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Taking ACTion on Anger: A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males in a school-
context.
Jennifer Livings
Submitted for the Degree of
Doctor of Psychology(Clinical Psychology)
School of PsychologyFaculty of Health and Medical Sciences
University of SurreyGuildford, SurreyUnited KingdomSeptember 2017
1
Statement of Originality
This thesis and the work to which it refers are the results of my own efforts.
Any ideas, data, images, or text resulting from the work of others (whether published
or unpublished) are fully identified as such within the work and attributed to their
originator in the text. This thesis has not been submitted in whole or in part for any
other academic degree or professional qualification.
Name: Jennifer Livings
2
Overview
This e-thesis summarises the four key components that have contributed to
the degree of Doctor of Psychology (Clinical Psychology). Parts 1 and 2 detail the
research projects undertaken during the course of study. Specifically, part 1 is a
systematic literature review investigating the status of psychologically-based
interventions for adolescent males with difficulties with anger and aggression. The
literature review highlighted a lack of diversity of interventions in the field, a lack of
interventions targeted specifically at males, a lack of UK-based studies, and a variety
of methodological issues with several studies.
Part 2 presents a feasibility study attempting to address some of the
limitations identified in the literature review. A short-term Acceptance and
Commitment Therapy-based intervention was designed, delivered and evaluated in a
school setting in London, UK. The intervention was designed specifically for
adolescent males, and was evaluated using quantitative (questionnaire) and
qualitative (focus group) outcome measures. The results indicate that the intervention
is acceptable to the participants and feasible (with some adjustments) to run in a
school setting. The questionnaire measures were, on the whole, unacceptable. In
regard to changes, quantitative outcomes were largely non-significant; several
explanations for this are proposed. Qualitative data suggested that the participants
experienced numerous positive changes following attending the group.
Part 3 presents a summary of the clinical experiences gained over the course
of training in the 5 clinical placements undertaken in different settings. Finally, Part
4 is a summary of the academic assignments successfully completed and passed
during the course of training.
3
Publications
Parts of this thesis have been presented at the following conference:
Livings*, J., Parker*, H., & John, M. (2016, November). Taking ACTion on Anger:
A feasibility study of a novel ACT-based anger intervention for adolescent
males delivered in a school setting. Poster session presented at the Third
BABCP ACT SIG / ACBS UK & Ireland Chapter Contextual Behavioural
Science Conference, Edinburgh, UK.
4
Table of Contents Page
Number
Acknowledgements 6
Research Part 1 – Literature Review 8
Research Part 2 – Empirical Paper 82
Appendices 145
Part 3 – Summary of Clinical Experience 251
Part 4 - Table of Assessments Completed During Training 254
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Acknowledgements
I would like to extend my gratitude to my friends, family, colleagues, and
supervisors, who have all helped me to successfully complete a demanding three-
year training course. Firstly, I would like to thank Mary John for being a strong,
professional role model, both as course director and my research supervisor, and for
always making time to support me, despite your demanding schedule. The course
team as whole have provided me with the knowledge, skills and confidence to
progress in my career as a clinical psychologist, and I would particularly like to
thank Melanie Smart, Nan Holmes, Kate Gleeson, and Laura Simonds for their
contributions to the training. Furthermore, my clinical supervisors on placements
have helped me to develop my skills and confidence in the “real-world” of the NHS,
and their optimism, encouragement, and faith in my abilities has engendered
confidence in me.
To my peers in Cohort 43; we have got through this together! I’m so grateful
to have been part of such a supportive, non-judgemental, and skilled group of people,
that have encouraged each other’s development, rather than competed against one
another – you are all amazing! Particular mention is needed for the members of
“Team Organic”; you have been a rock of support through the emotionally
demanding times on the course, and you have inspired me with your knowledge,
resilience, optimism, and determination.
To my friends and family, thank you for believing in me, understanding when
I have been unavailable as I have been buried under assignments, and provided me
with much needed fun and downtime outside the course.
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Finally, and most importantly, to Spencer. Thank you for putting up with me,
supporting me in every way possible, allowing me to be unreasonable, reminding me
that things will always be alright in the end, and making me smile in the tough times.
7
Research Part 1 – Literature Review
Title: Psychological interventions for anger and aggression in adolescent males: A
systematic review of 21st Century interventions
Word Count: 7993 (excludes abstract, figures, tables, and references)
8
Abstract
Mental health problems are becoming increasingly prevalent in children and
young people. For adolescent boys, conduct problems are a common manifestation of
this. This review considers psychological interventions for adolescent boys
struggling with anger, aggression and conduct problems. A systematic search of the
literature published since 2000 resulted in 19 articles, pertaining to 18 studies. A
recent time-frame was selected to ensure the interventions under review were
relevant to the current cohort of adolescents. It was found that, similarly to the more
historical research, much of the recent research is limited to interventions based upon
a social skills/CBT framework, highlighting a lack of breadth of intervention options.
In addition, many of the studies suffered from methodological difficulties. Over 50
different outcomes were considered across the studies; examples include self-report
measures of anger, teacher reports of behavioural problems, and measures of self-
esteem. Outcomes for the adolescents were, on the whole, mixed, with some authors
finding large effect sizes (e.g. Down, Willner, Watts, & Griffiths, 2011, d=1.07-
1.58), but many others finding much smaller effect sizes (e.g. Herrmann &
McWhirter, 2003, d=0.10-0.13), and/or non-significant results (e.g. Puskar, Grabiak,
Bernardo, & Ren, 2009). Suggestions for future research are provided including
developing interventions that are keeping up with modern youth, targeting
interventions at specific subgroups of adolescents (e.g. those who are at risk), and
developing a broader range of therapeutic approaches for this client group.
Key words: adolescent, anger, aggression, intervention, boy
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Introduction
Globally, up to 20% of children and adolescents are reported to suffer from a
“disabling mental illness” (see World Health Organisation, 2003). A 2015 survey of
48 Child and Adolescent Mental Health Services (CAMHS) in the UK showed that
276,468 children and young people were referred to them in that year (Children’s
Commissioner for England [CCE], 2016). Of these, the vast majority were over 11
years of age, and 41% were male (CCE, 2016). Whilst recent data is lacking, the
Office for National Statistics (2005) survey in Great Britain found prevalence rates
for children and young people experiencing a mental health problem to be as high as
1 in 10. Amongst adolescents (11-16 years old), boys were reported to have
experienced more mental health problems than girls (12.6% v 10.3%). The most
common mental health difficulty experienced by adolescent boys was conduct
disorder, with a reported prevalence rate of 8.1%. The figures suggest that a
significant proportion of adolescent boys struggle with their emotional wellbeing,
and specifically with conduct disorder. Conduct disorder is a persistent pattern of
behaviour that violates societal norms or the rights of others, and will include some
of the following: aggression to people or animals, destruction of property,
deceitfulness or theft, and serious violations of rules (American Psychiatric
Association, 2013). Given the estimated economic impact of conduct problems has
been suggested to be in the region of £260,000 per child (Parsonage, Khan &
Saunders, 2014), establishing the current status of effective interventions is important
at both an individual and societal level. The focus of this review was to establish
what psychological interventions currently exist to support adolescent boys with one
of the common markers of conduct and related difficulties; specifically, what
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interventions are available to support adolescent males with anger and aggression
difficulties.
An historical overview of the existing literature revealed several key areas for
development. Firstly, it became apparent that anger management interventions were
a significant area of research during the 1980s and 90s, but appeared to have declined
since. Much of this early research is based on a cognitive-behavioural therapy (CBT)
framework (see Lochman, Powell, Boxmeyer, & Jimenez-Camargo [2011] for a
description of typical components of CBT for conduct disorder in children and
adolescents). For example, Deffenbacher, Lynch, Oetting and Kemper (1996)
demonstrated that both social skills training and cognitive-relaxation coping skills
programmes were effective in reducing anger and aggression in 11-14 year olds.
Feindler, Ecton, Kingley and Dubon (1986) showed that their cognitive-behavioural
based “anger control” programme was effective at reducing aggressive acting out
behaviours in adolescent psychiatric patients. In their meta-analysis of 50 studies of
CBT for adults, adolescents, and children (n=1640), Beck and Fernandez (1998)
found a weighted mean effect size of 0.7 for CBT over controls.
Research in the 2000s appeared to be less common. Sukhodolsky, Kassinove
and Gorman published their meta-analysis in 2004 of CBT treatments for anger in
children and adolescents (total n=1953; mean percentage of males per comparison =
82%). The studies included were published between 1974 and 1997, resulting in
notable overlap (13 studies) with the Beck and Fernandez (1998) study. The authors
found beneficial effects of CBT for anger (d=0.67), and whilst age was not found to
be a significant moderator of outcome, a trend for more beneficial outcomes in older
children (15-17 years, d=0.74) as opposed to younger children (7-10 years, d=0.54),
was observed. In addition, interventions that were more behavioural in their focus
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were more effective. In one of the most recent meta-analyses, Fossum, Handegard,
Adolfsen, Vis, and Wynn (2016) evaluated the long-term treatment effect of
outpatient interventions for children and adolescents with conduct problems. 2,821
participants across 56 studies were included. 37 of these had been published since
2000, but only four of these focused on an adolescent-only population. The authors
concluded that there is an improvement in conduct problems pre- to post- treatment
(overall mean weighted effect size for between groups = 0.64), which was retained at
follow-up.
The lack of recent research into adolescent anger difficulties is important to
consider in relation to cohort effects. Today’s teenagers witness the presence of
global terrorism (Call et al., 2002), engendering a continued threat of violence.
Increased immigration has created a different sociocultural environment to that of
older generations, with the consequence being the potential for intergenerational (see
Call et al., 2002) and intergroup conflict (Larson, 2002). Perhaps the most notable
change is the increased availability of the internet, and particularly social media.
According to a recent survey of American teenagers (Pew Research Center, 2015),
92% go online every day, and 71% access more than one social media site. Whilst
social media has many potential benefits to young people (O’Keeffe, Clarke-Pearson,
& Council on Communications and Media, 2011), increased internet usage has been
associated with increased depression and loneliness (Kraut et al., 1998), and
cyberbullying has a notable presence (Smith et al., 2008). The unique experiences of
“Generation Z” (see Strauss & Howe, 1991) and beyond require consideration in the
continued evaluation, development and innovation of interventions, in order to
maintain cohort-relevance.
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A second observation from the existing literature is that the primary
theoretical approach researched is CBT. Blake and Hamrin (2007) reviewed the
literature on interventions for 4-18 year olds and found that CBT-based programmes
predominated, although they varied in their specific components (e.g. social skills
training, versus studies modifying attribution biases, etc). More recently, of the 56
studies in Fossum et al.’s (2016) meta-analysis, 52 of these were either behavioural
therapy, CBT, or a combination of these. One specific CBT-based intervention
appears to have been particularly well-researched. Aggression Replacement Training
(ART) has three main components; social skills training, anger control training, and
moral reasoning (see Fonagy et al. [2005] and Reddy and Goldstein [2001]). The
programme was originally implemented with high risk, institutionalised adolescents
(Glick & Goldestein, 1987) with results supporting its effectiveness. More recent
research has shown its effectiveness with children and adolescents recruited from
school settings (Gundersen & Svartdal, 2006).
Whilst there is a clear trend in the literature towards CBT-based
interventions, Multisystemic Therapy (MST) is one of the few notable alternatives
offered. MST is rooted in social-ecological and family systems theory, positing that
antisocial behaviour is multi-determined, including influences such as school, work,
family, culture, and others, as causal factors (Henggeler, 1999). MST emphasises
strengths within the system, and intervenes where sequences of behaviour are
maintaining difficulties (Henggeler, 1999). The current NICE (2013) guidelines for
children and young people with antisocial behaviour and conduct problems
recommend MST as one intervention for young people aged 11-17. Weiss et al.
(2013) found that compared to controls, parents and young people who were in
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receipt of MST reported “significantly greater rates of decrease in externalizing
problems” (d ranging from 0.25-0.43).
Whilst MST offers an alternative to the CBT model, it is highly resource
intensive, with a full-time therapist being available to see a family 24/7 (Fonagy,
Target, Cottrell, Phillips, & Kurtz, 2005). Although initial research demonstrates
some evidence for MST’s cost effectiveness (Cary, Butler, Baruch, Hickey, &
Byford, 2013), the start-up resources required could be a significant barrier to
enabling widespread access to it.
A third observation from the existing literature is that a sizeable proportion of
the research has focused on younger children and pre-adolescents (e.g. Kazdin,
Siegel, & Bass, 1992; Lochman, Burch, Curry, & Lampron, 1984; Sukhodolsky,
Golub, Stone, & Orban, 2005; van Manen, Prins, & Emmelkamp; 2004). Wilson,
Lipsey and Derzon (2003) carried out a meta-analysis of school-based interventions
for aggression, however only 21% of included studies contained populations aged 14
+. Similarly, in Fossum, Handegard, Martinussen and Morch’s (2008) meta-analysis,
only 12-13 of the 65 included studies had a mean age greater than 13, whilst Fossum
et al.’s (2016) meta-analysis contained only four studies with a mean age greater than
13. Furthermore, the research that has occurred with adolescents has produced mixed
findings. Wilson et al. (2003) reported that interventions tended to be more effective
for the youngest (under 5; effect size=0.33) and oldest (14 +; effect size=0.37)
participants, and more effective for higher risk young people (effect size=0.41 v 0.09
for general population). Similarly, Sukhodolsky et al. (2004) reported a trend for
greater benefits in older children. In contrast, Fossum et al. (2008) found effect sizes
with adolescents tended to be smaller than those with children (moderator
variable=mean age, d=-0.54).
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The aim of this systematic literature review was to build on the earlier
summary work to establish what research has occurred since the initial anger
management research of the 1980s and 90s. The review considers papers published
since 2000, with a focus on establishing what works for adolescent males with anger-
related difficulties. The review adds to previous research by a) broadening the scope
of the interventions included beyond CBT; b) focusing on adolescents only (age
13+); and c) focusing the search on males, given their higher prevalence of conduct
disorders. In addition, in the current context of global economic difficulties, the
review was seeking to establish the effectiveness of interventions that are feasible to
implement in regard to time and resources.
Method
The initial search terms and databases were generated through inspection of
the terms used by similar articles, and discussion with the principal supervisor and
research team. Final search terms and databases can be found in table 1.
Table 1
Search terms and databases
Generic term Specific search terms used Databases
Adolescent male
youth* OR juvenile* OR teen* OR young* OR adolescen* OR boy* OR pupil* (all in Abstract)
EBSCO search of:PsycINFOPsychology and Behavioural Sciences CollectionChild Development and Adolescent StudiesPsycARTICLESMEDLINE
Cochrane Collaboration search of:Cochrane reviewsCochrane trials
Anger or aggression
anger OR aggress* OR conduct (all in Abstract)NB: “conduct disorder” rather than “conduct” was used in the Cochrane search as the term “conduct” led to too many erroneous results as many studies included the word “conducted”.
Intervention intervention OR program*(all in Abstract)
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The initial EBSCO search was conducted first in January 2015, with the
following limiters applied:
1. Publication date: 2000-2015
2. Scholarly peer-reviewed journals
3. English language
This produced 4670 results and thus an additional limiter was applied to focus the
search on the relevant population:
4. Adolescence (13-17 years)
This produced 1517 results that proceeded to the initial abstract screening.
Consideration was given to include the term “therapy” as an addition to
“intervention” OR “program*”. However the inclusion of this into the EBSCO
search increased the results to over 2,700. An abstract screen of the 30 most relevant
articles produced only one potentially additionally relevant result. It was thus
decided that the “intervention” OR “program*” terms provided the optimum balance
of inclusiveness and specificity.
The search was also performed in the Cochrane collaboration database (only
limiter used = publication date; no option present for other limiters). This returned
164 “reviews”, which were combined with the 1517 results to produce 1681 total
results. Five duplicates were removed, resulting in 1676 articles that proceeded to
abstract screening. The Cochrane search also produced 245 “trials”. After duplicates
were removed, 173 additional trials remained for abstract screening.
To focus the search on the most pertinent populations, several further
exclusion criteria were applied, which are summarised in table 2. For example, as the
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desired population was adolescents, studies were only included if the participant
mean age was ≥ 13 years. Interventions that were looking at populations with dual
diagnoses (e.g. substance misuse) were excluded as it was thought that the
“anger/aggression” component may be confounded by other contextual factors. As
the focus of the review was to ascertain interventions available for adolescents
specifically, interventions that were parenting or family focused were excluded1.
Furthermore, as MST is highly resource intensive, it was decided to focus the review
on interventions that may be more financially feasible to implement. MST, and
interventions that were 6 months or longer in duration, were thus also excluded.
Whilst the focus of the review was on males, interventions that included both
genders were included. Mixed-methods papers were retained in the review, however
only the quantitative results are reported. Qualitative papers (and qualitative results
in mixed-methods papers) were excluded for ease of comparison and consistency
purposes, as the majority of studies were evaluated using quantitative measures.
The entire process was repeated in October 2015, and February 2016 to
capture any recent studies. One further relevant study was located (see figure 1 for
screening flow chart and table 2 for full breakdown of inclusion and exclusion
criteria).
1 Studies were however retained if the main intervention focused on the adolescent but it also included an additional parenting component.
17
Figure 1. Record selection process
18
Additional Searches in October 2015 and February 2016 (repeating above process), yielding n =1)
Final total studies included(n = 19)
Records screened via abstract(n=1849)
Records excluded(n = 1780)
Records after duplicates removed
(n = 1676)
Studies initially included(n = 18)
Records excluded(n= 51)
Records screened via full text(n = 69)
Records after duplicates removed(n = 173)
Table 2
Reasons for exclusion
Category for exclusion Reason for exclusion
Population issues Not on adolescentsOn non-western sampleLearning disability/developmental disability/neurological impairmentsIntervention only focused on girls
Intervention on dual diagnosisInpatient/residential/prison settingMean participant age was less than 13
Intervention issues Intervention clearly not psychologically basedUnrelated to violence/aggressionIntervention focused on dating violence/intimate partner violenceIntervention focused on bullyingPaper focused on parenting/family therapyLength of intervention greater than or equal to 6 monthsResource intensive intervention (e.g. Multi-systemic therapy)
Methodological issues Not in EnglishCase report/qualitative studyNot an intervention studyNot looking at anger/aggression as primary outcome
Other DuplicateStudy unrelated to topic
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Results
The 19 manuscripts selected for inclusion are summarised below, and in
tables 3-6. Two of these (Puskar et al., 2009; Puskar, Ren, & McFadden, 2015)
appear to be referring to the same study2, and will therefore be discussed as one
study.
Quality assessment
The Critical Appraisal Skills Framework (CASP) (2014) was used as a basis
for appraising individual studies, particularly the randomised controlled trial (RCT)
checklist. The CASP frameworks provide criteria by which to appraise studies
against, to assess their methodological rigour and the overall quality of the evidence
provided. It provides a series of questions for the reviewer to consider, with the
answers to said questions giving an indicator of the quality of the evidence. An
example of a question, in the RCT checklist is, “Aside from the experimental
intervention, were the groups treated equally”. The checklists were applied flexibly
to fit the particular studies and have helped guide the critique, but were not adhered
to rigidly given many of the studies were “pre-post” designs, for which there was not
a specific CASP checklist available.
Nature of intervention
11 studies were based around a broadly cognitive behavioural framework
(including social skills training) (Bidgood, Wilkie, & Katchaluba, 2010; Cheng,
Haynie, Brenner, Wright, Chung, & Simons-Morton, 2008; Down et al., 2011;
Hermann & McWhirter, 2003; Humphrey & Brooks, 2006; Langeveld, Gundersen &
Svartdal, 2012; Martsch, 2005; Moynahan & Stromgren, 2005; Puskar et al.,
2 One of the authors was contacted to request confirmation of this, but no response was received. Given the two papers referred to the same intervention, number of participants, and mean age, it was assumed that they referred to the same study.
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2009/2015; Robinson, Smith & Miller, 2002; Williamson, Dierkhising, & Guerra,
2013), and one (Hanselman, 2001) integrated this with an attachment-based
underpinning. Of the remaining six studies, all adopted a different approach,
including mindfulness (Singh et al., 2007), expressive writing (Kliewer et al., 2011),
a skills-based curriculum incorporating a martial art (Farrell et al., 2003), a brief
writing exercise aimed at buttressing self-esteem (Thomaes et al., 2009), an
intervention based on the Theory of Reasoned Action (TRA; Meyer et al., 2004), and
an “incremental theory” intervention targeting aggressive responses to victimisation
(Yeager et al., 2013).
Study design
11 of the studies were RCTs (Cheng et al., 2008; Down et al., 2011; Farrell et
al., 2003; Hermann & McWhirter, 2003; Kliewer et al., 2011; Langeveld et al., 2012;
Martsch, 2005; Puskar et al., 2009/2015; Robinson et al., 2002; Thomaes et al., 2009;
Yeager et al., 2013), three were controlled trials without randomisation (or failed to
mention if randomisation occurred) (Bidgood et al., 2010; Meyer et al., 2004;
Moynahan & Strømgren, 2005), and four were pre–post designs (Hanselman, 2001;
Humphrey & Brooks, 2006; Singh et al., 2007; Williamson et al., 2013).
Of the RCTs/controlled trials, six had a no intervention/waitlist control
(Bidgood et al., 2010; Farrell et al., 2003; Langeveld et al., 2012; Meyer et al., 2004;
Puskar et al., 2009/2015; Robinson et al., 2002), one had treatment as usual (TAU)
(Cheng et al., 2008), three had an active control/comparator group (Herrmann &
McWhirter, 2003; Martsch, 2005; Thomaes et al., 2009), and three had a mixture of
intervention and control groups (Down et al. 2011; Kliewer et al., 2011; Yeager et
al., 2013). In the Moynahan & Strømgren, (2005) study it was unclear what the
control group received.
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Five studies adopted a mixed methods approach (Down et al., 2011;
Hanselman, 2001; Humphrey & Brooks, 2006; Puskar et al., 2015; Robinson et al.,
2002), and the remaining 13 were purely quantitative.
Sample size
The participant numbers included in the studies varied hugely, from n=3
(Singh et al., 2007), to n=476 (Farrell et al., 2003). Across intervention and control
conditions, the 18 studies included a total of 2,754 participants, however many of the
studies suffered attrition, resulting in participants failing to provide follow-up data.
Seven studies had an initial sample of less than 40 (Down et al., 2011; Hanselman,
2001; Humphrey & Brooks, 2006; Moynahan & Strømgren, 2006; Robinson et al.,
2002; Singh et al., 2007; Williamson et al., 2013).
Target population
Seven studies recruited a sample from the general school population (Farrell
et al., 2003; Kliewer et al., 2011; Langeveld et al., 20123; Meyer et al., 2004; Puskar
et al., 2009/2015; Thomaes et al., 2009; Yeager et al., 2013); six included a targeted
population of students in school (Bidgood et al., 2010; Hermann & McWhirter, 2003;
Humphrey & Brooks, 2006; Robinson et al., 2002; Singh et al., 2007; Williamson et
al., 2013), and three included clinical/higher risk populations (Cheng et al., 2008;
Down et al. 2011; Martsch, 2005). One study used more than one recruitment route
(school or local psychiatry services; Moynahan & Strømgren, 2005), and one study
inconsistently reported how the young people were recruited for the intervention
(Hanselman, 2001).
Gender
3 Exact recruitment route for this study was unclear, however it does specifically state that school students were not referred due to behavioural difficulties.
22
The larger studies (n > 100) tended to have an approximately even balance of
both genders, with the exception of Cheng et al. (2008) who reported a sample of
approximately two-thirds males. The smaller studies (n < 100) were predominantly
male, with the exception of Moynahan and Strømgren (2005) who had more females
(n = 9) than males (n = 5). All but two of the studies (Martsch, 2005; Robinson et al.,
2002) included both males and females. Several studies did separate male and female
data in some of their analyses (Farrell et al., 2003; Humphrey & Brooks, 2006;
Kliewer et al., 2011; Langeveld et al., 2012; Singh et al., 2007; Thomaes et al.,
2009).
Age
Studies included participants ranging in age from 11-18, although all studies
had a minimum mean age of 13, where reported. Average ages tended to reside in the
13-14-year-old groups, with eight studies falling in this category (Cheng et al., 2008;
Down et al., 2011; Farrell et al., 2003; Humphrey & Brooks, 2006; Meyer et al.,
2004; Robinson et al., 2002; Singh et al., 2007; Thomaes et al., 2009). Four studies
featured adolescents with a mean age of 15 and above (Martsch, 2005; Moynahan &
Strømgren, 2005; Puskar et al., 2009/2015; Williamson et al., 2013), whilst two
studies failed to report an average age, instead reporting ranges of 14-17
(Hanselman, 2001) and 14-16 (Yeager et al, 2013). Four studies reported school
grades rather than ages; Bidgood et al. (2010) included 7th - 8th graders (equivalent of
ages 12-14), Herrmann and McWhirter (2003) included 7th - 9th graders (equivalent of
ages 12-15), Kliewer et al. (2011) included grade 7 (equivalent of age 12-13)4, and
Langeveld et al. (2012) simply stated “secondary school”, which starts from age 13
in Norway where this study was conducted.
4 This study was included to err on the side of inclusivity with regard to the minimum age of 13.
23
Ethnicity
Five studies systematically recorded an ethnically diverse sample. Ethnicities
identified included Hispanic, “Anglo”, African American, Black, African, Black
British, Latino, Mixed Race, Caucasian, White, White British, Latino, Asian
American, and “Other” (Herrmann & McWhirter, 2003; Humphrey & Brooks, 2006;
Robinson et al., 2002; Williamson et al., 2013; Yeager et al., 2013). Five studies
consisted of predominantly (Martsch, 2005; Puskar et al., 2009/2015; Thomaes et al.,
2009), or entirely (Hanselman, 2001; Singh et al., 2007) White/Caucasian
participants. Three studies consisted of predominantly African American or Black
participants (Farrell et al., 2003; Kliewer et al., 2011; Meyer et al., 2004). Four of the
studies failed to record information on ethnicity (Cheng et al., 2008; Down et al.,
2011; Langeveld et al., 2012; Moynahan & Strømgren, 2005), and one only did so in
an anecdotal manner (Bidgood et al., 2010).
