Cognitive behavioural anger treatment for adults with intellectual disabilities: effects of therapist experience on outcome.

BACKGROUND: Anger has been shown to be associated with aggression and violence in adults with intellectual disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger and violent behaviour in these patient populations. However, it has been suggested that the effectiveness of these types of interventions is influenced by the experience and training of the therapists. METHOD: In this service evaluation study, the pre- and post-treatment and 12-month follow-up assessment scores of 88 detained in-patient adults with intellectual disabilities and forensic histories who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was associated with treatment being delivered by qualified versus unqualified therapists. RESULTS: Overall significant reductions in self-reported measures of anger disposition and anger reactivity were found with no significant time × therapist experience interaction effects. However, the patients treated by qualified therapists improved significantly on measures of anger control compared with those allocated to unqualified therapists. CONCLUSIONS: Male and female detained patients with intellectual disabilities and forensic histories can benefit from an individual cognitive behavioural anger treatment intervention delivered by qualified and unqualified therapists, but therapist experience may be important in supporting patients to develop more complex anger control coping skills.

Anger rumination and imagined violence as related to violent behavior before and after psychiatric hospitalization.

OBJECTIVE: Anger rumination and imagined violence, in the context of anger/aggression proclivity, are examined for their direct and conjoint associations with violent behavior by psychiatric patients. METHOD: A secondary analysis of data from the MacArthur Violence Risk Study was conducted with 1136 acute civil commitment patients, assessed during hospitalization and after hospital discharge. Anger/aggression proclivity was assessed with the Brief Psychiatric Rating Scale hostility subscale, anger rumination was indexed using items from the Novaco Anger Scale, and imagined violence was measured with Grisso's Schedule of Imagined Violence. Violence, prehospitalization and posthospitalization, was indexed by the MacArthur project measure. RESULTS: Correlational analyses, mediation analyses, and moderated mediation analyses were conducted. Anger rumination significantly predicted pre- and posthospitalization violence, when controlling for age, sex, race, childhood physical abuse, and anger/aggression proclivity; and it partially mediated the relation between anger/aggression proclivity and violence. Imagined violence and anger rumination were highly inter-related. When imagined violence was added to the regression model, it was a significant predictor of prehospitalization violence; however, it did not moderate the association of anger rumination with pre- or posthospitalization violence. CONCLUSION: Anger rumination may be a mechanism through which anger activates violent behavior, which has important implications for psychotherapeutic intervention targeting. Future research should investigate the association between anger rumination and imagined violence, with attention given to revenge planning as a link.

Organization-Based Factors Bearing on Provider Screening and Referral Practices for Women Exposed to Intimate Partner Violence.

Essential steps in the provision of health care for women exposed to intimate partner violence (IPV) are screening and referral for specialized services, as might occur in primary care settings. Prior to participating in a cross-disciplinary IPV training program, medical care (N = 223) and social/behavioral practitioners (N = 197) completed a survey that ascertained current practices, provisions, and perceived barriers related to IPV screening and referral. Roughly half of the study participants did not routinely screen their patients/clients for IPV, with no differences for the professional groupings. Utilization of referral resources was significantly lower for medical care providers, 78.5% of whom did not use any. Perceived barriers to screening and referral were examined as practitioner-based and organization-based, and we identified tangible provisions (protocols and practice materials) as a relevant variable. As we conjectured, organization-based barriers were more strongly associated with lower rates of screening and referral than were practitioner-based barriers, regardless of professional grouping. Moreover, tangible provisions, controlling for perceived barriers, significantly added to routine screening and frequency of referral resources usage, particularly for medical care providers. Results are discussed in the context of a systems-level approach to improving IPV services in health care with organizational practice enhancements.

Sources of Social Support After Patient Assault as Related to Staff Well-Being.

Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with better well-being. Support from nonwork sources was related to less concerns about safety, but not to other well-being measures. However, 28% of staff did not receive effective support from any source postassault. Gaps in support as reported in this study and as found by other investigators call for systematic programming by hospital organizations to enhance the well-being of clinical staff, which in turn has implications for patient care.

