Research Editor's Note: This article is another in a series of reports summarizing findings from projects sponsored by the Group Psychotherapy Foundation.

I will begin this article with some personal reflections and then share with you the results of our project. This is a traumatic story for me as I recount the research "Psychodynamic Psychotherapy Group to Decrease Assaultive Behavior: A Randomized Clinical Trial." I was the principal investigator. I had finished teaching a course for staff from the New England region on how to conduct a psychodynamic psychotherapy group for assaultive men. Next, I interviewed men for three groups that were to run for six months. The groups were a Psychodynamic Psychotherapy Group (PPG), a Cognitive-Behavioral Therapy Group (CBTG), and a control condition. I was to interview all the people and assign them to randomly selected groups. I accomplished this, and the research project was well on its way.

After the third session, I suffered a major stroke. There was a very good likelihood that I would die. I was hospitalized for two months and had many months of rehabilitation.

The patients and staff all heard the news of the stroke and were kept aware of the "live or die" episode. I was known throughout the hospital by staff and patients because I had been there for 26 years. Patients would ask others how I was doing, having heard that I had had a stroke. After one week, when I regained consciousness, there was concern about how I would adjust to any mental limitations. I was very depressed, could not read, and was told that it was very unlikely that I would return to my work. It was devastating. To compensate, I wrote articles for publication. I could read what I wrote but could not read anything else. The staff in the rehabilitation hospital did not know what I was doing because they would have disapproved. I was not even permitted to go to the medical library. Through my writing, however, I kept my head on somewhat straight. I sent out my first article since the stroke while still hospitalized. That article, on chaos theory, was accepted for publication.

It was amazing, at least to me, that the groups continued. The groups were conducted by the pre-designated leaders. There were also approximately 12 staff working on the project. They said they knew what I was like and were sure that I would return. At their urging, four months post-stroke, I came to work to attend one of their staff meetings. I was still in treatment at the rehabilitation hospital. I very much wanted to get back "in the swing of things," but was very apprehensive. I really had very little idea of what to do at the meeting. In fact, all I did was come to staff meetings to observe. I knew the basic idea of the project and who the people were, but none of the details.

I will never forget that first meeting. I was in a wheelchair and had aphasia. I remembered very little about the project because of the stroke. The meeting was chaired by the statistician, who had taken my place on the research portion of the project. She was by far the most experienced in research, and many of the problems that surfaced were methodological issues. Everyone reported how they were doing and asked questions. I felt terrible because I remembered so little. This was a far cry from what I was used to doing and I knew it. I felt completely inadequate, but the staff did not seem to notice. The meeting proceeded. I felt like a figurehead, but they seemed happy just to have me there. I later felt it was much more. It was almost the transference to me that was experienced. I was there and that was enough.

The staff did not focus on my stroke, especially during the time when I was still not at work. Their reactions seemed characterized by denial. I was young to have had a stroke (52 -years-old) and was very active. I was at the top of my career. If something like that could happen to me, it could happen to anyone. However, the leaders talked about the stroke when I came back. The PPG leader, whom I knew for many years, said that when I returned she was then able to cry.

As I look back, I realize the stroke influenced everything, including the group dynamics. Patients discussed what was really important. I do not know how much they would have done anyway, but they were very forthright about their problems. Nothing was imposed on them. They said what they felt.

For me, the initial denial gave way to some acceptance but on a temporary basis. The word denial for me connotes knowing what I have but fighting all the way. I refused to give up. For example, I had to learn to walk all over again. I said "temporary" acceptance because I would have to use a cane and wear a brace.

I still have not fully accepted the stroke and in some ways that's good. I keep striving to get better, and I do. It keeps alive a hope for patients, staff, and myself. I feel like I am moving on the brink of what is possible. It gives all of us a future where there should be none. I do not know what my final state will be, but neither do the patients. The VA hospital staff let me do whatever I could, unlike any place else. This was one of the most important aspects of my rehabilitation.

The VA patients and staff can also strive against what seem to be overwhelming odds. It may be that we have not finished our grieving, but for me it is too soon to grieve. Perhaps it is in the cards for me to grieve someday, but not now.

Obviously, it was a long and difficult road back. I read the project and could not imagine that I would comprehend the material, let alone write and speak about it. But I did and now I will tell you about "Psychodynamic Psychotherapy Group To Decrease Assaultive Behavior: A Randomized Clinical Trial."

The Project
Assaultive behavior by patients is a serious problem in hospitals and outpatient facilities and is reaching epidemic proportions. The vast majority of assaults are perpetrated by men. While physical violence has been the greatest concern, verbal abuse and threats also have significant sequelae for the victim and negative consequences for the perpetrator. The operational definition for assaultive behavior for this study, therefore, includes physical and verbal aggression by male veterans.

The traditional intervention for assaultive patients is to use cognitive-behavioral group treatment that focuses on thoughts, behavior, and skill acquisition. Clients are encouraged to expand their repertoire of feelings through cognitive interventions. A new and innovative approach for dealing with aggression in hospitals, the psychodynamic psychotherapy group (PPG) for assaultive men, was developed by the author and pilot tested through a grant supported by the Group Psychotherapy Foundation. The PPG involves discussion of overt content and covert process issues displayed among members of a group including the leader. The goal is to change behavior by expanding the patient's capacity for feelings and altering how he responds to his feelings. There are few studies in the literature comparing outcomes of different group treatment modalities, particularly for assaultive behavior.