Setting
The larger studies tended to be based in schools (Bidgood et al., 2010; Farrell
et al., 2003; Herrmann & McWhirter, 2003; Kliewer et al., 2011; Langeveld et al.,
2012; Meyer et al., 2004; Puskar et al., 2009/2015; Thomaes et al., 2009; Yeager et
al., 2013) with the exception of Cheng et al. (2008) which was a mentoring scheme
based in the community. The smaller samples were from a range of contexts
including schools (Moynahan & Strømgren, 2005; Robinson et al., 2002; Williamson
et al., 2013; Singh et al., 2007), community mental health settings (Down et al.,
2011; Martsch, 2005), and one study included a one-off session in a local prison
(Hanselman, 20015).
Geographical location
5 It is unclear where the remaining sessions took place, but it appears to be in a community setting.
24
The majority (12) of the studies were based in the USA (Cheng et al., 2008;
Farrell et al., 2003; Hanselman, 2001; Herrmann & McWhirter, 2003; Kliewer et al.,
2011; Martsch, 2005; Meyer et al., 2004; Puskar et al., 2009/2015; Robinson et al.,
2002; Singh et al., 2007; Williamson et al., 2013; Yeager et al., 2013), however
within these there was diversity of geographical location, and thus likely diversity
within the religious and political ideologies of the populations. Two studies occurred
in the UK (Down et al., 2011; Humphrey & Brooks, 2006), two were based in
Norway (Langeveld et al., 2012; Moynahan & Strømgren, 2005), and one in each of
the Netherlands (Thomaes et al., 2009) and Canada (Bidgood et al., 2010).
Outcome measures
Versions of the State-Trait Anger Expression Inventory (STAXI; Spielberger,
1991) were the most commonly used measures, appearing in 4 of 19 studies (Down
et al., 2011; Herrmann & McWhirter, 2003; Puskar et al., 2015; Robinson et al.,
2002), however over 50 different outcome measures were used across the studies.
This was predominated by other questionnaire-based measures that explored an array
of outcomes, including (but not limited to) anger (e.g. Novaco Anger Control
Inventory; Novaco, 1975), “problem behaviours” (e.g. Child Behaviour Checklist
[CBCL]; e.g. Achenbach, 1991a), self-esteem (e.g. Self-Image Profile for
Adolescents; Butler, 2001), and attitudes (e.g. Attitudes towards Guns and Violence
Questionnaire; Shapiro, Dorman, Burkey, Welker, & Clough, 1997). Qualitative data
included interviews (Cheng et al., 2008; Down et al., 2011; Humphrey & Brooks,
2006; Robinson, Smith & Miller, 2002) and observations (Hanselman, 2001;
Humphrey & Brooks, 2006), but will not be discussed here.
Several of the studies used non-standardised outcome measures. In many
cases, this was school records/teacher reports of “poor behaviour” (Farrell et al.,
25
2003; Herrmann & McWhirter, 2003; Singh et al., 2007; Yeager et al., 2013). Others
included recidivism rates (Martsch, 2005), author devised questionnaires (Bidgood et
al., 2010; Meyer et al., 2004), narrative descriptions of progress (that were not
subject to formal analysis) (Hanselman, 2001), knowledge tests related to the
intervention (Farrell et al., 2003; Robinson et al., 2002), anecdotal participant
evaluations and comments (Puskar et al., 2015), mood thermometers (Hanselman,
2001), attitudinal measures (Farrell et al., 2003), experimental measures of
aggression using a computer game (Yeager et al., 2013), and peer reported
aggression levels (Yeager et al., 2013).
Whilst the majority of studies included at least two informant perspectives,
one study relied solely on self-report (Williamson et al., 2013), and one study
employed only a teacher-report outcome measure (Moynahan & Strømgren, 2005).
Seven of the studies relied on questionnaire data only.
Follow-up time scales
Six studies had no long-term follow-up, relying on post intervention outcome
measures (Bidgood et al., 2010; Cheng et al., 2008; Down et al., 2011; Hanselman,
2001; Moynahan & Strømgren, 2005; Williamson et al., 2013). Five studies provided
short – medium-term follow-up data (e.g. 4 weeks to 3 months) (Humphrey &
Brooks, 2006; Langeveld et al., 2012; Robinson et al., 2002; Thomaes et al., 2009;
Yeager et al., 2013). The remaining seven provided longer-term follow-up (5 months
- 1 year) (Farrell et al., 2003; Herrmann & McWhirter, 2003; Kliewer et al., 2011;
Martsch, 2005; Meyer et al. 2004; Puskar et al., 2009/2015; Singh et al., 2007).
Methodological/data issues
Three of the studies had particularly notable missing data/attrition at post-
test/follow-up (Farrell et al., 2003; Herrmann & McWhirter, 2003; Martsch; 2005).
26
Of the initial sample of 476 students in the Farrell et al. (2003) study, data was
available from 240 students (50%) at 6-month follow-up, and 195 students (41%) at
12-month follow-up. In Herrmann and McWhirter’s (2003) study, 207 participants
were originally recruited, however only 89 provided post intervention data and only
34 at one-year follow-up, which the authors attributed to the transient nature of such
a high-risk population. In Martsch’s (2005) study, 107 completed pre-test measures,
but only 87 completed the programme, 65 completed the entire post-test battery, and
only 31 completed entire test battery at follow up.
Two studies (Bidgood, 2010; Hanselman, 2001) failed to report psychometric
data on some of the questionnaire measures used. In addition, two studies
(Hanselman, 2001; Singh et al., 2007) did not employ any inferential statistical
analysis, relying instead on descriptive statistics. There were some instances of lack
of reporting of certain key information; e.g. Hanselman (2001) did not report results
of the “parent evaluations”, and one study failed to mention what the control group
received (Moynahan & Strømgren, 2005).
The studies will now be discussed in greater detail under the following four
categories: 1) Social/cognitive/CBT based interventions: Adolescent intervention
only; 2) Interventions with a parent component; 3) Aggression Replacement
Training6; 4) Other therapeutic modality.
1. Social/cognitive/CBT/Skills based interventions: Adolescent intervention
only
Of the 18 studies included in this review, seven were based on a
social/cognitive/CBT skills framework that focused solely on the adolescent (see
6 Whilst this intervention falls under the cognitive behavioural framework, as it is an established intervention in its own right, it has been discussed separately.
27
table 3). Within this group there were notable differences between the studies; some
included a more purist CBT group intervention (e.g. Down et al., 2011; Humphrey &
Brooks, 2006), others adopted more “lesson” based styles of teaching (Herrmann &
McWhirter, 2003; Robinson et al., 2002; Williamson et al., 2013), and others were
more integrative in their approach, incorporating aspects of emotion regulation
(Bidgood et al., 2010), and a greater emphasis on support systems (Puskar et al.,
2009/2015).
Several of these studies showed a positive effect at immediate follow-up. For
example, Down et al. (2011) compared the effectiveness of a “Personal
Development” (PD) group to a CBT based group intervention and a waitlist control
with adolescents in a CAMHS setting. Relative to the wait list control, the authors
found a significant increase in the PD group’s STAXI anger control score (d=1.58),
and, in both treatment groups, significant increases in the parent reported coping
skills (CBT: d=1.24; PD: d=1.78) and self-esteem (CBT: d=1.45; PD: d=1.07).
Herrmann and McWhirter (2003) evaluated a school-based anger management
programme including content on understanding the triggers, cognitive, physiological
and behavioural interactions that occur when angry, learning coping skills for
managing anger, and learning how to diffuse anger in others. At post-test,
improvements on measures of anger and aggression were observed in the
intervention group, although effect sizes were small (d=0.1, d=0.13, etc). However as
mentioned above, the study suffered notable attrition. Humphrey and Brooks (2006)
conducted a six session CBT intervention with 12 pupils at risk of exclusion. The
authors found promising results at their 4-week follow-up on teacher reported
measures of “total difficulties” (d=0.40), “conduct” (d=0.52), “pro-social” (d=0.62),
and “emotional” (d=0.48) domains of the Revised Rutter Teacher Scale (RRTS).
28
Robinson et al. (2002) evaluated the effectiveness of a CBT based teacher delivered
“Anger Control Curriculum” to 6th-8th grade boys (11-15 years) presenting with
emotional and behavioural difficulties. At post-test, significant improvements were
noted on self and teacher reported measures of anger and behaviour problems (effect
sizes ranging from d=0.68-1.79).
Notable age specific effects were also observed in some of the studies. In
addition to the main effects already mentioned, Down et al. (2011) found in their
CBT group, older adolescents improved more on the anger control measure
(age/outcome correlation r=0.74), whilst in the PD group it was the younger
adolescents who tended to make the greatest improvement (age/outcome correlation
r=-0.58). Bidgood et al. (2010) evaluated their “emotion management” programme in
children and adolescents from grade 1-8 (approximately age 6-14 years) who were
referred by the school or parents for having difficulties managing emotions
(primarily anger). The programme focused on training young people in skills to
manage emotions, with a significant focus on anger, as well as self-awareness of
emotions, triggers, etc. At post-test, no significant improvements were observed on
parent, teacher and child reported measures or behavioural and emotional symptoms
for children in grades 7-87, however non-significant improvements were observed on
some of the parent report measures for this age group, e.g. on total scores on the
emotional and behavioural difficulties scale (d=0.31).
Some studies produced mixed/less positive findings. Williamson et al. (2013)
piloted their 30 lesson “Positive Life Changes” intervention with a group of
adolescents already identified as at risk of exclusion from mainstream school. The
intervention occurred over 6 weeks, and included workbook homework tasks. At
7 Improvements were noted for younger children, but are not discussed here as this is outside the remit of this review.
29
post-test, significant decreases were found in participants’ propensity for physical
and verbal aggression (as measured by the “What would make you fight?” scale), but
not in actual levels of self-reported aggressive behaviour. Puskar et al. (2009)
implemented “Teaching Kids to Cope with Anger”; an eight-session programme in a
rural school in Pennsylvania. The programme focused on skills training for approach
and avoidant coping, and is grounded in a cognitive coping and stress framework.
The authors completed one-year follow-up of the participants but found no
significant changes in their responses on measures of coping. In a separate
publication, Puskar et al. (2015) provided evaluation of the programme using the
STAXI-2, but found no significant differences between treatment and control on 11
of 12 subtest measures (one reached marginal significance). Descriptive data
suggested that the overall scores of the intervention group followed a similar pattern
to the control group. More positive results were found from informal measures, e.g.
participant evaluations. The reported change may have been reduced by not selecting
“at risk” adolescents as the sample was a volunteer sample from a general school
population, as opposed to a psychiatric population.
Of those who collected follow-up measures, little maintenance of changes
was found. Attitudes towards guns and violence was the only significant change
observed by Herrmann and McWhirter (2003) that was maintained at one-year
follow-up. However there was a continued non-significant decline in state anger,
whilst trait anger remained lower than at pre-test. Puskar et al. (2009/2015) did not
observe any significant changes at post- or follow-up time points. Robinson et al.
(2002) found only one significant change was maintained at 4-week follow-up (the
intervention group was still significantly better than the control on the “anger
control” measure, d=0.88), although a non-significant improvement was maintained
30
at follow-up on the “anger-in” measure in the intervention compared to control
group. In addition, “angry temperament” remained significantly lower at post-test
before applying a Bonferroni correction. Humphrey and Brooks (2006) had more
positive results; whilst the improvements on “total difficulties” on the RRTS noted at
post-test were not maintained at follow-up, subscale changes were maintained
(d=0.48-0.62).
Studies also provided observations and suggestions for development. Puskar
et al. (2009/2015) suggested incorporating more “technology” (e.g. social media or
“virtual” Skype groups) in interventions for today’s computer-literate youth. The use
of a workbook to guide the intervention was used in Williamson et al.’s (2013) study;
this is appealing as it could allow interventions to be delivered more widely.
Herrmann and McWhirter (2003) suggested that the inclusion of booster sessions
may be a useful addition to programmes as this may help with maintaining any initial
treatment gains.
Limitations of these studies included small sample size (Down et al., 2011;
Williamson et al., 2013), attrition (Herrmann & McWhirter, 2003), lack of control
group (Williamson et al., 2013), lack of breadth of outcome measures used
(Humphrey & Brooks, 2006; Puskar et al., 2009/2015; Robinson et al., 2002;
Williamson et al., 2013), lack of long-term follow-up (Bidgood et al., 2010; Down et
al., 2011; Humphrey & Brooks, 2006; Robinson et al., 2002; Williamson et al.,
2013), failing to report psychometric properties of measures (Bidgood et al., 2010),
and some difficulties implementing studies in natural settings. For example,
Herrmann and McWhirter (2003) reported that the behavioural measure employed
(school records, e.g. detentions) was not consistently recorded.
31
In summary, there are clear beneficial effects of CBT-based programmes
immediately post-treatment, however the benefits are not always maintained longer-
term.
32
Table 3 Summary of Social/cognitive/CBT/Skills based interventions: Adolescent intervention only
Author /Date / Country
Aim of study Study design Participant information
Measures Intervention Outcome Limitations
Down et al. (2011)
UK-based study
To compare the efficacy of, and preferences for, two different anger management interventions for adolescents. Specifically, CBT v a Personal Development (PD) group.
Quasi experimental design: Treatment = PD group v active control (CBT) v waitlist control. Participants were randomly allocated to either of the intervention groups; as they were oversubscribed, an additional waitlist control was created.
Mixed methods.
33 adolescents and carers involved in a CAMHS service took part. 25 adolescents provided pre- and post- data. 16 males and 9 females participated.
Exact referral criteria were not stated.
Mean age of adolescents ranged from 13.02-13.79 years across the conditions (Range = 12-16 years).
No other demographic information provided.
Quantitative: Anger expression scale of the STAXIa, the “Profile of Anger Coping Skills” (PACS)b, and the Self-Image Profile for Adolescents (SIP-A)c
All of the above were completed by the adolescents, and the PACS was also completed by a parent.
Measures collected pre- and post-.
Qualitative: Participants from each treatment condition took part in a semi-structured
10 x 90 minute CBT versus “Personal Development” (PD) group versus waitlist control. PD group aimed at enhancing the adolescents’ motivation to change by encouraging a more pro-social identity.
PD group: Relative to waitlist controls, PD group showed significant improvements in their STAXI-control (d=1.58), PACS (d=1.78) and SIP self-esteem (d=1.07) scores.
CBT group: Relative to waitlist controls, CBT group showed significant improvement in their PACS (d=1.24), and SIP self-esteem (d=1.45) scores.
Age correlation: Older adolescents improved significantly more in the CBT group (r=0.74), whilst there was a tendency for younger adolescents to improve more in the PD group (r=-0.58).
Small sample, lack of long-term follow-up, questions over treatment integrity, lack of researcher / facilitator blinding.
33
interview, which was subject to IPA.
Herrmann and McWhirter (2003)
USA based study (Arizona).
To investigate the effectiveness of the Student Created Aggression Replacement Education (SCARE)programme. Specifically, the researchers wanted to investigate differences in anger and aggression between those who completed the programme compared to those who did not undertake the programme.
Experimental design. Intervention (SCARE programme) v active (vocational educational programme) control. Cluster randomisation at school level (two schools participated; one=intervention, one=control).
Quantitative.
207 students initially recruited. Total participants at post-test = 89 (67 males), and 34 at year-long follow-up.
Specific ethnicity data not available, but ‘approx.’ “50% Hispanic, 40% Anglo, 5% African American, 5% other”.
Sample identified as academically and behaviourally at risk.
Exact ages not provided but approximate age range is 12-15 years, given school grades.
Anger = STAXIa
Aggression = MPRId (Missouri peer relations inventory; child and parent reports); AGVQe (attitudes towards guns and violence; child report), and detention records.
One year follow-up.
SCARE programme versus active control. SCARE = devised from suggestions from students and a "meta-theoretical" approach focusing on anger management and coping skills. 15 different sessions delivered for an hour twice a week. Focused on a) recognizing anger and violence in the community; b) managing and reducing self-expressions of anger; c) defusing anger and violence in others.
Anger: State and trait anger were significantly lower in the intervention group compared to control group at post-test, but small effect sizes (d=0.1).
Aggression: Only the AGVQ was statistically different between groups at post-test (lower in SCARE group), but the effect size was small (d=0.13).
At one-year follow-up, no significant differences were found on anger measures between groups, however the AGVQ was still significantly lower in the SCARE group.
Significant attrition / small N at follow-up. MPRI poorly completed and only limited reliability / validity data available at time of use. Behavioural measure unhelpful at follow-up (inconsistently recorded by school).
Humphrey and Brooks
To evaluate the
Single group phase-change
Students at risk of anger-related
The Revised Rutter Teacher
4 weeks (6 x 1-hour sessions)
Quantitative: For ‘total difficulties’, significant
Small sample (n=12), only one
34
(2006)
UK-based study (inner city school).
effectiveness of a short-term CBT intervention for anger in reducing difficult school-based behaviours. In addition, the researchers aimed to explore what factors helped or hindered participants to progress in such an intervention.
(ABA) design. No control group; instead 4-week baseline, followed by intervention, followed by 4-week follow-up.
Mixed methods.
exclusion nominated by teachers.
8 males, 4 females, aged 13-14 (mean=14 years 2 months).
Mixture of Black British (7), African (2) and White British (3).
Scale for School Age Children (RRTS)f.
4-week follow-up.
Naturalistic non-participant observations and semi-structured interviews with participants.
CBT anger management programme. Main elements: Cognitive and behavioural components of anger, and using solution-focused techniques.
declines were observed at post treatment (d=0.40), but were not maintained at follow-up. However, sub-scales of ‘conduct’, ‘emotional’ and ‘prosocial’ showed positive results.Prosocial: Improvement from baseline to post intervention, maintained at follow-up (d=0.62).Conduct: Same pattern as prosocial, d=0.52.Emotional: Same pattern as above, d=0.48. No significant differences found for inattentive / hyperactive subdomain..
quantitative outcome measure (no self-report / parent report), short follow-up, lack of control group (compared to own baseline), lack of blinding for raters. Convenience sample (lack of randomisation). “Disproportionate” representation of black people.
Robinson et al. (2002)
USA based study.
To understand the impact of a CBT-intervention for anger on problem behaviours presented by “middle school” students. In addition, the researchers wanted to explore
Experimental: CBT intervention v no intervention control group. Cluster randomisation; one class from each school randomised to either treatment or control.
Mixed methods.
11-15-year-old (primarily 13-14 year olds, but mean ages not provided) male students identified as having ‘emotional and behavioural difficulties’.
3 schools recruiting a total of 41 students.
CBCLg (teacher report) and STAXIa (self-report).
4-week follow-up.
Knowledge recall tests.
A subsample of teachers (n=4) and students (n=9) were also interviewed to
Cognitive behavioural intervention taught by teachers. 10 sessions, twice per week for 50 mins each, followed by 5 practice sessions once a week.
Quantitative: At post-test, significant differences were found between several of the self-report STAXI scales and the teacher reported CBCL scores, favouring treatment over control (d ranged from 0.68-1.79). At 4-week follow-up, the only element that that showed a sustained significant improvement over the control was the "anger control" scale (d not
Short follow-up, lack of behavioural measures of anger/aggression, lack of blinding, small sample (41), no parent involvement, lack of active control
35
teacher and student perceptions of the intervention.
Mixture of white (n=14), black (n=24) and Hispanic (n=3) youth. IQ > 80.
ascertain their perception of the intervention.
provided but calculated using [mean 1-mean2] /mean SD = 0.88).
William-son et al. (2013)
USA based study.
To pilot the “Positive Life Changes” (PLC) intervention; a CBT intervention for at-risk adolescents aimed at reducing aggression and promoting social competence.
Pre-post design (no control group).
Quantitative
31 participants, 29 males 2 females from an urban, Southern California “alternative” high school (all participants had been expelled frompublic school).
Exact referral route unclear, but participants were offered “credit” towards their required school counselling hours if they attended, and were excluded if in substance misuse treatment or had already met their required counselling hours.
Mean age = 15.64
“What would make you fight” scaleh which includes scales on physical aggression propensity and verbal aggression propensity, “Self-report of behaviour” scalei to measure frequency of aggressive behaviour, and “Core Competency Survey”j which includes five subscales: positive sense of self, self-control, decision-making, moral beliefs, and prosocial connectedness.
PLC is a cognitive-behavioural group intervention to prevent adolescent aggression, grounded in a social information-processing model of cognition. Includes workbooks to guide each session.
Significant increases were observed in participants’ decision-making (d=0.43), sense of self (d=0.41), and moral beliefs (d=0.40), as well as decreases in propensity for physical and verbal aggression (d= 0.57 and 0.54 respectively). No significant differences in actual levels of aggressive behaviour, or in levels of self-control or pro-social connectedness.
Small sample (31; 29 were male, and only 27 completed the group), lack of control group for comparison, measures not well-known (although good psychometric properties reported); self-report only; no long-term follow-up
36
years (range 14-18)
Latino (51.6%), followed by mixed race (25.8%), African American (19.4%), and Caucasian (3.2%).
Bidgood et al. (2010)
Ontario, Canada.
To evaluate the Supporting Tempers, Emotions and Anger Management (STEAM) intervention for primary school-age and adolescent children. The researchers aimed to explore self, parent and teacher-reported changes in emotion management.
Largely a pre-post design, but also included an intervention v waist-list control component. No randomisation. Small waitlist control group, so some between group comparisons, but largely pre-post comparisons.
Quantitative.
143 children. Participant demographics were not reported; anecdotally there were a mixture of genders in each group and the sample was predominantly white.
Grades 1 – 8 (different intervention for grades 7-8). Specific ages not provided but range is approximately 6 – 14 years, with grades 7 and 8 being approximately 12-
Outcomes were measured on the Behavioral and Emotional Rating Scalek – parent and teacher versions. These assess strengths in the domains of: interpersonal, intrapersonal, school functioning, affective strength, and family involvement.
Author devised child self-report measure of “ability to handle emotion”.
STEAM: A school based programme combining emotion management and anger management. Emphasis on self-awareness and skills to express emotions. Significant focus on skills for managing anger specifically. 12 x 90 minute weekly sessions at local youth centre. Programme slightly different for 1-6 and 7-8 grades. Students were assigned
No significant improvement on parent, child or teacher reports in children in grades 7-8. Some non-significant improvement, particularly on parent measures (e.g. “total” score on the emotional and behavioural rating scale improved; d=0.31).
Younger children did show improvements but results are not reported here due to being outside the remit of this review.
Lack of randomisation, small number of older children (n=18 for 7th and 8th grades). Little demographic information available. Programme possibly too inclusive as some referral questions seemed anger related, others depression related. Children were interviewed for suitability - possible selection bias. Very broad age range - programme trying to catch all. No
37
14 years.
Teachers referred children whom they thought would benefit from the programme. Parents also given opportunity to refer. Broad referral criteria, e.g. “does your child hit or explode if angry?” “does your child seem sad or depressed?”, although most children referred for anger issues.
Sample from 5 schools.
(not randomly) to intervention or wait-list.
Parents were given the opportunity to attend three voluntary parent training sessions.
mention of facilitator training; measures used were incomplete (lots of missing data), one measure had no psychometric properties; no blinding; lack of long-term follow-up.
Puskar, et al. (2009)
USA based study.
To explore rural adolescents’ coping responses before and after a behavioural intervention
Quasi Experimental: Intervention v control. Randomisation of volunteer sample. No mention of what control group
179 participants in 9th -11th grade (14–18 years, mean = 15.61). Students from a “mainstream” high school in a rural area of Pennsylvania.
Adolescents coping skills measured via The Coping Responses Inventory-Youth Forml; assesses how adolescents cope with stressful life
“Teaching Kids to Cope with Anger” (TKC-A). TKC-A targets anger as a symptom, highlights violence as a potential
No significant differences were found in coping responses at any of the time points between intervention and control group.
Adolescents were not "at risk", limited outcome data - no measures of anger. Lack of behavioural- or third-party-report measures. Lack of
38
for anger. received.
Quantitative.More females (52.51%, n=94) than males (47.49%, n=85).
Mostly white (86%, n=154).
Volunteer sample from general school population.
experiences (e.g. approach or avoidance coping).
Measures administered at baseline, eight weeks post-intervention, six months post-intervention, and 1-year post-intervention.
consequence, and focuses on skills training based on a theoretical framework of cognitive coping and stress. Encourages support from wider networks. TKC-A specifically targets difficulties experienced by youth growing up in rural environments (e.g. coping with long geographic distances, lack of social support, etc). 8 x 45-min sessions.
parent inclusion in programme. No mention of what control group received. No mention of blinding. Limited applicability due to "rural" component of programme.
Puskar et al. (2015)
USA based study.
To evaluate the efficacy of the TKC-A intervention in rural adolescents on self-report measures of anger experience and anger
Experimental: Stratified randomisation by age and gender into intervention v no-intervention control.
Largely quantitative,
179 participants from general school population.
53% females, 46% males.
Ages ranged from 14–18 years (mean=15.61 years).
STAXI-2m (not including trait anger) used at baseline, post, 6-months post, and 1-year post.
Informal measures: (1) participants’ evaluations; (2)
TKC-A: Once a week for eight sessions. Groups consist of two main components 1) Psycho-educational about anger, cognitions, coping, etc.; 2) Skills practice – including role
No differences between treatment and control group on 11 of 12 STAXI-2 subtest measures; one (Anger index=general score of expressed anger) reached marginal significance after Bonferroni correction.
Participants, school staff
Only one self-report formal outcome measure, non-intervention control, participant sample not targeted for anger problems per se, not clearly reported within-group effects
39
expression. although included some informal, supplementary qualitative information.
86% White, non-Hispanic.
Participants from 3 rural south-Western Pennsylvanian schools.
anecdotal notes; and (3) mural comments.
play, practicing cognitive restructuring, etc. Programme is accompanied by workbooks including between-session practice activities. Participants completed murals in the final session to demonstrate what they had learned.
and family members completed positive evaluations; e.g. 100% thought it was applicable to daily life, and 94% gave it an overall rating of fair to excellent.
