016; 52: 292-300
        • Olfson M.
        • Wall M.
        • Wang S.
        • Crystal S.
        • Liu S.-M.
        • Gerhard T.
        • Blanco C.
        Short-term suicide risk after psychiatric hospital discharge.
        JAMA Psychiatry. 2016; 73: 1119-1126
        • Orth U.
        • Robins R.W.
        • Roberts B.W.
        Low self-esteem prospectively predicts depression in adolescence and young adulthood.
        Journal of Personality and Social Psychology. 2008; 95: 695
        • Otte S.
        • Streb J.
        • Rasche K.
        • Franke I.
        • Segmiller F.
        • Nigel S.
        • Dudeck M.
        Self-aggression, reactive aggression, and spontaneous aggression: Mediating effects of self-esteem and psychopathology.
        Aggressive Behavior. 2019; 45: 408-416
        • Paek J.
        Effect of Nonviolent communication program on interpersonal relations and empathic ability of psychiatric disabilities.
        Daegu University, Kyongsangbukdo, South Korea2015 ([Unpublished master’s thesis])
        • Pasmatzi E.
        • Koulierakis G.
        • Giaglis G.
        Self-stigma, self-esteem and self-efficacy of mentally ill.
        Psychiatriki. 2016; 27: 243-252
        • Pyszczynski T.
        • Greenberg J.
        • Solomon S.
        • Arndt J.
        • Schimel J.
        Why do people need self-esteem? A theoretical and empirical review.
        Psychological Bulletin. 2004; 130: 435
        • Raja M.
        • Azzoni A.
        Hostility and violence of acute psychiatric inpatients.
        Clinical Practice and Epidemiology in Mental Health. 2005; 1 (10.1186%2F1745-0179-1-11): 11
        • Rampling J.
        • Furtado V.
        • Winsper C.
        • Marwaha S.
        • Lucca G.
        • Livanou M.
        • Singh S.P.
        Non-pharmacological interventions for reducing aggression and violence in serious mental illness: A systematic review and narrative synthesis.
        European Psychiatry. 2016; 34: 17-28
        • Riemer D.
        Creating sanctuary: Reducing violence in a maximum security forensic psychiatric hospital unit.
        On the Edge. 2009; 15: 10-16
        • Rosenberg M.
        Rosenberg Self-Esteem Scale (RSE). Acceptance and commitment therapy.
        Measures Package. 1965; 61: 18
        • Rosenberg M.B.
        The surprising purpose of anger: Beyond anger management: finding the gift.
        PuddleDancer Press, 2005 (Chapter 2)
        • Rosenberg M.B.
        Nonviolent communication: a language of life.
        3rd ed. PuddleDancer Press, 2015
        • Roth S.L.
        • Qureshi A.
        • Moulden H.M.
        • Chaimowitz G.A.
        • Lanius R.A.
        • Losier B.J.
        • McKinnon M.C.
        “Trapped in their shame”: A qualitative investigation of moral injury in forensic psychiatry patients.
        Criminal Justice and Behavior. 2021; 49: 593-612
        • Schoenleber M.
        • Berenbaum H.
        • Motl R.
        Shame-related functions of and motivations for self-injurious behavior.
        Personality Disorders: Theory, Research, and Treatment. 2014; 5: 204
        • Seo S.G.
        • Kwon S.M.
        Validation study of the Korean version of the aggression questionnaire.
        Korean Journal of Clinical Psychology. 2002; 21: 487-501
        • Sharfstein S.S.
        • Dickerson F.B.
        Hospital psychiatry for the twenty-first century.
        Health Affairs. 2009; 28: 685-688
        • Song E.J.
        The effect of nonviolent communication program for community rehabilitation on empathy, interpersonal relationship, and social anhedonia in patients with schizophrenia.
        Journal of Korean Public Health Nursing. 2020; 34: 48-59
        • Spielberger C.D.
        • Krasne S.S.
        • Solomon E.P.
        The experiences, expression and control of anger.
        in: Janisse M.P. Individual differences, stress and health psychology. Springer Verlag, New York1998: 89-108
        • Stahl S.
        Leben kann auch einfach sein: So staerken Sie Ihr Selbstwertgefuehl. Korean. (Kim, Trans).
        in: Galmaenamu. 2016 (Original work published 2011)
        • Stewart D.
        • Bowers L.
        Inpatient verbal aggression: Content, targets and patient characteristics.
        Journal of Psychiatric and Mental Health Nursing. 2013; 20: 236-243
        • Suarez A.
        • Lee D.Y.
        • Rowe C.
        • Gomez A.A.
        • Murowchick E.
        • Linn P.L.
        Freedom project: Nonviolent communication and mindfulness training in prison.
        SAGE Open. 2014; 4
        • Wacker R.
        • Dziobek I.
        Preventing empathic distress and social stressors at work through nonviolent communication training: A field study with health professionals.
        Journal of Occupational Health Psychology. 2018; 23: 141-150
        • Weindl D.
        • Knefel M.
        • Glück T.
        • Lueger-Schuster B.
        Emotion regulation strategies, self-esteem, and anger in adult survivors of childhood maltreatment in foster care settings.
        European Journal of Trauma & Dissociation. 2020; 4100163
        • Wilkowski B.M.
        • Robinson M.D.
        The anatomy of anger: An integrative cognitive model of trait anger and reactive aggression.
        Journal of Personality. 2010; 78: 9-38
        • Wu Y.
        • Kang R.
        • Yan Y.
        • Gao K.
        • Li Z.
        • Jiang J.
        • Xueyang C.
        • Xia L.
        Epidemiology of schizophrenia and risk factors of schizophrenia-associated aggression from 2011 to 2015.
        Journal of International Medical Research. 2018; 46: 4039-4049
        • Yang J.W.
        • Kim S.
        Integrative review of nonviolent communication intervention studies.
        Perspectives in Nursing Science. 2016; 13: 36-47
        • Yang J.W.
        • Kim S.
        Effects of a nonviolent communication-based training program for inpatient alcoholics in South Korea.
        Perspectives in Psychiatric Care. 2021; 57: 1187-1194
        • Zarshenas L.
        • Baneshi M.
        • Sharif F.
        • Moghimi Sarani E.
        Anger management in substance abuse based on cognitive behavioral therapy: An interventional study (Report).
        BMC Psychiatry. 2017; 17: 375
        • Zubi Y.
        • Connolly P.
        Recollected experiences of first hospitalisation for acute psychosis among persons diagnosed with schizophrenia in South Africa.
        South African Journal of Psychiatry. 2013; 19: 5
        • Zuzelo P.R.
        • Curran S.S.
        • Zeserman M.A.
        Registered nurses’ and behavior health associates’ responses to violent inpatient interactions on behavioral health units.
        Journal of the American Psychiatric Nurses Association. 2012; 18: 112-126