Anger and depression among incarcerated male youth: Predictors of violent and nonviolent offending during adjustment to incarceration.

OBJECTIVE: Anger and depression are associated with a number of psychosocial problems, and their comorbidity may exacerbate maladjustment among incarcerated youth. The present study aims to identify whether anger and its different facets (cognitive, arousal, and behavioral), either independently or when conjoined with depressed mood, affects violent and nonviolent institutional infractions. METHOD: Male adolescents (14-17 years of age) were recruited within 48 hr of arrival at a juvenile detention facility and were administered psychometric measures of anger (Novaco Anger Scale) and depression (Center for Epidemiological Studies-Depression scale) at baseline, 1 month, and 2 months. Offending within the facility was assessed via self-report and institutional records. RESULTS: Controlling for prior offending and other background factors, individuals having high anger scores were more likely to offend over the 2-month period, compared to those with lower levels of anger. Novaco Anger Scale scores, especially the Behavioral facet, predicted both official- and self-reported (violent and nonviolent) institutional offending. There was evidence for the interaction of depression and anger at baseline predicting self-reported offending at 1 month only. CONCLUSIONS: Given that juveniles' self-report of emotional distress, particularly anger, is predictive of their violent and nonviolent infractions, focused intervention programs could reduce behavior problems during incarceration that add to juveniles' maladjustment and continued exposure to adversities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Dimensions of Anger Reactions-Revised (DAR-R): Validation of a brief anger measure in Australia and Spain.

OBJECTIVE: A validated, brief measure of anger is needed in clinical settings to screen for problematic anger. This study examined the validity of the seven-item Dimensions of Anger Reactions-Revised (DAR-R), including a version for the Spanish population. METHOD: Multiple psychometric instruments administered to 541 (76.6% female) adults in Australia and 1,115 (56.3% female) in Spain were analyzed. RESULTS: A two-factor model (anger response and anger impairment) was confirmed. Concurrent, convergent, and discriminant validity were supported. Anger response items strongly correlated with established measures of anger/aggression State-Trait Anger Expression Inventory (Aggression Questionnaire), whereas anger impairment items strongly correlated with anxiety Generalized Anxiety Disorder-7 and depression Patient Health Questionnaire-9 measures. Internal consistency and test-retest reliability (3 months) were good. Cut-off scores for problematic anger were established. There were no gender differences in anger in the Spanish sample, but Australian males had higher anger scores than females. CONCLUSION: Results substantiate the utility of the DAR-R as a concise, clinically informative measure of anger.

Anger intensification with combat-related PTSD and depression comorbidity.

Anger is becoming more widely recognized for its involvement in the psychological adjustment problems of current war veterans. Recent research with combat veterans has found anger to be related to psychological distress, psychosocial functioning, and harm risk variables. Using behavioral health data for 2,077 treatment-seeking soldiers who had been deployed to Iraq and Afghanistan, this study examined whether anger disposition was intensified for those who met screen-threshold criteria for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Anger was assessed with a 7-item screening measure previously validated with the study population. The study tested the hypothesis that anger would be highest when "PTSD & MDD" were conjoined, compared with "PTSD only," "MDD only," and "no PTSD, no MDD." PTSD and depression were assessed with well-established screening instruments. A self-rated "wanting to harm others" variable was also incorporated. Age, gender, race, military component, military grade, and military unit social support served as covariates. Hierarchical multiple regression was used to test the hypothesis, which was confirmed. Anger was intensified in the PTSD & MDD condition, in which it was significantly higher than in the other 3 conditions. Convergent support was obtained for "wanting to harm others" as an exploratory index. Given the high prevalence and co-occurrence of PTSD and MDD among veterans, the results have research and clinical practice relevance for systematic inclusion of anger assessment postdeployment from risk-assessment and screening standpoints.