(brief mention at start of results section). No blinding; no intervention control; possible diffusion of treatment within school; lack of other quantitative measures - e.g. teacher / parent report, could have used more systematic qualitative information.
a. Spielberger (1991); b. Willner, Brace, and Phillips (2005); c. Butler (2001); d. Borduin, Blaske, Treloar, and Mann (1989); e. Shapiro et al. (1997); f. Rutter (1967); g. Achenbach (1991a); h. Chan and Henry (2009); i. Farrell, Danish, and Howard (1992); j. Gardner, Williams, Guerra, and Walker (2011); k. Epstein and Sharma (1998); l. Moos (1993); m. Spielberger (1999)
40
2. Interventions with a parent component
Three of the studies included some reported parent involvement with the
programme, over and above completing outcome measures (see table 4). All three
studies included some reference to cognitive theory in their theoretical basis; Martsch
(2005) evaluated a CBT-based intervention, Hanselman (2001)’s intervention
included elements of CBT and attachment theory, and Cheng et al. (2008)’s
intervention was based on social cognitive theory. In addition, the three studies had a
similar degree of parent involvement; Martsch (2005) invited parents to two sessions,
Cheng et al. (2008) included three parent sessions within their programme, and
Hanselman (2001) supplemented their intervention with three parenting sessions.
Beyond these similarities, the three studies were quite different in their approach.
Martsch (2005) focused on whether the group process (high versus low
process) was an influential factor on outcomes in adolescent males who had been
court ordered to attend an aggression treatment programme. The high process group
involved more engagement from group members, with greater focus on group
cohesion, interaction and members taking responsibility for their experience in the
group. The low process group was more didactic and skills focused. In contrast,
Cheng et al. (2008) evaluated a mentoring programme for young people who had
been assaulted. The programme focused on skills training and consisted of six
sessions over 2-6 months. Hanselman (2001) investigated the role of dogs in therapy.
The author described a group anger management intervention that draws on both
CBT and attachment theory. The 10-session programme was supplemented by the
parenting sessions and a one-off “scared straight” session in a prison.
Cheng et al. (2008) observed some benefits of the intervention, with
41
significantly reduced “misdemeanours” and physical aggression in the intervention
group, when treatment adherence was considered. Furthermore, trends for
improvement were noted when comparing the intervention and control group in
regard to number of fights and fight-related injuries. The comparison group’s
“treatment as usual” may have diluted treatment effects.
Martsch (2005) found no significant main effects, however significant
differences between the two groups based on age were observed. Older adolescents
in the high-process groups fared better on parent measures of conduct disorder and
on self-reported parent/adolescent conflict compared to their same age low-process
peers. The opposite pattern was found for younger adolescents (younger adolescents
in the low-process treatment groups improved significantly more than their high-
process counterparts on these same two measures). Conversely, younger adolescents
in the high-process group improved more on measures of carelessness and
impulsivity compared to their low-process same age peers whilst, again, the opposite
was found for older adolescents. Whilst causal assumptions cannot be made due to
the lack of control group, both groups showed very little recidivism rates at post-test
(2 of 65 participants) and follow-up (3 of 31). The study did however suffer
difficulties with attrition (as described earlier).
Hanselman (2001) reported reductions in scores on measures of anger,
however these results should be interpreted with caution due to several
methodological difficulties. This included a small sample size (n=7), lack of control
group, lack of inferential statistics, lack of reporting psychometric data, inconsistent
reporting of some information (e.g. referral route), failing to report parent evaluation
data, and over-reliance on unstandardised descriptions of progress. The author also
offered many inferences, interpretations, and evaluations throughout the paper,
42
which lacked robust explanations (see table 4 for examples).
Given the diversity of the studies within this category, and the
methodological issues present in the Hanselman (2001) study, it is difficult to draw
conclusions about any added value of an additional “parenting” component.
43
Table 4
Interventions with a parent componentAuthor/ Date / Country
Aim of study Study design Participant information Measures Intervention Outcome Limitations
Martsch (2005)
USA-based study.
To compare the effectiveness of two cognitive-behavioural interventions for aggressive behaviours in adolescent males; a “high process” group in which group process and cohesion is emphasised, versus a more instructional “low process” group.
Experimental: Stratified random assignment of individuals to one of two interventions (treatment 1 v treatment 2). No neutral “control” group.
Quantitative.
107 completed pre-test measures, 87 completed programme, 65 completed entire post-test battery, 31 completed entire test battery at follow-up.
Separated by age (12.9-14.9 years versus 15-18.3 years) and then randomly assigned. Mean overall age = 15.96 years.
Court referred male adolescents in Wisconsin who have problems with aggressive behaviour.
Of the 65, 54 (83.1%) Caucasians, 9 (13.8%) African Americans, and 2 (3.1%) Hispanics.
Parents also invited to two group sessions.
Recidivism rates
Behaviour ratings: Revised Behaviour Problem Checklista - conduct disorder and socialized aggression scales (parent report).
Anger control: Novaco Anger Inventoryb (Self-report)
Social skills: Teenage Inventory of Social Skillsc
Social problem solving; Subscales of the Social Problem Solving Inventory – Revisedd.
Parent-adolescent conflict: Conflict Behaviour Questionnaire (teen and parent versions)e.
Outcomes measured at pre-test, post-test and follow-up (9 months later).
Comparison of two cognitive behavioural therapy interventions - low process versus high process. The low-process was more focused on teaching specific cognitive- behavioural skills. The high-process condition featured more emphasis on group cohesion, interaction, and participation. 2 hours per week for 10 weeks.
Results analysed at group level, therefore n=16 rather than 65.
No significant main effects.
Significant improvements in participant-reported conflict behaviour at post-test only. Not supported by parent report.
Age X group effects: Older adolescents improved significantly more in the high-process groups on parent reported levels of conduct disorder and, at post-test, on self-reported parent/adolescent conflict, when compared to their same age peers in the low process groups. The younger adolescents
Differential findings on treatment integrity, limited range of reporting perspective, high level of attrition at follow-up, no effect sizes reported.
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in the low-process treatment groups improved significantly more on these same two measures, when compared to their same age peers in the high process groups.
Opposite pattern for impulsivity/carelessness (older adolescents improved significantly more in low-process; younger adolescents better in high-process.
Cheng et al. (2008)
USA based study.
To evaluate the effectiveness of a mentor-implemented violence prevention intervention for adolescents who have presented to the Emergency Department following assault injury.
Experimental: Intervention V TAU. Randomised. Comparison condition received standard case management services.
Quantitative.
Participants identified via those who presented to the emergency department following assault injury aged 10-15 years (mean=13 and 12.9, intervention and comparison).
113 (of 166) completed post treatment data.
Sample was 2/3rds male. No further demographic information provided.
Urban hospital sample in Baltimore.
Outcomes focused on self -efficacy regarding violence and risk factors for violence. Data gathered via a mixture of questionnaires and survey/interview data.
Self-report: Items taken from Slaby’s Attitude about Interpersonal Violence Scalef,g, and the Perception of Environmental Violence Scaleh, i. Questions asked about social competence, conflict avoidance self-efficacy, history of fighting and weapon carrying (latter from the Youth Risk
Mentoring programme that consisted of 6 sessions over 2-6 months with adolescents, and 3 parent sessions. Sessions were “violence prevention” focusing on skills building and based on a social-cognitive framework.
A significant reduction in “misdemeanour activity” was found in intervention group, compared to control group (rate ratio=0.29), as well as an increase in self-efficacy. Interestingly, the low-treatment-adherers reported significantly higher self-efficacy than the high adherers.
Compared to control, he high-treatment-adherers group showed decreased physical aggression (rate ratio=0.51)
Lots of non-significant results, including youth reports of fighting and weapons carrying in the last 30 days, parent report of youth aggression, social competence and attitudes about retaliation. Some intervention present in comparison group. Lack of follow-up = unknown if
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Behavior Surveyj), their recent “misdemeanours” (e.g. property damage), friends’ problem behaviours, and their physical aggression..
Parent report: Aggression subscale of the CBCLk.
Interviews occurred at baseline and post treatment (6 months).
misdemeanours (rate ratio=0.09).
Majority of measures non-significant.
“trend” for effects would be sustained when mentoring relationship ceased. No behavioural measures.
Hansel-man (2001)
Explicit location of the group is not stated, but other references suggest a USA-based study, likely in New Jersey.
To describe a CBT and attachment informed group anger intervention for adolescents which incorporates the use of animals in therapy sessions.
Pre-post design (no control group). Author refers to the study as an ABA design, however there doesn’t appear to be a baseline period.
Mixed methods.
5 males, 2 females, aged 14–17 years.
Inconsistent reporting of nature of referral process; adolescents either applied through a newspaper or were advised by school to attend; however elsewhere article also states that courts referred adolescents.
Caucasian.
No mention of number of parents present.
Quantitative: State-Trait Anger Scale (STAS)l; Companion animal bonding scale (CABS)m, Beck Depression Inventory-IIn - all pre/post – unclear exact time points.
Mood thermometers (beginning and end of each session).
Qualitative: Parent evaluations of children’s abilities to work through their anger.
Narrative description provided on participant’s progress from facilitator.
Intervention: Combination of CBT and attachment, including having dogs in many sessions. 10 group sessions, 3 parent sessions, and a “scared straight” session in a prison, as well as a “guest speaker” (a well-known boxer who talked about his history of anger difficulties and how he now managed this).
No outcome information on parent evaluations.
Only means and standard deviations calculated.Authors reported a "significant decrease in the state anger and trait anger" but provided no p values/effect sizes, and a "significant” increase in CABS scores during companion animal bonding but again only provided means/sd.
BDI-II means increased; author explanation: "A significant increase in depression would be explained by the lack of use of drugs and alcohol
Author makes conclusions that are based on very little evidence due to lack of appropriate statistics (no inferential statistics or effects sizes). Author appears to have been group facilitator therefore significant bias in conclusions may be present (although doesn't actually say who facilitated). Author makes unsubstantiated
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during therapy. The adolescent becoming anxious and vulnerable because they are learning to feel. This was due to a lack of drugs in their system […]” (p.174).
Mood thermometer: "The mean scores were a significant increase in tension, confusion, anger, and depression. A significant decrease in fatigue also occurred […]" (p. 175). No p values/effect sizes.
conclusions (e.g. why depression scores may have gone up, that animals resulted in increased positive feelings) and erroneous statements (mood thermometers contradict other measures). Narrative outcome is unsystematic. Lack of parent feedback included in results / discussion. Very small sample. No mention of psychometric properties of measures. No control group. Too much of paper devoted to theory, not enough to evaluation.
a. Quay and Peterson (1987); b. Novaco (1975); c. Inderbitzen and Foster (1992); d. Maydeu-Olivares and D’Zurilla (1995) e. Prinz, Rosenblum, and O’Leary (1978) f. Slaby and Guerra (1988); g. Dahlberg, Toal, and Behrens (1998); h. Hill and Madere (1996); i. Hill and Noblin (1991); j. Whalen et al. (2003); k. Achenbach (1992); l. Not referenced by author and unable to locate reference. m. Poresky, Hendrix, Mosier, and Samuelson (1987) n. Beck, Steer, and Brown (1996)
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3. Aggression Replacement Training (ART) studies
Two studies of ART met the inclusion criteria (see table 5). Langeveld et al.
(2012) investigated the effectiveness of a 12-week ART programme in primary and
secondary school students in Norway using a sample of 112 young people.
Moynahan and Strømgren (2005) conducted a much smaller evaluation of ART; their
study included 14 children and adolescents who were referred by their schools or
psychiatry/rehabilitation services. This study included young people with ASD and
ADHD diagnoses, as well as those without a diagnosis.
Langeveld et al. (2012) showed overall positive results for improved social
competence and reduction in behavioural problems, however these results were
moderated by both age and gender. Boys and girls both improved in social
competence, but when gender was considered, no significant reduction was found in
behavioural problems for girls (of all ages). The authors explained this is likely due
to a pre-test floor effect. Younger (primary school age) participants (of both genders)
demonstrated the significant main effect described above, whilst secondary school
age participants did not. The intervention also appeared to be more effective for
those low in social competence and high in behavioural problems pre-treatment. In
contrast, null results were observed in Moynahan and Strømgren’s (2005) outcome
data. As in the Langeveld et al. study, the authors suggested this could be due to the
“normal range” scores observed pre-test. The authors also noted considerable
variation in the pre- and post-test scores for both groups (e.g. control group post-test
problem behaviour score, mean=91.57, SD=40.88), making interpretation of
outcomes difficult.
The results of both studies suggest interventions may be better targeted at
higher risk young people, whilst Langeveld et al.’s (2012) results also point to
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specific targeting of younger participants. Both studies lacked long-term follow-up of
their outcomes. In addition, Langeveld et al.’s study experienced high levels of
missing data at all time points, raising questions over the validity of the results and
acceptability of the intervention.
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Table 5Aggression Replacement Training (ART) studies
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a.
51
Author / Date / Country
Aim of study Study design Participant information
Measures Intervention Outcome Limitations
Langeveldet al. (2012)
Norway-based study.
To evaluate the possible mediating role of social competence in reducing behavioural problems in children and adolescents who have received the ART programme.
Multi-baseline experimental design: Intervention v control. Randomized to two experimental groups (delayed pre- and post-test design to provide control).
Half of the participants completed measures 4-weeks before the intervention (“pre-pre” time point), and half 4 weeks after the intervention (“post-post” time point).
Quantitative.
112 primary and secondary school pupils from 18 ART groups in Norway.
No further demographic information provided.
Not referred due to behavioural difficulties although exact referral route unclear; it appears post-graduate students and teachers may have selected students (see p.386).
Social Skills Rating Scale (SSRS)a: Measures social competence and behavioural problems and includes parent, teacher and self-reports. Domains covered include internalising and externalising problems, assertion, cooperation, self-control, parent-rated responsibility and student-rated empathy.
12-week ART programme aimed at reducing aggressive behaviours in youths. Structured programme consisting of three separate modules (social skills training, anger control training, and moral reasoning training).
Significant improvements in social competence (partial eta squared =0.23) and behavioural problems pre- to post- (partial eta squared =0.02). At “post-post” test, behavioural problems further decreased (partial eta squared=0.56).
Moderator analysesGender: Improvements for both genders in social competence, but only for boys in problem behaviours (girls = possible floor effect).
Age: Younger participants (primary) showed significant improvements on social competence measures and reductions in problem behaviours; only marginal reductions in behavioural problems for older children (secondary).
Effects also moderated by pre-treatment social competence / behavioural difficulties (complex picture).
No effect sizes for moderator analyses.
Significant number of non-responders at all time points, lack of long-term follow-up, lack of behavioural measure, no demographics provided so unclear of generalisability.
Moynahan and Stromgren (2005)
Norway-based study.
To evaluate if the ART intervention is successful at reducing problem behaviours and increasing social skills when delivered to a mixed sample of
Experimental: Intervention v control (unclear what control group received). No mention of how individuals were allocated to treatment or control.
Quantitative.
Study on adolescents and children (adolescent results only included here). 14 adolescents referred by school or local psychiatry services aged 14-20 years; 7 in ART group, 7 in control. lack
SSRS (teacher scales)a Measures social skills, problem behaviours and academic competence. Study only interested in social skills and problem behaviour subscales.
Minimum of 30 hours of ART. Enhanced components were added. 10-week course.
No significant differences found in pre- and post-test scores for the adolescents in the ART group in social skills or problem behaviours, although mean scores were within “normal range” at pre- and post-test.
Note: better results were found for children.
Using “low risk” individuals may have led to null results, very small sample, inclusion of ASD/ADHD may have influenced how group ran, lack of blinding, no long-term follow-up, lack of homogeneity
Gresham and Elliot (1990)
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4. Other therapeutic modality
Six studies did not fit into the first three categories, representing a
diverse range of approaches to managing aggression (see table 6). This
included “mindfulness” (Singh et al., 2007), an expressive writing
intervention (Kliewer et al., 2011), and a skills-based “curriculum” approach
(Farrell et al., 2003), as well as more experimental interventions. For
example, Thomaes et al. (2009) designed an intervention that was aimed at
buttressing self-esteem (i.e. protecting self-esteem from threat), as opposed to
boosting self-esteem and delivered it to 12-15 year olds in a general school
population. The intervention is aimed at individuals high in narcissistic traits,
with the underlying theory suggesting that protecting these individuals from
ego threat may reduce aggression associated with ego-threat. The intervention
consisted of a brief writing exercise that encouraged participants to focus on
their values and why they are important to them. In another unique
intervention, Meyer et al. (2004) evaluated the impact of a 12-session
multimedia curriculum aimed at reducing violence in schools. The curriculum
was based on the TRA and outcomes were measured based on the
subcomponents of the TRA via an author devised-questionnaire. Finally,
Yeager et al. (2013) focused on aggressive responses to victimisation,
comparing the effects of a six session “incremental theory” intervention to a
treatment control (“coping skills”) and a “no treatment”. The “incremental
theory” intervention taught the idea that people have the potential for change,
whilst the “coping skills” intervention taught skills on how to think positively
and cope productively in the face of victimisation or exclusion. Two of the
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studies focused on specific “types” of aggression; Thomaes et al. (2009)
looked specifically at narcissistic aggression., whilst Yeager et al. (2013)
focused on aggressive responses to victimisation.
Results were, again, very mixed in these studies. Thomaes et al.
(2009) and Kliewer et al. (2011) showed some initial promising results, but
these were no longer evident at follow-up. Meyer et al.’s (2004) within-
groups analyses at 5-month follow-up showed both groups worsening on
outcome measures, although the intervention group worsened on less
measures than the control. It is not clear whether these results were
significant or not.
More positive results were found by Singh et al. (2007), who
conducted a brief mindfulness-based intervention with three young
adolescents who were at risk of expulsion from school. The authors reported
reductions in aggressive behaviours or bullying during the “practice” phase of
mindfulness, and over the following year none of the adolescents were
excluded. Similarly, Farrell et al. (2003) found several positive results.
Following the implementation of the Responding in Peaceful and Positive
Ways sixth grade curriculum (RIPP-6), the authors conducted follow-up
research on the same schools by implementing a booster seventh grade
curriculum (RIPP-7). This 12-session programme aimed to reduce violence
by looking at communication skills, respect, valuing friendship, and conflict
resolution skills, incorporating the martial art “Aikido” as a component.
Although immediate main effects were somewhat disappointing, disciplinary
code violations for violent offenses during the eighth grade were over twice
as high in the control group compared to the intervention group. In addition,
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whilst not reaching significance, the RIPP-7 group also had less out-of-school
suspensions at 12-month follow-up (rate ratio=1.4). Furthermore, at 6-month
follow-up, significantly lower rates of non-physical aggression were reported
for boys (d=0.37) and increased attitudes supporting non-violence (d=0.27).
Regression analysis showed that at both 6 and 12-month follow-up, lower
levels of violent behaviour were reported for those with high pre-test levels of
violence in the RIPP-7 group compared to the control group. Finally, Yeager
et al. (2013) found favourable results for the incremental theory intervention,
and incorporated a range of outcome measures including an experimental
measure of aggression (d=0.47), prosocial behaviour (d=0.86), and teacher
reports of conduct problems (d=0.66). The latter measure was significantly
improved in the incremental theory group only for those who have previously
been victimised, providing support for the theoretical basis of their
intervention.
Several of the studies suffered methodological issues. For example,
Farrell et al. (2003) lost 50% of participants at 6-month follow-up, and only
41% remained at 12-month follow-up. Furthermore, differences were found
in age and grade-point average between the retained and attrited samples.
Questions around the validity/reliability of outcome measures used in Meyer
et al.’s (2004) could also be raised. Singh et al.’s (2007) research lacked
inferential statistics and relied entirely on adolescent self-report data to
confirm adherence to mindfulness practices. Other limitations of this study
included the extremely small sample, lack of control group, and concerns
over validity and reliability of outcome measures used.
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Table 6Other therapeutic modality studies
Author / Date / Country
Aim of study Study design Participant information
Measures Intervention Outcome Limitations
Thomaes et al. (2009)
Nether-lands based study.
To evaluate whether an experimental intervention aimed at protecting one’s self-esteem from threat (as opposed to boosting self-esteem) can reduce narcissistic aggression in a sample of adolescents in a “real-world” setting.
Experimental: “Randomised field experiment”. Intervention v active control.
Quantitative.
Participants were 405 12-15 year olds (mean=13.9 years) from two public middle schools within a ‘middle class’ area of the Netherlands.
52% male, 48% female.
90% = Caucasian, 10% = “other” (Turkish, Dutch Antillian, mixed).
Childhood Narcissism Scalea.
Global self-worth scale of the Self-Perception Profile for Adolescents (measuring trait self-esteem)b.
State self-esteem measured by a pictorial scale (taken from the Self Assessment Manikin)c.
Peer-nominated aggression measure (piloted in another study – see supplemental information online).
Aimed at buttressing self-esteem. Theorised that reducing the threat to self-esteem, as opposed to improving it, might reduce narcissistic aggression.
Intervention: 15-minute self-affirmation exercise in which participants wrote about their most important values and why they are important to them.
Control: Participants wrote about their least important values and why these values may be important to others.
Intervention: No significant association between narcissism and increased aggression, irrespective of levels of state self-esteem.
Control condition: Significant association between narcissism and increased aggression for students with low level state self-esteem but not high level state self-esteem.
Conclusion: Buttressing self-esteem can reduce narcissistic aggression for 1 school week. Results not present at longer-term follow-up.
Effect sizes not provided (although confidence intervals are provided).
Boys were more aggressive than girls overall.
Short-term follow-up (up to 9 weeks after initial intervention), very low treatment dosage, short-term effects (only lasted one week), intervention for narcissistic aggressive youth, not aggressive youth generally, not well known, robust outcome measures
Singh et al.
To evaluate the
Pre-post design, very
3 x 7th grade students at risk of
Non-standardised measures.
"Meditation on the Soles of the Feet":
For all three adolescents, little decline in aggressive
Very small sample, lack of inferential
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(2007)
Country of origin not explicitly stated but appears to be the USA.
effectiveness of a mindfulness intervention for adolescents with aggressive behaviour using a multiple-baseline design.
small n (n=3).
Quantitative.
expulsion. Students were aged 13, 13 and 14.
2 males, 1 female.
Caucasian.
All diagnosed with conduct disorder.
All had histories of aggressive behaviour at school and were referred for therapy from their school. High risk population; 2 had been inpatients several times and 1 had co-morbid learning difficulties8.
Baseline data: Consisted of retrospective school data on each individual's aggressive behaviour. Two weeks of teacher-reported prospective data was also collected.
Training phase and mindfulness practice phase: Teacher reported and self-reported incidences of behaviours.
Follow-up: School records were reviewed for records of incidences of expulsion or threat of expulsion.
Mindfulness intervention. Therapist met 3 x /week for 15 minutes to teach/practice intervention with young person for 4 weeks. There was then a "mindfulness practice" stage that lasted 25 weeks; the therapist only saw the young person for 15 minutes once a month. Follow-up occurred over the following school year.
behaviour or bullying was observed in the intervention phase, however “substantial” decline was observed during the “practice” phase. None of them had further threats/actual expulsion.
statistics (only percentages and means), lack of standardised outcome measures, retrospective data collection for baseline (no mention of quality of this data keeping), different measure for follow-up, unable to determine treatment fidelity (relies on adolescent self-report), self-report collected by researchers, no control group, no blinding, threat of expulsion may have been the driver for behaviour change.
Meyer et al. (2004)
To undertake a process and outcome
Quasi-experimental: Treatment v
Participants were from the general school population,
Authors devised a questionnaire based on the
12-lesson multimedia curriculum based
Results show that both groups deteriorated rather than improved, although
Lack of randomisation, lack of blinding, lack of
8 Note, paper describes the client as having comorbid learning disabilities, however quotes his IQ as 105. It is therefore assumed that the authors are describing learning difficulties, as opposed to intellectual disability.
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USA based study.
evaluation of the Get Real About Violence Curriculum in a sample of adolescents. The intervention is aimed at reducing verbal and physical aggression and behaviours that may contribute to this aggression.
no-intervention control, but no randomisation.
Quantitative – including process and outcome evaluation.
168 in experimental school, and 125 in the control school.
Age=12-14 years.
55% male, 45% female – experimental school, 50/50 control school.
Ethnicity: Majority African American (approx. 77-80% across the two schools), “white” second most represented ethnicity (approx. 7-8% across the two schools), as well as Asian, Hispanic and “other” ethnicities.
Participants from a “moderate-sized Midwestern city”.
subcomponents of the TRA (e.g. behaviours, intentions, subjective norms, etc.) and measured these in relation to verbal aggression, spreading rumours about a fight, watching a fight and fighting.
Instructors completed questionnaires indicating their perspectives on delivering the intervention and students’ response to it.
5-month follow-up.
on the theory of reasoned action (TRA). Employs a range of mediums to promote a violence prevention messages. Themes include (amongst others) addressing attitudes and norms around violence and discussing alternative ways of resolving problems that do not involve violence. Control group = no intervention.
there was less decline in the experimental group than there was in the control group, and more instances of improvement in the experimental group on some of the measures. Experimental group significantly outperformed control group at post-test on intention to spread rumours (d=0.10), intention to watch a fight (d=0.16), and 3 of 12 measures of global beliefs and opinions about fighting and violence (d=0.06, 0.30, 0.29).
Post-tests occurred at 1 and 5 months after intervention, however there was so little change observed at 1 month that only 5-month data was used.
Teachers reported positive process outcome results, rating the curriculum “quite favourably” and observed that they would be likely to teach the curriculum again.
Note all effect sizes calculated via this author using
psychometrically robust measures (although author had piloted questionnaire), very broad definition of "outperformed" i.e. may have both got worse, but intervention group worsened less, therefore possible overstating claims.
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(mean 1-mean 2) / mean SD.
Kliewer et al. (2011)
USA based study.
To evaluate the efficacy of two school-based expressive writing interventions in a sample of 12-13 years olds living in a “high violence” neighbour-hood.
Experimental: Cluster randomisation to 1 of 3 conditions (2 x intervention, 1 x active control).
Quantitative.
258 7th grade students from a general school population (although in a deprived, high-crime area). Specific ages not mentioned but 7th grade=12-13 years.
Gender: Percentage male=40-52.1%.
Ethnicity: Percentage “African American” =87.6-97.4%.
Over 90% of participants had experienced 5 or more types of “victimisation”, e.g. being threatened, being slapped, hit or punched.
Participants
Outcomes included self and teacher reported data measured at baseline, 2 and 6-month follow-up.
Self-reported aggression: Rated on the Physical Aggression subscale of the Problem Behaviour Frequency Scalesd.
