Cognitive behaviour therapy CBT is the treatment of choice for common mental health problems, but this approach has only recently been adapted for people with learning disabilities, and there is a limited evidence base for the use of CBT with this client group. Anger treatment is the one area where there exists a reasonable number of small controlled trials. This study will evaluate the effectiveness of a manualized week CBT intervention for anger. The intervention will be delivered by staff working in the day services that the participants attend, following training to act as 'lay therapists' by a Clinical Psychologist, who will also provide supervision. This is a multi-centre cluster randomized controlled trial of a group intervention versus a 'support as usual' waiting-list control group, with randomization at the level of the group.
We hope also to identify factors relating to characteristics of participants or settings that are associated with Anger management learning disabilities adults outcomes. Managemeent All Figures Return to Figure. J Ment Health. Staff training will follow a training manual developed within the project for this purpose. Readiness for cognitive therapy in people with intellectual disabilities. In each participating centre, at least two wherever possible, three staff will be recruited to act as lay therapists.
Top ten sorority. Not supported
Identified by service staff as having problems in managing their anger 2. The purpose of anger management is to help a person decrease anger. The study incorporates a wider range of outcome measures than previous studies, and includes an analysis of the cost consequences of delivering the intervention. Dixabilities somewhere else where you can begin to calm down. Anger treatment is the one area where disabilitiies exists a xdults number of small controlled trials. It's that saying, "Nothing forces you to be angry. Evidence for adylts of bias in cluster randomised trials: a review of recent trials Kanagement in three general medical journals. They're the people who are always stewing about how no one else seems to know how to drive, or how their man child boyfriend would be helpless without them. For each service user a key worker, and where applicable, a home carer will also be recruited not all service users will have a home carer depending upon their residential setting. This paper outlines an Anger Management Programme specifically tailored for people with moderate to severe learning disabilities Domina porno sex bdsm the principles of Cognitive Behavioural Therapy in a group setting. Both service user and therapist interviews will be Anger management learning disabilities adults according to a semi-structured interview schedule, containing questions that encourage the participants to focus on 'personal meaning' and making sense of their experiences of the therapeutic process.
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Background and study aims Many people with learning disabilities find it hard to control their anger. Anger management teaches people to recognize what makes them angry and learn skills that they can use to cope better with those situations. All of the published studies have reported that people who take part in an anger management group show less anger at the end than people who are waiting for treatment, and they stay less angry for several months afterwards.
The aim of this study is to evaluate the effectiveness of an anger management intervention for people with mild to moderate learning disabilities. Who can participate? Adults aged 18 to 65 attending a service for people with mild to moderate learning disabilities, and identified by service staff as having problems in managing their anger.
What does the study involve? Participants are randomly put into one of two conditions, according to which day service they attend. Half of them take part in staff-led anger management groups. The other half are supported as usual by staff while they wait for treatment waiting-list group. Anger management is usually taught by Clinical Psychologists. In this study, the group therapy takes place in the services that the service users attend during the day, and the therapists are staff in those services.
A Clinical Psychologist teaches the staff how to work with a treatment manual. The manual was written for use by therapists who have never done this before. It gives full details of how to run each session of a week anger-management course. At the end of the 12 weeks, there is a six-month follow-up period.
Then the staff who work with the waiting-list groups are taught how to use the manual, so that the waiting-list groups can also be offered anger management. We train the staff how to use the manual; then, when the groups are running, we check that the staff are running them properly and if they are running well; and at the end, we talk to staff about how they found it to run a group and if there has been any effect on the rest of their service.
The main point of the study is that we assess how well people are doing before and after they take part in an anger management group, and six months later. We measure how angry and aggressive people get and how well they cope with difficult situations, both in the service and at home, how they feel about themselves, and what they thought of the group.
We also find out if it costs less to support people after they have been part of an anger management group. We do all this by talking to the service users themselves, their key-workers in the service, and their home carers. What are the possible benefits and risks of participating? We believe there to be no significant risks to participants or society. There is a hypothetical risk that a client's condition could be worsened by participation in the group, but the likelihood of this happening is extremely small.
