CBT Improves Anger Management in Intellectually Disabled

Deborah Brauser

March 27, 2013

Group-based cognitive-behavioral therapy (CBT) may help people with intellectual disabilities to better manage their anger, resulting in a decrease in aggression, new research suggests.

A randomized controlled trial (RCT) of 179 adults in day services for people with intellectual disabilities in the United Kingdom showed that the participants who received 12 weeks of group-based, anger management–focused CBT at these facilities had improved anger coping skills and decreased levels of challenging behaviors compared with those who received treatment as usual.

"CBT is the treatment of choice for common mental health problems, and widening access to CBT is seen as a major policy priority," said lead author Paul Willner, DSc, from the Department of Psychology at Swansea University in Wales, in a release.

However, he noted that the delivery of CBT to people with intellectual disabilities "is underdeveloped" and that there is limited evidence of its effectiveness in this patient population. Therefore, the investigators note optimism regarding their study.

"It provides evidence of the effectiveness of a CBT intervention for this client group and demonstrates that the staff who work with them can be trained and supervised to deliver such an intervention with reasonable fidelity," the authors write.

The study was published online March 21 in the British Journal of Psychiatry.

Serious Consequences

The researchers note that because this patient population often has difficulty controlling their anger, subsequent aggression can have serious consequences, including exclusion from mainstream services, involvement with law enforcement, and/or emergency placements.

For the study, 179 adults with mild to moderate intellectual disabilities who were identified as having problems controlling their anger were enrolled between February and September 2010 from centers in Scotland, England, and Wales.

The participants were randomly assigned to receive either 12 weeks of CBT (n = 90; 71.4% men; mean age, 37 years) or treatment as usual ("control group"; n = 89; 70% men; mean age, 38.5 years). The intervention consisted of once-a-week group sessions plus homework assignments that focused on anger management.

Two to 4 care staff members or "lay therapists" were chosen from each center to undergo 1 day of training with a clinical psychologist in administering the CBT intervention and using the therapy manual. Supervision of these lay therapists, who had previously worked with people with intellectual disabilities for a median of 9 years, was also provided throughout the study.

The primary outcome measure was improvement in response to hypothetical anger-provoking situations on the Provocation Index at 10-month follow-up.

Other measures included the Profile of Anger Coping Skills alone (PACS) and with the self-rated Imaginal Provocation Test (PACS-IPT, which asked about situations known to provoke anger), the Glasgow Depression and Anxiety Scales (GDS/GAS), an adaptation of the Rosenberg Self-Esteem Scale (RSES), and the Comprehensive Quality of Life Scale–Intellectual Disability. The Aberrant Behavior Checklist and the Modified Overt Aggression Scale (MOAS) were also administered.

In addition, "keyworkers" (individual staff members with primary responsibility for each participant) were asked about the outcomes.

Decreased Response to "Real" Triggers

Results showed that overall fidelity of the intervention was assessed as "relatively good."

There were no significant between-group differences found for the primary outcome measure of self-reported scores on the Provocation Index. However, the keyworkers reported significantly lower scores for the participants receiving CBT at the 10-month follow-up (P = .023).

"It was evident that personally salient events were captured poorly by the Provocation Index, and that many service users had difficulty in imagining some of the hypothetical situations envisaged," write the investigators. "With hindsight, the Provocation Index was not an ideal primary outcome measure."

Self-reported scores on the PACS-IPT, which measured response to real triggers, decreased significantly for the participants in the intervention group vs the control group at 16-week (P < .01) and 10-month (P < .05) follow-ups.

Both the participants and the keyworkers also reported significantly higher anger coping skills for the intervention group at 16 weeks (P = .001 and P = .002, respectively) and at 10 months (P = .01 and P = .006, respectively).

In addition, significantly decreased levels of challenging behavior at 16 weeks' follow-up were also reported by keyworkers for the intervention participants on both the Aberrant Behavior Checklist–Hyperactivity (P = .001) and the Aberrant Behavior Checklist–Irritability (P = .005).

No between-group differences were found for self-reports of depression, anxiety, self-esteem, or quality of life — or for keyworker-reports on the MOAS.

Untapped Resource

"We believe that this is the first methodologically robust RCT of any CBT-based intervention for people with intellectual disabilities," write the investigators.

"Although some doubts have been expressed about the feasibility of conducting RCTs with [this patient population], we did not experience any significant difficulties in recruitment, retention or assessment, beyond what might be considered normal attrition of services and individuals."

They add that the study provided 2 major conclusions. It showed that this patient group "can be taught by means of a brief and relatively inexpensive group-based intervention to cope with anger more appropriately" and that staff can effectively deliver this type of intervention with limited training.

"Care staff are an untapped resource that could be used to increase the availability of psychological interventions," write the researchers.

However, they note that these lay therapists should be closely supported by qualified clinical psychologists.

The study was supported by the NIHR Health Technology Assessment Program and by the National Institute for Social Care and Health Research Clinical Research Center. The study authors have reported no relevant financial relationships.

Br J Psychiatry. Published online March 21, 2013. Abstract