Teacher reports: Rated students on the Aggressive Behaviour subscale of the Achenbach System of Empirically Based Assessmente. Teachers also rated students’ emotional lability using the subscale from the Emotion Regulation Checklistf.
Participants were encouraged to write 2 x a week for up to 20 minutes on their deepest thoughts and feelings around violence. The intervention lasted for 8 sessions over a 5-week period. 3 conditions. 1) Standard expressive writing; 2) Enhanced expressive writing where students were encouraged to not only write, but also use other ways of expression such as poetry, song, etc.; 3) Control - writing about non-emotive topics.
2-month follow-up, Teacher-ratings: Aggression/lability was lower among youth in the standard expressive writing condition compared to the control (d=0.48), and the “enhanced” writing condition (d=0.31). Participants with high levels of community violence victimisation benefited the most from the standard expressive writing intervention on measures of teacher-rated aggression lability. Participants with increasing levels of witnessing community violence increasingly benefitted from the enhanced writing intervention, whilst all students showed a positive effect for the standard writing condition (effect size not quoted but displayed graphically).
Boys and girls benefitted equally.
However, students did not report the same positive
Different teachers completed some of the follow-up data therefore may have been different styles of rating, some of the teachers were not blind to treatment condition. No data available on those who declined to participate; lack of parent-report; benefits were relatively small (lack of dose); authors suggested incorporation into a bigger intervention may be helpful.
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attended 1 of 3 urban middle schools in South-Eastern USA.
NB. Teacher rated aggression and emotional lability were combined into a composite score due to high correlations.
findings that teachers did, and the positive teacher observations were not replicated at 6-month follow-up.
Farrell et al. (2003)
USA-based study.
To evaluate the impact of the Responding in Positive and Peaceful Ways–7 (RIPP-7) curriculum in sample of students who have previously received RIPP-6.
Experimental: Cluster randomisation via class into intervention v no intervention control.
Quantitative.
476 students (10 clusters, n=239 in intervention; 11 clusters, n=237 in control). All students should have received RIPP-6 in the previous year.
Clusters consisted of “nonspecial education” classrooms.
Gender: Intervention = 118 boys and 121 girls; control = 106 boys and 131 girls.
Age at start of school year = 11.9-15.9 years (mean = 12.8
Problem Behaviour Frequency Scales - student self-reportd.
Revised Children’s Manifest Anxiety Scaleg.
Knowledge of the intervention test
Attitudes towards violence via students indicating their level of agreement with statements relating to violenceh.
School disciplinary code
RIPP-7 is a 12 (weekly) session curriculum on developing skills based on respect, communication, and valuing friendship. It involves experiential exercises, including employing techniques from the martial art of Aikido. RIPP-7 builds upon RIPP-6 (a 25 session 6th grade curriculum based on social cognition and emotional processes). The focus of RIPP-7 is more on conflict resolution skills.
Complete data only on 195 students at 12-month follow-up.
No significant differences between intervention and control post-test regarding disciplinary code violations. However, during the beginning of the following academic year (8th grade), disciplinary code violations were over twice as high in the control group than in the intervention group (significant difference, rate ratio=2.1). Pattern continued in the latter half of 8th grade, though not as pronounced.
Gender differences: Boys in the intervention reported significantly lower rates of nonphysical aggression (delta=0.37), and greater
High levels of attrition and significant differences between the attrited students and those that stayed at school; more older students and those with a lower grade point average transferred out of school. Can only interpret programme as an add-on to RIPP-6, rather than a stand-alone programme. Intervention addressed violence prevention, as opposed to anger specifically.
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years).NB: Intervention didn’t begin until February of the academic year, hence mean age would have been > 13.
Ethnicity: 97% Black or African American.
Schools in Richmond, Virginia. High levels of poverty and crime.
violations.
Where possible, data was collected at post-test and 6 and 12-month follow-up.
levels of knowledge of course content (delta=0.65). At 12 months, they reported less favourable attitudes toward the use of violence (delta=0.34).
Pre-test violence levels: Those with higher pre-test levels of violence who received the intervention had lower predicted follow-up scores. General pattern of treatment effects increasing as pre-treatment violence levels increase. Similar pattern observed for nonphysical aggression and delinquent behaviour (mixture of significant and non-significant results).
No other notable significant effects.
Conclusions: Main effects not hugely supportive, but better results for those with high pre-test scores and for boys.
Yeager et al. (2013)
To evaluate the effectiveness of an
Experimental: Intervention (incremental theory group)
230 9th and 10th graders completed the intervention (14-16 years).
Questionnaires measuring adolescents’ implicit theories
Compared effectiveness of an incremental theory intervention with a
Only 74% provided post-survey data.
Incremental theory group
Short interventions so may not be representative of all coping skills
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USA-based study.
incremental theory intervention compared to a coping skills intervention in reducing aggressive responses to victimisation.
v treatment control (coping skills) v no treatment control.
Cluster randomisation via class.
Quantitative.
Sub sample of 92, collected at 4-weeks post intervention.
Gender: 55% male, 45% female.
Ethnicity: 57% Latino, 10% Asian American, 9% African American, 17% White (non-Latino), and other.
64% of students received free or reduced price lunch.
Medium-large school in San Francisco, randomly selected from local large schools.
of personality, e.g. asked to agree/disagree with the statements about whether certain people (e.g. bullies) can changei.Baseline aggression=peer reported aggression levelsj.
Experimental computer game designed to assess level of aggression (and prosocial behaviour) in response to victimisation and exclusionk,l.Depressive symptoms via the Children’s Depression Inventorym.
Self-reported levels of peer victimisation.
3-months post
generic coping skills intervention in reducing aggression in response to victimisation and exclusion. Each intervention consisted of 6 x 50 minute sessions over 3 weeks. Interventions were similar in content, but two key differences: incremental theory intervention taught the idea that people have the potential for change, whilst the coping skills intervention taught skills for thinking positively and coping productively in the face of victimisation or exclusion.
participants assigned their victimisers significantly less hot sauce (measure of aggression) than their coping skills group peers, although not significantly less than no intervention control group. (d=0.47 when comparing intervention to two control groups combined; no further effect sizes provided.) They also wrote significantly more pro-social notes to their fictional aggressors than control groups (d=0.86).
Teachers nominated incremental theory group participants significantly more frequently for having reduced conduct problems than controls (d=0.29). This effect was further qualified by peer victimisation status; amongst those who had been victimised by peers, teachers were more likely to nominate those in the incremental theory group as having reduced their conduct problems than controls (d=0.66).
Amongst those who
interventions. Is this the most ecologically valid measure of aggression (computer game)? Short follow-up (at 3 months, only the teacher measure was used, others sooner). Perhaps too specific in its focus on type of aggression for generalisation.
62
intervention: Teachers reported on reductions in conduct problems.
experienced peer victimisation, both incremental theory and coping skills participants showed significantly less depressive symptoms post group, compared no intervention controls (d=0.60 and 0.66).
Incremental theory group participants were significantly less likely to be absent or late (d=0.27) than control groups combined.
a. Thomaes, Stegge, Bushman, Olthof, and Denissen (2008); b. Harter (1988); c. Bradley and Lang (1994); d. Farrell, Kung, White, and Valois (2000); e. Achenbach (1991b); f. Shields and Cicchetti (1995); g. Reynolds and Richmond (1978); h. Farrell, Meyer, and White (2001); i. Yeager, Trzesniewski, Tirri, Nokelainen, and Dweck (2011); j. Thomaes et al. (2009); k. Williams and Jarvis (2006); l. Lieberman, Solomon, Greenberg, and McGregor (1999); m. Kovacs (1992)
63
Discussion
The literature review has examined what research has been published since
2000 in regard to interventions for anger and aggression in adolescent males. This
review builds on previous reviews/meta-analyses by focusing on more recent
research, broadening the focus from CBT-only interventions, and focusing solely on
adolescents. On the whole, the review supports some of the earlier findings; the
literature is still predominated by a CBT approach, which tends to facilitate some
improvements, which may or not be maintained long-term. The review also included
evaluation of alternative interventions, which show some tentative support for their
effectiveness, e.g. mindfulness (Singh et al. 2007), and the skills-based curriculum
approach initiated by Farrell et al. (2003).
The review highlights that there are a number of programmes that appear to
work well for reducing anger and aggression in adolescents, at least to some extent;
e.g. Humphrey and Brooks (2006) found positive results, with effect sizes ranging
from 0.40 to 0.62. Several of the studies used a randomised controlled trial approach,
strengthening the validity of their results. In addition, the majority of programmes
used multiple informant perspectives when recording outcomes, and several
supplemented questionnaire data with more ecologically valid outcomes (e.g. school-
based behavioural measures). Furthermore, some of the researchers have explored
the characteristics of participants and discovered helpful information about the
effectiveness of programmes. For example, several studies either demonstrated
(Farrell et al., 2003; Langeveld et al., 2012) or suggested based on their findings
(Moynahan & Strømgren, 2005; Puskar et al., 2009) that interventions may be more
effective when targeted specifically at “at-risk” adolescents. Given that 7 of the 18
studies focused on a “general population”, there is clearly a need for more targeted
64
intervention for vulnerable young people. There was also a suggestion from some
studies that differentiating programmes by gender (Farrell et al., 2003) and age
(Martsch, 2005) may be helpful. Intuitively appealing adaptations and/or suggestions
for adjustments to programmes were also provided, including the use of a workbook
to structure a programme (Williamson et al. 2013), and the use of technology and
media to appeal to modern youth (Puskar et al., 2009). The use of a “higher dosage”
or additional booster sessions (as suggested by Herrmann & McWhirter, 2003) may
be helpful, as some studies have shown short-term treatment gains (e.g. Thomaes et
al., 2009). Alternatively, incorporating effective brief interventions into broader
intervention packages (as suggested by Kliewer et al., 2011) may help with
improving and/or maintaining treatment gain, and (due to their brevity) could
potentially reduce attrition.
Considering areas for future development, whilst there is evidence that CBT
can effect change, the lack of diversity in interventions is limiting. There were some
interesting “one-off” interventions that may warrant further exploration and
validation. For example, two studies (Thomaes et al., 2009; Yeager et al., 2013)
focused on specific “types” of aggression and their potential causal factors.
Classifying aggression in this way may be helpful to consider in future research; if
interventions are designed at targeting the “causes” of anger and aggression, it would
be helpful to know the “type” of aggression being targeted. This may be less relevant
for interventions targeting how individuals respond to feelings of anger.
Many of the studies in the review experienced methodological difficulties.
Critical problems included small sample size, lack of long-term follow-up, lack of
inferential statistics, attrition, and limited outcome measures. Additionally, the
variety of measures used across studies creates difficulties in making comparisons
65
between interventions. There were also incidents of authors making unsubstantiated
conclusions (e.g. Hanselman, 2001). Only five studies adopted a mixed-methods
approach; whilst the qualitative data from these was not analysed in this review, a
lack of qualitative data generally across studies could result in a fairly superficial
exploration of interventions, and a lack of clarity over what the effective mechanisms
of change are within interventions. Only two studies focused solely on boys, despite
there being evidence for differential effects of the interventions on boys and girls
(e.g. Langeveld et al., 2012). Finally, the majority of the studies (12) were based in
the USA, raising questions over the generalisability of the findings. This issue of
generalisability is further complicated by the heterogeneous populations within the
USA-based studies.
In conclusion, the literature review highlights that further research is required
in the field of adolescent male anger and aggression. Positive examples of helpful
interventions have been found (effect sizes up to d=1.79; Robinson et al., 2002), but
also a lack of volume and breadth in the twenty-first century research field. There are
historically well-established interventions for anger, based around a social-cognitive-
behavioural framework, and indeed some more recent research continuing to support
this (e.g. Humphrey & Brooks, 2006). However this approach does not produce
consistently, clear positive results (e.g. Williamson et al., 2013), and results are not
always maintained at long-term follow-up (e.g. Puskar et al., 2009/2015). In addition,
the approach is not acceptable to all, evidenced by the level of attrition experienced
in some studies (e.g. Herrmann & McWhirter, 2003; Martsch, 2005). Addressing
this, there are also some examples of emerging unique and innovative programmes.
However, on the whole, the field is lacking in diversity of approach. Research into a
broader range of therapies, including interventions specifically targeted at adolescent
66
males (particularly “at-risk” individuals) would be helpful. Future studies should also
aim for greater methodological rigour including long-term follow-up, a range of
outcome measures, and more studies conducted within the UK. This is essential for
drawing any substantial conclusions about the effectiveness of these interventions
going forward. In addition, researchers should consider following the example of
Herrmann and McWhirter (2003) and involve young people in the design of
intervention programmes, to ensure that therapies appeal to modern youth; whether
this be via inclusion of technology or creative techniques requires further
consideration and discussion with the client group. Given the current prevalence of
conduct disorders in boys, there is still much need and scope for new, innovative,
targeted interventions for adolescent boys with anger difficulties.
67
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Research Part 2 – Empirical Paper
Title: Taking ACTion on Anger: A feasibility study investigating
the effectiveness and acceptability of an ACT-based anger intervention for
adolescent males in a school-context.
Word count 9998 (excluding abstract, tables, figures, references, and
appendices)
82
Abstract
Introduction: Conduct disorder (and associated anger and aggression) is
prevalent amongst UK adolescent males, and can result in significant individual and
societal consequences. Interventions to support this client group are therefore vitally
important. Current evidence supports a cognitive behavioural therapy (CBT)
approach to managing anger, however few alternatives are available, and existing
interventions are not targeted specifically at males. This study aimed to address this
by drawing on the growing research interest in ‘third-wave’ therapies. The purpose
of this study was to evaluate the acceptability, feasibility, and preliminary
effectiveness of a short-term ACT-based group anger intervention for adolescent
males.
Method: A mixed-method pre-post design was employed. Participants were
year 8 and 9 adolescent males with mild-moderate anger difficulties, recruited from a
school setting. The 5-week intervention, entitled “Taking ACTion on Anger”, was
delivered in school. The Strengths and Difficulties Questionnaire (SDQ), Adolescent
Anger Rating Scale (AARS), and the Mindful Attention Awareness Scale-
Adolescent (MAAS-A) were collected at pre-group, post-group and at 3-month
follow-up. A focus group was also completed at post-group and analysed via
Inductive Thematic Analysis.
Results: Of the 17 participants who began the intervention, 15 completed.
The intervention was acceptable to the boys, and relatively feasible to run in a
school. Repeated measures analysis of variance (ANOVA) comparisons between the
three time points were largely non-significant. Positive changes were suggested by
the effect sizes and the qualitative analysis. Questionnaires were largely unacceptable
to the boys and raised issues of reliability.
83
Conclusion: Preliminary support was found for the acceptability and
feasibility (with some modifications) of “Taking ACTion on Anger”. Effectiveness
of the intervention was supported in the qualitative data, but requires further
quantitative verification. Future research should consider different outcome
measures, a larger sample, and the use of a control group to achieve power and
evaluate cause-effect relationships.
Key words: adolescent, anger, aggression, intervention, boy, ACT, acceptance and
commitment therapy
84
Introduction
A recent UK survey of 48 Child and Adolescent Mental Health Services
(CAMHS) reported that 276,468 children and young people were referred to these
services over the course of a year. 41% of these referrals were for males, with the
majority being over 11 years old (Children’s Commissioner for England, 2016).
National figures suggest that 1 in 10 children suffer from a mental health problem,
with conduct disorders being the most common, experienced by 5.8% of all children,
6.6% of adolescents, and 8.1% of adolescent males (compared to 5.1% of adolescent
females) (Office for National Statistics, 2005). Conduct disorder includes displays of
aggression (American Psychiatric Association, 2013); given the link between anger
and aggression, it is reasonable to assume that many of these boys have difficulties
with managing anger. Furthermore, research in America highlights that the
“diagnostic” picture may significantly underrepresent the prevalence of anger-related
issues (see McLaughlin et al., 2012). Parsonage, Khan and Saunders (2014) suggest
that a child with conduct problems can carry an economic cost of approximately
£260,000. Effective interventions addressing the difficulties that these young men
experience is therefore important at an individual and societal level.
There currently exists a good evidence base for CBT-based interventions for
anger (see Beck & Fernandez, 1998), and specifically for anger in children and
adolescents (see Sukhodolsky, Kassinove, & Gorman, 2004). Interventions based on
social cognitive-behavioural problem-solving approaches are recommended in
current National Institute for Clinical Excellence (NICE) (2013) guidelines for
children and young people with antisocial behaviour and conduct problems. However
CBT approaches are not for everyone; a recent literature review of anger
interventions for adolescent males (Livings, John, & Morison, unpublished thesis)
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highlighted that whilst some research has continued to support the
social/cognitive/CBT framework (e.g. Down, Willner, Watts & Griffiths, 2011;
Humphrey & Brooks, 2006), effective results from this approach are not guaranteed
(e.g. Puksar, Grabiak, Bernardo & Ren, 2009). Furthermore, today’s adolescents are
very different to those researched at the peak of interest in this field (c. 1990s). One
of the most notable differences is the increased availability of the internet and social
media, with 92% of American teenagers reportedly going online every day (Pew
Research Centre, 2015), potentially leaving little space for ‘down-time’ or reflection.
This lack of ‘head space’ may be relevant to consider when designing interventions
relevant for ‘Generation Z’ (see Strauss & Howe, 1991), as for some of these young
people it may be helpful to learn ways of ‘getting out’ of their preoccupied minds,
rather than (or in addition to) learning to ‘challenge unhelpful thinking’.
Multi-Systemic Therapy (MST) has also produced positive outcomes for
clients with complex difficulties (e.g. Weiss et al., 2013) and is recommended by
NICE (2013) for young people aged 11-17 with conduct disorders. However MST
requires a full-time therapist being available to see a family 24/7 (Fonagy, Target,
Cottrell, Phillips, & Kurtz, 2005). Given the current financial constraints on the UK
public sector services, interventions with lower costs are desirable.
In addition to the difficulties mentioned with CBT and MST, Livings, John
and Morison (unpublished thesis) highlighted a lack of diversity of interventions,
limited interventions targeting males, and a lack of UK-based studies. Whilst there is
clearly a valid place for CBT and MST, there has more recently been a movement in
research towards ‘third-wave’ therapies9. In particular, mindfulness and ACT-based
approaches may be relevant for this client group for several reasons.
9 As of December 2016, 171 RCTs of ACT had been published (see Hayes, 2016).
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Firstly, their theoretical underpinnings fit well with the concept of anger.
ACT is a transtheoretical model based around 6 core constructs. Each of these core
constructs may be helpful for dealing with problem anger and aggression in the
following ways; 1) Contact with the present moment – aimed at focusing attention on
the here-and-now, rather than in the past or future (e.g. ruminating or plotting
revenge); 2) Acceptance – learning to sit with difficult thoughts and feelings (such as
anger) rather than having to do something with them (such as lashing out); 3)
Cognitive defusion – creating separation from powerful thoughts (e.g. “he’s taking
me for a mug!”), and noticing these simply as thoughts, as opposed to something that
one has to action; 4) Self-as-context – becoming in touch with the part of oneself that
is the container of thoughts, feelings, memories, etc, and noticing them pass by,
rather than being caught up in these experiences; 5) Values – re-connecting with
what is important to you (e.g. being caring, rather than being aggressive), and 6)
Committed action – taking action in line with your values, rather than action that
may steer you away from them (see Harris, 2009). Eifert and Forsyth (2011) have
explored an ACT approach to managing anger, publishing a self-help book on this
(Eifert, McKay, & Forsyth, 2006). Roberton, Daffern and Bucks (2012) described
the difficulties with under-regulation of anger (e.g. acting out anger) and over-
regulation (e.g. suppression), and posit that emotional acceptance, awareness and
flexible emotional regulation strategies may be helpfully integrated into
interventions, making specific reference to mindfulness and acceptance based
approaches. Wright et al. (2009) described how mindfulness and acceptance could be
helpful for anger, via observation of one’s experiences improving tolerance of them,
breaking ruminative cycles, and improving self-awareness leading to more conscious
choices about behaviours. Denson (2015) also discussed the mechanisms by which
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mindfulness and other strategies may help with reactive anger (see figure 1),
highlighting the link between mindfulness and possible improved executive
functioning (see Chiesa, Calati & Serretti [2011] for a review of this literature).
Mindfulness-based interventions for anger may therefore have wider implications
than simply reducing reactive aggression.
Figure 1. Theoretical impact of interventions for reactive anger (Denson,
2015)
Secondly, third-wave interventions are generating significant evidence to
support their effectiveness across a range of populations and presentations. Weare’s
(2012) review of mindfulness based interventions with children and adolescents
reported its beneficial effects on a wide range of variables, including wellbeing,
depression, attention, anxiety, and behavioural problems, and are well-tolerated by
young people (Burke, 2010; Huppert & Johnson, 2010). Similarly, ACT has been
researched as a therapeutic intervention for depression, pain, stress, anxiety, and
psychosis, with results showing tentative support for its effectiveness (see Öst, 2014;
Powers, Zum Vorde Sive Vording, & Emmelkamp, 2009; and Ruiz, 2012). However
ACT research on adolescents is still very much in its infancy. In their 2011 review,
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Murrell and Scherbarth found only four published studies of ACT with adolescents.
More recently, Livheim et al. (2015) conducted a “transdiagnostic test” of ACT with
adolescents, by piloting an intervention with Australian adolescents with depression,
and Swedish adolescents experiencing stress. Australian participants showed
significant improvements in depressive symptoms (d=0.86) and decreases in
psychological inflexibility (d=0.73). In the Swedish sample, measures of stress
improved significantly in the ACT group (d=1.2). The transdiagnostic support
currently being generated for third-wave therapies suggests that they have the
potential to be helpful for anger too.
Further potential benefits of third-wave therapies to this client group include
the fact that mindfulness and its focus on ‘being present’ may be a helpful antidote to
the stress of the twenty-first century communication age, and the preoccupied mind
that this may generate. The interventions can also be delivered in group10 formats,
and may therefore be cost-effective.
In light of the above, the aim of this study was to design, deliver, and
evaluate the feasibility, acceptability, and preliminary effectiveness of a novel ACT-
based anger intervention for adolescent males. As there is a clear need for low-cost,
preventative approaches, the proposed intervention – entitled “Taking ACTion on
Anger” - was a short-term (5-week) skills-based intervention that could be delivered
in groups in school to boys with mild-moderate anger difficulties.
The research aimed to address the following questions:
1. How acceptable is an ACT-based intervention to adolescent males with
anger difficulties?
10 MBSR and MBCT are both group programmes, and ACT has previously been delivered in group format (e.g. Livheim et al., 2015).
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2. How acceptable are the measures used?
3. Following intervention, were there any changes observed in the
adolescents on anger, wellbeing, and ACT variables?
3a. Were there any changes on measures of instrumental anger,
reactive anger, anger control, and total anger, as measured by the
Adolescent Anger Rating Scale?
3b. Were there any changes in general wellbeing, as measured by the
Strengths and Difficulties Questionnaire?
3c. Were there any changes in levels of mindfulness, as measured by
the Mindful Attention Awareness Scale – Adolescent version?
3d. Were there any changes in levels of distress tolerance, as
measured by the Computerised Mirror Tracing Persistence Task?
3e. Were there any changes in value-guided living, as measured by the
Valued Living Questionnaire?
4. How feasible is it to provide an ACT intervention within the school
context?
Method
Study design
The study follows a within-participants mixed-methods quasi-experimental
design. Participants were compared against themselves at pre-treatment, post-
treatment and 3-month follow-up. The study follows a “Triangulation: Convergence”
model (Cresswell & Clark, 2011) whereby quantitative and qualitative data are
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collected concurrently and given equal weight, analysed separately, and merged at
the interpretation stage. To lessen the possibility of bias, qualitative data was
analysed first.
The study formed part of a parallel research project. Both researchers
contributed equally to the design and facilitation of the intervention. The projects
were separated at the data analysis stage; the author of this research project analysed
data gathered from the adolescents, whilst the parallel-researcher analysed data
gathered from the school and teachers.
Participants
School demographics: Participants were recruited from year 8 and 9 male
students attending a secondary school in inner-city London, UK. The school is in the
top 30% most deprived neighbourhoods of the country. Recent school OFSTED
reports indicate that nearly three-quarters of students are eligible for support through
the pupil premium fund11 and there are a higher number of minority ethnic
backgrounds than most schools of similar size. There are slightly more male than
female students, and almost 40% of students do not have English as their first
language.
Recruitment process. Senior Leadership Team (SLT) members were
provided with the inclusion criteria for the pupils’ participation (see table 1) and
subsequently selected students for inclusion. SLT members were advised that the
intervention was targeted at students who would typically be presenting with
persistent disruptive behaviour in class connected to anger and aggression, but that
their difficulties were not so severe that they were (for example) having regular
contact with the criminal justice system. The researchers thus relied largely on
11 The pupil premium fund is allocated to students who are either looked after children or eligible for free-school meals.
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teacher assessment of “mild-moderate” anger difficulties, guided by the above
information and inclusion / exclusion criteria. Students and parents were contacted
by the research team to discuss participation and gain consent from both parties.
Table 1
Inclusion and Exclusion Criteria
Inclusion criteria Exclusion criteria
Displaying a moderate level of difficulty managing anger/aggression.Communicates in English.Attends school regularly.
Receiving psychological intervention elsewhere.
Severe and enduring mental health difficulties.
Identified as high risk of harm to self or others, e.g. expressing suicidal ideation, or extensively involved with the criminal justice service.
Not in mainstream schooling (e.g. internally excluded).
Unable to speak or read English.
Neurodevelopmental disorders including autism.
Final sample. Sample size was limited by the practical constraints of the
school and the feasibility nature of the study. It was agreed with the school that three
groups containing 5-7 students would run, providing a total sample of 15-21
participants. For the quantitative outcome measures, using repeated measures
ANOVA analysis at three time points, this is sufficient for detection of large effects
(partial η2=0.14; power=0.80, α=0.05, required sample=12).12 18 individuals were
subsequently invited to participate in the intervention, 17 of which consented and
commenced the programme, and 15 completed the programme13. 14 participants
provided the complete data set, all of which were in year 9 (2 of the 3 who failed to 12 Using the same power and α, to detect a medium effect (partial η2 =0.06) would require a sample of 28, and to detect a small effect (partial η2 =0.02) a sample of 82. 13 See attendance / attrition section in results section for further information.
