Description
This assignment asks you to answer the questions below for all three of the case studies. You will need to describe;Describe the type/s of aggression displayed in the case study (reactive, instrumental, or assertive, etc…)Apply a theory that best explains the type of aggression demonstrated (instinct, frustration-aggression, social learning, etc..) Your answer should be 2 paragraphs for each case studyYou should answer all of the questions for each case study.Font size should be 12-point, times new roman, double spaced, and have a running head and page number.Support your answers with research and citations from our readings and the lecturesAttached below are the case studies as well as sources. I ask that if you can complete the task while only referring to the provided sources then please do so, if not you are welcome to use other peer-reviewed scholarly sources. Please properly cite all sources.
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Case Study 1
Tammy works for the restaurant, Arnaud’s in the French Quarter. She has noticed lately
that she has not felt like going into work or serving with her normal lively style. A
promotion promised to her was not awarded and she felt like she could do nothing to
change that. Although she perceives her work ethic to be stellar, she is often late for her
shift, sometimes texts on her phone during her shift, and sometimes has a wrinkled
uniform. Her boss has spoken to her about this but she feels like he will lighten up when
he gets to know her better. Tammy feels mistreated and hopeless about her prospect of
getting a promotion. She gets mad and tells her coworkers how bad the situation and
particularly her boss is being. She gets the group of waiters to start calling him a little
tyrant in their lounge and starts hanging pictures up of him in emperor uniforms.
Case Study 2
Jerry has been working out all summer for his big shot at college swimming. He focuses
on his technique in the pool and his times have steadily been going down. Lately, he has
noticed his body feeling strong and more ready for the challenge of each workout. His
coach has asked that he not overtrain this summer but he is feeling ready to start
increasing his mileage in the pool. Mastering each phase of his swim has motivated Jerry
to drive to the pool at 5:00 a.m. and begin workouts before all other swimmers are in the
pool. A coach asks him to start working on his strokes and he snaps back, “shut up I am
doing my best.” His teammates think he is crazy, his significant other encourages his
drive, and his parents are concerned that he might hurt himself.
Case Study 3
Alice is a mother of five children with a heart condition. She often discusses with her
friends that she is worried about dying before her children reach college. When her
children start fighting she jumps in and tells them in a firm manner, we don’t do that to
each other, go to your rooms. they almost always listen and obey. Her friends are
extremely supportive and she has doctor’s visits regularly when she is not shuttling the
children.
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/257822305
Cognitive-Behavioral Therapy in the Treatment of Anger: A Meta-Analysis
Article in Cognitive Therapy and Research · February 1998
DOI: 10.1023/A:1018763902991
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Some of the authors of this publication are also working on these related projects:
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Cogn itive Therapy and Research ‚ Vol. 22 ‚ No. 1‚ 1998 ‚ pp. 63-74
Cogn itive-Behavioral Th erapy in the Treatm ent of
An ger: A Meta-Analysis
Rich ard Beck1 an d Eph rem Fernan dez1 ‚2
Anger has com e to be recognized as a significan t social problem worthy of clin ical
attention an d systematic research. In the last two decades ‚ cognitive-behavioral therapy
(CBT) has emerged as the m ost com m on approach to an ger m anagement. The overall
efficacy of this treatm ent has not been ascertain ed ‚ and therefore‚ it was decided to
con du ct a m eta-an alysis of this literature. Based on 50 studies in corporatin g 1‚640
subjects‚ it was fou nd that CBT produ ced a gran d m ean weighted effect size of .70 ‚
indicatin g that the average CBT recipient was better off than 76% of un treated subjects
in terms of anger reduction . This effect was statistically significant ‚ robust‚ and relatively
hom ogen eou s across studies. These fin dings represent a quan titative integration of 20
years of research into a coherent pictu re of the efficacy of CBT for anger m an agement.
The results also serve as an im petu s for con tinu ed research on the treatm ent of anger.
KEY WORDS: anger; cognitive-behavioral therapy; me ta-analysis.