Validation of the Novaco Anger Scale-Provocation Inventory (Danish) With Nonclinical, Clinical, and Offender Samples.

Anger has high prevalence in clinical and forensic settings, and it is associated with aggressive behavior and ward atmosphere on psychiatric units. Dysregulated anger is a clinical problem in Danish mental health care systems, but no anger assessment instruments have been validated in Danish. Because the Novaco Anger Scale and Provocation Inventory (NAS-PI) has been extensively validated with different clinical populations and lends itself to clinical case formulation, it was selected for translation and evaluation in the present multistudy project. Psychometric properties of the NAS-PI were investigated with samples of 477 nonclinical, 250 clinical, 167 male prisoner, and 64 male forensic participants. Anger prevalence and its relationship with other anger measures, anxiety/depression, and aggression were examined. NAS-PI was found to have high reliability, concurrent validity, and discriminant validity, and its scores discriminated the samples. High scores in the offender group demonstrated the feasibility of obtaining self-report assessments of anger with this population. Retrospective and prospective validity of the NAS were tested with the forensic patient sample regarding physically aggressive behavior in hospital. Regression analyses showed that higher scores on NAS increase the risk of having acted aggressively in the past and of acting aggressively in the future.

Intimate Partner Violence Victims Seeking a Temporary Restraining Order: Social Support and Resilience Attenuating Psychological Distress.

Social support has been found in many studies to be a protective factor for those exposed to intimate partner violence (IPV), but personal resilience has received far less attention. The present study concerns 136 female IPV victims seeking a temporary restraining order (TRO) from a Family Justice Center (FJC). The relationships between IPV victimization, social support, resilience, and psychological distress were examined. Hierarchical regressions found that both perceived social support and self-reported resilience were inversely associated with distress symptoms. Higher social support was associated with lower trauma symptoms, controlling for abuse history, demographics, and resilience. Higher resilience was associated with lower mood symptoms and lower perceived stress, controlling for abuse history, demographics, and social support. No significant associations were recorded for anger symptoms. These findings suggest that fostering resilience can have important health benefits for IPV victims, above and beyond the well-known benefits of social support. Ways that resilience might be cultivated in this population and other implications for practice are discussed.

Well-Being and Safety Among Inpatient Psychiatric Staff: The Impact of Conflict, Assault, and Stress Reactivity.

Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors. Whether workplace violence adversely affects staff well-being may be related not only to its presence, but also to an individual's stress reactivity. At a large public psychiatric hospital, an online survey was completed by 323 clinical care staff, of whom 69.5 % had experienced physical assault in the previous 12 months. Staff well-being (depression, anger, and physical health) and staff safety concerns were adversely affected by conflicts with other staff members and by individual reactivity to social conflict and to assault. To improve staff well-being, in addition to safety protocols, interventions should target staff relationships, personal health maintenance practices, and individual coping skills for dealing with adverse workplace experiences.

Violence associated with combat-related posttraumatic stress disorder: The importance of anger.

The importance of anger with regard to violence among veterans with combat-related PTSD has received little attention. We previously proposed that in PTSD the activation of threat-related cognitive networks strongly potentiates anger in a positive feedback loop and that inhibitory controls on aggression can be overridden when PTSD and anger activation are conjoined. We predicted that violence would be intensified when combat-related PTSD was conjoined with anger. We used the National Vietnam Veterans Readjustment Study (NVVRS) public use data set, selecting the male combat theater veterans, which entailed 1,200 from the main survey (Study 1) and 259 from the clinical interview component (Study 2). Anger indices were constructed from NVVRS variables. PTSD was assessed by continuous symptom scores and by clinical diagnostic measures. Conjoined anger and PTSD was associated with greatly increased violence. PTSD was not associated with violence in the absence of anger. This result was obtained using alternative measures of PTSD and of anger in both the main survey and the clinical interview component. These findings call for reconceptualizing the association of PTSD and violence. Concerted attention should be given to anger as a risk factor for violence in the assessment and treatment of combat-related PTSD, and as an important portal of entry for treatment.

