Predictors of Treatment Response to a Psychoeducational Intervention for Anger in Chronic Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: The investigators examined predictors of treatment response to anger self-management training (ASMT) among patients with chronic moderate-severe traumatic brain injury (TBI). METHODS: A multicenter randomized clinical trial comprising 90 participants with moderate-severe TBI was conducted. Fifty-four participants who were randomly assigned to receive active treatment and provided complete data were included in the current secondary analysis. Model averaging was used to examine the relative importance and significance of pretreatment variables for predicting change during treatment. Dependent variables were pre- to posttreatment changes in trait anger (TA) and anger expression-out (AX-O) subscale scores of the State-Trait Anger Expression Inventory-Revised. Predictors included demographic, injury-related, and neuropsychological variables, including both objective and self-reported measures of executive function, as well as readiness to change and participation of a significant other in treatment. RESULTS: Change in both dependent variables was predicted by higher baseline anger. Greater change in TA was additionally predicted by White race, higher education, shorter posttraumatic amnesia, and worse self-reported (but not objectively measured) executive dysfunction; the latter predictor may have indicated better self-awareness. Greater change in AX-O was additionally predicted by better episodic memory and, paradoxically, lower readiness to change. CONCLUSIONS: Further research should focus on adapting psychoeducational anger treatments to better serve the diverse populations affected by moderate-severe TBI. These findings suggest that providing memory aids to support the use of learned strategies after treatment cessation would be beneficial. Further research should also examine the construct of readiness to change and specific aspects of executive function that may affect treatment response in psychoeducational treatments. These findings were derived from only one model of anger intervention, and the relevance to other treatment approaches cannot be assumed.

Psychoeducational Interventions for Problematic Anger in Chronic Moderate to Severe Traumatic Brain Injury: A Study of Treatment Enactment.

OBJECTIVES: Treatment enactment, a final stage of treatment implementation, refers to patients' application of skills and concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm, multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic brain injury and problematic anger. METHODS: Seventy-one of 90 participants from the parent trial underwent a telephone enactment interview at least 2 months (median 97 days, range 64-586 days) after cessation of treatment. Enactment, quantified as average frequency of use across seven core treatment components, was compared across treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment were explored. RESULTS: More than 80% of participants reported remembering all seven treatment components when queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants as a barrier to enactment, as was the reaction of other people to attempted use of strategies. CONCLUSIONS: Treatment enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to everyday life.

Anger Self-Management Training for Chronic Moderate to Severe Traumatic Brain Injury: Results of a Randomized Controlled Trial.

OBJECTIVE: To test efficacy of 8-session, 1:1 treatment, anger self-management training (ASMT), for chronic moderate to severe traumatic brain injury (TBI). SETTING: Three US outpatient treatment facilities. PARTICIPANTS: Ninety people with TBI and elevated self-reported anger; 76 significant others (SOs) provided collateral data. DESIGN: Multicenter randomized controlled trial with 2:1 randomization to ASMT or structurally equivalent comparison treatment, personal readjustment and education (PRE). Primary outcome assessment 1 week posttreatment; 8-week follow-up. PRIMARY OUTCOME: Response to treatment defined as 1 or more standard deviation change in self-reported anger. SECONDARY OUTCOMES: SO-rated anger, emotional and behavioral status, satisfaction with life, timing of treatment response, participant and SO-rated global change, and treatment satisfaction. MAIN MEASURES: State-Trait Anger Expression Inventory-Revised Trait Anger (TA) and Anger Expression-Out (AX-O) subscales; Brief Anger-Aggression Questionnaire (BAAQ); Likert-type ratings of treatment satisfaction, global changes in anger and well-being. RESULTS: After treatment, ASMT response rate (68%) exceeded that of PRE (47%) on TA but not AX-O or BAAQ; this finding persisted at 8-week follow-up. No significant between-group differences in SO-reported response rates, emotional/behavioral status, or life satisfaction. ASMT participants were more satisfied with treatment and rated global change in anger as significantly better; SO ratings of global change in both anger and well-being were superior for ASMT. CONCLUSION: ASMT was efficacious and persistent for some aspects of problematic anger. More research is needed to determine optimal dose and essential ingredients of behavioral treatment for anger after TBI.

Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment.

Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.

Anger self-management training for people with traumatic brain injury: a preliminary investigation.

OBJECTIVE: : To examine the feasibility and gather preliminary data on the efficacy of a fully manualized, 8-session, psychoeducational treatment for irritability and anger after traumatic brain injury (TBI), called anger self-management training (ASMT). PARTICIPANTS: : A total of 10 persons with moderate to severe, chronic TBI with significant cognitive impairment and elevated levels of anger and irritability participated in the study; 8 had significant others (SOs) who participated in portions of the treatment and provided pre- and posttreatment measures; 1 SO provided only data. MAIN OUTCOME MEASURE: : Two subscales of the State-Trait Anger Expression Scale-Revised and Brief Anger-Aggression Questionnaire. DESIGN: : Pre- to posttreatment pilot study. RESULTS: : There was significant improvement on all 3 measures of self-reported anger, with large effect sizes (>1.0), and on 1 of 3 SO-reported scales. Qualitative feedback from participants was positive and dropout rate was low (1 of 11). CONCLUSIONS: : The treatment model represented by the ASMT appears worthy of further study in persons with TBI who have both problematic anger and cognitive impairment.

State standards for domestic violence perpetrator treatment: current status, trends, and recommendations.

We empirically surveyed and analyzed existing standards for the treatment of perpetrators of domestic violence across the United States. Specific areas examined included: presence and scope; administrative entity for certifying; screening and risk assessment protocols; minimum length of treatment; theoretical or conceptual orientation; treatment content; preferred or allowable modalities of treatment; whether research findings are mentioned; methods for revising standards; and minimum education and training required for providers. We examined trends using several methods including comparisons between present and previous survey data (Maiuro et al., 2001). Positive trends were evident including increased use of multivariate models of treatment content, use of an intake assessment prior to treatment, use of a danger/lethality assessment to manage risk, recognition of the need for program evaluation and supportive research, and the requirement of a minimum level of formal education as a prerequisite for providers. We identify specific areas for further research and development and make recommendations for improving existing practice and standards of care.

Can Internet-based education improve physician confidence in dealing with domestic violence?

BACKGROUND AND OBJECTIVES: Domestic violence (DV) is a common, under-recognized source of visits to health care professionals. Even when recognized, physicians are reluctant to deal with DV, citing a lack of education and lack of confidence in addressing issues presented by DV patients. Only a small number of DV education programs have been shown to lead to improvements in professional knowledge and confidence, and these are intensive, multi-day courses. We sought to develop an on-line DV education program that could achieve improvements in physician confidence and attitudes in managing DV patients comparable to classroom-based courses. METHODS: We created an interactive, case-based DV education program targeted to physicians caring for DV patients. We tested the effectiveness of this program in changing attitudes and beliefs in a randomized, controlled trial of Kansas physicians who volunteered to participate in a study of on-line continuing medical education. We measured program effectiveness with an externally developed and validated pretest/posttest instrument. RESULTS: Sixty-five physicians completed the pretest/posttest, 28 of whom were assigned to receive the on-line DV program. We found a +17.8% mean change in confidence (self efficacy) for physicians who took the DV program versus a -.6% change for physicians who did not take the program. We also found improvements in other important areas associated with poor management of DV patients. These changes were similar or greater in magnitude to those reported by others who have used the same survey tool to evaluate an intensive, multi-hour classroom approach to DV education. User satisfaction with the on-line program was high. CONCLUSIONS: An interactive, case-based, on-line DV education program that teaches problem-solving skills improves physician confidence and beliefs in managing DV patients as effectively as an intensive classroom-based approach. Such programs may be of benefit to those seeking to improve their personal skills or their health care delivery system's response to DV.