Assaultive Behavior Intervention in the Veterans Administration: Psychodynamic Group Psychotherapy Compared to Cognitive Behavior Therapy

Article excerpt

PURPOSE. To compare the efficacy of a psychodynamic psychotherapy group (PPG) and a cognitive-behavior group (CBG) for male veterans with a history of assault.

METHODS. Data collected included the Addiction Severity Index, the Overt Aggression Scale, and the State-Trait Anger Expression Inventory. Subjects (N = 27) were assigned randomly to a central group, PPG, or CBG. Analyses included an overall comparison of the groups as well as repeated-measures analyses and adjustments for covariates.

FINDINGS. The PPG showed a trend toward improvement of overt aggression and significant improvement of trait aggression compared with CBG. There were no differences in state aggression or efforts to control aggression.

CONCLUSIONS. Both the PPG and CBG are effective treatments for aggression.

Search terms: Aggression, psychotherapy

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Assault is a serious problem in hospitals and outpatient facilities and is reaching epidemic proportions (Love & Hunter, 1996). The rate of assault in hospitals reflects the increasing violence in society (Lion & Dubin, 1996; Love & Hunter; Shultz, 1994; Tardiff, 1999). To compound the problem, the reported statistics are acknowledged to represent only the tip of the iceberg. The assault rate may be underreported by as much as 80% (Lion, Snyder, & Merrill, 1981) and reflects a critical incidence measure at best (Lanza & Campbell, 1991; Silver & Yudofsky, 1999).

In the Department of Veterans Affairs context, the majority of assaults are perpetrated by men. While most concern has been with physical violence, verbal abuse and threats have significant sequelae for the victim and negative consequences for the perpetrator. The operational definition for assaultive behavior includes verbal and physical aggression by male veterans. This study is an extension of a project previously funded by the Group Psychotherapy Foundation in which a psychodynamic psychotherapy group (PPG) was developed and piloted as a specific treatment model for assaultive male veterans. Although studies such as that of Hardy and Shapiro (1998) compared psychodynamic and cognitive behavioral therapy, there are few controlled studies that compare group treatment outcomes for assaultive behavior. Two approaches to deal with assaultive behavior are psychodynamic therapy and cognitive-behavior therapy.

The goal of psychodynamic group psychotherapy is to change behavior by expanding the patient's capacity for feelings and how he responds to his feelings. Hassan, Cino-Mars, and Sigman (2000) found that handling of aggression depended on the group context of the aftershocks of the explosive outburst, the leaders' understanding of contributing factors, countertransference feelings, and coping mechanisms. They also cited the relative fragility, strength, and tolerance of both leaders and members of a group in dealing with aggression. Livingston and Livingston (1998) found that promotion of safety along with appreciation of shame and narcissistic vulnerability were important in the treatment of aggression. Kraus (1997) stated that aggression in groups was both negative and positive. Too often, aggression was seen only as negative, yet Kraus argued the helpfulness of aggression needed to be appreciated--for example, the aggression in the man who rescues a child from a burning building.

The traditional approach in group treatment for assaultive behavior is to use a cognitive-behavior group (CBG) that focuses on thoughts, behavior, and skill acquisition. MacKenzie and Prendergast (1992) and Palmer, Brown, and Barrera (1992) had a significant drop in both state (emotional state that varies in intensity) and trait (relatively stable personality trait) anger in a CBG. The key difference between CBG and PPG is that CBG focuses on cognitions and PPG focuses on feelings.

Some limitations of the psychodynamic group are its length, cost, and lack of quality research. …