Where is the study run from? July to December Who is funding the study? Paul Willner. A multi-centre phase III cluster randomised controlled trial of a manualised anger management intervention for people with mild to moderate learning disabilities. To evaluate the effectiveness, compared to normal care, of a manualised anger management intervention, delivered to people with mild to moderate learning disabilities in a service setting, in reducing levels of reported anger.
Day care centres will be randomised to receive either a manualised cognitive behaviour therapy CBT intervention consisting of 12 weekly psycho-educational group sessions supplemented by 'homework' or usual care. Participants in both groups will be followed up for 6 months post-intervention. Provocation Index PI as completed by the service-user, at follow-up. The PI is a direct measure of felt response to defined situations that may provoke anger and has frequently been used with this service-user group for the current purpose.
Outcome measures will be taken at baseline, immediately after the support as usual SAU or intervention in both groups in parallel and 6 months after the completion of the intervention or SAU.
Validated questionnaires will be completed to assess the following domians: 1. Anger assessed by the PI as completed by a key-worker and a home carer 2. Mental health will be assessed by using the Glasgow Depression and Anxiety Scales and an adaptation of the Rosenberg Self-Esteem Scale for people with a learning disability 5.
Key-workers' attributions in respect of challenging behaviour will be measured by the Controllability Beliefs Scale CBS Additionally, interview data for qualitative analysis will be collected from participants, therapists and service managers, and a health economic evaluation will be undertaken of the costs and consequences of the invervention.
Services: 1. Reported anger control problems among at least four service users who meet individual inclusion criteria and want to participate 2. Availability of at least two staff members willing to be trained as group leaders 3. Service manager provides written agreement to participate Service Users: 1.
An adult attending a service for people with mild to moderate learning disabilities 2. Identified by service staff as having problems in managing their anger 3. Wishing to learn to improve their anger management 4. Able to provide informed consent 5. Able to complete the assessments 6. Aged 18 to 65 years, either sex. The service is already running an anger management programme similar to this one 2. There are no suitable facilities for group work Service Users: 1.
Attending the service for a reason other than a diagnosed learning disability 2. Currently receiving psychological treatment for anger or aggression 3. Urgently requiring referral to a Clinical Psychologist for individual treatment of anger or aggression 4.
If for any other reason the supervising Clinical Psychologist makes a clinical judgement that participation in the group would be counter-indicated. Plain English Summary Background and study aims Many people with learning disabilities find it hard to control their anger. Paul Willner Trial website. Study information Scientific title A multi-centre phase III cluster randomised controlled trial of a manualised anger management intervention for people with mild to moderate learning disabilities Acronym Study hypothesis To evaluate the effectiveness, compared to normal care, of a manualised anger management intervention, delivered to people with mild to moderate learning disabilities in a service setting, in reducing levels of reported anger.
Secondary outcome measures Validated questionnaires will be completed to assess the following domians: 1. Eligibility Participant inclusion criteria Services: 1. Additional files.
Figure 3. Centres will be recruited, and baseline data will have been collected on all participating service users of a particular centre , before randomisation of that centre takes place. The trial design is summarized in Figure 1 Figure 1. They haven't gotten enough sleep lately, and they're tired and cranky. Behavioural and Cognitive Psychotherapy. After all, not everyone gets so wound up by the things that set them off. Currently receiving psychological treatment for anger or aggression 3.
Anger management learning disabilities adults. Not supported
While you might feel that you just explode into anger without warning, there are in fact physical warning signs in your body. Becoming aware of your own personal signs that your temper is starting to boil allows you to take steps to manage your anger before it gets out of control. Look at your regular routine and try to identify activities, times of day, people, places, or situations that trigger irritable or angry feelings.
Maybe you get into a fight every time you go out for drinks with a certain group of friends. Or maybe the traffic on your daily commute drives you crazy. You may think that external factors—the insensitive actions of other people, for example, or frustrating situations—are causing your anger. But anger problems have less to do with what happens to you than how you interpret and think about what happened. Common negative thinking patterns that trigger and fuel anger include:.
When you identify the thought patterns that fuel your anger, you can learn to reframe how you think about things. What would I say to a friend who was thinking these things? Once you know how to recognize the warning signs that your temper is rising and anticipate your triggers, you can act quickly to deal with your anger before it spins out of control.