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provide the full data set were in year 8), and were aged 13-14 (mean=13.77). School
records indicated 10 of the participants were “Black or Black British”, two were
“White”, and two were “Mixed or Dual background”. 14 of the 15 programme
completers participated in the focus groups. The remaining participant in group one
was interviewed separately as he was not in school on the day of the scheduled focus
group; his data was transcribed and analysed in the same manner as the focus group
data.
Measures
Quantitative measures – Self report. A range of questionnaires were
selected to assess change between the three time points (see table 2 / appendix 2 for
full details).
Adolescent Anger Rating Scale (AARS) (Burney, 2001). The AARS is a 41-
item self-report anger scale, with responses scored on a Likert scale ranging from 1-
4. Participants are asked to rate how often they have experienced a series of
situations when angry, e.g. “have difficulty controlling my temper”. Response
options range from “hardly ever” to “very often”. The AARS consists of three
subscales: ‘Instrumental Anger’ (IA), ‘Reactive Anger’ (RA), and ‘Anger Control’
(AC), which can be combined14 to give a Total Anger score. Higher scores (lower for
AC) indicate greater difficulties with anger. Burney (2001) reports high internal
consistency, ranging from α=0.81-0.92 across scales15.
Strengths and Difficulties questionnaire (Youth report version) (SDQ)
(Goodman, 2001). The SDQ is a 25-item self-report measure of overall wellbeing in
children and adolescents. Respondents are presented with a series of statements
14 See manual (Burney, 2001) for details of how scales are combined. 15 Using the norms provided, it is impossible to score below “average” for IA, and below “moderately low” for RA and AC for the comparison group used for this study (boys grades 6-8).
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about their wellbeing, e.g. “I get very angry and often lose my temper”, and provide
answers on a 3-point Likert scale, ranging from “not true” to “certainly true”. In an
initial pilot study of UK 11-16 year olds (Goodman et al., 1998), internal consistency
was generally good although varied across its five subscales (α=0.61-0.82). The five
subscales include: emotional symptoms (α=0.75), conduct problems (α=0.72),
hyperactivity-inattention (α=0.69), peer relationship problems (α=0.61), and a
prosocial scale (α=0.65). The first four subscales are combined to create an overall
‘total difficulties’ score (α=0.82). In addition, the hyperactivity-inattention and
conduct subscales are combined to create an ‘externalising difficulties’ score, whilst
the emotional symptoms and peer relationship problems subscales are combined to
create an ‘internalising difficulties’ score. Higher scores (lower for prosocial scale)
are indicative of greater difficulties. The scores are classified, ranging from “close to
average” to “very high” (or “very low” for prosocial scale) (see appendix 3). These
categories are developed from a UK sample (see
http://sdqinfo.org/py/sdqinfo/c0.py16).
The Mindful Attention Awareness Scale – Adolescent version (MAAS-A)
(Brown, West, Loverich & Biegel, 2011). The MAAS-A is a 14-item questionnaire
assessing levels of mindfulness. Participants complete answers on a 6-point scale,
ranging from “almost always” to “almost never”, which are then averaged to give a
mean mindfulness score (range=1-6). An example includes “I find myself doing
things without paying attention”. In their sample of 14-18 year olds, Brown et al.
(2011) reported high internal consistency (α=0.82 and 0.84).
Valued Living Questionnaire (VLQ) (Wilson, Sandoz, Kitchens & Roberts,
2010). The VLQ assesses the ACT concept of “values”. It contains 10 valued living
16 A peer-reviewed publication does not exist for these norms. Personal communication with the author of the SDQ (Goodman) advised referencing the “youth in mind” website for this data.
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domains (e.g. family relations, education/training, recreation) and participants are
asked to rate on a 1-10 scale a) how important each of these domains are to them,
with 1 being “not at all important” and 10 being “extremely important” and b) how
consistently they have lived by them over the past week, with 1 being “not at all
consistent with my value”, and 10 being “completely consistent with my value”.
Internal consistency varied across the authors’ two studies (α=0.58-0.83; second
study α=0.75-0.77).
Quantitative measures – Behavioural.
The computer-based Mirror Tracing Persistence Task (MTPT) (Strong et
al., 2003). The MTPT was selected as a measure for distress tolerance, which
requires participants to trace the outline of an object with the cursor on a computer
programme, whilst the cursor is programmed in reverse, i.e. when moving the mouse
left, the cursor moves right. When a participant takes too long to move the cursor, or
makes errors, a loud error sound is made and the participant must start again.
Frustration tolerance is measured via time elapsed before participants quit the task.
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Table 2
Details of Measures
Authors Measure Age group Description of measure Details of scales Psychometric properties
Burney (2001)
Adolescent Anger Rating Scale (AARS)
11-19 year olds
41 item self-report scale measuring instrumental anger, which measures the “rate and intensity of delayed angry responses that result in a desired and planned goal of revenge and/or retaliation”; reactive anger, measuring the “rate and intensity of angry responses that are immediately expressed when an event is perceived as negative, threatening, or fearful”; and anger control, measuring “an adolescent’s propensity to proactively resolve instrumental and/or reactive responses to anger”. Questions are measured on a 4 point Likert scale. Higher scores = greater difficulties managing anger.Norms were developed from
Instrumental scale range = 20-80Reactive scale range = 8-32Anger Control scale range = 13-52Total Anger = 41-164
Cronbach’s alpha for boys grades 6-8:Instrumental = 0.92; Reactive = 0.81; Anger control = 0.84 Total scale = 0.92
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a sample of 4,187 adolescents in the USA.
Goodman (2001)
Strengths and Difficulties Questionnaire (Self-Report) (SDQ-SR)
11-17 years 25 item self-report questionnaire, 3 point Likert scale. Scale covers: 1. emotional symptoms, 2. conduct problems, 3. hyperactivity/inattention, 4. peer relationship problems, 5. prosocial behaviour.Higher scores = greater difficulties (excluding prosocial scale where higher scores = higher prosocial behaviour).Sum of scales 1-4= total difficulties score Sum of 1 and 4 = internalising difficultiesSum of 2 and 3 = externalising difficulties
Scales 1 – 5 range = 0-10Internalising range = 0-20Externalising range = 0-20Total difficulties range = 0-40
Pilot study (Goodman, Meltzer & Bailey, 1998) Cronbach’s alpha in a sample of 11-16 year olds:Total difficulties: 0.82Emotional symptoms: 0.75Conduct problems: 0.72Hyperactivity: 0.69Prosocial behaviour: 0.65Peer problems: 0.61
Retest stability. Total difficulties: 0.62Emotional symptoms: 0.57Conduct problems: 0.51Hyperactivity: 0.60Prosocial behaviour: 0.51Peer problems: 0.54
Brown, West, Loverich and Biegel (2011)
Mindful Attention Awareness Scale – Adolescent (MAAS-A)
14-18 years 14 item, 6 point Likert self-report scale assessing mindfulness, defined as “a receptive state of mind in which attention, informed by a sensitive awareness of what
Mean scores can range from 1-6.
Cronbach’s alpha = 0.82 and 0.84
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is occurring in the present, simply observes what is taking place” (pp. 1024). Higher scores = higher levels of mindfulness. Participants are given a mean score over the 14 items (range = 1-6).
Wilson, Sandoz, Kitchens & Roberts (2010)
Valued Living Questionnaire (VLQ)
No specific age clearly recommended but piloted on undergraduates.
Originally used as therapeutic tool within act. 10 different valued domains. Each of the 10 valued domains are rated on Likert scales ranging from 1-10.Participants rate a) how important each of these are to them, and b) how consistently they have been living their life by them over the past week. The two scores are then combined to create a composite score; a measure of how much an individual has been living life by values that are important to them.
Importance score = sum of 10 valued domains. Range = 10 -100. Consistency score = sum of 10 valued domains. Range = 10 -100.Composite score = “the product of the Consistency and Importance ratings […] calculated for each domain represented in thequestionnaire. The mean of these products is the valued living composite.” (p. 257).
Cronbach’s alpha:Ranged from 0.58 to 0.83 in first study but better in second study (0.75 to 0.77).
Test retest reliability:Importance scale: Overall = 0.9. Individual items ranged from 0.61 to 0.82.
Consistency Scale: Overall = 0.58. Individual items ranged from 0.43 to 0.61.
Composite score: Overall = 0.75. Individual items ranged from 0.57 to 0.79.
Strong, Lejuez,
Computerised Mirror Tracing
Unclear what age range
Distress tolerance task whereby participants trace the
n/a n/a
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Daughters, Marinello, Kahler & Brown (2003)
Persistence Task
originally designed for (likely adults given its basis in addictions research), however has since been used in research with adolescents aged 10-14 (Seymour, Macatee & Chronis-Tuscano, 2016)
outline of a shape on a computer screen. The cursor moves in the opposite direction. A buzzer sounds and the cursor returns to the start if the participant moves the cursor outside of the shape outline or pauses for more than two seconds. Participants can end the task by pressing a certain key. Distress tolerance is measured by time taken to terminate task.
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Qualitative measures. A semi-structured exploratory focus group was
completed with the participants at post-group. The focus group interview questions
were designed by the research team (see appendix 4).
Process notes / informal measures. Facilitators completed unstructured
interviews of one another after each group and recorded informal journal-style
process and content notes on each session delivered (see example in appendix 5). A
briefer focus group was also completed with the participants at 3-month follow-up
(appendix 6). This data was not subject to formal analysis; however the 3-month
participant data was transcribed and reviewed at a more surface level to establish
what the participants had remembered, and if any further reflections had arisen since
the end of the group that may confirm or contradict the themes that arose from the
post-group focus groups.
Procedure
Process of developing intervention. The intervention was designed by the
author and the parallel researcher. The development of the intervention was overseen
by the research supervisor, an experienced CAMHS clinical psychologist. External
consultation was also sought on the protocol from an experienced clinical
psychologist with extensive practise of delivering and supervising individual and
group-based ACT interventions. Consultation on the appropriateness and
acceptability of the content to an adolescent audience was sought via a focus group
with an opportunity sample of adolescent males. The protocol was modified
accordingly following all stages of consultation.
The protocol drew on existing ACT literature, including “ACT on life, not on
anger” (Eifert et al., 2006), and “Get out of your mind and into your life for teens”
(Ciarrochi, Hayes, & Bailey, 2012). The sessions were structured around the
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“hexaflex” ACT model, with each activity aimed at developing one or more of the
six core ACT constructs.
To ensure the content was engaging and relevant, there was an emphasis on
interactive exercises, metaphors, adapted mindfulness exercises (e.g. mindfulness of
music), popular culture, and role models. An accompanying workbook provided key
points from each session, with space to complete exercises and homework activities.
The workbook also aided manualisation of the intervention and promoted treatment
fidelity.
Intervention delivery. The intervention and focus groups were delivered by
the author and the parallel researcher. A school-based facilitator also attended each
session to ensure that school policies were adhered to. The programme ran for five
weeks, with each session lasting for one hour, with additional time in the final
session for completing measures and the focus group. A preliminary session involved
discussing information sheets, gaining consent to participate from the young people,
and completing pre-group questionnaires. The school-based facilitator was assigned
to facilitate a weekly mindfulness practice between scheduled sessions17. A summary
of the session structure can be seen in table 3, and full details of the protocol can be
found in appendix 7.
Table 3
Summary of Programme Structure
Session Content
17 Due to school staff issues, the school-based facilitator changed between group 1 and group 2. The same individual facilitated groups 2 and 3.
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Preliminary session Information sheets, consent forms, pre-group measures
Session 1 – Chilling with your tiger: For warriors, not zombies
Introducing key metaphors – Mindless Zombie, Wise Warrior, and Anger TigerIntroducing Defusion, Committed Action, Acceptance, and Mindfulness
Session 2 – Pursuing your values with courage and strength
Dropping the struggle with experiential avoidance via embracing acceptanceValues – what do you want people to say about you at your 18th birthday party?Role models activity – LeBron James
Session 3 – The “Anger Mask”
Video clips and discussions around what emotions anger masks – link to Acceptance and Choice PointIntroduced Self-As-Context - sky and weather metaphorDefusion – using “silly” accents
Session 4 – Dropping the struggle
The illusion of control – idea of not having control over one’s feelings (“Fall in Love with the Spot on the Floor”) but having control over actions via practicing acceptance (“Urge Surfing”)
Session 5 – Becoming a wise warrior for good
Review of metaphors, key concepts, and key activities Action planning and goal settingCertificates of achievementPost-group measures including focus group
Analytic strategy. Both quantitative and qualitative data were used to
address the four research questions.
Quantitative analysis. Attendance data was used as a proxy-measure of
acceptability of the group. Acceptability of the measures were explored via looking
at completion rates, floor and ceiling effects, and calculation of Cronbach’s alpha.
Repeated measures ANOVAs were used to explore differences between the three
time points on the questionnaire data. In addition, effect sizes (Cohen’s d) were
calculated for pre-post and pre-follow-up comparisons. Given the small sample,
small N analysis was undertaken; reliable and clinical change calculations were
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computed for each of the participants using the Leeds Reliable Change Calculator
(Morley & Dowzer, 2014). Feasibility was assessed via attendance data.
Qualitative analysis. Focus group data was used for each of the research
questions. The three focus groups were subject to inductive thematic analysis,
following Braun and Clarke’s (2006) suggested approach. The author adopted a
critical realist perspective, focusing largely on manifest content. Given the feasibility
nature of the research, and the relatively few existing studies on ACT with
adolescents or ACT with anger, it was felt that a data-driven rather than theory
driven approach would be appropriate. The mixed-methods approach was more
aligned to a critical-realist perspective than a social constructionist perspective,
hence the focus on manifest content. However, the author was alert for any notable
exceptions in which the participants’ words may have had more than one meaning;
for example, if their words contradicted their non-verbal cues, or if it was very
apparent that their intended message was different from their spoken words.
Recordings of each focus group were listened to several times and transcribed
by the researcher. Each transcript was read and re-read to gain initial familiarity with
the data and generate ideas for codes. Each transcript was then coded, and re-coded
when overlap was observed between codes. Consultation with the supervisor
occurred to ensure initial codes had appropriate face validity and sufficient depth of
analysis, and to discuss initial theme generation. The above process was then
repeated for the individual interview that occurred with one participant in group one
who was absent from the focus group. No new codes emerged for this interview.
Codes were then organised into initial themes, and transcripts were again reviewed
and recoded when necessary. Movement back and forth between codes and themes
occurred until final themes were generated that were sufficiently coherent and
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explained the majority of data. Finally, appropriate extracts were selected to
represent the predominant themes that emerged. All participants were given
pseudonyms to protect anonymity. An audit trail of this process and examples of
coded extracts can be seen in appendix 8.
A summary of how the data was analysed in relation to the research questions
is displayed in table 4.
Table 4
Analytic Strategy
Research question Quantitative analysis Qualitative analysis
How acceptable is an ACT-based intervention to adolescent males with anger difficulties?
Attendance Focus groups
How acceptable are the measures used?
Missing data / whether measures were completed or notFloor and ceiling effectsCronbach’s alpha
Focus groups
Following intervention, were there any changes observed in the adolescents on anger and ACT variables?
ANOVAEffect sizesSmall N analysis
Focus groups
How feasible is it to provide an ACT intervention within the school context?
Attendance Focus groupTreatment fidelity
Ethical approval. Ethical approval was acquired from the Faculty of Arts
and Human Sciences at the University of Surrey (see appendix 9). Given the age of
the participants, both the individuals taking part and their parents provided informed
consent for the young people to participate in the research (see appendix 10).
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Students and parents were provided with a written information sheet. Consent from
parents was then obtained verbally through discussion with the researcher or member
of school staff over the telephone. Participants signed consent forms in the
preliminary session. Participant data was stored confidentially on an encrypted USB
stick. All data in the report was anonymised and pseudonyms were employed to
protect participants’ confidentiality. Participants were offered the right to withdraw
from the study at any point, and the right to withdraw their data up until the end of
their intervention, after which time data would be analysed and written up.
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Results
Information on data normality will first be presented. Quantitative data will
then follow, and will be structured in relation to each research question. Finally,
overall qualitative data will be presented. The integration of quantitative and
qualitative data under the main research questions will occur in the discussion.
Assessing normality
Normality of distribution was considered by examining skewness and
kurtosis, performing Kolmogorov-Smirnov tests, and visual inspection of histograms,
plots and box plots (see appendix 11). There was some indication of non-normality
of some of the data at some time points. However, as the majority of variables
approximated a normal distribution at the majority of time points, and given that
ANOVA is considered robust to violations in assumptions (e.g. see Norman, 2010),
it was decided to proceed with parametric analyses.
How acceptable is an ACT-based intervention to adolescent males with anger
difficulties?
Attendance/Attrition. Attendance rates are summarised in figure 2. Overall
attendance for the three groups was high at 89%. Of the 17 participants who began
the groups, two failed to complete; one in group two withdrew, and one in group
three moved to another school. One further participant (group two) completed the
group but failed to provide follow-up data as he was excluded from school, leaving a
total of 15 participants (88%) who completed the group and provided post-group
data, and 14 who provided follow-up data (82%).
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Session
1
Session
2
Session
3
Session
4
Session
5
Total p
rogram
me atte
ndan
ce0
20
40
60
80
100
Group 1 (n=7) Group 2 (n=5) Group 3 (n=5) Overall (n=17)
Figure 2. Attendance rates (%)
How acceptable are the measures used?
Missing data / Completion of measures. One participant completed the
incorrect version of the SDQ at post-test; his responses on this were thus omitted
from analysis. Across all completed measures, 10 data points were missing,
amounting to 0.28% of the total recorded data. Guidelines for pro-rating the SDQ
(see http://sdqinfo.org/py/sdqinfo/c0.py) and AARS (see Burney, 2001) were
followed. As the MAAS-A provides a “mean” as its overall score, for the two
occasions a data point was missing on this measure, a mean of 13 questions was
used, rather than 14.
VLQ. The participants did not like completing the VLQ, and regularly failed
to complete it fully or to give due care when completing it by, for example, circling
the same number for everything. The VLQ data was thus excluded from analysis.
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MTPT. Due to logistical difficulties with computer access, only three
students attempted the MTPT at pre-treatment only. It was therefore not included in
quantitative analyses, although participant comments on the task were retained in
qualitative data.
AARS, MAAS-A, SDQ. 100% of the 14 participants who finished the group
completed these measures at pre, post and follow-up. One participant completed the
incorrect version of the SDQ at follow-up, and so was excluded from analysis.
Floor and ceiling effects. The number of participants falling above clinical
cut-offs (see appendix 3 for details) are displayed in table 518. Notable floor effects
were present, as 60-100% of participants (across the three time points) scored in the
non-clinical range. This suggests that for this cohort of adolescents, the AARS in
particular, as well as the SDQ, were not detecting the boys’ difficulties, and are
perhaps aimed at a higher risk and/or different client group.
Table 5
No. of participants reaching clinical thresholds at each time point
No. above clinical threshold at pre- (n=15)
No. above clinical threshold at post- (n=15)
No. above clinical threshold at follow-up (n=13 for SDQ; n=14 for other measures)
AARS instrumental 3 0 0AARS reactive 3 4 3AARS control 0 0 1AARS total 4 0 0SDQ conduct 6 5 4SDQ hyperactivity 5 4 4MAAS-A n/a n/a n/a
18 Data included only on most applicable variables, rather than all SDQ subscales.
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Cronbach’s α. Alphas were calculated for all scales, excluding the AARS
total anger scale19, and can be seen in table 6. Additional reliability analyses can be
found in appendix 12. Alphas were particularly low and/or inconsistent for all SDQ
scales, excluding SDQ prosocial. Considerable caution should therefore be employed
when interpreting outcomes from these scales.
Table 6
Cronbach’s alphas
Scale No. of items in scale
Pre-group alpha (n=17)
Post-group alpha (n=15)
Follow-up alpha (n=13)
AARS control 13 0.804 0.675 0.498 AARS instrumental 18 0.924 0.794 0.798 AARS reactive 8 0.831 0.741 0.765b
MAAS-A 14 0.628a 0.697b 0.848b
SDQ prosocial 5 0.624 0.567 0.634 SDQ hyperactivity 5 -0.276 0.395b 0.797 SDQ emotional 5 0.347a 0.664b 0.373d
SDQ conduct 5 0.446 0.355 0.761 SDQ peer 5 0.015 0.807 0.161e
SDQ total 20 0.397a 0.772c 0.644e
NB: N (no. of participants) varies due to missing data and declining number of students at each time pointa. n=16; b. n=14; c. n=13; d. n=12; e. n=11
Following intervention, were there any changes observed in the adolescents on
anger and ACT variables?
Inferential statistics. Data from the three groups were combined and
analysed via repeated-measures ANOVAs. A Bonferroni correction was applied to
all post-hoc comparisons. Descriptive data, ANOVA outcomes, and effect sizes are
presented in table 7. There was a significant difference in anger control
(F(2,26)=4.18, p<.05), with pairwise comparisons revealing a significant decline
between post-test and follow-up (p<.05, d=0.76). No other differences were
statistically significant.
19 This was not calculated as the AARS total anger score is calculated using a specific formula, as opposed to simply summing subscales.
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Table 7
Descriptive data, ANOVA outcomes, and effect sizes for all quantitative variables (to 2 d.p)
Measurea Range obtained
Pre (mean, SD)
Post (mean, SD)
Follow-up (mean, SD)
ANOVA – main outcome
Pre - Post Pre - Follow up
F
(2,24)c
P value
Effect size (d)
Desired effect?b
Effect size (d)
Desired effect?b
AARS inst. 21-49 28.29 (10.25) 25.50 (4.90) 24.50 (3.94) 3.09 0.08 0.37† Yes 0.53†† YesAARS reac. 10-32 18.86 (5.87) 17.50 (4.43) 17.43 (5.10) 0.66 0.53 0.26† Yes 0.26† YesAARS cont. 23-48 33.21 (7.43) 33.36 (6.13) 29.43 (4.15) 4.18 0.03 -0.02 - 0.65ꜞꜞ NoAARS total 53-120 78.93 (20.26) 74.64 (11.42) 77.50 (11.36) 0.82 0.47 0.27† Yes 0.09 -SDQ emot. 0-5 1.56 (1.12) 2.19 (1.91) 1.90 (1.58) 1.56 0.25 -0.42ꜞ No -0.26ꜞ NoSDQ cond. 2-7 3.54 (1.90) 3.38 (1.80) 2.92 (2.29) 0.94 0.40 0.08 - 0.29† YesSDQ hyp. 3-7 4.23 (1.17) 4.19 (1.80) 4.69 (2.39) 0.46 0.64 0.03 - -0.26ꜞ NoSDQ peer 0-5 2.00 (1.35) 2.08 (2.53) 2.27 (1.64) 0.08 0.93 -0.04 - -0.18 -SDQ int. 1-8 3.56 (1.81) 4.27 (4.04) 4.17 (1.97) 0.64 0.54 -0.24ꜞ No -0.33ꜞ NoSDQ ext. 5-13 7.77 (2.52) 7.58 (3.12) 7.62 (4.25) 0.03 0.97 0.07 - 0.05 - SDQ total 6-17 11.33 (3.44) 11.85 (6.46) 11.79 (5.09) 0.08 0.93 -0.10 - -0.11 -SDQ pro. 3-10 6.31 (2.36) 6.23 (1.88) 6.15 (1.91) 0.04 0.96 0.04 - 0.07 -MAAS-A 3.43-5.64 4.05 (0.64) 4.09 (0.77) 4.30 (0.83) 0.75 0.48 -0.06 - -0.33† Yes
a. Full names or measures are: AARS instrumental anger, AARS reactive anger, AARS anger control, AARS total anger, SDQ emotional problems, SDQ conduct problems, SDQ hyperactivity-inattention, SDQ peer relationship problems, SDQ internalising, SDQ externalising, SDQ total difficulties, SDQ prosocial behaviour, MAAS-A.b. Reported if d ≥ 0.2 (i.e. minimum small effect size)c. Degrees of freedom varied according to N and whether sphericity was violated. F (2, 24) correct for SDQ conduct, hyperactivity, peer, externalising, total and prosocial. F (2,26) correct for AARS reactive, anger control, and MAAS-A. F (2,12) correct for AARS instrumental and AARS total, F (2,11) correct for SDQ emotional and internalising.† Non-significant small effect in desired direction. †† Non-significant medium effect in desired direction Significant at p<.05 levelꜞꜞ Non-significant medium effect in undesired directionꜞ Non-significant small effect in undesired direction
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Effect sizes. With the exceptions of anger control, SDQ hyperactivity-
inattention, and SDQ externalising, the most pertinent measures (instrumental anger,
reactive anger, total anger, SDQ conduct, and MAAS-A) moved in the desired
direction, whilst less directly relevant measures moved in the undesired direction
(SDQ emotional and SDQ internalising), or displayed little change (SDQ peer
relationship problems, SDQ prosocial, and SDQ total difficulties).
Small N analysis. Reliable and clinically significant change scores were
calculated for the AARS, MAAS-A, SDQ conduct and SDQ hyperactivity-
inattention, as these were thought to be most relevant to the study. ‘Criterion A’20
was used to set the level for clinically significant change as the descriptive data for
the participants in the study appeared similar to (or ‘better’ than) the ‘normative
samples’ available for comparison. They were therefore compared to themselves as
the clinical population.
As seen in table 8, the majority of participants did not demonstrate reliable
change, a moderately-sized minority showed reliable improvement on some
measures, whilst a much smaller minority declined on some measures. Few
demonstrated clinically significant change, although this is unsurprising given the
stringent criteria set. Of particular note, approximately 1/4 of students improved on
instrumental anger and total anger scores at post-test, whilst over 1/3 of students’
mindfulness scores increased at follow-up. Anger control however showed a similar
pattern to the ANOVA results, with around 1/5 of students deteriorating at follow-up.
20 See Leeds manual (Morley & Dowzer, 2014) for explanation of this.
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Table 8
No. of participants who have reliably changed at post- and follow-up
Pre-Post (n=15) Pre-Follow up (n=13 or 14)Improve* (CSC)
No change
Decline Improve (CSC)
No change
Decline
AARS instrumental
4 10 1 3 11 0
AARS reactive
2 12 1 1 13 0
AARS control
2 11 2 0 11 3
AARS total
4 10 1 3 10 1
SDQ conduct
0 15 0 1 12 0
SDQ hyp–inatt
1 13 1 4 (3) 5 4
MAAS-A 2 (1) 11 2 5 (1) 8 1*Statistical reliable improvement; CSC = where relevant, of those who reliably improved, no. clinically significantly changed
How feasible is it to provide an ACT intervention within the school context?
