AC Assessment and Treatment of Anger Webinar · Assessment and Treatment of Anger in Service...

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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:General@DeploymentPsych.orgWebsite:DeploymentPsych.orgFacebook:http://www.facebook.com/DeploymentPsychTwitter:@DeploymentPsych

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