ac assessment and treatment of anger webinar · assessment and treatment of anger in service...
TRANSCRIPT
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AssessmentandTreatmentofAngerinServiceMembersandVeterans:AnOverview
CenterforDeploymentPsychology
UniformedServicesUniversityoftheHealthSciences
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• Differentiatebetweenangerandaggression.• Describetheprevalenceofanger-relatedproblemsinVeteransandServiceMembers.• Identifyassessmentandtreatmentstrategiesforproblematicanger.
Learning Objectives
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• Definitionofangerandaggression• DescriptionofproblemsrelatedtoangerinServicemembersandVeterans• Prevalenceofanger-relatedproblemsinServicemembersandVeterans• Assessmentandtreatmentofproblematicanger
Outline
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Anger and Aggression
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“Astrongfeelingofbeingupsetorannoyedbecauseofsomethingwrongorbad;thefeelingthatmakessomeonewanttohurtotherpeople,toshout,etc.;thefeelingofbeingangry.”
Anger
“Astrongfeelingofannoyance,displeasure,orhostility.”
Merriam-WebsterDictionary;OxfordDictionary
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“Hostileorviolentbehaviororattitudestowardanother;readinesstoattackorconfront.”
Aggression
“Aforcefulactionorprocedure(asanunprovokedattack)especiallywhenintendedtodominateormaster;hostile,injurious,ordestructivebehaviororoutlookespeciallywhencausedbyfrustration.”
Merriam-WebsterDictionary;OxfordDictionary
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Construct of Anger
Eckhardt etal.(2004);Taftetal(2012)
U.S.ArmyphotoillustrationbyPfc.PaigePendleton,1st Cav.Dive.PAO.PublicDomainimage.
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Construct of Anger
Fernandez(2013)
Emotionthatinvolves
Cognitiveappraisal
Actiontendency
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Anger, Physical Aggression,and Violence
Anger
PhysicalAggression
Fernandez(2013)
Violence
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Dichotomy of AngerStateAnger
• Emotionalstate• Feelingsvaryinintensity
• Frommildannoyanceorirritationtointensefuryorrage
TraitAnger• Chronicindividualdifferencesinthefrequency,intensity,anddurationofstateangerepisodes
Spielberger (1988)
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Integrative Cognitive ModelHostileInterpretation
RuminativeAttention
EffortfulControl
Wilkowski &Robinson(2010)
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• Emotion• Episodic• Varyingintensity
• Mood• Relativelyprolonged• Generallylessintense
• Temperament• Recurrent• Pervasive
Trichotomy of Anger
Fernandez(2013)
.S. Army photo by Timothy L. Hale/released. Public Domain image.
1414U.S.MarineCorpsphotobyCpl CaitlinBrink/released.
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• UseofDSM-VDefinitions• Dysfunctionalormaladaptive• IntermittentExplosiveDisorder
• Stimulus-ResponsePerspective•Weighingtheresponseagainstthestimulus• Over-reactionvs.under-reaction
Problematic Anger
Fernandez(2013)
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• Interpersonalconflict• Familyenvironment•Workenvironment• Psychotherapy
• Impairedjudgement• Increasedrisk-taking
• Physicalhealthrisks• Hypertension• Arteriosclerosis
Possible Consequences of Problematic Anger
Fernandez(2013)
U.S.NavygraphicbyMassCommunicationSpecialist3rd ClassMarkEl-Reyes/released.(Imageedited)PublicDomainimage.
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• 35year-oldmaleVeteran• MedicallydischargedfromU.S.Armyin2012• Twodeploymentsbutneveroutsidethewire• Attendinglocaluniversity• Encouragedtoseektherapybyacademiccounselor• Motivationfortreatmentislow• Preferstoseektreatmentincommunity
Case Example
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Problems Related to Anger and Aggression in Service Members and Veterans
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• Challengesinobtainingaccurateunderstandingastothescopeoftheproblem
• Conceptualization
• Measurement
• Sampling
Prevalence of Anger Problems
Worthen etal.(2014);Fernandez(2013)
U.S.ArmyphotoillustrationbyStaffSgt.MarkBurrell.PublicDomainimage.
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• Populationbasedestimates• Variabilityinmeasurement• Amongpost-9/11veterans,theestimatesrangefrom32%to57%• Prevalenceofproblemsrelatedtoangerappearstobesimilaramongmenandwomen
Prevalence of Anger Problems
PewResearchCenter(2011);Sayeretal(2010);Wheeler(2007);Worthen etal(2014)
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• PTSDanddepressionsignificantlyincreasedfromthe3to12-monthtimepointsforbothNationalGuardandActiveDuty
• MagnitudeofincreasewasgreaterforNationalGuardthanActiveDuty
• AmongNationalGuardfunctionalimpairmentandeitheralcoholmisuseoraggressivebehaviorsbetween3and12monthsincreasedsignificantly
• AmongActiveDutyalcoholmisuseandaggressivebehaviorsdidnotchangesignificantly
Vulnerability of National Guard vs. Active Duty Soldiers (OIF)
Thomasetal.(2010);Tayloretal.(2013)
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• FactorscontributingtoangerproblemsreportedbyOEF/OIFVeterans:•Mostproblemsdirectlyfollowedseparationfrommilitary• Lossofstructure• PTSD•Moralinjury
• Increasedsocialisolationforwomenexperiencingproblemswithanger
What Contributes to Anger-Related Problems?