Reduction of assaultive behavior following anger treatment of forensic hospital patients with intellectual disabilities.

Anger is related to violence prior to hospitalization, during hospitalization, and after discharge. Meta-analyses have established treatment efficacy in reducing anger, but few studies have addressed whether reduced anger leads to lowered aggressive behavior. This study concerns individually-delivered anger treatment, specialized for offenders with intellectual disabilities, delivered twice weekly for 18 sessions to 50 forensic hospital patients. Assessments involved patient self-report of anger, staff ratings of anger and aggression, and case records of assaultive incidents. Physical assault data were obtained from records 12 months pre-treatment and 12 months post-treatment. Significant reductions in assaults following treatment were found by GEE analyses, controlling for age, gender, length of stay, IQ, and pre-hospital violence. Following treatment, physical attacks reduced by more than half, dropping from approximately 3.5 attacks per patient 6 months prior to treatment, versus approximately 1 attack per patient in the 6-12 month interval post-treatment. In hierarchical regressions, controlling for IQ, reduction in physical assaults was associated with pre-to post-treatment change in anger level. These findings buttress the efficacy of anger treatment for patients having histories of violence and have significance for patient mental health, hospital staff well-being, therapeutic milieu, hospital management, and service delivery costs.

A cross-sectional survey of factors related to inpatient assault of staff in a forensic psychiatric hospital.

AIM: To understand staff factors associated with patient aggression towards the staff of an inpatient forensic psychiatric hospital. BACKGROUND: Violence by patients is a serious concern in psychiatric hospitals and staff are the most frequent targets of physical and verbal assault. Assault and its consequences can severely disrupt the hospital environment and impair the functioning of staff members and patients. This study examined the interplay of staff dispositional and interpersonal factors associated with patient violence. DESIGN: This cross-sectional study surveyed the staff of a large public forensic hospital. METHODS: A sample of 348 psychiatric staff participated in an online survey about their workplace experiences, psychosocial characteristics and well-being. Data were collected from November - December 2011. FINDINGS: Nearly all staff reported verbal conflict with patients (99%) and 70% reported being assaulted during the previous 12 months. Verbal conflict with other staff (92%) was also high. Multiple regression analyses indicated that in addition to static risk factors (i.e. staff position, years of experience and gender), the risk of assault was associated with the frequency of conflicts with staff and patients, which in turn was moderated by personal stress reactivity. CONCLUSION: Physical violence by patients was a pervasive threat for a high proportion of staff. Frequent conflict interactions with volatile patients contributed the most risk, but reactivity to conflict was a dynamic risk factor. The strain associated with assault risk and stress reactivity could be prospectively mitigated by resilience enhancement programming for staff.

Evaluation of the dimensions of anger reactions-5 (DAR-5) scale in combat veterans with posttraumatic stress disorder.

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α=.86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g., HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166-173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.

Utility of the Dimensions of Anger Reactions-5 (DAR-5) scale as a brief anger measure.

BACKGROUND: Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self-report batteries or as screening tools. This study examines the psychometric properties of a shortened 5-item version of the Dimensions of Anger Reactions (DAR), an existing screening tool. METHODS: Responses to the DAR-5 were analysed from a sample of 486 college students with and without a history of trauma exposure. RESULTS: The DAR-5 demonstrated strong internal reliability and concurrent validity with the State Trait Anger Expression Inventory-2 (STAXI-2). Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and nontrauma subsamples. A screening cut-off point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores. Further discriminant validity was found with depression symptom scores. CONCLUSIONS: The results support use of the DAR-5 for screening for anger when a short scale is required.

A brief screening instrument for emotionally unstable and dissocial personality disorder in male offenders with intellectual disabilities.

