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Agenda
A cognitive model of anger Individual interventions Pilot study data of group CBT in anger
Violen e
Help patient:
alter disinhibitors or inhibitors consider alternative cognitions or beliefs s ills training eg assertiveness graded exposure maintenance plan
A-B-C analysis
Patients will try to prove how awful the World is to them Try to stay focused on what you MIGHT be able to alter Loo for typical situations Loo for frequency of behaviours and severity Establish what happens afterwards, repairs to property, sul iness, how they feel etc
Inhibitors
Inhibitors include:
Police / courts Partner Children Financial Job In therapy Pride Light public place
Disinhibitors
Drugs
Alcohol Cannabis Other drugs especially amphetamine Anxiolytic or other prescribed drugs
Alternative cognitions
Cognitive diary emphasis upon cognitions not situations Teach re thin ing errors Evaluate diary in session Would everybody thin this way ? Personal disclosure Normalise anger (adaptive) Consider alternative cognitions Be persistent Be realistic
Assertiveness training
Ac nowledge our patients live in difficult environments Angry patients overcompensate after allowing someone to treat them badly Demonstrate an early assertive response Role play early assertive response Be realistic and on their wavelength Give information to supplement Encourage practice
Graded exposure
Builds upon hierarchy of high ris situations Teach relaxation Imaginal exposure plus relaxation
Summary
Engage the patient Identify the ABCs and modify them Reduce dis-inhibitors & increase inhibitors Identify & challenge cognitions Teach assertiveness & social s ills Expect ambivalence Be safe
Further reading
Beyond Anger: A guide for men (2000)
Thomas Harbin Marlowe & Co New Yor ISBN-1-56924-621-1
Further reading
Overcoming Anger and irritability (2000)
William Davies Robinson Press London ISBN-1-85487-595-7
Rationale
Too many referrals Many patients do not attend Wasted sessions Potential benefits of peer feedbac in a group situation It might be fun
Aims
Pilot study Evaluating the feasibility of doing CBT in group format for anger Determine the number of drop outs Test the assessment tools
Method
Series of groups Quasi-experimental method Ratings pre & post intervention Standardised and self report measures
Sample
Patients referred to the Clinical Psychology service for help with anger DSM I diagnosis of Intermittent Explosive Disorder or one of the personality disorders Adult Able to spea English Recognise they have a problem No organic disorder or severe substance abuse
Measures
STAXI
state anger trait anger control of anger expression of anger
CBT intervention
Pre group screening assessment of ris / suitability 6 wee ly sessions (1 hour) Post group summary individual Follow up
Session 1
Ground rules of the group Advantages/ disadvantages of change Cognitive model Discussion of inhibitors & disinhibitors Diary eeping
Session 2
Extensive homewor review Shape up diary eeping Loo for common thin ing errors
Session 3
Identify high ris situations Identifying cognitive themes Discuss coping strategies Reinforce awareness of inhibitors & disinhibitors
Session 4
Personal belief systems Downwards arrow Early warning signs
Session 5
Challenging belief systems Start maintenance of gains Review and revise cognitions Assertiveness
Session 6
Role play difficult situations Re-evaluate pros & cons of change Personal cue cards Review maintenance of gains plans
Follow up
Evaluation of therapy STAXI and other measures Idiosyncratic staying well plan 6 month booster session
Maintenance plan
Identify how things have changed re-evaluating costs and benefits What has been learned from therapy Maintain diary Self therapy Reading Booster sessions
Results characteristics
N= 119 referred N= 70 (59%) attended for initial rating 56% of referrals didnt get any therapy N= 67 were offered therapy Only 9% had the full course of therapy
Characteristics II
78% were male Mean age 32 years Mean 26 incidents per month 54% admitted to harming people during incidents 66% met DSM I criteria for intermittent explosive disorder 34% met criteria for personality disorder 49% had criminal convictions 61% reported abuse experiences during childhood
STAXI results
Of those seen:
92% scored above 75th percentile for anger traits 92% scored below the 25 th percentile for control over anger
Results
Predicting attendance Age, marital status, children etc are of no significance in determining who will attend for therapy Those who do attend
Perceive their problem to be more severe Were predicted to derive more benefit by therapists
Attendance
90 80 70 60 50 40 30 20 10
n ted 1 8 1
Attendance
attendance
at
STAXI changes
STAXI State anger scores
90 89
88
87
86
85
ating
State anger (S-Ang) reduces (t=2.84 [21], p =.01) Both scores are greater than 95 th percentile
Anger control
TA I control scores
16
14
12
10
4 re treat ent
n of treat ent
ating
Anger Expression
AXI Anger expression
9
92
90
re treat ent
Rating
Anger traits
anges in A trait s res
ean
re t reat ent
treat ent
res
t per entile
Incidents
er f incidents
0
20
e n
0 re tre t ent
Number f incidents reduces fr m 2 per month (IQR= 4-28) to per month (IQR= 2- 2) (Z= -3.406, p =.00 )
Perceived severity
Self assessed severity rati
7.5
7.0
.5
.0
5.5
5.0
ati
Self assessed severity reduces from 7 to 5 (z= -3.139, p=.002) From >mar edly troublesome to < mar edly troublesome
Results Summary
Reduced State anger Increased control of anger (NS) Reduced anger expression Reduced anger traits Fewer incidents Less severe problem
Conclusions
Group CBT for anger is feasible and safe Patients appreciate the intervention Most patients will not persist with the treatment
Conclusions II
Those who do should experience a reduction in the number of incidents STAXI scores should alter indicating a reduction in anger traits and the expression of anger Patients will still have a problem with anger at the end of the intervention
Our questions
How much therapy would be needed to eliminate the problem ? What was the active ingredient in this intervention? Is this intervention more effective than 1:1 CBT? Can we enhance the rate of participation ?
References
Awenat, F., Siddle, R ., & Jones, F. (2002) The anger characteristics of people who attend for treatment compared with non-attenders. Clinical Psychology, 13, 19-23. Siddle, R ., Jones, F., & Awenat, F. (2003). Group CBT in Anger: A pilot study. Behavioural and Cognitive Psychotherapy, 30, (5) pp ??. Siddle, R., & Jones, F. (2002). Domestic iolence and anger: what can primary care nurses do ? British Journal of Community Nursing, 7, (8),401- 406.
Any questions ?