CBT for patients who have anger problems

Dr Ron Siddle Manchester Mental Health & Social Care Trust

Agenda
A cognitive model of anger Individual interventions Pilot study data of group CBT in anger

Cognitive model of anger

Situation Appraisal Anger level Inhibitors/ disinhibitors Angry Incident

Patients model of anger

ome od or somet ing e ks ead

Violen e

Overview of CBT therapy

Engage the patient Assess the problem Identify
cognitions and beliefs inhibitors and disinhibitors A-B-C of incidents

Help patient:
alter disinhibitors or inhibitors consider alternative cognitions or beliefs s ills training eg assertiveness graded exposure maintenance plan

Engaging the patient

Expect that 75% may not recognise they have a problem Dont confront the patient Tactical withdrawal Discuss the problem from their point of view Try to use their style of language Be honest regarding your concerns / policy re violence etc Personal disclosure can help Realistic aims

Assess the patient

Do they perceive themselves to have a problem ? STAXI / NAS Forensic history Childhood history (brief) Family/ wor situation Substance abuse High ris situations Costs and benefits of change Ris to you as the therapist

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

High ris situations ?

Pain Tiredness Unfairness &frustration Lac of respect Teasing iolence

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

Pain Tiredness Quiet dar places

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

Any questions so far?

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

Group CBT in the treatment of anger: A pilot study

Ron Siddle Freda Jones Fairuz Awenat Behavioural & Cognitive Psychotherapy (2003) , 31, p 69-83

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

Number of incidents last month Self perceived severity of problem

CBT intervention
Pre group screening assessment of ris / suitability 6 wee ly sessions (1 hour) Post group summary individual Follow up

Assess the patient

Do they perceive themselves to have a problem ? Forensic history Childhood history (brief) Family/ wor situation Substance abuse High ris situations Group suitability

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

East West North

0 1st e Qtr n 2nd Qtr 3rd Qtr 4th Qtr

Attendance decl ne m7 e n1t by e n

attendance

at

STAXI changes
STAXI State anger scores
90 89

ean State anger score (S-Ang)

88

87

86

85

84 re treat ent nd of treat ent

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

ean anger control scores (A / on)

14

12

10

4 re treat ent

Increase in control of anger (t=-1.6 [24], p= .12 )

n of treat ent

ating

Anger Expression
AXI Anger expression
9

AXI anger expression (AX/Ex) ean

92

90

re treat ent

End of treat ent

Rating

Reduced expression of anger (AX/Ex) (t= 2.59 [23], p=.01)

Anger traits
anges in A trait s res

ean

re t reat ent

treat ent

ean re u ti n in ( -Ang) s (t= . [ ] p=. ) er entile anges

r > t t >

res

t per entile

Incidents
er f incidents
0

20

e n
0 re tre t ent

After 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

edia self assessed severity rati

.5

.0

5.5

5.0

.5 Pre treatme t Post treatme t

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 ?

Any questions or comments from you ?

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 ?