INTRODUCTION
With viole nt crime rising among adole scents ‚ wide spread familial abuse ‚ continuing racial discord ‚ and recent acts of te rrorism ‚ attention has turne d to ange r
as a major proble m in human re lations (Koop & Lundbe rg ‚ 1992; Novello ‚ Shosky ‚
& Froehlke ‚ 1992) . Yet ange r disorde rs have bee n ne glected in diagnostic classifications and treatme nt programs (Eckhardt & Deffe nbache r‚ 1995; Kassinove &
Sukhodolsky ‚ 1995) . Incre asing re fe re nce s to ange r appe ar in PSYCINFO and othe r
database s‚ and practitione rs are increasingly cognizant of the ramifications of ange r
in their clients (Abikoff & Kle in ‚ 1992; Fernande z & Turk‚ 1993 ‚ 1995; Koop &
Lundbe rg‚ 1992) ‚ but little is known about how best to treat ange r disorde rs.
In a surve y of the lite rature on ange r‚ it was found that the vast majority of
ange r tre atment outcome studie s had utilize d a cognitive -behavioral approach. The
pre sent study there fore e valuate d the e fficacy of cognitive -behavioral the rapy ( CBT)
1
Southern Methodist University‚ Dallas‚ Te xas 75275.
2
Address all correspondence to Ephrem Fe rnandez ‚ Ph.D.‚ Departme nt of Psychology‚ Southern
Methodist University‚ Dallas‚ Texas 75275-0442.
63
0147-5916/98/0200-0063$15.00/0 Ó
1998 Plenum Publishing Corporation
64
Beck and Fern an dez
in the tre atment of ange r. Instead of a narrative re view‚ a meta-analysis was conducte d to quantitative ly inte grate the re sults of individual studie s e mploying CBT
for ange r control.
Cogn itive-Beh avior al Th erap y Applied to Anger
Cognitive -be havioral therapy draws upon the rich traditions of be havior modification and rational-e motive or cognitive the rapy (Me ichenbaum ‚ 1976) ‚ paying attention to social cognition (Dodge ‚ 1993) as well as individual constructions of
reality (Mahone y‚ 1993) . It may combine a varie ty of technique s such as relaxation ‚
cognitive re structuring ‚ proble m-solving ‚ and stress inoculation ‚ but rathe r than being a mere form of technical e cle ctism ‚ it is theore tically unifie d by principle s of
le arning theory and information processing. This approach has elicite d much interest in the treatme nt of affe ctive disorde rs such as anxie ty and depression as re ve aled
in recent meta-analyse s by Dobson (1989) and Van Balkom (1994) . The status of
CBT for ange r‚ however‚ re mains uncle ar.
Yet the last 20 ye ars has see n an accumulation of research on the e fficacy of
cognitive -behavioral the rapy in the tre atment of ange r proble ms. This re search has
focused pre dominantly on Novaco ’s (1975) adaptation of Me iche nbaum ’s stre ss inoculation training (SIT) initially develope d for the tre atment of anxie ty (Me ichenbaum ‚ 1975). Using a coping skills approach ‚ stre ss inoculation inte rve ntions are
typically structure d into three phase s: cognitive pre paration ‚ skill acquisition ‚ and
application training. During this performance -base d intervention ‚ the client is e xposed to cognitive reframing ‚ re laxation training ‚ image ry‚ modeling ‚ and role-playing to e nhance ability to cope with proble m situations.
In SIT for ange r proble ms‚ clie nts initially identify situational “ trigge rs” which
pre cipitate the onset of the ange r re sponse . Afte r ide ntifying environme ntal cue s‚
the y re hearse self-state ments intende d to re frame the situation and facilitate healthy
response s (example s of cognitive self-state ments include : “ Relax‚ don ’t take things
so personally ” or “ I can handle this. It isn ’t important enough to blow up over
this ” ). The se cond phase of tre atment require s the acquisition of re laxation skills.
The cognitive se lf-state ments can the n be couple d with relaxation as clie nts attempt ‚
afte r e xposure to the trigge r‚ to mentally and physically soothe themselve s. Finally ‚
in the rehe arsal phase ‚ clie nts are expose d to ange r-provoking situations during the
session utilizing image ry or role-plays. The y practice the cognitive and relaxation
te chnique s until the mental and physical re sponse s can be achie ve d automatically
and on cue . This basic outline of SIT can also be supple mented with alte rnative
te chnique s such as proble m-solving ‚ conflict manage ment ‚ and social skills training
as in the social cognitive model of Lochman and colle ague s (Lochman & Lenhart ‚
1993) .