Worthen &Ahern(2014)
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• Factorsassociatedwithhigherprevalenceofangerproblemsreportedbyveterans:• Conditionsassociatedwithanger
• Combatexposure• DeploymenttoIraq• Pre-deploymentfunctionalimpairment
• Lowereducationlevel• Lessunitcohesion• Lowerrank• Physicalorsexualabusehistory
What Contributes to Anger-Related Problems?
PewResearchCenter(2011);Sayeretal(2010);Wheeler(2007);Worthen etal(2014);Elbogen etal.(2010);Renshaw&Kiddie(2012);Wrightetal.(2012);Afari etal.(2015);Jakupcak etal.(2007);Tayloretal.(2013);Balie etal(2015)
U.S.ArmyphotoillustrationbyPfc.PaigePendleton,1st Cav.Dive.PAO.PublicDomainimage.
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• Estimatesduringthepriormonthfor:• Physicalassault10%• Alltypesofphysicalaggression29%
• Combatexposureassociatedwithpost-deploymentphysicalaggressionandviolence
• Riskofviolenceincreasedwithgreaterintensityandfrequencyofcombatexposure
• Limitationsincludedneglectofpre-militaryviolencerisk
• SymptomsofPTSDrelatedifferentlytobehavior• Alcoholmisusestronglyassociatedwithaggression
Post-Deployment Aggression and Violence in OEF/OIF Veterans
MacManusetal.(2015)
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• Traumaticexperienceleadstorapidescalationofthreatperception,transformsangerrapidly,andresultsinnearautomaticaction.
Anger and PTSD
Chemtob etal.(1997)
Cognitiveprocessing
Behavioralreactions
Physiologicalarousal
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• PossiblereasonsforincreasedproblemswithangerandaggressioninVeteranswithPTSD• Informationprocessingdeficits• Heightenedthreatperception• Co-morbiddepression,alcoholuseproblems,andTBI• Trust• Shameandguilt• Powerlessness
PTSD, Anger and Aggression
Taftetal.(2012)
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• Forbothmenandwomen,emotiondysregulationfullyaccountedforrelationshipbetweenPTSDandimpulsiveaggression• Difficultydistinguishingbetweensafevs.potentiallyunsafeindividualsandenvironmentalcues• PTSDinterventionsmaybeaugmentedwithemotionregulationskillstraining
PTSD and Aggression
Milesetal.(2015)
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• Cognitiveandbehavioraleffortsinresponsetostressorthatisperceivedasexceedingresources• Multidimensionalwiththreeoverlappingconceptualapproachestoclassification:• Orientation•Method• Focus
Coping: PTSD and Anger
Tiet etal.(2006);Folkman &Lazarus(1991)
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Assessment of Anger in Service Members and Veterans
30U.S.AirForceillustrationbyStaffSgt.JamalD.Sutter/releasedpublicdomainimage.
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• Relationships• Family• Friends•Coworkers/Supervisors
• Health• Legal
Motivation for Treatment
DEAPublicDomainimage.
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• State-TraitAngerExpressionInventory-2(STAXI-2)• NovacoAngerScaleandProvocationInventory(NASPI)• AngerDisordersScale(ADS)• AggressionQuestionnaire(AQ)• RevisedConflictTacticsScales(CTS-2)
Assessment Measures
Fernandez(2013);Taftetal.(2012)
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• Usedirectandnon-judgmentalapproach• Discusslimitsofconfidentiality• Beginwithpresentingproblem• Inquireexplicitlyregardinganger-relatedproblems• Indicatefrequency,duration,andintensityofanger
• Assessaggression• Conductinterviewwithcollateralsource(s)• Performsafetyassessment
Assessment Recommendations
Fernandez(2013);Taftetal.(2012)
34U.S.ArmyillustrationbySgt.BrandonBanzhaf,3rd BCTPAO,1st Cav.Div.PublicDomainimage.
Violence Risk AssessmentViolenceRiskAssessment:
StaticFactorsDispositionalHistorical
DynamicFactorsClinicalContextual
34Elbogen etal.(2010)
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Prototype of Checklist for Assessing Violence Risk Among Veterans
Elbogen etal.(2010)
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Anger Management Techniques and Treatments for Service Members and Veterans
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• Groupvs.Individual• Researchoneffectivenessoftreatments
• Cognitive-behavioraltechniques
• Challenginganger-relatedthoughts
• Relaxationskills
• Effectivecommunication
• Copingstrategies
• Processandmotivationalissues
• Conveyingsenseofhopefulnessand
optimism
Anger Management Techniquesand Treatments
Taftetal.(2012)
U.S.AirForcephotoillustrationbyMasterSgt.LanceCheung.PublicDomainimage.
