A Comparison of Group Anger Management Treatments for Combat Veterans With PTSD: Results From a Quasi-Experimental Trial

Posttraumatic Stress Disorder Symptom Clusters, Exposure to Potentially Morally Injurious Events, and Aggression Among Army Veterans

OBJECTIVE

Very few studies have examined the association between posttraumatic stress disorder (PTSD) symptom clusters and aggression since the change in PTSD diagnosis criteria a decade ago. Furthermore, these studies have used measures based on PTSD criteria of the DSM-IV. The current study therefore examines the association between PTSD symptom clusters, exposure to potentially morally injurious events (PMIEs), and various types of aggression following the change in PTSD criteria and in accordance with the criteria of the DSM-5-TR.

METHOD

A sample of 167 Israeli combat veterans completed validated self-report questionnaires tapping PTSD symptoms, exposure to PMIEs, and aggression levels.

RESULTS

Our analysis revealed a significant positive relationship between the number of court-martials, betrayal-based PMIEs, all PTSD symptom clusters, and aggression. We also found that the arousal cluster, as well as the number of court-martials and age, predicted aggression, whereas the re-experiencing cluster predicted lower aggression levels.

CONCLUSION

Besides an updated understanding of the association between all PTSD symptom clusters and various forms of aggression, these findings emphasize the importance of targeting arousal symptoms and especially anger in treatment of veterans with PTSD symptoms and those who report experiences of betrayal. The findings also suggest clinicians to consider arousal symptoms, age, and history of court-martials when conducting either clinical or actuarial risk assessments of veterans.

Testing a Novel Trauma-Informed Treatment for Anger and Aggression Following Military-Related Betrayal: Design and Methodology of a Clinical Trial

INTRODUCTION

Difficulty controlling anger is a common postdeployment problem in military personnel. Chronic and unregulated anger can lead to inappropriate aggression and is associated with behavioral health, legal, employment, and relationship problems for military service members. Military-related betrayal (e.g., military sexual assault, insider attacks) is experienced by over a quarter of combat service members and is associated with chronic anger and aggression. The high level of physical risk involved in military deployments make interconnectedness and trust in the military organization of utmost importance for survival during missions. While this has many protective functions, it also creates a vulnerability to experiencing military-related betrayal. Betrayal is related to chronic anger and aggression. Individuals with betrayal-related injuries express overgeneralized anger, irritability, blaming others, expectations of injustice, inability to forgive others, and ruminations of revenge. Current approaches to treating anger and aggression in military populations are inadequate. Standard anger treatment is not trauma-informed and does not consider the unique cultural context of anger and aggression in military populations, therefore is not well suited for anger stemming from military-related betrayal. While trauma-informed interventions targeting anger for military personnel exist, anger outcomes are mixed, and aggression and interpersonal functioning outcomes are poor. Also, these anger interventions are designed for patients with posttraumatic stress disorder. However, not all military-related betrayal meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 definition of trauma, though it may still lead to chronic anger and aggression. As a result, these patients lack access to treatment that appropriately targets the function of their anger and aggression.

MATERIALS AND METHODS

This manuscript describes rationale, design, and methodology of a pilot clinical trial examining Countering Chronic Anger and Aggression Related to Trauma and Transgressions (CART). CART is a transdiagnostic, transgression-focused intervention for military personnel who have experienced military-related betrayal, targeting chronic anger and aggression, and improving interpersonal relationships. The pilot study will use an interrupted timeseries design, where participants are randomized to a 2-, 3-, or 4-week minimal contact waitlist before starting treatment. This design maximizes the sample size so that all participants receive the treatment and act as their own control, while maintaining a robust design via stepped randomization. This trial aims to (1) test the acceptability and feasibility of CART, (2) test whether CART reduces anger and aggression in military personnel with a history of military-related betrayal, and (3) test whether CART improves interpersonal functioning.

RESULTS

The primary feasibility outcome will be the successful recruitment, enrollment, and initiation of 40 participants. Primary outcome measures include the Client Satisfaction Survey-8, the State Trait Anger Expression Inventory-2, Overt Aggression Scale-Modified, and the Inventory of Interpersonal Problems-Short Version.

CONCLUSION

If outcomes show feasibility, acceptability, and initial effectiveness, CART will demonstrate a culturally relevant treatment for chronic anger, the most frequent postdeployment problem, in a sample of active duty service members who have suffered a military betrayal. The DoD will also have an evidence-based treatment option focusing on interpersonal functioning, including relationships within the military and within families.