The purpose of the present study was to e valuate the overall e ffective ne ss of
such cognitive -be havioral treatme nts for ange r by using the methodology of metaanalysis. This e ntaile d computing various summary statistics of the stre ngth of treatment e ffect‚ as well as infe rential tests of the specific re se arch hypothe sis that CBT
statistically significantly re duce s ange r. Finally ‚ the se re sults were conve rted into
CBT for An ger
65
measure s of practical significance . This is particularly informative in the curre nt
climate of manage d health care where there is a pre mium on time-limite d interve ntions like CBT and growing demands for e mpirical evide nce to support the
choice of tre atments. This quantitative synthe sis of the lite rature will also familiarize
reade rs with the main parame ters of rese arch on this topic and gene rate considerations for furthe r rese arch in this area.
Meta-An alys is
Me ta-analysis is a quantitative procedure for evaluating tre atment effe ctiveness
by the calculation of e ffect size s (Fernande z & Boyle ‚ 1996; Glass ‚ McGaw‚ &
Smith ‚ 1981; Rosenthal ‚ 1991). The e ffect size e xpre sse s the magnitude of difference
betwee n tre ated and untre ate d subje cts. Because e ffect size is e xpre sse d in standard
deviation units ‚ it e nable s comparisons among studie s and the computation of summary statistics such as the grand ave rage effe ct size ‚ an inde x of overall effe ctiveness
for the tre atment. Despite its advantage s over narrative and quasistatistical methods
of re view (Fe rnande z & Turk‚ 1989) ‚ meta-analysis has raised certain concerns which
call for spe cific solutions (Fernande z & Boyle ‚ 1996) . For e xample ‚ it has bee n argue d that effe ct sizes obtaine d from studie s of varying quality may not be directly
comparable ; conse que ntly‚ it is now customary to weight e ffects sizes‚ typically according to obje ctive crite ria such as sample size ( which de te rmine s statistical
powe r). Concern has also be en raised about possible inflation in effe ct sizes due
to sampling only publishe d studie s which are more like ly to re port significant re sults
than are non-publishe d studie s (the file-drawe r proble m); this can be counte racted
to some extent by including unpublishe d studie s and also by conducting te sts of
robustne ss that provide a margin of tolerance for null results (Rosenthal ‚ 1995) .
To date ‚ the only docume nted attempt to meta-analyze studie s of ange r manage ment was done by Tafrate (1995) . Howe ve r‚ this revie w has certain methodological limitations. First‚ stringe nt inclusion criteria restricte d the numbe r of CBT
studie s re viewed to only nine . This small numbe r of studie s is unre pre sentative of
the last 20 years of rese arch on CBT. Tafrate confine d his survey to adult sample s
of mostly colle ge stude nts. No doubt ‚ stude nts have ange r proble ms too‚ but the
ne gle ct of nume rous studie s of CBT for oppositional childre n and adole scents
(populations of primary conce rn) is proble matic. Only three of the studie s revie wed
by Tafrate were base d on clinical sample s‚ thus placing limits on the ecological significance of results. Unpublishe d results were ignore d ‚ and due to the small numbe r
of studie s actually re viewed‚ the conclusions re ache d were probably susceptible to
sampling bias. Finally ‚ Tafrate ne glected tests of homoge neity‚ te sts of significance
or tests of robustne ss‚ or weighing of effe ct size s based on any of the design feature s
of the studie s; as e mphasize d earlie r‚ the se statistics have now become standard
practice in meta-analytic revie ws‚ and they can significantly affe ct the conclusions
reached.
To improve upon Tafrate ’s (1995) initial revie w‚ the pre se nt study e xpande d
inclusion criteria ‚ incorporate d unpublishe d studie s‚ and weighte d all e ffect size s.
As de taile d below‚ the scope of the revie w was broade ned to incorporate dive rse
66
Beck and Fern an dez
sample s re ceiving a combination of cognitive and be havioral technique s. In this way‚
more than five time s the numbe r of CBT studie s re viewed by Tafrate were metaanalyze d here .
METHOD
Inclu sion Criteria
A compute r se arch of PSYCINFO and Dissertation Abstracts International from
1970 to 1995 was conducte d. Using keywords such as an ger control ‚ anger treatm ent‚
and an ger m an agem ent and cross-re fe re nce s among article s‚ a total of 58 re levant
studie s of CBT were identifie d. Eight of these were single -case or small-sample
studie s (n < 4) and hence were e xclude d. The final sample consiste d of 50 nomothetic studie s incorporating a total of 1640 subje cts. All studie s provide d data
on at le ast one ange r-relate d depe nde nt variable .