Attendance/Retention. High attendance rates indicate that it was feasible to
recruit and retain participants for the group in a school setting.
Treatment fidelity. Due to issues acquiring time in the school timetable and
limited staff availability, the weekly in-between session mindfulness practices were
not implemented at all for group one, and were inconsistently implemented for
groups two and three. In addition, timetable clashes resulted in sessions not always
being scheduled a week apart. For group three, the programme therefore occurred
over a period of four weeks. The introduction of a ‘rewards and consequences’
system was implemented halfway through group one to promote appropriate
behaviour.
Informal process notes. Facilitator’s interviewed one another and completed
informal process notes each week regarding their experience of running the
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intervention. As these process notes were not subject to formal analyses, they will
not be commented upon in detail here, however full details of this can be found in
appendix 13. Superficial review of these notes highlighted that facilitators reported
several benefits but also logistical challenges of running the groups in a school.
Qualitative
Four overarching themes were generated from the analysis, along with two
subthemes (see figures 3-6). Each theme was considered by the author in relation to
the research questions and the associated explanatory power provided. The Content
and Changes themes contained the richest information in relation to the research
questions, followed by Culture of the group, and finally Contextual considerations.
Theme 1: Content (figure 3). Reference was made to specific content of the
group with comments focussing upon its value, engaging content, its interactive/fun
nature, and its relatability. Mindfulness received a mixed audience, with some boys
valuing it, and others finding it disengaging. Vincent reported that despite sometimes
arriving at the group feeling angry, “the mindfulness process would actually help me
because...umm... my eyes would be closed and I would be relaxed so I wouldn’t
really be feeling any anger because I’d be noticing what’s around the room…”.
Similarly, when asked what was helpful, Thomas spoke about mindfulness: “like
when we sat facing the wall and like umm, we did that thing can’t remember what it
was called (Facilitator: “The mindfulness?”). Yeh mindfulness.” Others thought:
“Stuff that was unhelpful was like... […]...that mindfulness.” (Dean).
The boys made repeated reference to the ‘characters’ used in the programme,
which appeared to be memorable and engaging. Dean found the characters and the
idea of consequences of anger helpful, reporting “The thing that I found, like,
helpful, was...like...the wise warrior, and the mindless zombie and the consequences
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that would happen, if you don’t treat your anger properly.” Taylor valued and related
to the metaphor of the tiger representing his anger, reporting that “I can now know
that there’s a [sic] actual tiger, and the tiger’s inside of me, the tiger’s my anger, and
that I should walk beside my tiger...”
Many of the boys enjoyed the ‘urge surfing’ donut-eating task, aimed at
promoting acceptance/willingness to feel difficult feelings. Vincent appeared to
grasp the purpose of the task, alluding to the notion of resisting powerful urges, “[…]
what you did the urge thing […] and how we really want to eat it but try not to. And
then when we put it in our mouth, but instead of biting it straight away, you have to
umm let it stay in our mouth. And, that represents anger…”.
Whilst less salient in the data, the workbook was also received positively;
Kalim noted that he liked the workbook as “it made me write stuff...like, personal
stuff, like people who...is [sic] my inspiration.”
The questionnaires, and in particular the AARS, were not well received, with
many of the boys finding them disengaging, un-relatable, and too long. Gabriel
commented “you know when you do one yeh, and you find there’s like five more
pages, it just gets frustrating”. One of the most notable barriers was the language
used in the AARS. Freddie found this completely un-relatable, commenting “You
know where it says […] take it out on a [sic] animal […] That…that doesn’t make
sense, at all. […] Because, why would you hit umm a [sic] animal?”. Freddie’s
opinion was shared by many of the boys;
Gabriel : [...] it was stressful, irrelevant, and […] I found them, like,
what’s it called, offensive, because they were saying things like, starting a
fire like I’m mentally ill, like, who does that…what normal person?
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Some of the boys in group one in particular reported a mixed opinion on the
content; for example, Lequan reported that he had “...found it helpful, in some ways
and not helpful. […] …when we were talking about LeBron James […] ...that kind
of was helpful. But last week’s one was not really helpful, it was just boring.” Most
of the boys, however, reported an overall value and appreciation for the content.
When asked if they would recommend the group to their friends, Fazal, Callum and
Finley unanimously responded “Yeh”, with Fazal further adding that “it helps you to
like control yourself and it teaches you ways to like…[…] handle yourself in like,
tough situations.” Taylor compared his experience to a previous anger intervention,
reporting that “I was going to anger management for a bit, recently…yeh…couple
years ago. It’s rubbish. This…proper. This…I would say this is like, obviously
planned and stuff, this is proper anger management.”
Theme 2: Changes (figure 4). Notable changes reported by the boys
included having choice and control over how they respond, getting into less trouble
at school, and broader changes such as attitudes towards peers.
Freddie, Farouk and Taylor discussed having less fights, with Farouk
observing that “For me it’s surprising, ‘cause, like, every day I used to get in
trouble.” The three boys also reported receiving less disciplinary code violations at
school. In addition to the more obvious, behavioural changes, Thomas reported
subtler attitudinal changes towards his peers, observing “Like, I don’t pick arguments
with them for no reason”. In addition, some participants described thinking through
the consequences of their actions more. Lequan reported that in reference to teachers
“getting on my nerves” he has now come to the conclusion that “…if I started
shouting back at them...getting rude to them...it’s going to make the situation a whole
lot worse. And I could get in even more trouble than I already am in. So I just say
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‘okay’.” Lequan’s comment also highlights that participants reported learning that
they have ‘choice’ over how they respond when feeling angry. Gabriel commented
on this specifically, noting that;
What I learnt is that […] when I’m angry I have a choice of different paths to
take…whether to…carry on and get myself in more trouble, or calm down.
Participants also reported changes in terms of their skill development. Of
particular note, Freddie reported devising his own mindfulness exercises; “[…] I’ve
been doing the…umm, mindfulness thing, by myself as well. […] By making my
own one.” Others however found it more difficult to develop the mindfulness skills;
Finley reported struggling with the ‘quietness’ of the tasks, stating that “…it’s just…
it’s too quiet. My mind just keeps going away...”
Several participants made specific reference to the concept of ‘control’ in
relation to their anger. Whilst learning to ‘control’ emotions is not a desired outcome
of an ACT-intervention, the boys seem to be using the term in reference to
controlling their actions, e.g. Lemar referred to getting into trouble less since the
intervention. “‘cause I’ve controlled myself”.
Finally, whilst many participants reported tangible changes, a few struggled
to identify any. Despite Gabriel’s learning regarding ‘choice’, he found it difficult to
further identify specific changes, commenting that “…there might have been a few.
Might’ve been, but maybe I haven’t noticed them, but there might have been a few.”
Theme 3: Culture of the group (figure 5). The overall theme pertains to the
‘process’ variables associated with groups, and consists of two subthemes;
‘Interpersonal factors’, and ‘Structural factors’. Within the interpersonal factors
subtheme, the benefits of being in a group, and the support and normalisation this
provides emerged as a common thread across all groups. Omarr commented on the
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support the group provided, observing that “When you say something personal, you
know that... you know that whatever you say can be...you can be helped by other
people.” In addition, Gabriel referred to the benefits of ‘normalising’, stating that “…
if you’re in a group […] you know that, it’s not only you that goes through what
you’re going through. Like, other people, go through it too.” Fazal compared being
in a group to a one-to-one session, commenting on the reduced ‘awkwardness’ the
group provides, as well as the opportunity to learn from peers,
In the group, you can hear more people’s ideas, and what they think, so you
can use that as well for advice.
The relatability of facilitators was mentioned by several participants, with
many commenting on the desire to have a facilitator who had experienced similar
difficulties to them. Thomas felt he would like to have had someone participate in the
group “that’s experienced, like, building up loads of anger and maybe committing a
crime or something like that...”. Similarly, Finley described how he would like a
facilitator who misbehaved at school and had a difficult life, but who had now turned
their life around, stating that an individual with these experiences “can understand
[…] …how you feel. […] …because they’ve been through it.” However not all
participants thought a ‘similar’ facilitator would be helpful, citing concerns about
whether they would feel able to be open;
Callum: …say if […]…there was a black man sitting there, we’ll probably be
more…not…more connective… (Another group member: More open). Yeh
we…we won’t really be more open…
The structural factors subtheme refers to the foundations of a group that are
not linked to content or interpersonal variables, but are fundamental to the success of
groups, for example boundaries, behaviour management, confidentiality, etc (see
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figure 5). Trust and confidentiality were discussed as important, with participants
having differing views on whether they felt this was present. Omarr felt that he could
not trust the facilitators completely “…because you don’t work at the school, and
then you could just go off and tell other people…”. Conversely, Gabriel felt his
confidentiality was more protected with external facilitators, expressing concern
about teachers “[…] in the staff room, gossiping about your business...” Adopting a
slightly different perspective on confidentiality, Callum commented on the ‘safety in
numbers’ provided by the group;
…‘cause you know other people sharing their feelings you might as well,
‘cause you know that, they’re going to keep your feelings and you’re going to
keep theirs.
Participants commented on ‘behaviour management’, with some observing
the importance of having rules and behaviour being managed. Omarr felt that the
presence of a particular school-based facilitator was helpful as “She’s the one that
made us, like, behave properly in the session.”. Freddie, Taylor and Gabriel
discussed the rules and consequences in the group, and agreed that rules were
“alright”, highlighting the safety this provides.
Theme 4: Contextual considerations (figure 6). This consisted of two sub-
themes; ‘Practical factors’ and ‘Inter- and intra-personal factors’. The overall theme
referred to the factors outside of the group that influenced the boys’ perceptions and
experiences of the group, and their capacity to change. The practical factors
subtheme focused on logistical issues associated with group attendance, whilst the
inter- and intra-personal factors subtheme focused on the relational and individual
influential factors.
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Within the practical factors subtheme, discussion around ‘pacing’ of the
group occurred recurrently, in reference to frequency of sessions, length of sessions,
and timing of sessions. The overall picture was one of the boys wanting ‘more’;
Fazal indicated a preference for longer session duration, stating that “…if its longer,
you can get like…more…more advice and like…umm, like, more ways to help you.”
Thomas however would have preferred increasing the total number of sessions,
citing a need for more discussion time; “I think we should’ve have done it maybe
twice a week […] ‘cause there might have been something you wanted to say and
then for the next week we didn’t.” Finley echoed a need for more time for discussion,
observing that more sessions would enable opportunity to “talk more in detail about
the wise warrior and the…the mindless zombie, and role models and all that.”
The boys also discussed how the group fit into their other commitments.
Sometimes the group was seen as a better option to their alternative; for example,
many of the boys appeared to make reference to the group being an easier/better
option than attending their lessons;
Gabriel : So that I can miss maths.
Dean: ‘Cause double history is like the worst lesson ever.
At other times, the group was seen as conflicting with more important
demands. For many of the boys, this was particularly noticeable when the question
was posed of holding the group after school rather than during school-time. Farouk
observed that “after school…got stuff to do, like playing football”, and Lequan
shared a similar perspective, stating that “people have got things to do after school”.
However this view was not unanimous; Thomas expressed reservations about the
lessons he was missing in order to attend, stating that he “…probably would have
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preferred it after school because, umm, my ***** lessons is like PSHE so its
teaching me different things throughout society...”.
In addition to the above ‘practical’ contextual considerations, the boys also
mentioned various inter- and intra-personal factors that influenced their experience
of the group, and their ability to make changes. In particular, some of the boys
mentioned having a ‘history’ with teachers which meant that they, at times, felt as
though they were pre-judged with regard to any incidents of difficult behaviour. For
example, Farouk reported that “…if I tell the teacher, he won’t listen… […] …I told
him, that it wasn’t me, and then they wouldn’t listen.” The implication here being
that, for some of the boys, they were trying to make changes in a context of a
negative pre-judgement, which was difficult for them.
The boys also talked about other ‘external influences’ that affected their
pathways to change. Taylor described parental pressures as promoting change; “…
this is the exact same words my mum said to me. If you don’t get GCSEs…or don’t
get a good GCSE by the end of this…ermm, by year 10, you’re not coming to my
house again.” Gabriel observed the impact of school pressures and maturity on
promoting positive change, commenting that year 9 entails “more responsibility” and
that “GCSEs is [sic] around the corner”.
Follow-up focus group. The brief ‘check-in’ follow-up focus groups were
not subject to the same rigorous analysis as the main, post-group focus groups;
however they were nonetheless transcribed and reviewed. There was no obvious
evidence of contradictory or additional themes emerging. Furthermore, the follow-up
focus groups revealed that the boys had continued to retain much of the content from
the group. Members of all groups recalled the ‘wise warrior/mindless zombie’
metaphors, and the ‘urge-surfing’ exercise. Other key details remembered included
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the use of ‘LeBron James’ as a role model, the use of the ‘tiger’ to represent anger,
the idea of taking different pathways, and several of the interactive exercises
including mindfulness, the ‘accents’ defusion exercise, the ‘self-as context’ weather
exercise, and the ‘falling in love with a spot on the floor’ exercise.
Reflexive account. The process of gathering, transcribing, analysing, and
summarising the qualitative data required the author to adopt a reflective-scientist-
practitioner perspective. Given the author’s competing roles of devisor, facilitator
and evaluator of the intervention and the focus group, it was important to guard
against competing interests in the process of interacting with the qualitative data. The
author adopted a semi-structured format to the focus group to promote adherence
with a pre-set objective agenda (as opposed to the author’s personal agenda), and
adopted a critical-realist position, relying largely on the manifest content of
transcripts to reduce the opportunity for bias in interpretation. A full reflexive
account of this process can be found in appendix 14.
Figure 3. Theme
1: Content
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Figure 4. Theme 2: Changes
122
Figure 5. Theme 3:
Culture of the group
(and associated subthemes)
123
Figure 6.
Theme 4:
Contextual
considerations (and associated subthemes)
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Discussion
How acceptable is an ACT-based intervention to adolescent males with anger
difficulties?
High attendance levels and the qualitative data suggest that the intervention
was acceptable to participants. The boys reported favourably on the content,
engaging well with key metaphors and exercises, and requesting ‘more’ of the
intervention. The majority of the boys valued being in a group, appreciating the
support and normalisation provided by peers, and having the space to express
themselves. Mindfulness received a mixed reception, with some boys valuing it and
others finding it difficult to participate in fully. Given that research suggests that
mindfulness is generally received positively by young people (e.g. Huppert &
Johnson, 2010), one explanation for some boys failing to engage with it may be the
lack of dosage (particularly the lack of in-between session mindfulness practices).
This may have resulted in inadequate mindfulness skill development, and consequent
disengagement. The boys had varied responses to external facilitators, with many
valuing the fact that facilitators were separate from the school. Some however felt
cautious of trusting external facilitators, whilst others mentioned the addition of a
more relatable facilitator would have been helpful. Overall, the results suggest the
group is an acceptable intervention to the participants.
How acceptable are the measures used?
Several of the outcome measures were unacceptable to participants. Issues
included poor completion (VLQ), difficulties relating to content (AARS), floor
effects (AARS, SDQ), poor internal consistency (SDQ), and logistical difficulties
(MTPT). The exception to this was the MAAS-A, which did not evoke strong
antipathy from the boys and was completed well.
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The qualitative data revealed that the boys generally found the questionnaires
too long and there were too many of them; this may explain the poor completion of
the VLQ, particularly given the frequency (weekly) of administration. The AARS
produced notable floor effects and was disliked by nearly all, who reported finding
many of the questions only applicable to a much higher risk client group. This was
supported by the fact that the ‘normal population’ (normative data provide in the
AARS manual from a US sample of same age boys) scored ‘worse’ on this measure
than the participants in this study at pre-intervention. Cross-cultural differences may
exist between US and UK adolescent males and the manner in which they express
anger, rendering this measure less applicable to the study participants.
The low alphas on the SDQ indicate difficulties with this measure, however,
as Cortina (1993) observed, alpha is affected by the number of items in a scale. The
low number of items per scale in these questionnaires, as well as the small sample,
may therefore partially explain the low (even negative) alphas seen. Nonetheless, the
boys also lacked motivation to complete the questionnaires, which could have
translated into careless answering. The floor effects further question this measure’s
suitability for this client group.
The MTPT appeared to have good face validity, and may be a useful measure
to revisit in future studies as a behavioural measure of frustration tolerance,
providing the logistics of completing the measure are established in advance.
The results suggest that the VLQ, AARS and SDQ were unsuitable for this
client group, whilst the MAAS-A and MTPT may be helpful to retain in future
research.
Following intervention, were there any changes observed in the adolescents on
anger and ACT variables?
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The quantitative and qualitative data revealed a mixed picture of results in
regard to changes. Firstly, all quantitative results require caution in interpretation,
and should be considered within the context of the aforementioned difficulties with
the questionnaires. Furthermore, the small sample size and associated lack of power
reduces the likelihood of finding significant changes in large scale analyses.
ANOVAs showed that differences between time-points were, for the most
part, non-significant. The exception to this was a significant reduction in anger
control from post-test to follow-up. It is unclear why anger control decreased
between these two time-points; this may have been due to chance, or related to issues
with the questionnaire. Many of these questions21 relied on problem-solving skills
and therefore executive functioning abilities, which are not fully developed until well
into our twenties (e.g. Sowell, Thompson, Holmes, Jernigan, & Toga, 1999). One
question was phrased as a double-negative, which resulted in the boys often
answering in a manner inconsistent to the rest of their results. Furthermore, two of
the questions reference “ignoring”; from a theoretical view point, ACT is not about
increasing one’s capacity to “ignore”, but instead learning to notice, accept and be
with difficult feelings.
Effect sizes provide a measure of the size of differences and are arguably
more useful for interpreting results than statistical significance. Indeed, focusing
solely on p-values has been subject to criticism, as they reveal nothing about the
magnitude of differences and are reliant on sample size (e.g. Sterne & Smith, 2001;
Sullivan & Feinn, 2012). In general, the measures that might be most expected to
change (instrumental anger, reactive anger, total anger, SDQ conduct, MAAS-A),
displayed (non-significant) improvements in the desired directions. Whilst other less
21 See appendix 15 for a breakdown of the questions in this subscale.
127
directly relevant measures moved (non-significantly) in the undesired direction (SDQ
emotional, SDQ internalising). The exceptions to this general rule are SDQ
externalising which showed no change, and SDQ hyperactivity-inattention and anger
control, which moved in an undesired direction.
The possible reasons for anger control’s suggested decline have already been
discussed. One explanation for the possible undesired changes in SDQ emotional,
internalising and hyperactivity-inattention could be that the boys’ increased levels of
mindfulness raised awareness of their internal states, resulting in them being more
alert to (and thus reporting) more difficult feelings. The boys may have lacked the
ability to transfer their mindfulness skills to ‘non-angry’ feelings (e.g.) ‘restlessness’,
due to a lack of dosage of mindfulness, and not enough explicit discussion around the
transferability of these skills to other feelings. The lack of change in SDQ
externalising can be explained by the opposing direction of changes of SDQ conduct
and SDQ hyperactivity-inattention, which constitute this scale.
N=1 results show that the majority did not change reliably, a minority reliably
improved on some measures, and a small minority reliably declined. The intervention
in its current form may therefore be sufficient to prevent deterioration, as opposed to
promoting significant positive change. This fits within the broader picture of the
boys’ pre-intervention scores predominantly residing in the ‘normal range’ and it
thus being very difficult to demonstrate positive change. This may also further
explain the non-significant changes from the ANOVAs. In light of this, the fact that
some effect sizes in the appropriate direction were nonetheless discovered is a
promising result.
Qualitative data suggests that the boys experienced a number of positive
changes including having more choice and control over their responses when angry,
128
receiving less disciplinary code violations at school, thinking through the
consequences of actions more, and positive shifts in attitudes towards peers. Skill
development was a mixed picture, with some boys feeling that they gained
mindfulness skills, whilst others struggled with this. The lack of between-session
practice may explain this mixed result.
Overall, the qualitative data suggests the boys experienced several positive
outcomes from attending the group, which received mixed support from the
quantitative data. The less robust quantitative outcomes may be due to the small
sample, low pre-intervention scores, and difficulties with the questionnaires.
How feasible is it to provide an ACT intervention within the school context?
Treatment fidelity data highlighted logistical challenges with running the
intervention in a school setting, particularly with regard to it not being prioritised in
the school timetable. However the participants attended regularly and were generally
happy to attend during the school day. Participants (and facilitators, as reported in the
informal process notes) both felt ‘more’ of the group would have been helpful.
In summary, the boys’ qualitative data and quantitative attendance data
suggest it is feasible to run the group in school largely as it is, with a preference for a
longer duration. The treatment fidelity data implies that greater logistical integration
of the intervention into the school timetable would assist in the feasibility of
continuing to implement it in a school-setting.
A summary of the overall conclusions to each research question is provided
in table 9.
Table 9
Summary of results
Research question Quantitative Qualitative Overall summary
129
results resultsHow acceptable is an ACT-based intervention to adolescent males with anger difficulties?
Very acceptable Very acceptable Very acceptable
How acceptable are the measures used?
Largely unacceptable
Largely unacceptable
Largely unacceptable
Following intervention, were there any changes observed in the adolescents on anger and ACT variables?
Mixed picture of results
Several positive changes identified
Evidence for some positive changes, which requires further replication using more appropriate quantitative measures
How feasible is it to provide an ACT intervention within the school context?
Feasible Feasible - with some modification, particularly in the initial set-up of the group
Feasible, with some suggested alterations
Limitations
Given the feasibility nature of the study, it unsurprisingly experienced some
methodological difficulties. Fidelity to the treatment manual was not always
achieved, limiting the internal validity of the findings. As this was the first time the
group had run, small changes were made by the facilitators, for example the
introduction of a rewards and consequence system during group one. Further fidelity
issues included the lack of consistent between-session mindfulness practices, and the
combining of some sessions into a double session. Whilst these issues reduced the
internal validity of the findings, the resultant effect is likely to reduce treatment
effects, as the boys had less time to practice and process the material. The potential
value of the intervention may therefore be underestimated.
130
The small sample and lack of control group limits the inferences that can be
made about generalisability and cause-effect relationships. However the boys’
qualitative feedback suggests that they gained specific benefits from the group itself,
in addition to other external influences on change. In addition, the reliance on SLT
members to select boys with “mild-moderate” anger difficulties is dependent on a
somewhat subjective assessment of the boys’ difficulties. Whilst a screening tool
may have provided a more objective assessment for inclusion into the intervention,
given this was a school-based study, the ecological validity provided by using
teacher assessment and their knowledge of the boys was deemed a helpful part of the
inclusion process.
The outcome measures had several limitations already described. In addition,
the reliance solely on self-report data is limiting. The mixed-methods approach does
however provide an added layer of depth and understanding. In addition, the 3-month
follow-up is a strength of the study, where many previous studies have restricted
evaluation to pre- and post- data (e.g. Bundy, McWhirter, & McWhirter, 2011;
Cheng et al., 2008; Down et al., 2011). Furthermore, the results are due to be
combined with a parallel research project at a later date which is investigating the
teachers’ perspectives on changes in the boys, as well as school-based behavioural
data.
It is possible the boys may have filtered their focus group feedback, as they
wanted to continue to participate in the intervention in order to miss lessons. In
addition, the qualitative data was gathered and analysed by the main researcher, who
was also the devisor and co-facilitator of the group. A potential implication of this is
that the boys may have attempted to protect the feelings of the facilitator in their
feedback. However, facilitators explicitly encouraged the boys to be honest in their
131
feedback, and transcripts revealed several occasions when the boys were able to
provide critical feedback.
Implications of study: Existing research
Research into ACT is still in infancy compared to the more traditional first-
wave CBT approaches. This study adds to the overall volume of research on ACT, as
well as the literature specifically on anger, and on adolescents. To this author’s
knowledge, there are no existing studies evaluating ACT for anger in adolescents.
Whilst a relatively strong evidence base for traditional CBT exists (e.g. Sukhodolsky
et al., 2004), the lack of diversity of interventions, interventions targeted specifically
at males, and UK-based studies, was a significant gap in the literature. “Taking
ACTion on Anger” provides the first-step in developing an alternative intervention
for adolescent males with anger difficulties.
The transdiagnostic nature of ACT may also provide much broader benefits
than some of the more traditional approaches to anger management. For example,
mindfulness interventions for adolescents with a wide range of presenting difficulties
have been associated with improvements in wellbeing, greater resilience, increased
sustained attention, improvements in sleep, and even reduced blood pressure (see
Weare, 2012). Adolescents in receipt of this intervention may therefore demonstrate
benefits beyond those simply pertaining to anger.
Implications of study: Future research
The study has provided preliminary evidence on the acceptability and
effectiveness of “Taking ACTion on Anger”, which was, on the whole, well-received
and appears to have resulted in some positive changes for the participants. Future
research requires replication of the intervention in the context of a larger sample and
control group.
132
A useful future development would be to consider an intervention that is
longer in duration (e.g. a term, rather than a half-term) and/or is accompanied by
later ‘booster’ sessions. Booster sessions have previously been suggested as a way of
maintaining treatment gains (Herrmann & McWhirter, 2003). Farrell, Meyer,
Sullivan and Kung (2003) found that their 12-week booster intervention produced
several positive outcomes, particularly for boys or for those presenting with higher
pre-test violence levels. A desire for ‘more’ of the intervention arose in the
qualitative and informal data, and this extra session time could be used for greater
discussion of the flexibility of mindfulness skills and their applicability to other areas
of the individuals’ life, to encourage transferability of this skill.
Future research should also consider the systemic context in which
interventions occur. Whilst the intervention was deliberately targeted solely at the
adolescents with the aim of developing a low-cost intervention, several of the boys
commented on the difficulties of a ‘bad reputation’. Relationships with teachers has
previously emerged as a difficulty for similar adolescents (e.g. Humphrey & Brooks,
2007). Future research should consider supplementing interventions with
systemically-informed conversations with school staff (e.g. regarding problem-
saturated narratives), to enable greater transferability of learnt skills into the wider
school environment.