The immediate objective was to examine the comparative efficacy of psychodynamic group psychotherapy with that of cognitive-behavior group therapy in decreasing assaultive behavior among male veterans. We hypothesized that: (1) PPG participants would show a greater decline in overt aggression than subjects in the CBG; (2) PPG participants would show a greater decline in the intensity of aggressive feelings than subjects in CBG; and (3) PPG participants would demonstrate more effort to control their anger than subjects in CBG. The ultimate objective was to offer the most effective treatment modality to mental health clinicians to use with patients in order to decrease assaultive behavior and improve safety in healthcare facilities.

Intervention-the Psychodynamic Psychotherapy Group: The PPG was designed to help patients cope with their aggressive impulses. The focus of the group was: to help patients identify, understand, and deal with underlying problems resulting in aggressive behavior; to improve interpersonal relationships; and to find more appropriate ways of expressing feelings, particularly those associated with aggressive behavior.

Comparison Group-Cognitive-Behavior Group: The CBG employed cognitive restructuring, relaxation, coping skills, and social-skills training (McKay, 1992; Solomon, Gerrity, & Muff, 1992). There were two goals for each client: to reduce levels of anger in provocative situations, and to learn effective coping behaviors to stop escalation and resolve conflicts. The primary focus was on education and skill acquisition, and the leader was often highly directive. He or she usually initiated most interactions with group members and there were typically fewer member-to-member interactions than in process-oriented therapies. Because of the length of our study, the CBG went on for six months, as did the PPG.

Male patients who had assaulted during the previous six months while either in or out of the hospital were eligible for participation in the pilot study. Thirty-nine consenting patients were randomly assigned to the treatment group (PPG), the comparison group (CBG), or a control condition (i.e., routine care).

The two groups met for one and one-half hour sessions weekly for six months. They were held in different off-ward locations and met at the same time. The groups were led by different therapists who had received training in the model they provided (Lanza, 1998). Data collected from subjects included the Addiction Severity Index (ASI, McClellan, 1993) (as a baseline measure), repeated measures of aggressive behavior using the Overt Aggression Scale (OAS; Yudofsky), and repeated measures of anger using the State-Trait Anger Expression Inventory (STAEI, Spielberger, 1991). The Aggression Observation Scale for Group Psychotherapy (AOSGP, Lanza, in press) assessed experiences within the PPG.

The groups were compared on changes in aggressive behavior (OAS), aggressive feelings (STAEI), and control of anger (STAEI) over the course of the intervention. These analyses included an overall comparison of the groups as well as repeated measures analyses and adjustments for covariates.

Findings
There were many difficulties in maintaining interest among non-group control patients, and almost all dropped out. By the end of the study, there were only two control patients remaining, and it was decided to not include them. The control condition may have been too demanding with not enough gain for this length of time.

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

While the numbers in the pilot research sample were small, and high attrition was a concern, the results are nonetheless very interesting. There are two thoughts worth pursuing. First, at least in this setting, using a traditional PPG for assaultive men appears to be at least as good as CBG, and perhaps superior. Gains were stronger for participants in the psychodynamic group.

Second, long-term work appears to be cost effective, especially when one calculates the cost of assaultive behavior. Aggression/violence develops over a long time. For many people it is not quickly learned (though there are others who have brain structures that give sudden rise to aggression). Despite knowing of its long-term nature, we insist on short-term psychotherapy allegedly because long-term treatment is too expensive. The thinking behind this is you can treat more patients in a six-to-eight week group and capture many more patients than with long-term therapy. The reality is that it will take a long time to unlearn what it took a lifetime to acquire.

However, the difficulty is that the PPG is hard to conduct and difficult to measure. We do need expert clinician-researchers to further investigate the utility of the PPG and the treatment of long-term aggression. Replication with larger samples and lower attrition will provide stronger conclusions. The current findings are quite encouraging regarding the potential value of psychodynamic group therapy for a very challenging population.

Marilyn Lanza, DNSc, ARNP, CS, FAAN is Associate Chief of Nursing Service Research at the Veterans Administration Hospital in Bedford, Massachusetts.

References

Lanza, M.L. (1998). A multidisciplinary course to teach staff to conduct psychodynamically-oriented group psychotherapy for assaultive men. Perspectives in Psychiatric Care, 34(1), 28-35.

Lanza, M.L. (1998). Aggression Observation Scale for Group Psychotherapy. Group, 12(1), 15-38.

Lanza, M.L., Aggression Observation Scale for Group Psychotherapy (AOSGP): The next phase. Group. In press.

McKay, M. (1992). Anger Control Groups. In McKay and K. Paleg Eds. "Focal Group Psychotherapy", Oakland, CA: New Harbinger Publications, 163-194.

McLellan, A.T. (1993). Addiction Severity Index, Administration Manual, 5th ed. Philadelphia, PA: Pennsylvania Veterans Administration Center for Studies of Addiction.

Solomon, S.D., Gerrity, E.T., Muff, A.M. (1992). Efficacy of treatments for Posttraumatic Stress Disorder. Journal of the American Medical Association, 268, 633-638.

Spielberger, C.D. (1991). State-Trait Anger Expression Inventory: Revised Research Edition. Odessa, Florida: Psychological Assessment Resources.Use of a Psychodynamic Psychotherapy Group to Decrease Assaultive Behavior.

This article was published in the February/March 2003 issue of The Group Circle.