In te rms of the inde pende nt variable ‚ only cognitive -behavioral tre atments for
ange r were se lected. Studie s using pu rely cognitive or behavioral interventions alone
were not include d ‚ nor were treatme nts aimed sole ly at re laxation. Typically ‚ the
study include d was one in which some form of cognitive reappraisal or re structuring
was com bined with some technique of promoting relaxation. The sample s were
pre dominantly clinical such as prison inmate s‚ abusive pare nts ‚ abusive spouse s‚ juve nile de linque nts ‚ adole scents in re side ntial treatme nt‚ childre n with aggre ssive
classroom behavior ‚ and mentally handicappe d clie nts ‚ but also include d colle ge
stude nts with re porte d ange r proble ms.
Thirty-five studie s use d self-reporte d ange r as a de pe nde nt variable . Effe ct
sizes for 28 of the 35 studie s were calculate d e xclusive ly from se lf re ports of ange r.
The re maining se ven studie s combine d depe nde nt measure s of ange r and aggre ssion into e ffe ct size e stimate s. Fifte e n studie s of school childre n and adole scents
in place ment (eithe r re side ntial or de tention facility) re fe rred to ange r but only
re porte d be havioral ratings of aggre ssion. Since aggre ssive be havior has be en the
focus in CBT inte rve ntions for childre n and adole scents ‚ aggre ssion ratings se rve d
as the de pe nde nt variable for the se studie s. For younge r populations ‚ measure s of
se lf-re porte d ange r are not always fe asible and behavioral ratings of aggre ssion
be come a valid alte rnative ‚ just as se lf-re ports of depre ssion and anxie ty in childre n
may be le ss acce ssible than the behaviors corre sponding to the se mood disturbance s.
Calcu lation of Effect Sizes
Glass ’s d (e ffect size) was calculate d for each study whe re means and standard
deviations were available for treatme nt and control groups (Glass e t al.‚ 1981). For
studie s utilizing single group ‚ pre- ve rsus postte st de signs ‚ and any othe r studie s
not reporting means and standard deviations ‚ e ffect size was e stimate d from t- and
F-value s. Whe re multiple depende nt variable s were reporte d ‚ e ffect sizes were av-
CBT for An ger
67
erage d across variable s to yield one e ffect size per study‚ thus minimizing nonindepende nce in the data.
Adopting proce dures recommende d by Rosenthal (1991) ‚ e ach effe ct size was
weighte d by sample size ‚ and ave rage d to yield a grand weighte d mean d base d on
50 studie s. Weighting e ffect size s by sample size is an unbiase d and obje ctive procedure for assigning different weights to studie s that vary in statistical powe r. The
grand weighte d mean d was tested for significance (d compare d to zero) using a
one -sample t-test‚ and 95% confide nce inte rvals were calculate d. A chi square was
also calculate d to te st for heteroge ne ity of variance within the se t of e ffect size s.
The heteroge ne ity te st is the basis for a de cision on whe ther or not to search for
mode rator variable s; in case of significant heteroge ne ity‚ it would be ne cessary to
disaggre gate the e ffect sizes according to the variable s influe ncing e ffect size. Finally‚ to addre ss the file-drawe r proble m a fail-safe N‚ as re commende d by Rosenthal ( 1991) ‚ was calculate d to test for robustne ss. A robust finding indicate s that
the probability of a Type I e rror arising from unpublishe d ‚ nonsignificant re sults ‚
is ne gligible . As strongly recomme nde d by Rosenthal (1995) ‚ a Binomial e ffect size
display (BESD) was also constructe d to provide a more concrete impre ssion of the
relative outcome s in tre atment and control groups.
RESULTS
A total of 50 effe ct size s was obtaine d for the 50 studie s (Table I). O f the se ‚
40 utilize d control groups while 10 use d single -group ‚ repe ated-measure s de signs.
The sample size and de sign feature s for each study are also tabulate d.
As summarize d in Table II‚ the effe ct size s range d from ¯0.32 to 1.57 ‚ SD =
0.43. With only one e xce ption ‚ all effe ct size s were positive in value . The grand
mean unwe ighte d d was 0.81. The grand mean weighte d effe ct size was 0.70. This
differe d significantly from zero‚ t (49) = 13.28 ‚ p < .0001. The 95% confide nce inte rvals for the mean unweighte d e ffect size range d from 0.69 to 0.93. A ste m and
le af plot is shown in Table III to display batche s of e ffect sizes. As can be see n ‚
the effe ct sizes approximate d a normal distribution. Most of the e ffect sizes were
betwee n 0.5 and 0.99 ‚ and six e ffect sizes reache d about 1.2 ‚ thus making this the
mode . A notable outlie r was the one negative value in the data set.