More comprehensive preparatory work with schools regarding the logistics of
running the intervention is also recommended. This should include spending more
time embedding the intervention within the school timetable, early identification of a
school-based facilitator who has capacity to co-facilitate, and wider promotion to the
whole school of the intervention. Consideration should be given to selection of
facilitators, with a mixture of school-based and non-school based appearing to strike
133
a good balance. Additionally, consideration should be given to relatability of
facilitators.
Finally, future research should consider alternative quantitative outcome
measures, and reducing the number of measures employed. The result suggests the
SDQ and AARS are not appropriate for this client group, however researchers may
wish to retain the MTPT and MAAS-A, and consider an alternative self-report
measure of anger, for example the Reactive and Proactive Aggression Scale (RPAS;
Raine et al., 2006). The RPAS is shorter than the AARS (23 items), and appears to
have less ‘extreme’ examples of aggression in its questions. It has shown good factor
structure and internal consistency (α=0.81-0.91) in the author’s initial validation
study on a US sample. The questionnaire has since been translated and validated in a
Dutch sample of children, adolescents, and adults (α=0.83-0.91; Cima, Raine,
Meesters, & Popma, 2013) and Italian “non-clinical” adolescents (α=0.75-0.86;
Fossati et al., 2009), suggesting it may be transferable cross-culturally and more
suitable for lower-risk client groups. Implicit behavioural measures, parent
perspectives on change, and an extended follow-up period, would also provide more
robust evaluation of the intervention. Limited time and logistical barriers to gathering
the computer-based behavioural data prevented us from gathering this.
Conclusion
“Taking ACTion on Anger” is an acceptable intervention for adolescent
males with anger difficulties. Preliminary evidence provides tentative support for its
effectiveness, particularly in relation to qualitative data, however this requires further
validation. Future research should consider employing a larger sample size with
control group, extending the duration of the intervention, investing greater resources
in the preparatory phase of delivering the intervention, working systemically with
134
schools to increase transferability of intervention gains, and employing alternative
outcome measures.
135
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List of Appendices
(Appendix 1 – Guidelines for Authors - Removed for E-thesis 146)
(Appendix 2 – Copies of Measures – Removed for E-thesis 158)
Appendix 3 – Clinical Cut Offs: SDQ and AARS 162
Appendix 4 – Focus Group Interview Schedule 163
Appendix 5 – Examples of Process Notes 165
Appendix 6 – Follow-Up Focus Group Interview Schedule 167
Appendix 7 – Intervention Protocol 168
Appendix 8 – Qualitative Analysis Audit Trail 184
Appendix 8a – Reference Document 1 186
Appendix 8b – Reference Document 2 200
Appendix 8c – Reference Document 3 204
Appendix 8d – Thematic Map 1 215
Appendix 8e – Thematic Map 2 216
Appendix 8f – Thematic Map 3 217
Appendix 8g – Examples of Coded Extracts 218
Appendix 9 – Ethical Approval 225
Appendix 10 – Information and Consent Forms 226
Appendix 11 – Normality Analyses 232
Appendix 12 – Additional Reliability Analyses 240
Appendix 13 – Informal Process Notes Discussion 243
Appendix 14 – Reflexive Account of Qualitative Analysis Process 244
(Appendix 15 – Anger Control Subscale Question - Removed for E-thesis 248)
145
Appendix 1 – Guidelines for Authors - Removed for E-thesis
146
Appendix 1 – Guidelines for Authors - Removed for E-thesis
147
Appendix 1 – Guidelines for Authors - Removed for E-thesis
148
Appendix 1 – Guidelines for Authors - Removed for E-thesis
149
Appendix 1 – Guidelines for Authors - Removed for E-thesis
150
Appendix 1 – Guidelines for Authors - Removed for E-thesis
151
Appendix 1 – Guidelines for Authors - Removed for E-thesis
152
Appendix 1 – Guidelines for Authors - Removed for E-thesis
153
Appendix 1 – Guidelines for Authors - Removed for E-thesis
154
Appendix 1 – Guidelines for Authors - Removed for E-thesis
155
Appendix 1 – Guidelines for Authors - Removed for E-thesis
156
Appendix 1 – Guidelines for Authors - Removed for E-thesis
157
Appendix 2 - Copies of Measures – Removed for E-thesis
158
Appendix 2 - Copies of Measures – Removed for E-thesis
159
Appendix 2 - Copies of Measures – Removed for E-thesis
160
Appendix 2 - Copies of Measures – Removed for E-thesis
161
Appendix 3 – Clinical Cut Offs: SDQ and AARS
SDQ. Clinical cut-off categories for the SDQ are displayed below.
Interpretation category
SDQ subscale
score
Close to
average
Slightly raised
(slightly lowered
for prosocial)
High (low
for
prosocial)
Very high
(very low for
prosocial)
Emotional
problems
0-4 5 6 7-10
Conduct problems 0-3 4 5 6-10
Hyperactivity 0-5 6 7 8-10
Peer problems 0-2 3 4 5-10
Prosocial 7-10 6 5 0-4
Total difficulties 0-14 15-17 18-19 20-40
AARS. The AARS manual includes a guide to interpretation which requires
converting raw scores to T scores. T scores are then interpreted in reference to a
comparative normative sample. T scores can then be categorised from very low to
very high, allowing calculation of the number of participants falling above clinical
threshold (moderately high and above for IA, RA and TA, and moderately low or
below for AC) at each time point.
162
Appendix 4 – Focus Group Interview Schedule
General experience of group
1. Talk about your experience of participating in the ACT group:
What were the helpful aspects?What were the unhelpful aspects?What would you change?
Logistics of the group
2. How did you find the process of being in a group (as opposed to individual support)?
3. How did you find the format of the group?
Weekly sessions with in-between practices?Missing school time – would you prefer after school?Length of sessions/Total number of sessions?How helpful was having a workbook to follow?
Effects of group
4. Have you noticed any changes in your life since completing the ACT group?
Do you feel better/worse/ the same?Why do you think these things have changed?
Logistics of the data collection
5. What was your experience of completing the questionnaires?
Were they too long?Did they make sense to you?
a. What about the computer task?
Future planning
163
6. If you were designing a group for boys your age with anger difficulties what would you like in it?
What would you not like in it?
7. Is there anything else that you wanted to feedback?
164
Appendix 5 – Examples of Process Notes
Week x, group x
The logistics of data collection was quite stressful due to other events
occurring at the school, room changes, young people not being in the correct room
when trying to locate them, etc. We had four young people who attended the group
today (one couldn’t be found, and one didn’t want to attend). Only one young person
managed to complete the computer task due to these pre-group stressors. This was a
stressful start to the group, and we were concerned about the effect the
disorganisation of the session would have on the participation of the boys and the
tone of the group. However the four boys participated and behaved extremely well in
the session. They wanted to contribute a lot and the knowledge of school penalty
points and in session ‘reward and consequence’ points seemed to manage their
behaviour. They shared good examples, participated well in the exercise about who
inspires them, and completed the workbook well. Overall, it was a very positive start
to the group (logistics aside) – possibly better due to small group, or “better
behaved” young people attending this group? Facilitators both felt that separating
two of the boys from the start was positive, implementing the rewards and
consequences chart from the start was helpful, and that they felt more authoritative
and more confident in running the group this time round. The school facilitator was a
calming presence in the room and the facilitators both feel she will be an asset to the
group.
Week x, group x.
Four boys attended today. School facilitator still unable to do mindfulness in
between practice. Two boys turned up a bit late so session started a bit late. Overall
really positive session. Facilitators spent time recapping main themes and trying to
165
convey key messages of controlling actions rather than feelings, and sitting with
difficult feelings. All boys participated well today, definitely encouraged by reward
chart. They sat quietly in the mindfulness, and participated on both main tasks of the
session. I felt able to draw more out of them today, rather than giving them too many
answers (possibly due to time being less pressured). School facilitator was stricter in
terms of giving out consequence points today, but I was impressed with one boy
continuing to stay engaged and earn his reward points back (rather than disengaging).
They were all able to urge surf and I felt this task conveyed message of control really
well. Interesting how positive facilitators came away feeling today, feeding off the
participation and positivity of the boys.
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Appendix 6 – Follow-Up Focus Group Interview Schedule
1. What can you remember from participating in the ACT group?
a. What made you return each week?
b. If you had to tell someone about the group, what would you say?
2. Have you been able to use any of the ideas we talked about in your day-to-
day life, since finishing the group?
a. If you haven’t been able to use them, why do you think this is? What
barriers have you come up against?
3. Have you noticed any further changes in your life since completing the ACT
group? (Do you feel better/worse/ the same? Why do you think these things
have changed?)
4. If I/We asked your teacher/ and carers/other family members what would
they say was different about you?
5. Would you be interested in participating in another group like this?
6. Now that more time has passed since you completed the group, are there any
changes you would make to the content or how the group is delivered?'
7. Anything else you wanted to feedback?
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Appendix 7 – Intervention Protocol
Session ObjectivesSession 1.Chilling with your tiger: For warriors, not zombies
1.5 hours in duration to allow time for questionnaires
Get to know each otherPsychoed/mythbustingIntroduce ACT for Anger and basic principles of ACTIntroduce MindfulnessHomework – what have they tried in the past
Activity ACT Principle Duration Resources
Questionnaires and mirror tracing task 30 mins Questionnaires, computers, pencils
Introducing our role Open with – we’re not here to tell you what to do. Introduce choices
– the main theme of these workshops is about choices. What we hope you will take from these workshops is a new set of skills to enable you to make choices about your life.
Why they are here - teachers think anger / reactions might be getting in the way of their values, where they want to go in life
You get out what you put in
5 mins Powerpoint
Workbook section to complete on role models
Introduce each other Introductions – say your name, and name of someone who inspires
you, could be someone you know / celebrity. Name 3 things about that person that you find inspiring. Facilitators to do their own
Values 15 mins Include space in workbook
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examples
Group Rules & Commitment Ask young people first. Write on flip chart. Include the following if they don’t come up with them:Don’t talk over each other / Be respectful (include bad language) / Confidentiality / Phones off / Commitment. Include risk statement within confidentiality and leaving the group if they break it.Sign the rules & commitmentCommitment = to rules and doing homework and mindfulness practices in between.You are part of a research study - important role as you may be shaping future services.
10 mins Contract in workbook
Powerpoint group rules
Introduce anger / ACT – myth busting quiz Young people to complete workbook individually quickly, and then we go through Powerpoint with explanations below. Young people to buzz simultaneously if they think it’s a fact or a myth. Young people to explain their thoughts.Buzzers (10 seconds to test at start).Fact or myth 1: No one has ever got into trouble for feeling angry
Fact! Our thoughts and feelings don’t have power, our actions have power. They can seem very powerful, but we have a choice how to respond.
Introduce the idea of choice pointFact or myth 2: Venting your anger is healthy and helpful
Myth! Effect it has on you and effect it has on others Practicing angry response for future angry situations
Defusion
15 mins Buzzers
Powerpoint with myths/facts on them.
Powerpoint with zombies, wise warrior, and tiger images and key words about each one.
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Anger will pass with time – not due to ventingFact or myth 3: I can’t control myself when I get angry
Fact/Myth...but really a myth. Right now, it might feel like you can’t control what you do when you
get angry. We’d like to teach you strategies on how to choose your responses
when you are feeling angry, so that you are in control At the moment, what you are doing is fighting the “anger tiger”.
Sometimes you might win if you catch him off guard, often you’ll come away with scrapes and scars (detention, hurt feelings, telling off from parents).
Instead what we would like to teach you is to “walk with the tiger”. Rather than battling with difficult feelings, if you can learn to accept having them and walk with them, you can be much more in control of your life.
You can walk with the tiger to what’s important to you (parties, family events, better education), rather than being battered and bruised by him.
Fact or myth 4: My anger is bad Myth! We all experience anger, and a range of emotions – “good”
and “bad” thoughts and feelings. Can feel painful, and it can feel like we want to get rid of them, and
we therefore often get stuck in a battle with them. E.g. “I’m feeling angry, therefore I must do something with this anger – shout/punch/swear/kick stuff over, etc.
The battle with the anger is what causes us the problems, rather than the anger itself.
The tiger itself is not bad – it’s how we relate to the tiger.
Defusion
Defusion
Committed Action
Acceptance
Acceptance
Experiential avoidance(Dropping the struggle)
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So, how do we learn to walk with the tiger? We become wise warriors, rather than mindless zombies!
Facilitators to explain metaphors as below.
The wise warrior learns to accept his tiger, and walks with him towards what’s important. The alternative? A mindless zombie – responds to urges, attacks anything it sees, doesn’t know what it wants out of life, forever battling with the tiger and likely to end up with a lot of injuries along the way.
Wise warrior: Notices difficult thoughts and feelings, but isn’t controlled by them. Willing to experience them, rather than get rid of them. Awareness that he is more than his thoughts and feelings. Knows what is important to him in life and pursues this.
Mindless Zombies: As soon as he feels something, he gets caught up and overwhelmed by it – whether that be hunger, fear, anger. No awareness of himself as anything other than something that responds to urges. Unwilling to feel difficult emotions (e.g. hungry, scared) so will respond as soon as he feels them. No awareness of what is important to him, so directionless (running around in circles).
Metaphors for all key ACT principles
Mindfulness task: One step towards becoming a wise warrior is to learn to observe
what’s happening within you. We will be practicing this in all of our sessions. Learning to slow down, notice what’s going on, notice our thoughts and feelings, all in the aim of choosing how to respond, rather than responding like a zombie
Present moment
Defusion
10 mins
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Really important part of the course - like learning a musical instrument. If you never practice, you won't develop the skills.
Homework: First: Say one thing you have learned today?Do first 3 columns for 3 examples over the past month. We will do the 4th column next week. Attend mindfulness practice classes.
5 mins Homework summary on powerpoint and in workbook.
In-between session mindfulness practice at school? NotesAs in session Give copy of mindfulness script to session facilitator
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Triggersomething someone says or does, situations e.g. getting a bad mark on homework
How I feltfrustrated, ashamed, guilty, stressed, afraid, controlled, disappointed, threatened, upset, embarrassed
What I didShouted, ignored, repressed angry feelings, punched something
What were the costs?relationships, school, health, energy emotional
Session ObjectivesSession 2Pursuing your values with courage and strength
Explore the following:Cost of acting on angerValuesChoice pointCommitted action
Activity ACT Principle Duration ResourcesMindfulness exercise – Mindfulness of body after doing exercise
Debrief – What did you notice? Where you able to observe your experience, rather than getting caught up in it?
What do you remember from last week? – Recap main metaphors
Present moment
Defusion
10 minutes Mindfulness script
Reviewing homework and completing 4th column - Costs of actions. Examples might be punching, shouting, swearing, storming off, slamming doors, breaking things, ignoring people.
Link back to fighting the tiger – each time they have done something to get rid of feeling angry/embarrassed/frustrated or acted out feeling angry, they have battled with the tiger. It is all an effort to avoid unwanted thoughts/feelings/physical sensations. Perhaps we can learn to accept the tiger and walk alongside him, rather than battle with him? Perhaps okay to have the angry tiger with us, but experience life with him rather than trying to get rid of him?
Experiential avoidance
Acceptance
15 minutes Workbook
Introducing values (and goals) Values 20 minutes Powerpoint/Workbook
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What’s the point in learning to walk with your anger tiger? So that instead of getting into battles with him, you can focus your energy on what’s important to you in life. We call these things “values”. (See powerpoint/workbook for details).
Use analogy of football: Ronaldo - practising every day for the values of being committed, hard-working, challenging himself, being a good team player. Associated goal might be winning the Ballon D’Or, but Ronaldo is having a meaningful life every day as he is living by his values, whether he achieves the award or not.
Values versus goals exercise: Several individual cards with examples of values or goals listed on them. Participants to sort into piles of what are values and what are goals. Facilitators to summarise at the end:
Values are what are important and meaningful to you in life. They are what you want to stand for. They are things you can always live by. They are different to “goals”. You can always work towards a value, you can never tick it off your list. A goal you can tick off once you’ve achieved it e.g. go to my friend’s party, make a million pounds, go to university, get married, etc. A value is something you can always be – e.g. being a supportive friend, being hard working, being a learner, being loving/caring, etc.
Exercise: 18th birthday speech. To help you to figure out what your values are, imagine you are at your 18th birthday party, and someone close to you is standing up to give a speech about you. What would you like them to say about you? What qualities would they say you had? If they were describing how you have lived your life so far, what do you want them to say? Note, you might want to look back at your role models from the first session –
Values v goals cards
Complete section in workbook
174
what did you admire about them that perhaps you would also like to stand for?- NB If they see “be rich/handsome, etc, ask them how they would want
to be described if they had achieved all of those things? What other things would they like people to say about them?
Do in pairs and feedback one value to group. Facilitators will walk round.
Wise warrior vs mindless zombie: Pursuing your values with courage and strength. In the face of frustration, setbacks, failure, and resentment, can you pursue what’s important to you? This is tough, but if you can learn to mindfully observe your thoughts and feelings, rather than getting tangled up in them, it gives you more freedom to make choices.
Talk through biography of Lebron James (faced adversity and frustration but continues to pursue values)
Can you think of anyone else who has stayed true to their values, even when faced with adversity or anger-provoking situations?
Values
Psychological flexibility
5 minutes Powerpoint/workbook
LeBron James biography
Powerpoint collage of LeBron James experiencing difficult emotions and separate one of success.
Complete Valued Living Questionnaire (VLQ) 5 minutes VLQs
Homework task First: Say one thing you have learned today?Set a value guided goal to complete for the following session Valued Living Questionnaire (VLQ) if not time in lesson
5 minutes Workbook
Mindfulness practice at school NotesAs in session Give copy of script to session facilitator
Session Objectives
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Session 3:The Anger Mask
Acceptance / Willingness to feel – difficult emotions / feelingsVideos to demonstrate complex emotions involved when people get angry and anger masking thisAwareness and acceptance of difficult emotionsIntroduce self as context
Activity ACT Principle
Duration Resources
Mindfulness of MusicDebrief – What did you notice? Where you able to observe your experience, rather than getting caught up in it? Did you hear anything that you didn’t expect to, when you really paid attention?
Present moment
Defusion
10 mins Music clip: https://www.youtube.com/watch?v=eRCJow2tKso
Mindfulness script
Recap of last week and review values homework – did they manage to complete their goal. If not, why not? Were the barriers internal or external?
Values
Committed action
10 mins
Anger masking difficult emotions:Video of Phil Mitchell being angry. Discuss what’s happening in pairs and feedback:
- What unwanted emotions are being masked by anger?
- What emotions is he unwilling to experience here?- Refer to choice point – what choice could he have
made differently? What would have been more in line with his values?
- Refer to zombie tiger battle versus wise warrior walking alongside the tiger
Acceptance / Willingness to feel
Choice over behavioural responses
15 mins Videos of Phil Mitchell https://www.youtube.com/watch?v=Bt0m3VLnG34
Powerpoint of tiger/zombie and wise warrior with relevant characteristics superimposed.
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Group discussion- Refer back to week 1 homework task – what
emotions do you find often might be being masked by anger? (Facilitators may wish to self-disclose here if appropriate)
- Summary: If we allow ourselves to experience these emotions – whether happy, sad, lonely, frustrated, rejected, then we can choose how to respond and respond in line with what’s important to us. Alternative – mindless zombie – not thinking through responses, acting on impulse, often taking us away from our values (not many of us value hurting other people/not achieving at school, etc).
Values
Another metaphor....Young people to get up and act out the sky and various parts of the weather.
- Sky and the weather. Weather = thoughts and feelings. Sometimes difficult, sometimes wonderful, but always pass. The sky is always present and will survive all types of weather unharmed. No matter how bad the weather gets, the sky cannot be harmed. The sky will accept all weathers. The sky is the part of you that is always present, that experiences all of your thoughts and feelings. This part of you also experiences them passing. Thoughts and feelings come and go, but the part of you that is
Self-as-context
5 mins Laminated pictures of the sky, lightening, clouds, sun, etc.
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like the sky, which experiences them and observes them, is always present.
- The task of the wise warrior is to be the "sky". Noticing and observing all weathers, and all thoughts and feelings, noticing them coming, and noticing them passing again. Rather than getting caught up in the storms. No matter how intense the thunderstorms get, the sky is always there.
What can help you to be the sky and learn to be with difficult feelings? Mindfully notice what you are thinking and feeling and separate from it via defusion.
Defusion exercises: Using “silly accents” to say normally angry thoughts, e.g. “He is winding me up on purpose – he’s taking me for a mug!”. Participants to practice this as a group.
Once you have done this – choice point, i.e. once you have separated from your angry thoughts, you can choose how to respond. You are now a wise warrior, rather than a mindless zombie.
Defusion 10 mins Accents: The queen, Mr T, whisper, Arnold Schwarzenegger, Simon Cowell, Keith Lemon, etc/
Complete Valued Living Questionnaire (VLQ) 5 mins VLQs
HomeworkFirst: Say one thing you have learned today?
- At some point over next week, mindfully listen to a genre of music which makes you experience a
5 mins Homework summary on powerpoint and in workbook
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difficult feeling e.g. embarrassed, sad, upset, annoyed, angry - see if you can sit with it and observe your experience, thoughts, feelings, urges, rather than do something to get rid of it. Record in workbook.
- Practice defusion exercise. Record in workbook and read section in workbook.
- Complete a value guided goal.
Mindfulness practice at school NotesMindfulness of music – alternative songs provided Give copy of script to facilitator
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Session ObjectivesSession 4:Dropping the struggle
What to do with unwanted emotion?Drop the struggle / Illusion of control / Acceptance
Activity ACT Principle Duration ResourcesMindfulness of Emotion exercise - Externalising an emotion.
Debrief – What did your emotion look like? Where you able to see it as separate from you? Did it seem easier to manage when it was separate from you?
Present moment
Defusion
10 mins Mindfulness script
Recap on previous weekReview homework
Value guided goal Mindfulness of music / Staying with a difficult experience Defusion
What were the difficulties? Were barriers internal or external? What would a wise warrior do?
10 mins
Illusion of control: Control works well in our external world, not so well in our internal world. We would like to have control over our thoughts and feelings, but we don’t really have this! They will come and go whether we like it or not.
Exercise: “Fall in love with that spot on the floor.” Participants talked through an exercise where they are encouraged to fall in love with a spot on the floor. Learning point – you can’t make yourself fall in love with that spot on the floor, just like you can’t make yourself not feel angry.
Rather than trying to control thoughts and feelings/struggle with them. Learn to accept
Acceptance
Dropping the struggle
10 mins Script for falling in love with spot on floor
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them, and be a wise warrior.
What we can control is our actions - what we do with our mouths, hands and feet.
Exercise: There will be times in the future that the urge to act on your anger will be strong, the tiger will be giving you a bumpy journey and you’ll want to put it in its place – can you continue to walk with it? Complete exercise - Urge surfing of sugary donuts and not licking lips. Choice point – choose to let your mind tell you what to do, or walk with the tiger. Encourage young people to use defusion exercises from last week to help them.
Acceptance / Willingness
10 mins Donuts
Urge surfing script
Complete Valued Living Questionnaire (VLQ) 5 mins VLQs
HomeworkFirst: Say one thing you have learned today?
Value guided goal
5 mins Workbook
Mindfulness practice at school NotesLeaves on a stream Give copy of script to session facilitator
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Session ObjectivesSession 5:Becoming a Wise Warrior for Good
(2 hours in duration to allow questionnaires and focus group)
Review of everythingCommitment plan for futureComplete questionnaires and focus groups
Activity ACT Principle
Duration Resources
Mindfulness exercise – dropping an anchorDebrief – if you are in mindful, wise mode, rather than mindless mode, you can always pause, take a minute and choose how to respond. Dropping an anchor in the present can help.
Present moment
10 mins Mindfulness script
Recap of previous session Review homework
Value guided goalWhat were the difficulties? Were barriers internal or external? What would a wise warrior do?
10 mins
Recap of what we covered over all sessionsRevisit Zombie summary fighting the tiger and compare to wise warrior walking alongside the tigerEncourage group to reflect on the differencesThe easy option is the zombie – doesn’t require a brain! But doesn’t get you where you want to be either!
Psychological flexibility
20 mins Powerpoint with zombie and warrior and examples of session exercises
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Willingness action plan: Begin to complete in class and share – young people to continue to complete at home
Give out certificates
Values and Committed action
15 mins Workbook
Certificates
Questionnaires (SDQ x 2, VLQ, AARS, MAAS-A), mirror tracing task 30 mins Copies of questionnaires
Focus group 30 mins Focus group scheduleDictaphones x 2Memory sticks
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Appendix 8 – Qualitative Analysis Audit Trail
All focus groups were facilitated by the author.All recordings were transcribed by the author to gain initial familiarity with the data. The table below describes the overall process; accompanying reference documents follow the table. Given that the researchers observed that group one was distinct from groups two and three in terms of the higher level of behavioural difficulties, group one’s focus group was analysed first to ascertain if emerging themes were distinct from groups two and three. When reviewing the qualitative data that emerged it was felt that the overall themes were similar, and as a result the three groups were combined in the analysis.Date Summary of work done Reference document12th August 2016
Reading and deciding on approach. Focus on entire data set, hence largely data driven (rather than theoretical), realist, and focusing mainly on manifest content with some latent content analysis (at the level of understanding inferred meaning from body language, tone of voice, etc, as opposed to further interpretation). Critical realist model.Re-listened to recording of group 1, post focus groupFirst reading of group 1, post focus group – notes re possible codes made
Document 1
Second reading of group 1, post focus group – notes re possible codes made
Document 1 and later added to transcript
15th August 2016
Third reading of group 1, post focus group – notes re possible codes made
Document 1 and later added to transcript
Re-listened to recording of group 2, post focus group
First reading of group 2, post focus group – notes re possible codes made
Document 1 and later added to transcript
Second reading of group 2, post focus group – notes re possible codes made
Document 1 and later added to transcript
16th August 2016
Code generation and organisation Document 2
22nd August
Draft coding of transcripts – condensing information from first two
See transcripts
184
2016 readings into draft codes. Read over twice to ensure all codes had been considered.Meeting with supervisor for initial code and theme review/generation
Document 3
23rd August 2016
First and second readings and re-listening of group 1 individual interview
Annotated directly on transcript
Coding individual interview – compared to codes already generated from first 3 focus groups to see if any new codes developed. No new codes.