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• Reductionindepressionsymptoms,generalanxiety,andpsychoticpronethinking• Reductiononsuicidalideation(notaftercontrollingfordepressionandhopelessness)• Decreaseintraumarelatedanger
PTSD Treatment andComorbid Symptoms
Minnen etal.(2015)
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• DevelopedforuseatSanFranciscoVAMedicalCenterandSanFranciscoGeneralHospital• CombinedCBTapproach• Developedforgroups;twelve90-minutesessions• Idealnumberofparticipantsiseight• VTCaseffectiveaslivegroup• Conduciveforindividualtherapy• Atleast2weeksofabstinencerecommended
Anger Management for Substance Abuse and Mental Health Clients (SAMHSA, 2002)
Reillyetal.(2002);Morland etal.(2010)
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• PsychoeducationandAngerMeter
• Check-inProcedures• AngerControlPlan• DeepBreathing• AggressionCycle• ProgressiveMuscleRelaxation• ABCDModel• ThoughtStopping• AssertivenessTrainingandConflictResolution
Anger Management for Substance Abuse and Mental Health Clients (SAMHSA, 2002)
Reillyetal.(2002)
PublicDomainimagebySGTDanielSchroeder.
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Resources
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• http://aftredeployment.dcoe.mil/topics-anger• http://maketheconnection.net/symptoms/anger-irritability
• http://www.ptsd.va.gov/public/problems/anger-and-trauma.asp
• AngerandIrritabilityManagementSkills(AIMS):DevelopedspecificallyforVeterans.Practicalskillsandtoolstomanageangeranddevelopself-control.
• http://www.veterantraining.va.gov/aims/
Resources
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http://www.samhsa.gov
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• Descriptionsandschedulesofupcomingtrainingevents
• Blogupdateddailywitharangeofrelevantcontent
• Articlesbysubjectmatterexpertsrelatedtodeploymentpsychology,includingPTSD,mTBI,depression,andinsomnia
• Otherresourcesandinformationforbehavioralhealthproviders
• LinkstoCDP’sFacebookpageandTwitterfeed
CDP Website: deploymentpsych.org
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• CognitiveProcessingTherapy(CPT)forPTSDinVeteransandMilitaryPersonnel(1.25CEs)
• ProlongedExposureTherapyforPTSDinVeteransandMilitaryPersonnel(1.25CEs)
• EpidemiologyofPTSDinVeterans:WorkingwithServiceMembersandVeteranswithPTSD(1.5CEs)
• ProviderResiliencyandSelf-Care:AnEthicalIssue(1CEs)
• MilitaryCulturalCompetence(1.25CEs)
• TheImpactofDeploymentandCombatStressonFamiliesandChildren,Pt1(2.25CEs)
• TheImpactofDeploymentandCombatStressonFamiliesandChildren,Part2(1.75CEs)
• TheFundamentalsofTraumaticBrainInjury(TBI)(1.5CEs)
• Identification,Prevention,&TreatmentofSuicidalBehaviorinServiceMembers&Veterans(2.25CEs)
• DepressioninServiceMembersandVeterans(1.25CEs)
OnlineLearninghttp://www.deploymentpsych.org/content/online-courses
NOTE:Allofthesecoursescanbetakenforfree,orforCECreditsforafee
AllofthesecoursesandseveralothersarecontainedintheServingOurVeteransBehavioralHealthCertificateprogram,
whichalsoincludes20+hoursofContinuingEducationCreditsfor$350.
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ProviderSupportCDP’s“ProviderPortal”isexclusivelyforindividualstrainedbyCDPinevidence-basedpsychotherapies(e.g.,CPT,PE,andCBT-I)
• Consultationmessageboards
• Hostedconsultationcalls• Printablefactsheets,
manuals,handouts,andothermaterials
• FAQsand1:1interactionwithanswersfromSMEs
• Videos,webinars,andothermultimediatrainingaids
ParticipantsinCDP’sevidence-basedtrainingwillautomaticallyreceiveanemailinstructingthemhowtoactivatetheirusernameandaccessthe“ProviderPortal”
sectionatDeploymentpsych.org.
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CenterforDeploymentPsychologyDepartmentofMedical&ClinicalPsychology
UniformedServicesUniversityoftheHealthSciences4301JonesBridgeRoad,ExecutiveOffice:Bldg.11300-602
Bethesda,MD20813-4768
Email:[email protected]:DeploymentPsych.orgFacebook:http://www.facebook.com/DeploymentPsychTwitter:@DeploymentPsych
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