There are many techniques that can help you cool down and keep your anger in check. Focus on the physical sensations of anger. Take some deep breaths. Deep, slow breathing helps counteract rising tension.
The key is to breathe deeply from the abdomen, getting as much fresh air as possible into your lungs. Get moving. A brisk walk around the block is a great idea. Physical activity releases pent-up energy so you can approach the situation with a cooler head.
Use your senses. You can use sight, smell, hearing, touch, and taste to quickly relieve stress and cool down. You might try listening to a favorite piece of music, looking at a treasured photo, savoring a cup of tea, or stroking a pet. Stretch or massage areas of tension. Roll your shoulders if you are tensing them, for example, or gently massage your neck and scalp. Slowly count to ten.
Focus on the counting to let your rational mind catch up with your feelings. If you still feel out of control by the time you reach ten, start counting again. When you start getting upset about something, take a moment to think about the situation. Ask yourself:. Learning how to resolve conflict in a positive way will help you strengthen your relationships rather than damaging them. Always fight fair. Fighting fair allows you to express your own needs while still respecting others.
Make the relationship your priority. Respect the other person and their viewpoint. Focus on the present. Rather than looking to the past and assigning blame, focus on what you can do in the present to solve the problem. Be willing to forgive. Resolution lies in releasing the urge to punish, which can never compensate for our losses and only adds to our injury by further depleting and draining our lives. Take five if things get too heated.
If your anger starts to spiral out of control, remove yourself from the situation for a few minutes or for as long as it takes you to cool down.
Know when to let something go. It takes two people to keep an argument going. If a conflict is going nowhere, you can choose to disengage and move on. Taking care of your overall mental and physical wellbeing can help ease tension and diffuse anger problems. Manage stress. Try practicing relaxation techniques such as mindfulness meditation, progressive muscle relaxation, or deep breathing. Talk to someone you trust. But talking about your feelings and seeking a different perspective on a situation is not the same as venting.
Simply venting your anger at someone will only fuel your temper and reinforce your anger problem. Get enough sleep. A lack of sleep can exacerbate negative thoughts and leave you feeling agitated and short-tempered. Try to get seven to nine hours of good quality sleep. Exercise regularly. Be smart about alcohol and drugs. They lower your inhibitions and can make it even harder to control your anger. When things get tense, humor and playfulness can help you lighten the mood, smooth over differences, reframe problems, and keep things in perspective.
When you feel yourself getting angry in a situation, try using a little lighthearted humor. Avoid sarcasm, mean-spirited humor. If in doubt, start by using self-deprecating humor. We all love people who are able to gently poke fun at their own failings. Even if the joke falls flat or comes out wrong, the only person you risk offending is yourself.
When humor and play are used to reduce tension and anger, a potential conflict can even become an opportunity for greater connection and intimacy. Anger management classes allow you to meet others coping with the same struggles and learn tips and techniques for managing your anger. Therapy , either group or individual, can be a great way to explore the reasons behind your anger and identify triggers. Therapy can also provide a safe place to practice new skills for expressing anger.
Some examples are, "Take it easy", "Chill out", "Be calm", "It's not a big deal", or "Will I really care about this tomorrow? For example you could imagine yourself sitting on a tropical island beach as waves gently lap the shore, or lying in a field on a warm summer day as the grass and wildflowers sway in the breeze. It's hard to feel angry at the same time that you're amused at something. If someone's annoyed you, try picturing them in a funny or absurd way.
For example, if your boss has been sending you nitpicky emails all day, imagine them as a giant squawking parrot sitting behind a computer. This is another option you may not always have access to, but if you can it may help to run around the block, or bang out a bunch of push ups in your room. If you've already gotten really angry it's often too late. The best way to control your temper is to employ a mix of approaches to prevent as many blow ups as possible in the first place.
I'll cover a lot of ideas below, and this section will make up the bulk of this article. After all, not everyone gets so wound up by the things that set them off.
It's that saying, "Nothing forces you to be angry. On some level you're allowing yourself to feel that way. These factors may contribute to a person's anger, but they don't fully let them off the hook. Do you use any of these phrases to excuse your outbursts? Temperament - "I've always been a hothead. I can't help it. People should know that by now. We're a fiery people. My family situation was nuts growing up. He should have brought it up with me later if he didn't want me to get mad.
