An application of cognitive-behavioral anger management training in a military/occupational setting: Efficacy and demographic factors

Military Medicine, Jun 2003 by Linkh, David J, Sonnek, Scott M

Objective: This treatment outcome study evaluated the efficacy of a cognitive-behavioral psychoeducational anger management training application offered in a military/occupational setting. Additionally, demographic factors were analyzed to identify any relationship among age, gender, occupational/educational status, and anger subscale scores or treatment effects. Method: The State-Trait Anger Expression Inventory was used as a pretest/post-test measure for 91 total participants in a series of four-session cognitive behavioral anger management training groups conducted through Francis E. Warren Air Force Base mental health clinic over an 18-month period. Results: Significant improvements (p

Introduction

Anger has been increasingly recognized over the past 25 years as a significant contributor to negative outcomes in general health, mental health, and particularly interpersonal relationships.1 Furthermore, increasing recognition of the frequency and risk associated with workplace violence has underscored the need for making practical anger reduction programs available within the occupational setting.2 Prevention and treatment of "problem anger" in the military setting has become increasingly important as a changing sociopolitical climate within the military and in the larger society has evolved an attitude of intolerance for overt expression of anger and emphasized interpersonal conflict resolution skills. This, combined with increasing concern about workplace violence, has increased the need for, and consequently demand for, brief and effective anger management interventions that can be provided in or near the workplace and with minimal impact on work schedules. The seminal work of Novaco3 and further contributions of Deffenbacher et al.1,4-10 have been crucial to developing relatively short-term cognitive behavioral interventions for reduction of general anger.

Protocols for anger management training using cognitive behavioral interventions have been widely adapted for limited use with various populations (correctional,11 inpatient,12 student,9 and occupational samples13) and have differentially used skills training in relaxation, assertiveness, conflict resolution, and cognitive restructuring to name a few.8 The efficacy of such interventions has been well documented, especially involving student populations.7,8,10 However, the ability to generalize these approaches and results to real world problems remains an open question.12 Anger studies have been almost exclusively conducted in controlled settings with highly selected samples (i.e., Ref. 6) Clearly, "Introduction to Psychology" students as used extensively by other authors may respond very differently than individuals self-identified as experiencing problem anger in an occupational sample. Research using a military population, essentially a diverse occupational sample, was felt to be worth pursuing based both on its similarities and substantial differences from the other populations studied and the relative importance of anger/self control in the military environment.

The purpose of this study was twofold; first and foremost, it was conceived as an outcome study to determine the efficacy of the applied intervention. Second, there was an attempt to detect and explore any demographic factors related to the self-perception or expression of anger and treatment response.

Cognitive behavioral intervention was selected for this study based on established efficacy in treating anger in various settings as well as its suitability to a brief psychoeducational group modality. A four-session format met community and clinic practical requirements and is cited as the lower limit for which significant treatment effects have been obtained.12,14 The State-Trait Anger Expression Inventory (STAXI) was selected for use in the present study based on its widespread use and acceptance, its ability to measure and differentiate a variety of anger attributes for analysis and comparison, and ease of administration in a group setting.15

The participants in the intervention were active duty military personnel, Department of Defense civilian employees, and spouses of military members seeking care for anger problems. No inducements were offered for participation. All participants attended voluntarily. No selection or exclusion criteria were used.

Subjects and Methods

The intervention consisted of groups conducted monthly for four consecutive, weekly 75- to 90-minute sessions. The intervention was developed by the authors with a standard curriculum and facilitated by either the lead investigator or one of two civilian clinical social workers on the clinic staff. The group was psychoeducational in design with didactic and experiential components (Table I.). The treatment approach was cognitive-behavioral and was advertised to the general population at Francis E. Warren Air Force Base, Wyoming through base-wide electronic mail, posted flyers, base newspaper, electronic marquee, and informational briefings. The group was held at the mental health clinic conference/group room and was provided free of charge to all participants. No formal intake or screening process was used, however all facilitators were licensed clinicians who could offer additional intervention or referral as warranted. Some clients referred to the group were receiving individual or marital treatment in the mental health clinic or receiving spousal or child maltreatment interventions through the Family Advocacy Program (a family protective and advocacy service to military families). The study was conducted over an 18-month period from September 1999 to March 2001 and included 91 total participants. Group size ranged from 3 to 10 participants per session (averaging 5.69 per session.) The STAXI was self-administered at the beginning of session 1 and immediately upon completion of session 4. The group curriculum was standardized in terms of topics covered and informational handouts used with each group. Supervision and oversight was provided to the facilitators by the lead investigator. Data were analyzed upon completion of the 18-month intervention period.