Since any effe ct size is a standard de viation unit (z-score ) ‚ it can be conve rted
into a pe rcentile by asce rtaining the area unde r the normal curve that is bounde d
betwee n that z-score and the tail e nd of the curve . Thus ‚ the grand weighte d mean
effe ct size of 0.70 corresponds to an are a unde r the curve of 0.5 + 0.258 ‚ which
in turn means that the average subje ct in the CBT treatme nt condition fared be tter
than 76% of those not receiving CBT.
To furthe r illustrate the practical importance of these re sults ‚ a binomial e ffect
size display was adde d ( Table V I). This first e ntaile d conve rsion of the grand
weighte d mean d to r‚ which turne d out to be 0.33; as note d in the table ‚ half the
value of r was the n adde d or subtracte d from 0.5 ‚ revealing that subje cts re ceiving
CBT e xpe rienced a 67% treatme nt succe ss rate whe re as control subje cts had only
a 33% succe ss rate .
68
Beck and Fern an dez
Table I. Effect Sizes and Sample Sizes for Individual Studies of CBT on Anger a
Study
Acton & During ( 1992)
Barth ‚ Blythe ‚ Schinke ‚ & Schilling
(1983)
Benson ‚ Rice ‚ & Miranti ( 1986)
Boswell (1984)
Cain (1987)
Dangle ‚ Deschner ‚ & Rasp ( 1989)
Deffe nbache r‚ Story‚ Stark ‚ Hogg ‚ &
Brandon (1987)
Deffe nbache r‚ Story‚ Brandon ‚ Hogg ‚
& Hazaleus (1988)
Deffe nbache r‚ McNamara ‚ Stark ‚ &
Sabadell (1990a)
Deffe nbache r‚ McNamara ‚ Stark ‚ &
Sabadell (1990b)
Deffe nbache r & Stark ( 1992)
Deffe nbache r‚ Thwaite s‚ Wallace ‚ &
Oetting (1994)
Deffe nbache r‚ Lynch ‚ Oetting‚ &
Kemper ( 1996)
Deschne r & McNeil (1986)
Faulkne r‚ Stoltenbe rg ‚ Cogen ‚ Nolde r‚
& Shooter (1992)
Feindle r‚ Ecton ‚ Kingsle y‚ & Dubey
(1986)
Feindle r‚ Marriott‚ & Iwata (1984)
Gaertner ( 1984)
Glick & Goldstein ( 1987)
Hinshaw ‚ Henke r‚ & Whalen ( 1984)
Jackson ( 1992)
Ke nnedy ( 1992)
Larson (1991)
Lochman (1985)
Lochman ‚ Burch ‚ Curry‚ & Lampron
(1984)
Lochman & Curry ( 1986)
Lochman ‚ Lampron ‚ Gemmer ‚
Harris ‚ & Wyckoff (1989)
Lochman ‚ Ne lson‚ & Sims ( 1981)
Macphe rson ( 1986)
Mandel ( 1991)
McDougall ‚ Boddis‚ Dawson ‚ &
Haye s ( 1990)
Moon & Eisler (1983)
Moore & Shannon (1993)
Napolitano (1992)
Novaco ( 1975)
Olson (1987)
Omizo ‚ He rshberger ‚ & Omizo (1988)
Pascucci (1991)
Rhoades (1988)
Rokach ( 1987)
Rose ngren (1987)
Saylor ‚ Benson ‚ & Einhaus (1985)
Schlichter & Horan (1981)
Shivrattan ( 1988)
Smith & Beckner (1993)
Steele (1991)
Sample
DV
De sign
N
d
Abusive pare nts
Abusive pare nts
SR
SR
PP
TC
29
20
0.85
1.09
SR ‚ BR
SR
SR
BR
SR
PP
TC
TC
PP
TC
54
30
62
12
32
0.40
-0.32
0.83
0.92
1.04
College students
SR
TC
30
1.27
College students
SR
TC
32
0.59
College students
SR
TC
29
0.45
College students
College students
SR
SR
TC
TC
36
94
1.43
0.82
School children
SR
TC
80
1.32
Abusive spouses
Abusive spouses
SR ‚ BR
SR ‚ BR
PP
PP
47
32
0.32
1.57
Clinical adolesce nts
BR
TC
21
1.16
Adolescent (school)
Inmates
Juvenile delinquents
School children
Clinical adolesce nts
Inmates
School children
School children
School children