STEP-Home transdiagnostic group reintegration workshop to improve mental health outcomes for post-9/11 Veterans: Design, methods, and rationale for a randomized controlled behavioral trial

BACKGROUND

Many post-9/11 U.S. combat Veterans experience difficulty readjusting to civilian life after military service, including relationship problems, reduced work productivity, substance misuse, and increased anger control problems. Mental health problems are frequently cited as causing these difficulties, driven by unparalleled rates of mild traumatic brain injury, posttraumatic stress, and other co-occurring emotional and physical conditions. Given the high prevalence of multimorbidity in this cohort, acceptable, non-stigmatizing, transdiagnostic interventions targeting reintegration are needed. The STEP-Home reintegration workshop has the potential to significantly improve skills to foster civilian reintegration, increase engagement in VA services, and improve mental health outcomes in Veterans with and without diagnosed clinical conditions.

METHODS/DESIGN

Ongoing from 2019, a prospective, two-site, randomized trial of 206 post-9/11 U.S. military Veterans randomized to receive either 12 sessions of the STEP-Home transdiagnostic reintegration workshop (SH; Active Intervention) or Present Centered Reintegration Group Therapy (PCRGT; Active Control Intervention). Primary outcomes are reintegration, anger, and emotional regulation post-intervention and at 3-months post-intervention. Secondary outcomes include measures of mental health, functional and vocational status, and cognition.

CONCLUSION

This study addresses an important gap in transdiagnostic interventions to improve civilian reintegration in post-9/11 Veterans. STEP-Home is designed to promote treatment engagement and retention, opening the door to critically needed VA care, and ultimately reducing long-term healthcare burden of untreated mental health illness in U.S. Veterans.

TRIAL REGISTRATION

Clinicaltrials.gov: D2907-R.

Development and refinement of the mobile anger reduction intervention for veterans with posttraumatic stress disorder

OBJECTIVE

Problematic anger is commonly reported among veterans with posttraumatic stress disorder (PTSD) and is associated with numerous psychosocial impairments. There is a clear need to develop innovative and effective anger interventions. One of the cognitive mechanisms associated with anger is the hostile interpretation bias, which is the tendency to interpret ambiguous interpersonal situations as hostile. The current study presents a successive cohort design methodology to develop and refine a mobile treatment application, entitled Mobile Anger Reduction Intervention (MARI), which uses interpretation bias modification techniques to modify hostile interpretation bias.

METHOD

Two cohorts (total N = 13) of veterans with PTSD and problematic anger used the MARI application for 4 weeks. After each cohort, qualitative and quantitative data were used to modify the MARI application. The intervention is described, as well as the qualitative and quantitative findings and subsequent changes made to the mobile application based on participant feedback.

RESULTS

Treatment adherence was high (90% of participants completed all sessions). Participants reported that they found the treatment helpful and easy to use and experienced improvements in hostile interpretation bias and problematic anger.

CONCLUSIONS

This study demonstrates the utility of a successive cohort treatment design for the development of mobile interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Religious and Spiritual Implications in Functional Anger

The topic of spirituality has been of interest for many years in the helping professions ( Matise et al., 2018; Pargament, 2011). Another level of interest is how spirituality may be connected to anger that is culturally informed ( Subarimaniam et al., 2020). This writing approaches the topic of functional anger as impacted by the religious and spiritual beliefs with case vignettes pertinent to students, pastoral counselors, nurses, social workers, psychologists, psychotherapists, and other helping professionals.

Problematic Anger in the Military: Focusing on the Forgotten Emotion

PURPOSE OF REVIEW

Problematic anger is common in veteran and military populations, yet understudied relative to other mental health difficulties. However, in recent years, more clinical and research attention has been turned to problematic anger. This paper highlights important new findings in the epidemiology, course, and neurobiology of anger, the associations of anger with other mental health problems and risk, and next steps for research and practice.

RECENT FINDINGS

In longitudinal research, findings show that problematic anger changes over the life course of military members and veterans, and that deployment increases the likelihood of problematic levels of anger. Problematic anger is related to a range of mental health issues, most perniciously aggression and suicidality. Promising new assessment and treatment approaches are emerging, including innovations that leverage digital technology. Key areas of research include advancing assessment of problematic anger to identify patterns of heterogeneity, as well as advancing the evidence base for anger treatments. Recommended progress in clinical practice include conducting routine assessment of problematic anger in veteran and military populations, developing prevention and early intervention for at risk individuals, and optimizing the timing of interventions throughout the military lifecycle.