I'm stressed out. It's not my fault. Angry people often aren't tuned in to how irritated they feel a lot of the time. They sometimes catch themselves off guard by losing their temper 'out of nowhere', because they weren't focused on how their annoyance had been building up inside them.
Figure out the personal signs that you're starting to become angry. Some common ones are: Thinking annoyed thoughts, like about how incompetent your boss is, or how dismissive your boyfriend can act.
Sometimes you'll be in one annoying situation, and your warning sign will be that you'll start thinking about something else that irritates you , e. In addition to that, map out what your anger looks like at different intensity levels. What are the signs that you're minorly irritated? What's the collection of symptoms that lets you know you're becoming moderately annoyed? What are the indicators that an outburst is seconds away, and you need do something about it as soon as possible?
Some general ones are: Being at work Being around your kids Being around your partner Being around your parents Driving Being in a hurry Shopping Being in a crowded bar Taking part in a hobby that frustrates you, e. As I mentioned a little earlier, angry people are sometimes caught off guard by their own tempers. A statement you'll often hear along those lines is, "I don't know what happened. I just got so mad all of the sudden and before I knew it I had put my hand through the wall and scared my girlfriend half to death" If you've been through this what likely happened is that you were in a tense situation where your anger was building, but you were too caught up in the conflict at hand, and didn't notice what was happening with your mood until you were enraged and past the point of no return.
Some examples of these tense, risky situations are: A drawn-out argument with a partner A long, stressful day at work An outing with friends where there's a lot of simmering, unresolved drama An awkward evening with the family, where everyone's on edge and picking at each other.
When a person explodes under these circumstances their anger may have started ramping up before they were even in the situation, and they were anticipating how poorly it could go. They may have worked themselves up on the drive to their job, or before meeting their buddies, or while they waited for their partner to get home before they confronted them. Once the actual situation started, little things began to happen that caused their frustration to build e. After twenty minutes of petty bickering, or half a shift of getting picked on, it's then that they snapped 'out of nowhere'.
Monitoring your anger helps you get out of trouble situations before it's too late when no amount of calming breathing or relaxing imagery will help you. Checking in on yourself is something you can do throughout the day.
It's especially important to start checking in on your mood when you're in a triggering situation, or you've already noticed yourself starting to get annoyed.
Whatever your level of anger, take steps to reduce it. If you've gotten really mad you won't be able to think straight in the moment. In these cases it helps to have a pre-set plan.
For example, if a father frequently snaps at his kids when they squabble at home, his plan could be that when he's about to lash out that he'll go his bedroom for five minutes, during which time he'll sit on his bed and breathe deeply. If possible he'll get his wife to step in and hold down the fort while he's away.
At the end of the five minutes he'll come back downstairs and deal with the kids' behavior. On the link below you'll find a training series focused on how to feel at ease socially, even if you tend to overthink today. It also covers how to avoid awkward silence, attract amazing friends, and why you don't need an "interesting life" to make interesting conversation.
Click here to go to the free training. Depressed people tend to think in a self-effacing, pessimistic, hopeless way that sustains their depression.
The thoughts of angry people can be distorted in the usual ways our thinking can go awry. In their case their distorted thoughts cause them to get madder.
For example, they might see the world in overly Black or White terms, or assume they know what other people are thinking. If someone spills something on them, they think the person did it on purpose. If someone gives them some constructive criticism, they'll see it as a personal attack and go on the defensive.
They're the people who are always stewing about how no one else seems to know how to drive, or how their man child boyfriend would be helpless without them.
For example, if their partner asks them to take out the garbage, they may think something like, "Ugh, they're always trying to control me. What's their problem?! The idea of a person getting away with something rankles them to the core of their very being.
They feel they're justified in giving the person a piece of their mind, or getting in their face, or purposely cutting them off in traffic. Similarly, they may think that if that if someone upsets them, and they don't show their anger in response, then they're basically declaring that what the other person did was okay. Angry people tend to have the unrealistic unconscious expectation that life should never annoy them and they should never have to feel frustrated or not get what they want.