BR
SR
BR
BR
SR
SR ‚ BR
SR
BR
BR
TC
TC
TC
TC
TC
PP
TC
TC
TC
36
19
111
22
40
37
37
80
76
0.68
1.33
0.72
1.29
0.32
1.29
0.21
0.38
0.28
BR
BR
PP
TC
20
32
0.36
0.24
School children
Inmates
Adolescent volunteers
Juvenile delinquents
BR
SR
SR ‚ BR
BR
PP
TC
TC
TC
12
21
26
18
0.65
1.28
0.53
0.64
College students
Clinical adolesce nts
Inmates
College and adult
Clinical adult
School children
Clinical adolesce nts
Forensic in-patients
Inmates
Adolescent volunteers
Clinical adolesce nts
Juvenile delinquents
Juvenile delinquents
Inmates
Juvenile delinquents
SR ‚ BR
SR
SR
SR ‚ BR
SR
BR
BR
SR
SR
SR
SR
SR
BR
SR
BR
TC
TC
TC
PP
TC
TC
TC
TC
TC
TC
TC
TC
TC
PP
TC
20
42
75
17
83
24
28
21
95
13
14
19
28
18
19
1.52
0.22
0.68
1.03
0.76
0.84
0.56
0.91
0.69
1.00
1.13
1.20
0.22
0.55
0.57
MR individuals
School children
Adult volunteers
Clinical adolesce nts
College students
School children
School children
CBT for An ger
69
Table I. (continued )
Study
Stermac (1986)
Whiteman ‚ Fanshel ‚ & Grundy
(1987)
Wilcox & Dowrick (1992)
Wu (1990)
Sample
DV
Design
N
d
Forensic patie nts
Abusive parents
SR
SR
TC
TC
40
24
1.31
1.52
Clinical adolescents
Divorced women
SR
SR
PP
TC
10
26
1.20
0.49
a
CBT = Cognitive-behavioral therapy; DV = de pendent variable; N = sample size; d = effect size; SR
= self-reported anger ‚ BR = behavioral ratings of anger/aggre ssion‚ TC = treatment ve rsus control
de sign ‚ PP = pre/postdesign.
Table II. Meta-Analytic Summary Statistics for Studies of CBT on Ange ra
Total N = 1‚640 subjects
Grand weighte d mean d: 0.70
95% confidence intervals for unweighted d: 0.69 to 0.93
d compare d with zero: t (49) = 13.28 ‚ p < .0001
2
Heteroge neity of ds: c (49) = 61.71 ‚ p > .10
Fail-safe N: 790; crite rion = 225
a
CBT = cognitive -behavioral therapy.
Table III. Stem and Le af Display of Effect Sizes from
Studies of CBT on Ange ra
Fre quency
Stem
1.00
12.00
18.00
16.00
3.00
¯0.
0.
0.
1.
1.
Leaf
3
222223333444
555556666677888899
0000112222223334
555
Range = ¯0.32 to 1.57
Mean (unweighted) d = 0.81
Standard deviation = 0.43
Median = 1.75
Mode = 1.2
a
CBT = cognitive behavioral therapy; Each stem which
represents the first digit of an effect size is attache d to
several leave s‚ each denoting the first decimal place of
an effect size .
The fail-safe N of 790 was well above the minimal criterion of 225 ‚ indicating
a robust finding. The te st of he teroge neity reve ale d a c 2 (49) = 61.71 ‚ p > .10. This
indicate s homoge ne ity of e ffect size value s‚ and the refore ‚ no ne ed to se arch for
mode rator variable s.
70
Beck and Fern an dez
Table IV. Binomial Effect Size Display of Treatment
(CBT) Versus No Treatment of Anger a
Condition
Treatment
Control
å
Success
Failure
å
67
33
100
33
67
100
100
100
200
a
CBT = cognitive -behavioral therapy. The numbers are in
pe rcentages. To obtain them ‚ d must first be converted to r
(cf. Rosenthal ‚ 1991) ‚ which is halved and then added to or
subtracted from 0.5 (depe nding on the condition) ‚ before
multiplication by 100.
