Cognitive Behavioral Affective Therapy (CBAT) for Maladaptive Anger in a Community Sample: A Randomized Controlled Trial

P.I. Dr. Fernandez and Ph.D. student Brandon Perez will train about five undergraduate students in the recruitment procedures. Participants will be recruited by sending electronic announcements and IRB-approved recruitment materials to 1) counseling and psychotherapy clinics, 2) anger management support groups, and 3) social media platforms. Materials will contain study and contact information (study email address and Google Voice number) for potential participants to contact study staff. Interested participants will sign consent forms and be screened for eligibility via an electronic version of the consent form and a brief screening instrument, both presented using an online App (created on Thunkable) for administration of questionnaires. After successfully completing screening, participants will enter their phone number and email address. Participants who do not satisfy screening criteria will be notified accordingly.

Consent and Screening: Participants will first go through the informed consent procedure, where they will be told about the purpose of the study, expectations for them as participants, etc. Informed consent is expected to take approximately 10 minutes. Participants will then be asked to complete a screening questionnaire which is expected to take no more than 3 minutes. These procedures are done via the earlier-mentioned Smart Phone Application. Eligible participants will be randomly assigned to one of two groups: (i) a treatment group receiving Cognitive Behavioral Affective Therapy (CBAT), or (ii) a comparison group receiving Emotional Education (EE). Each group will receive separate links to videos (specific to the content of that group) and pre-recorded by Dr. Fernandez. There will be two videos per week, each lasting about 50 minutes (no more than 8 hours total) over the course of 4 weeks. At 1-month follow-up, each group will be required to view/listen to a final 50-minute videorecording that recaps the specific content for that group.

Questionnaires and other measures: Anger will be screened using the 10-item trait scale of the STAXI-2. At pre-treatment, post-treatment, and follow-up, anger will be assessed using two psychometric instruments, the Anger Parameters Scale and the Anger Expressions Scale. During each of these three phases, anger will also be measured via self-monitoring with reference to a graphical display. These measurement techniques have been effectively used and described in our previous studies.

Online Sessions: The video for session 1 will deal with orientation and self-monitoring. Participants will practice self-monitoring their anger during that first week of orientation. If a participant has no anger on a given day, no monitoring is necessary. Following this week, the comparison group participants will continue to self-monitor their anger for 4 weeks during which they will view/listen to videos on the general topic of emotions (including anger, fear, sadness, as well as positive emotions such as joy). CBAT participants will continue to self-monitor their anger for 4 weeks during which they will view/listen to videos on anger regulation techniques. These videos will cover anger prevention, anger intervention, and anger postvention consecutively. During the prevention phase, an individually tailored behavior contract against anger will be signed by each participant that allows them to reward themselves for adhering to anger reduction goals. Contracts such as these are commonly used in behavior modification. Not legally binding they are formal agreements made collaboratively between provider and participant. They are designed to build motivation and commitment to change. Specifically, both parties agree on the desired or adaptive behaviors, the points to be awarded for such behaviors, and the points to be deducted in the case of maladaptive behaviors. The net number of points is then regularly reviewed by both parties and any appropriate rewards are then "given." In CBAT, rewards are typically watching a favorite movie, dining out at a favorite restaurant, etc. Participants will work with investigators over email to draft and electronically sign their contracts. Research Assistants will review participant progress on their contracts during their regular check-in phone calls. While there is no feasible way to ensure total adherence to the contract - either with in-person or online CBAT training - the phone calls are useful in encouraging participation and self-monitoring. For EE, participants will receive self-monitoring training with an emphasis on the definition of emotion, and types of emotions. Instead of specific skills for regulating anger or other emotions, a range of emotions (e.g., fear, anxiety, sorrow, grief, melancholy, guilt, embarrassment, self-consciousness, pride, contempt, jealousy, surprise, and happiness) will be illustrated with sources from art, literature and the humanities in general. While the comparison group will not receive any skills training for anger regulation, emotional education will receive educational information on negative emotions (such as anger) and positive emotions too.

CBAT participants will also engage in anger prevention techniques such as behavioral rehearsal of anger-provoking situations and stimulus control for discriminating and avoiding situations that are likely to culminate in anger. Intervention techniques include use of thought-stopping, distraction, reappraisal, and replacing maladaptive cognition with coping statements. The postvention phase will train participants in dealing with residual anger through expressive writing and verbal disclosure. Gestalt therapy empty chair dialogue will be used for overcoming unresolved anger. Finally, affective strategies of humor and forgiveness will also be broached.