They become angry when those standards inevitably aren't met. For example, they'll believe they should be able to get through their work day with no unexpected annoyances, or be able to do a commute where every other driver behaves perfectly.
For example, they may spend hours thinking of all the ways their boyfriend is selfish. Along the same lines, angry people have a tendency to ruminate. If someone's annoyed them in the past, they won't let it go. During confrontations, angry people may have fleeting fantasies of becoming violent, e. Even if they don't act on them, the thoughts still ratchet up their irritation. You can reduce your anger if you learn to identify and dispute these thoughts as they occur.
Try to see their actions the same way you would if a pigeon pooped on your car. It's still a bit irksome, but you can't really hold it against the bird. It's just random bad luck. Don't feel you have to even the score every time someone bothers you. Revise your expectations about how often life will bug you. Accept that no matter what you do, things will happen that will be irritating.
If you catch yourself ruminating, try to think of something else. Or at least be aware you're doing it. Also be aware of any fantasies of retaliation you have, and respond in the same way. Implementing practices to calm yourself and reduce that stress will cut down on your baseline level of grouchiness.
Exercise - Physical activity is a great stress reducer. Make time for yourself - When we're stressed we often forget to set aside time to recharge our batteries. Learn relaxation techniques - e. Do very fun things - By this I mean doing things that are fun enough that you look forward to them, and they noticeably boost your mood.
Do straight-up relaxing activities - e. The points above about relaxation can help, but if you've got big stresses in your life, calming activities can seem like Band-Aids. If your life is stressful enough, you're only going to have so much power to reduce your anger through other methods. Approaches like reframing your thinking can help, but they won't save you every time. It's anything but a simple, overnight fix, but the true long-term solution is to take steps to remove the stress at its source.
It's beyond the scope of this article to list every stressful life event that may be affecting you, or how to deal with it, but some examples are: It's not always possible, but in the end it may be better to get out of a bad job, or an unhealthy, conflict-filled relationship.
If getting out isn't an option, then try to mend your relationship, or make some changes at work. Improve your parenting skills if your kids are a constant source of frustration. Take steps to treat any mental health conditions that contribute to your temper. Sometimes when people get angry it's obvious they're blowing up over nothing, or are actually mad at something else and taking out their frustration on an easier target.
However, we often get angry for totally justifiable reasons. That's why the emotion exists. It alerts us to when we've been wronged, and motivates us to do something to fix the situation. When people have anger problems their core reasons for getting angry may be correct, but they often go too far in expressing the emotion.
Learning anger management techniques doesn't mean you have to start letting people walk all over you, or swallow all your feelings and opinions. While it's perfectly okay to feel angry, and you might have a legitimate gripe you want to share, what's not alright is to express your anger in an aggressive, destructive, intimidating way that tramples all over other people. Instead, learn to communicate assertively.
Assertiveness, in contrast to aggressiveness, is when you stand up for your rights and needs, but do so in a way that respects the rights and needs of others.
For example, if you feel your partner sometimes makes jokes at your expense in front of her friends, an aggressive response may be to yell at them on the drive home after a party. This point is related to assertiveness skills.
If someone wrongs you it's not healthy in the long run to suppress those feelings, as they'll just come out later. You might reach a breaking point and explode. You may take your temper out on an undeserving target. You could suppress so much anger that you develop a grouchy, negative personality, or become depressed. Not bottling things up involves bringing up bothersome issues as they happen and in a productive manner, like the point above mentions. Of course, it's not practical or realistic to tell others about every instance in which they make you feel slighted, but at the same time, you can probably bring things to people's attention a lot sooner than you normally would.
For example, if your friend has a habit of being unreliable, you may give them a pass the first two times they do it, but say something on the third. In the past you may have let them flake on you for months without saying anything, only to suddenly erupt at them one day.
If you find you have a hard time asserting yourself in this way, it's a skill you can develop. Try to get into a habit of listening to other people and trying to understand where they're coming from, as opposed to feeling you have to win every argument and defend your position at all costs. Resist the urge to speak right away. If you give it time, you'll be way less likely to say something careless in the heat of the moment.