DISCUSSION
Effectiven ess of Cogn itive-Beh avior Th erap y in th e Treatm ent of An ger
Re se arche rs have incre asingly focuse d the ir atte ntion on CB T as a tre atme nt for ange r disorde rs. O ve r the past 20 ye ars ‚ many individua l studie s have
sugge ste d that CBT is an e ffe ctive ‚ time -limite d tre atme nt of ange r proble ms.
O ur m e ta-analysis of 50 nom othe tic studie s of 1 ‚640 subje cts re ve ale d a
we ighte d me an e ffe ct size of 0.70 ‚ sugge stive of mod e rate tre atme nt gains.
Since this is in standar d de viation units ‚ it can be infe rre d that the ave rage
subje ct in the CBT condition was be tte r off than 76% of control subje cts. More ove r‚ this e ffe ct was signific antly diffe re nt from what would be e xpe cted unde r
chance . The grand e ffe ct size was also robust e nough to be unaffe cted by unpublishe d null re sults ‚ and it was re lative ly homoge ne ous across studie s. Since
the populat ions inve stigate d consiste d large ly of abusive pare nts or spouse s ‚
viole nt and re sistant juve nile offe nde rs ‚ inmate s in de te ntion facilitie s ‚ and aggre ssive school childre n ‚ it is appare nt that CBT has ge ne ral utility in the clinical manage me nt of ange r.
The se findings imply that the appare nt popularity of CBT in the treatme nt of
ange r is justifie d by its e ffectivene ss in achie ving the de sire d treatme nt goals. The
results are congrue nt with othe r meta-analyse s docume nting the effe ctiveness of
CBT in the tre atme nt of othe r affe ctive disturbance s‚ in particular ‚ de pre ssion
(Dobson ‚ 1989) and anxie ty (Van Balkom e t al. ‚ 1994) .
At the same time ‚ it may be note d that the grand weighte d e ffect size of 0.70
in this revie w is smalle r than Tafrate ’s ( 1995) reporte d effe ct size of 1.00 for CBT
studie s (which were labe le d as “ multicompone nt” ); this is probably because the latte r consiste d of only nine publishe d studie s‚ none of which were weighte d according
to statistical power. O n the othe r hand ‚ by sampling unpublishe d results ‚ revie wing
studie s with clinical populations ‚ and weighing effe ct sizes by sample size ‚ the present study may have produce d a slight deflation of effe ct size ‚ but one that is probably more reliable .
CBT for An ger
71
Fu ture Con sid eration s
This study was an attempt to summarize and docume nt the progre ss made
ove r the last two decades of rese arch on CBT for ange r tre atment rese arch. The
clinical implications of the meta-analysis are e ncouraging. Clinicians treating clie nts
with ange r control proble ms can now substantiate the ir choice of CBT in the treatment of ange r‚ and expe ct at least mode rate improve ments in the ir clie nts. Moreove r‚ the pre sent findings may se rve as a benchmark against which to evaluate othe r
psychological and pharmacological treatme nts for ange r. O utcome efficacy aside ‚
future re search might also addre ss the cost-e ffectivene ss of the se treatme nts ‚ an
issue of growing interest in the curre nt era of manage d care.
New variations of CBT might also be explore d. Deffe nbache r and colle ague s
have alre ady take n a step in this dire ction with the developme nt of a package calle d
“ cognitive relaxation. ” O n the othe r hand ‚ Lochman and colle ague s have emphasized training pe ople in e ncoding of social stimuli and proble m-solving within a
social context. With additional studie s in these areas‚ it is forsee able that the most
active ingre die nts of CBT may be ide ntifie d and integrate d to produce an e ven
more e ffective regimen for managing ange r.
Anothe r viable frontie r of re search might be client variable s relate d to treatment outcome . These may center around se lf-e fficacy‚ locus of control ‚ impulsivity
versus refle ctivity‚ and a host of traits predisposing individuals to respond to treatment in se le ct ways. Clarification of these variable s may enable the careful matching
of clie nts to spe cific treatme nt re gime ns.
Finally‚ ecological validity re mains a goal for most tre atment outcome research.
In ange r manage ment ‚ well-controlle d laboratory studie s have re ve aled e ncouraging
tre atment e ffects. But the generalizability of these findings to various clinical and
multicultural populations ofte n nee ds to be establishe d. Ultimate ly‚ the ability to
pre dict and control ange r as it occurs spontane ously in differe nt groups of pe ople
within the ir own naturalistic se ttings is a challe nge worth addre ssing.
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