Personality disorder is prevalent among offenders with intellectual disabilities (ID), and it is associated with their risk for violence and recurrent offending behaviour. A new staff-rated instrument, the Personality Disorder Characteristics Checklist (PDCC), designed to screen for ICD-10 dissocial and emotionally unstable personality characteristics was evaluated for its reliability and validity, as applied to 129 male forensic patients with ID. Internal consistency and test-retest reliability were very good. Supportive evidence for concurrent and discriminant validity was obtained in conjunction with an established staff-rated instrument, but not for patient self-report measures. Construct validity support was found for the PDCC in association with violent offence and hospital assault history and in significantly accounting for the number of physical assaults in hospital, controlling for multiple covariates. Results for the new measure were favourable in comparison to established instruments. It clinical utility for treatment planning and for the management of risk is discussed.

Anger and postcombat mental health: validation of a brief anger measure with U.S. soldiers postdeployed from Iraq and Afghanistan.

The involvement of anger in the psychological adjustment of current war veterans, particularly in conjunction with combat-related posttraumatic stress disorder (PTSD), warrants greater research focus than it has received. The present study concerns a brief anger measure, Dimensions of Anger Reactions (DAR), intended for use in large sample studies and as a screening tool. The concurrent validity, discriminant validity, and incremental validity of the instrument were examined in conjunction with behavioral health data for 3,528 treatment-seeking soldiers who had been in combat in Iraq and Afghanistan. Criterion indices included multiple self-rated measures of psychological distress (including PTSD, depression, and anxiety), functional difficulties (relationships, daily activities, work problems, and substance use), and violence risk. Concurrent validity was established by strong correlations with single anger items on 4 other scales, and discriminant validity was found against anxiety and depression measures. Pertinent to the construct of anger, the DAR was significantly associated with psychosocial functional difficulties and with several indices of harm to self and to others. Hierarchical regression performed on a self/others harm index found incremental validity for the DAR, controlling for age, education, military component, officer rank, combat exposure, PTSD, and depression. The ability to efficiently assess anger in at-risk military populations can provide an indicator of many undesirable behavioral health outcomes.

Psychometric evaluation of a Dutch version of the Dimensions of Anger Reactions.

Two studies were conducted to investigate the psychometric properties of a Dutch translation of the Dimensions of Anger Reactions, a brief test to measure anger disposition. In the first study, the factor structure, internal consistency, and validity of the scale were examined in a sample of 97 students. Factor analysis essentially yielded one factor, although further inspection found some evidence for a two-factor structure referring to "anger response" and "impairment." The internal consistency was acceptable, and convergent and divergent validities were supported by a theoretically meaningful pattern of correlations with other self-report measures, such as the Aggression Questionnaire, Barratt's Impulsivity Scale-11, and the Symptom Checklist-90. In a second study, the test-retest reliability of the scale was examined in a separate sample of 37 students. A correlation coefficient of .84 was found, supporting the reliability of the scale. Altogether, it can be concluded that the Dutch Dimensions of Anger Reactions seems to be reliable and valid for assessing anger disposition.

Cognitive-behavioural therapy v. social activity therapy for people with psychosis and a history of violence: randomised controlled trial.

BACKGROUND: Aggression and violence are serious problems in schizophrenia. Cognitive-behavioural therapy (CBT) has been shown to be an effective treatment for psychosis although there have been no studies to date evaluating the impact of CBT for people with psychosis and a history of violence. AIMS: To investigate the effectiveness of CBT on violence, anger, psychosis and risk outcomes with people who had a diagnosis of schizophrenia and a history of violence. METHOD: This was a single-blind randomised controlled trial of CBT v. social activity therapy (SAT) with a primary outcome of violence and secondary outcomes of anger, symptoms, functioning and risk. Outcomes were evaluated by masked assessors at 6 and 12 months (trial registration: NRR NO50087441). RESULTS: Significant benefits were shown for CBT compared with control over the intervention and follow-up period on violence, delusions and risk management. CONCLUSIONS: Cognitive-behavioural therapy targeted at psychosis and anger may be an effective treatment for reducing the occurrence of violence and further investigation of its benefits is warranted.