Whole books have been written about this topic, so I can't begin to do it justice in one paragraph. If you usually get angry during fights with your partner or family members, read up on how to fight fair and respectfully.
Also, during arguments with our loved ones, there are common interpersonal dynamics that can come into play that can cause disagreements to quickly escalate e. Knowing about them will aid you in preventing these situations from getting too hairy. This is another area where I can only bring it to your attention and then leave it to you to look for further information on your own.
If you often get pissed off at your co-workers or boss it could help to bolster your work-related people skills. For example, you may need to learn skills in working as an effective part of a team, dealing with difficult co-workers or customers, managing other people, or getting along with superiors. Insight alone won't cure you, but it can give you an idea of some issues you need to address.
There's a popular notion that anger is like an iceberg.
Cognitive behaviour therapy CBT is the treatment of choice for common mental health problems, but this approach has only recently been adapted for people with learning disabilities, and there is a limited evidence base for the use of CBT with this client group. Anger treatment is the one area where there exists a reasonable number of small controlled trials. This study will evaluate the effectiveness of a manualized week CBT intervention for anger. The intervention will be delivered by staff working in the day services that the participants attend, following training to act as 'lay therapists' by a Clinical Psychologist, who will also provide supervision.
This is a multi-centre cluster randomized controlled trial of a group intervention versus a 'support as usual' waiting-list control group, with randomization at the level of the group. Outcomes will be assessed at the end of the intervention and again 6-months later. After completion of the 6-month follow-up assessments, the intervention will also be delivered to the waiting-list groups. Qualitative data will be collected to assess the impact of the intervention on participants, lay therapists, and services, and the study will also include a service-utilization cost and consequences analysis.
This will be the first trial to investigate formally how effectively staff working in services providing day activities for people with learning disabilities are able to use a therapy manual to deliver a CBT based anger management intervention, following brief training by a Clinical Psychologist.
The diagnostic term 'learning disability' is used in the UK to refer to people who meet the World Health Organization definition of 'intellectual disability' "significant impairments of both intellectual and functional ability, with age of onset before adulthood" , and is equivalent to the term 'mental retardation' as used until recently in the USA [ 3 ]. It is only recently that CBT has been adapted for people with learning disabilities, and the evidence of its effectiveness in this population consists largely of case studies and case series.
There is a relatively large case-study literature describing successful outcomes for CBT in a variety of mental disorders [ 4 - 7 ].
However, the evidence from controlled trials is sparse. Anger is a frequent problem for many people with learning disabilities. Aggression is the main reason for an adult with a learning disability to be regarded as having severe challenging behaviour [ 9 ] and to be referred for resource intensive intervention [ 10 ].
Left unchecked, aggression resulting from uncontrolled anger can lead to serious consequences, which include exclusion from services, breakdown of residential placements, and in extreme cases, involvement with the criminal justice system [ 11 - 13 ].
Aggressive behaviour can also have an impact on the psychological well-being of staff [ 14 ] and the quality of care they provide [ 15 ]. Challenging behaviour has traditionally been managed pharmacologically or behaviourally [ 19 , 20 ].
However, following the demonstration that a CBT anger management intervention can decrease anger and aggression [ 21 - 23 ], the past 20 years has seen an increasing take-up of anger management as the first-line approach to these problems. With the exception of two small controlled trials in depression [ 24 , 25 ], anger is the only psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with learning disabilities.
Several phase 2 trials have now been published in which CBT for anger has been compared with a waiting-list control condition. These include seven studies of anger management groups in community settings and one series of studies of individual treatment in a forensic setting [ 26 ], as well as a single study of individual therapy in a community setting [ 16 ]. However, these typically have been relatively small studies, and have not used fully randomized allocation to treatment [ 26 , 27 ].
The published studies are fully consistent in reporting that anger interventions are effective in helping people with learning disabilities to manage their anger better, and that treatment gains are maintained at three or six-month follow up [ 26 ]. There is also evidence that treatment gains generalize across settings. There is little information as to which are the crucial components of the intervention. However, one recent study reported a significant correlation between decreased anger reactivity and increased usage of anger coping skills, thus providing some evidence that the specific psycho-educational content of the anger management curriculum is intrinsic to its effectiveness [ 28 ].
A recent Cochrane review of interventions for aggressive behaviour in people with learning disabilities [ 27 ] identified only four studies suitable for inclusion, including one study of group-based CBT for anger [ 29 ] and one study of individual CBT for anger [ 30 ].
The review concluded that: "The existing evidence on the efficacy of cognitive behavioural and behavioural interventions on outwardly directed aggression in children and adults with learning disabilities is scant. There is a paucity of methodologically sound clinical trials. Given the impact of such behaviours on the affected individual, his or her carers and on service providers, effective interventions are essential.
It is also important to investigate cost efficacy of treatment models against existing treatments. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes of reduction in outward directed aggression, improvement in quality of life and cost efficacy as measured by standardised scales" [ 27 ].
This trial will evaluate the effectiveness, compared to normal care, of a manualized anger management intervention, delivered to people with mild to moderate learning disabilities in a service setting and by service staff, in reducing levels of reported anger.
This is a multi centre cluster randomized controlled trial of a manualized anger management group intervention versus a 'support as usual' waiting-list control group, with randomization of the group rather than the individual. A cluster randomized design, with one group per participating centre, was adopted to avoid the contamination between arms that would result if intervention and control groups were recruited within the same centre. Published studies of anger management in people with learning disabilities typically report large effect sizes.
As there is no basis for estimating an ICC in the present context, we have used a value just above the range of ICC values reported in a recent systematic review [ 32 ], which varied between 0. This allows for the level of clustering that we would expect to see between participants naturally. As this is a group-based intervention, the effect in the intervention arm may well be to increase the degree of clustering. The analysis of the study will allow for this, but the sample has only been inflated to allow for the underlying level of clustering of service users within services rather than the component that relates to intervention effect.
Thirty services providing day activities for people with mild to moderate learning disabilities will be recruited, on the basis that they report significant anger control problems among some of their service users. Within the current mixed-economy of care such services may be run by statutory or independent sector providers, and may vary in their mode of operation from traditional day centres to individualized community-based activity programmes.
In order to recruit a sufficient number of centres within the time frame of the project, it is being implemented in three different regions, one in Wales, one in England and one in Scotland. In each region, 10 services will be identified, of which 5 will be randomly allocated to the intervention group and 5 to the control group.
Within each group a minimum of 4 and a maximum of 9 service users will be recruited, which will mean a total of approximately service users recruited on to the trial. For each service user a key worker, and where applicable, a home carer will also be recruited not all service users will have a home carer depending upon their residential setting. In each participating centre, at least two wherever possible, three staff will be recruited to act as lay therapists.
Staff will be nominated by their manager and selected on the basis of their motivation to take on this role and their openness to use a cognitive behavioural approach, without reference to formal qualifications. Service Managers will also be recruited from each participating centre.
Randomisation will be performed using the method of minimisation [ 33 , 34 ]. Centres will be balanced on their service users' average baseline self-reported Provocation Index scores, the number of service users recruited and the average number of hours a week spent by the service user with at least one trainer outside of sessions. Centres will be recruited, and baseline data will have been collected on all participating service users of a particular centre , before randomisation of that centre takes place.
Selection bias can be a problem in cluster-randomised trials if participants are recruited after cluster allocation has been revealed [ 35 ]. Therefore, all services and participants will be recruited and assessed prior to randomisation.
In order to maintain engagement in services randomised to the control group, training is offered at the end of the study, and both groups will receive funding to cover the costs of replacing the staff who act as lay therapists.
The research assistants who undertake the assessment of the outcomes will not have any involvement in the delivery of the intervention. As far as is possible they will be blinded to the group allocation of the service, although during direct interaction with the service user the group allocation may become apparent.
Where this occurs it will be recorded. Participants will receive a manualized CBT intervention [ 28 ], consisting of 12 weekly psycho-educational group sessions supplemented by 'homework'.
Before the start of the intervention, a Clinical Psychologist will provide the lay therapists with training sessions, covering the principles of anger management and use of the therapy manual, followed by fortnightly supervision during the intervention. Additional training sessions could be provided, at the discretion of the trainer. Staff training will follow a training manual developed within the project for this purpose.
Topics addressed over sessions include: the triggers that evoke anger; physiological and behavioural components of anger; behavioural and cognitive strategies to avoid the build-up of anger and for coping with anger-provoking situations; and acceptable ways of displaying anger assertiveness.
Presentation relies heavily on brainstorming e. After the first session, about a third of each session, is devoted to discussion by facilitators and group members of one or two participants' experiences, focussing primarily on problem solving around ways in which situations might have been handled differently to produce a better outcome.
In addition to simplifying the language used in sessions, we avoid wherever possible the use of written materials, in favour of pictorial representations. Towards the end of every session, participants are asked to undertake a homework assignment, which consists of working with a staff member to complete a functional analysis 'hassle log' , of a situation in which they have been angered that week, which is described, analysed and evaluated, using a pictorial work-book.
At the end of the intervention, reports are provided on each of the participants, and recommendations are made for further input by staff to maintain and increase treatment gains. A version of each report will also be produced in a format accessible to the service user. All participants will be followed up post intervention, ie 16 weeks post randomisation and again 6 months later. The week time point is chosen to allow two weeks before the start of the week intervention for staff training, and two weeks to take account of likely delays due to centre closures or staff absences.
A contractual agreement has been negotiated with participating services. Consent will be sought from five types of participants: the service users themselves, their key-workers and home carers, lay therapists and service managers. Written consent is taken from the service managers, lay therapists, key-workers and home carers, using consent forms and procedures that comply with standard Research Ethics Committee guidelines.
For therapists and service users selected for interview after the end of the intervention see below , a separate consent will be taken at the time, using the same procedures as above. Adaptive behaviour will be assessed using the short form of the Adaptive Behavior Scale [ 36 ], which is completed by the service-user's key-worker or home carer. Quantitative measures will be administered before and after treatment and at 6-months after the end of treatment. The researchers undertaking these outcome assessments will not have any involvement in training or supervision of the therapists.
They will undertake fidelity monitoring, but they will do this in a region other than the one where they conduct assessments.
The main outcome measure will be the Provocation Index PI as completed by the service-user, at follow-up. The PI is a direct measure of felt response to defined situations that may provoke anger that has frequently been used with this service-user group [ 37 , 8 ].
It consists of a list of 25 different situations that can evoke anger, each of which is rated on a four-point scale for the amount of anger that it would evoke. Scores on this measure have been shown to correlate with staff-reported levels of aggression [ 8 ]. Assessment will also involve completion of the PI by a key-worker [ 31 , 28 ]. For this and other measures, in the event that a service-user's key-worker is involved in the trial as a lay therapist, then the measure will be completed by another staff member.
Both assessments have been either designed or validated for assessment of people with learning disabilities, and were used to assess behaviour in a recent RCT of pharmacological treatment of aggressive challenging behaviour in adults with a learning disability [ 40 ]. Key-workers' attributions in respect of challenging behaviour will be measured by the Controllability Beliefs Scale CBS [ 41 ]. Mental health will be assessed by using the Glasgow Depression and Anxiety Scales, which are established measures of depression and anxiety among people with a learning disability [ 42 , 43 ], and an adaptation of the Rosenberg Self-Esteem Scale for people with a learning disability [ 44 ].
While it is predicted that successful acquisition of anger control skills might improve mental health and quality of life, these measures will also serve to detect adverse effects of treatment. Service users will be randomly selected from a "short list" of those participants who are considered to have sufficient expressive language ability to be interviewed. This part of the research is not hypothesis driven but aims to gain an 'insider's perspective' from which a theoretical framework regarding the subjective experiences of service users can be developed.
Both service user and therapist interviews will be conducted according to a semi-structured interview schedule, containing questions that encourage the participants to focus on 'personal meaning' and making sense of their experiences of the therapeutic process. A related, but separate, part of the qualitative evaluation aims to gain an understanding of service policies and practices for service users who express anger inappropriately.
The economic analysis will be in the form of a service-utilization cost and consequences analysis. The costing will be undertaken as follows;. Resource inputs would include:. These will be valued using standard methods with unit costs provided by the study sites.
The CSRI is a validated tool to measure total package resource use and has been used in evaluations involving service users with psychiatric problems and service users with learning disabilities [ 47 , 48 ].