All directly on transcripts
Theme generation, recoding and reorganising to generate coherent themes
Document 3, and theme maps 1 and 2
5th September 2016
Refining of themes and codes, numbering frequency of codes
Document 3, theme map 3
Generating final themes Document 3, theme map 3
Beginning to extract examples from transcripts for results section
11th
December 2016
Re-reading of transcripts with “fresh eyes” to check for any missed/unnecessary codes
Document 3, final theme maps (main body)
Tweaked two code names to better represent data
Document 3, final theme maps (main body)
Above led to generation of additional “no change” code
Document 3, final theme maps (main body)
Theme salience decided upon in relation to research questions posed
Empirical paper
Supervisor reviewed transcripts to check validity of codes and themes
185
Appendix 8a – Reference Document 1
Inductive thematic analysis – initial ideas on codesAll of the information below (apart from “initial reading of group 1 post focus group notes”) were later added directly to transcripts for ease of reading. The author did not initially annotate directly on transcripts to avoid subsequent readings being influenced by previous thoughts on codes (i.e. allowing each reading to look at “blank” transcripts). After the 3rd reading of group 1, and the 2nd readings of groups 2 and 3, the notes below were added to the transcripts. 12 th August 2016
Initial reading of group 1 post focus group
Line 6 – control Line 8 – relaxed Line 13 – helpful and not helpful, boring
Line 15 – characters, consequences
Line 17 – mindfulness unhelpful
Line 20 – making new friends
Line 22 – how to interact with people from different backgrounds
Line 26 – meeting new people
34 – meeting new people – “I know him”
44 – benefits of group – being helped by other people
46 – dull on own – better in group. Group can be helpful and unhelpful – distracting/difficult
50 – new ideas – external facilitator
52 – trust 58 – trust 65 – teachers serious, facilitators can take a joke
69 – importance of school facilitator – balance between behaviour management and not disliking teacher
71/73 – facilitator 93 – preoccupation with lessons being missed and wanting to tailor timing of intervention to fit with this.
99 – increased frequency 111 – increased duration Theme of wanting to miss school time??
118 – missing education lessons bad thing
Theme of not wanting it to impact on lessons?
122 – value of workbook being overlooked?
124 – less angry at my sister
131 – learning to think before act
133 – tiger is calmer – use of group metaphor
144 – exerting more thought and self control in reactions
146 – not answering back 148 – thinking through the consequences
154 – concerned about questionnaires – these don’t relate to me? I would never have thought of that
158 – questionnaires – weird
167 – too many questionnaires
168 – questionnaires were repetitive
190 – more games 193 – play fifa
199 – snacks 204 – donut activity – good
Theme of interactive activity??
186
211 – angry frustration games
Second reading of group 1 post focus group
4 – wise warrior – use of character good?
6 – control - Code: distal impact of group?
8 – group and mindfulness -> relaxed Code: immediate emotional impact of group?
12 – LeBron James – helpful – Code: making group engaging, characters they can relate to?
15 - characters and consequences helpful – Code: metaphor, personalised to individual (consequence)?
19 – it was the same things – Code: not engaging, repetitive, didn’t see the point?
20 – meeting new friends – Code: broader impact of group/unforeseen benefits?
22 – taught me how to interact with people from other areas – Code: broader skill development?
26 – met new people
30 – are you going to put it on in assembly? Code – confidentiality concerns?
34 – meet new people: Code – broader impact of group
44 – helped by other group members Code: effect of peers/group process?
46 / 48 – peers also distracting. Code: effect of peer/group process
50 – outside facilitators bringing something new. Code: fresh perspective?
52/56/58 – can’t trust: Code trust/confidentiality
65 – facilitators can take a joke Code: group process, authority?
69 / 71 – school facilitator important: Code group process, authority?
80s and 90s – additional sessions during specific lessons. Code: group as soft option?
118 – not wanting to miss lesson. Code: school v group tensions?
120 – liked the workbook, made me write personal stuff. Code: personalisation of group
122 – missed lots of pages in workbook that were important. Code: value of group, personalisation important?
124 – less angry at my sister. Code: anger related change
131 – think before you act. Code: impact of group?
133 – tiger is calmer. Code: using metaphor/characters from group/ impact of group
138 – c point. Code: impact of group, consequences
144 – c point, now comment why? Code: impact of group, control?
146/148 – don’t answer back, don’t want to make the situation worse. Code: making choices? Consequence?
154 – questionnaires concerning. Code: mismatch between
160 – questionnaires weird. Code: detrimental effects of group?
190 – more games. Code: group as a soft option? Group more interactive?
187
individuals and measures? Inappropriate measures? Detrimental effects of group (concern)?
Labelling individuals?
200 – snacks. Code: group as a soft option?
203 – donut activity. Code: use of metaphor, interactive
212 – more frustration games. Code: interactive, soft option, not taking seriously?
15 th August 2016 Third reading of group 1 post focus group
2 – characters/metaphors = helpful.
6 – control; Code: controlling anger
8 – mindfulness = relaxing. Code: immediate impact of group; relaxation; skill learning
13 – some parts helpful, some parts not helpful. Code: ambivalence? Relatable content = good, some = boring
15 – characters = good, consequences = good. Code: relatable content
17 – mindfulness – always the same. Code: lack of clarity around purpose?
20/22 – meeting new people. Taught me how to interact with people from surrey. Code: unforeseen benefits of the group? Broader skills development
26 – met new people. Code: benefits of group? Importance of peers? Broader skill development?
30 – concerns over recording being played in assembly. Code: group process? Trust?
44 – helped by other people. Code: group / peer benefits?
46 /48 – one-to-one would be dull, but group can sometimes be distracting. code: group process
50 – external facilitators = good, not sticking to procedure of school, new things to show us. Code: group process? Novelty of facilitators
52 – can’t trust you fully. Code: trust / group process
58 – go out and tell other staff. Code: trust/ group process
65 – facilitators can take a joke, teachers can’t. code: group process, authority, facilitator style?
69 – **** made us behave properly, not ****. Code: need for boundaries/authority/ group process. Importance of balance!
80s – lots of reference to wanting more sessions, focused around which lessons they would be missing. Code: group as a soft option?
118 – missing lessons a bad thing, education important. Code: tension between soft option v importance of education.
120 – workbook, good, write stuff. Personal stuff.
122 – missed pages that were important. Code:
124 – less angry at my sister. Code: distal
188
People who inspire me. Code: making it personal/tailored. Content.
personal content = valuable.
changes?
131 – mindfulness. Think before you act. Code: content not entirely clear? Think before you act = clear take home message.
133 – my tiger is more calm. Code: distal benefits of group, metaphor/character important
144 – teacher c point, less angry, trying to earn it off. Code: distal benefits of group, thinking things through/less impulsive.
148 – don’t want to get into more trouble. Code: thinking before acting, thinking of consequence
154 – questionnaires – bit concerning. Code: content not relatable
158 – some of the questionnaires – bit weird. Content not relatable.
168 – half of them mean the same thing. Code: content not relatable, not clear?
174 – computer task, very frustrating. Code: measure effective?
190 – more games. Code: not taking group seriously? Content – engaging. Group as soft option?
199 – more snacks. Code: group as soft option? Group seen as fun?
203 – donut activity. Code: content = good, understanding purpose, metaphor = good.
209 – fifa. Code = make group engaging/interactive, group as soft option?
First reading of group 2 post focus group
4 – tiger = helpful. Code: content. Character/metaphor = good. Relatable.
6 – nothing unhelpful. Code: content = good.
10 – characters helpful, choosing the road. Code: clear messages, consequences, content, characters/metaphors = good.
12 – choice of paths to take. Code: content, clear, simple messages, consequences, choice
16 – choices. Code: choices
18 – 20 – group all good, not unhelpful. Code: content = good.
26 – make it longer, so I can miss it maths. Code: group as soft option?
29 – consequences don’t take away reward points. Code: not fair? Group organisation? Group process?
31 – yeh that wasn’t fair (consequence). Code: not fair? Group organisation.
38 – awkward one-to-one, relate to people your own age. Code: group process, importance of peers – relatable, group = comfortable.
40 – awkward on own, fear of being judged, not only you that goes through it. Code: judgement from teachers? Importance of peers, support from group – group process. Group = good.
44 – sharing your emotions. Code: peer support, group process
189
50 – group = comfortable. Code: feeling comfortable, safe? Group process? Boundaries?
56 – one to one, too much pressure. Code: importance of group process.
62/64 – good to have outside facilitators, teacher might bring up stuff, feel more comfortable. Code: trust, group boundaries, group process, safety in group? Feeling comfortable.
66 – teachers might have a vendetta/not like you, external facilitators don’t know you. Code: not judged.
68 – can trust you two. Code: trust
70 – teachers gossip. Code: trust, group boundaries, confidentiality.
72 – teachers might tell parents. Code: external facilitator important, trust/confidentiality
80 – male facilitator might be more helpful, can relate to how it feels. Code: relatable facilitator
84 – more banter with a man. Code: relatable facilitator
91 – time to think about it in the week (once a week). Code: in between session reflection? Consolidation?
97 – missing lessons. Code: group as a soft option?
102 – get more out of it (longer session time). Code: group = valuable?
110 – Thursdays, no. code; tension between group and lessons?
115, 116 – would not come if after school. Code: group not that valuable? Group organisation – not impede on liked activities?
133 – would like more sessions to avoid lessons they get in trouble in (less likely to get C points). Code: group as a soft option/positive alternative to lessons? Group as a way of staying out of trouble?
141 – talking to people getting more out of it. Code: need for more time talking, rather than just content? Personalised? Sharing important – group process. Group as a way of preventing anger spilling into lesson – proximal outcome of group.
149 – 155 mixed feelings on workbook – didn’t really do it properly. Code: organisation of group, relevance of content needs to be clear
156 – didn’t like writing, prefer talking. Code: importance of discussing/sharing, group process? Overloaded with content?
160 – use workbook to prompt thinking about group content. Code: workbook as reminder of content? Reinforces group messages?
170 – books help finish off goals. Code: reinforcing group messages? Goals = important? Clear messages?
172 /174 – not been in fight. Code: outcomes, distal benefits
176 – every day used to 178 /180/181– not 187 – thinking about GCSEs –
190
get in trouble. Code: outcomes, distal benefits
been on top 10 c points. Code: outcomes, distal benefits
code; thinking about consequences/goals, systemic influences (mum)
192 /193 – thinking about priorities, values. Code; outcomes, values
197 – they’re in year 9, picking options. Code – systemic influences on changes
201 – might’ve been a few, but not noticed. Code: outcomes – not noticed changes
205 – chose the right path. Code: thinking before acting, choices.
207 - getting blamed for things. Code: systemic influences on outcome – negative.
209 – unable to articulate why things have improved. Code: not sure what they’ve learnt/where to attribute outcomes?
213 – feeling victimised by teacher, not being listened to. Code: systemic influences on changes – negative.
215/219 – doing mindfulness thing by myself, making my own one. Code: skill development, outcomes – distal
224/226/232 – questionnaires stressful, irrelevant, offensive/deep questions. Code: content = disengaging, not relatable. Too invasive? Not pitched appropriately for level of risk?
234 – issues with questionnaire – could understand if someone had really bad anger issues. Code: inappropriate content, not pitched at appropriate level, disengaging
242 – take it out on a animal – doesn’t make sense at all. code: not relatable
250 - questionnaires were good. Code: content okay.
254 – computer task frustrating. Code: measure effective?
259 – call parents to celebrate child’s behaviour. Code: celebrating outcomes, need for systemic approval, importance of rewards
265 – boxing, physical things, hold your anger in and control it. Code: content not clear enough? Missing key messages? Need more interaction
271 / 273 – bring in an older person who has experienced anger. Code: importance of relatable facilitator
275/276/278 – not liking consequences, but rules are fine. Code: importance of safety/boundaries in group? Group shouldn’t be a place of punishment??
282 – proper anger management, obviously planned. Code: importance of feeling like the group is planned?
288 – more music. Code - different styles of presentation – interactive
292 – party – code: celebration, rewards
303 – maybe the cross roads….code: helpful content, choices, empowerment/responsibility?
191
Second reading of group 2 post focus group
4 – my anger is tiger, I should walk beside it, like the guy on the board. Code: character/metaphor important, relatable content – tiger in particular feels like anger?
10 – mindless zombie/wise warrior = helpful, choosing the right path. Code: character/metaphor, choices, empowerment/responsibility?
12 – choice of different paths to take, carry on, getting in trouble or calm down: Code: choices, consequence, responsibility?
16 – choose to go with my anger or stop it from escalating: code: choices, outcomes, responsibility
22 / 26 – two hours instead of one, miss maths. Code: group better option than school? Group soft option?
28 – consequences don’t take away your reward points. Code: group should not be about punishment.
31 – yeh that wasn’t fair. Code: fairness important.
38 – awkward if one to one. Code: group process, relate to peers
40/42 – going to be judged by teacher on own, group not just you that’s going through it. Code: group process, normalised by peers – we’re all in this, mutual support of peers, non judgement
44/50 – share your emotions (in a group) – code: group process = supportive, comfortable
56 – one to one, all attention on you. Code: group process – too intense one-to-one
60/62/64 – helped having external facilitator as teacher might bring things up, feel more comfortable. Code: group boundaries important, non-judgment, safety
66- fear of being judged by teachers who already carry knowledge about them. Code: separation from school/prior knowledge = important
68 – can trust you two. Code: trust/confidentiality
70 – teachers, gossip, risk being brought up in next lesson code: confidentiality, boundaries
72 – might tell parents. Code: confidentiality, fear of other
80 – male facilitator good – experienced it. Code:
84 – more banter with a man –
192
consequences, boundaries/safety/containment of group.
relatable facilitator, experts by experience
code: relatable facilitator
91 – week to think about the session. Code: between session reflection helpful
93/97 – reference to missing certain lessons. Code: group more enjoyable than lessons? Motivations behind attending the group?
100/102 – get more out of it. Code: group is valuable
114 – don’t want it after school, stuff to do. Code: priority of group compared to other commitments
131 – more sessions, missing sessions you are normally in trouble in. Code: ulterior motive for attendance (avoidance)
141 – talk about difficult experiences, sea rejecting: Code – benefits of group beyond content e.g. mutual support, off loading
146, 147 – skipped bits of workbook. Code: content not valued by facilitators? Not clear enough messages?
152/156 – didn’t like it, more writing. Better to say it than write it down. Code: workbook = burden? Talking and sharing mutual experiences?
160 – workbook helpful as prompt in the future regarding decisions: Code: ??
170 – finish off your goals (in the books). Code: importance of goals, beneficial effects of group outside of group
172/174 – not been in a fight – Code: distal effects of group, outcomes
178 – not been on top 10 c points – code: distal effects of group, outcomes
187/193– changed for GCSEs – code: systemic influences on change values/goals, priorities
197 – they’re in year 9 – more responsibilities, GCSEs around the corner: Code – systemic/maturational influences on change,
201 – not noticed changes. Code: no change, not noticed change
205 – chose the right path – Code: choices.
207 – ongoing frustrations when getting blamed for things by teachers.
213 – someone else laughing, me getting blamed. Code: labelled by school?
215 – making my own mindfulness up. Code: benefits lasting beyond group, distal benefits, skill development?
224/226/232 – questionnaires = stressful, offensive, questions too deep. Code: content unrelatable, you think I’m worse than I am?
234 – understand that question for someone with really bad anger issues: Code: unrelatable, labelling?
240 – take it out on animal, doesn’t make sense – code:
250 – questionnaires were good. Code: content
254 – computer task, frustrating.
193
unrelatable acceptable? Code: valid measure
259 – phone parents at end of group. Code: systemic acknowledgement of achievement / reward / celebrate progress
265 – boxing, physical. Hold in anger. Control it. Code: controlling anger, channelling anger, missing the point?
271 – facilitator to have experienced anger problems. Code: relatable facilitator
273 – guy talking about near miss . Code: relatable facilitator.
275 - 278 – get rid of consequences, not the rules. Code: not wanting punishment, group to be fair, boundaries and behaviour important – group process
282 – this is proper. This is obviously planned and stuff. Code: importance of planning, facilitators taking the group seriously
286 – music. Code: engaging, different presentation styles
292 – party at the end. Code: celebration
303 – maybe the crossroad. Code: choice
First reading of group 3 post focus group.
2 – didn’t want to participate at first, but that changed. Code: taking a while to settle in/warm up?
2 – more people to help them. Code: support – more wanted
8 /14– do less mindfulness. Code content, not engaging. Lacking skills? Inaccessible (too quiet).
10 – more of that donut thing. Code: content, engaging
16 – anger, something to get rid of and control. Code: control, getting rid. Missing the point?
24 – force people to attend so they realise it’s helpful. Code: taking a while to warm up to group? Initial barrier to engagement?
30 – characters helpful. Code: metaphor/character
34 – put other role models in (other than basketball). Code: role models – content, personalised, relatable
40 – express your feelings more, being taken out of the room if needed. Code: opportunity to offload, issues around group/confidentiality/trust/embarrassment?
46 – group – connect outside group, one2one=shy and not express yourself, know that they’re going to keep your
50 – additional benefits of group – people getting to know you as a person, rather than judging you. Code: building bonds with other people?
50 – misbehaving with friends (bad thing). Code: group dynamics/process, influence of peers (negative)
194
feelings and you’re going to keep theirs (note possible contradiction to previous point). Code: mutual trust/support, confidentiality, importance of peers modelling, less intense/embarrassing than one to one?52 – group changes people’s perceptions of individuals. Code: broader effects of group (unforeseen), social effects
58 – one-to-one = awkward, wouldn’t share. Group = hear other’s ideas, advice. Code: support/advice from group/peers, removes embarrassment factor
60 -at first, came to miss lessons, now its helping. Code: group as a soft option v group helping, slow burner
62 – teachers would think you are a bad person. Code: facilitator not bringing history. Not judging.
78 – wouldn’t be as open with a black man. Code: group safety, facilitator safety/boundary, relatable can be bad too?
82 – facilitator been through misbehaving – they can understand. Code: facilitator relatable
84 – session format (Weekly) allows time to think and do mindfulness. Code: importance of in between session reflection?
88 – wanting to time to talk about wider issues – life and the streets. Code: sharing wider systemic issues important – content not included? Content too narrow?
96 – reminder that we should control our anger. Code: control, frequency important, in between sessions a good reminder
104 – talking about wider issues that could get us out trouble would be good – problem solving. Code: content to be broader – more focus on systemic issues
112 – talk in more detail about wise warrior/mindless zombie, and role models. Code: content – lacking detail, pace too fast
116 – urge surfing – do more. Code: interactive activity good. Metaphor = good.
195
and problem solving.121 – longer = more likely to stick in your head. Code: ??
127 – more advice and help. Code; need for more time on content, more strategies
131 – period 5 and 6 – help us when we go home. Code: focus on lessons being missed? Transferability to different environments?
134 – thoughtful about when in day to time lessons. Code: organisation – what will make learning most transferable
138 – period 5 and 6 – think about it and then walk away Code: organisation and influence on transferability.
145 – workbook helps to think back to previous week. Code: value of content, reminders helpful to sustain learning
147 – good to take home as a reminder. Code: transferability of learning, need for reminders
157/160 – anger’s gone, calmed down more since I’ve been. Think and sorting out. Code: distal changes, capacity to think through, make choices
164/166 – not getting in trouble for getting angry. Can relax, calm myself down. Code: distal changes, keeping calm
168/170 – less c points, not in trouble for as big things. Code: distal changes
170 – teachers see you as misbehaving (Rather than anger). Code: teacher’s perceptions/preconceptions?
172 – characters, and thinking about future: Code: characters, future/consequences
180 – control. Code: control
184 – questionnaires, starting fires, bit weird. Code: questionnaires unrelatable.
186 – never knew people could do stuff like that Code: unrelatable
188 190– made me realise I knew people who would use weapons. How it harms others. Code: encouraging wider systemic thinking. Thinking about consequences to others
202 – happy to do questionnaires
204 – same
206 – a bit too long though. Code: questionnaires acceptable
208/209 – computer task – frustrating and stressful. Code: frustrating, valid measure
216 – didn’t really mind the task
196
224 – task made me feel worse. Code: valid measure, inaccessible (too frustrating)?
228 – tasks involving role models: Code: relatability, accessibility, role models, engaging/interactive
234 – games. Play board games and talk about feelings. Code: interactive content, making it fun??
240 – people who don’t get angry should come too. Code: content helpful/accessible to broader range of people.
252 – helps you to control yourself and teaches how to handle tough situations. Code: control (actions), content = strategies
260 – might not be able to trust teachers (depends on teacher257-258). Code: trust
273 – depends what subject you’re missing. Code: impact of group on schooling
278 – don’t mind two hours.
Second reading of group 3 post focus group.
2 – didn’t want to get involved at start; more people to help. Code: support important. Overcome initial barriers to engaging with more encouragement?
8 /10 – do less mindfulness, more donut thing. Code: content – engaging or disengaging.
14 – mindfulness, too quiet, never listen. Code: accessibility of mindfulness? Skill development (lack of)?
24 – force people to do it for a week. Code: barriers to initial engagement? Warming up to it?
30 – mindful zombie and wise warrior – helpful. Code: characters, metaphors = good content
32 – basketballer – have other role models. Code: role models, need material to be more relatable/personalised.
40 – express your feelings, taken out of room. Code: group process – sometimes need one-to-one? Valued opportunity to express feelings
46 – group = better as people to connect with outside. Less shy, show your feelings, keep each others feelings. Code: trust, confidentiality, normalisation of sharing feelings
50/52 – get to know your personality (not just that you’re angry). Code: broader, social benefits of group (unforeseen)
50 – with friends can misbehave (bad thing). Code; group process -influence of peers
58 – one to one would be awkward, people wouldn’t share. Code: intensity of one-to-one versus less pressure of group.
58 – use group’s ideas and advice. Code: group = more ideas
60 – first, just came to 62/64 – teachers would 66/68 – don’t mind who
197
miss lessons, now helping. Code: initial impressions - Soft option? Programme helpful
hold past information. Code: facilitators being open/non-judgemental
runs it. Code: ambivalence?
78 – black man facilitating – wouldn’t be as connected or open. Code: diversity/relatability issues?
82 – someone been through misbehaving. Code: relatability of facilitator/similarity
84 – frequency of sessions gave us time to think and do mindfulness. Code: organisation promotes time for reflection
88 – would like to discuss broader issues. Code: opportunity for more systemic discussions? Anger too narrow?
96 – Monday reminds us to control our anger for the rest of the week. Code: control, organisation – need for reminders
104 – longer sessions, talk about stuff that happened. Code: opportunity to discuss wider system issues, anger too narrow
106 – and how to deal with things in a better way. Code: more content on strategies = good.
112 – more sessions, to talk in more detail about characters and role models. Code – more time good, more opportunity for discussion/reflection
116 – more activities like surfing. – Code: metaphor, interactive activities = good
121 – more sessions, longer likely to stick in head. Code: need for greater volume to maintain learning.
127 – longer, more learning, more advice. Code: longer = greater opportunity for more advice.
131 – timing at end of day – in mind when we go home. Code: organisation – out of sight out of mind? materials/processes to remind/increase salience of messages = helpful
145 -workbook good as reminder. Code: materials/processes to remind/increase salience of messages = helpful
147 – take home and use it as a reminder. Code: need or prompting, increasing salience?
156/158 – anger’s calmed down since coming to group – its just something there, don’t really need to take it out on other people, sort it out with them. Code: sitting with! Making choices (rather than impulsive responses)
164/166 – not getting in trouble in class for being angry – can relax and calm myself down. Code: emotion regulation skill – core ACT skills code??
168/170 – less c points, anger makes things worse, teachers see it as misbehaving. Code: consequences, not understood by teachers?
172 – wise warrior, mindfulness, thinking about future. Code: characters/salience, consequences/values
198
180 – not in trouble as much, controlled myself. Code: control (over actions - ACT)?
184 – questionnaires, interesting but weird. Code: not relatable
186 – never knew people could do stuff like that. Code: not relatable.
188 – knew people who would hold weapons. Code: encouraging wider systemic thinking?
190 – it harms other people. Code: consequences
200 – didn’t understand how someone could feel that when angry. Code: not relatable
202 – happy to do them. Code: questionnaires -fine.
208/209 – computer task frustrating and stressful. Code: valid test.
226 – food. Code: group = social, fun?
228 – tasks and role models. Code: relatable, interactive
230 – games related to controlling self. Code: control (Actions), interactive, fun
234 – board games and talk about our feelings. Code: emotional expression, interactive, fun
252 – recommend group, helps you to control yourself and teaches ways to handle yourself. Code: control, strategies
256-259 – honesty depends on teacher. Code: facilitator and prior relationship important.
260 – might not be able to trust teachers. Code: trust
272 – 2 hour sessions – depends on what missing. Code; conflict between missing lessons and attending group
199
Appendix 8b - Reference Document 2
Code identification: Following “rough notes” in document one, these were condensed into the codes below. Codes that are highlighted in groups 2 and 3 are additional codes to those already established in the previous transcripts. 16 th August 2016
Group 1, post focus group. Summary of identified codes:
Control Keeping calm / relaxed HelpfulBoring Characters ConsequencesMindfulness New friends Interacting with people
from other backgroundsGroup support Group distraction New ideasTrust Facilitator style Lessons missed – goodFrequency Duration Lessons missed – badUnhelpful Valued content Less angry/negative
consequences of angerThinking before acting/less impulsive
Metaphor Engaging
Not answering back Un-relatable RelatableInteractive Fun DisengagingRepetitive Skill development Confidentiality Influence of peers Authority Easy optionSchool v group tension Personalised content Making choicesGenerating concern/offence
Ambivalence Lack of clarity around purpose
Boundaries Clear messages Valid measure
Group 2, post focus group. Summary of identified codes. Highlighted = additional to group 1.
Character Metaphor RelatableClear messages Consequences ChoicesEasy option Fairness ComfortableJudgement Safety HelpfulGroup support Support from peers BoundariesIntense/pressure Trust ConfidentialityFacilitator relatable Between-session reflection Valued contentSchool v group tension Group not valued Talking time valuedAdditional re-enforcers of group content/messages to increase salience
Goals/values Less angry/negative consequences of anger
Systemic influences on changes
No change Thinking before acting
Lack of awareness of cause of changes
Skill development Un-relatable
Generating concern/offence
Disengaging Valid measure
200
Rewards Celebration Need for systemic approval
Lack of clarity around purpose
Interactive No punishment
Group planning important
Empowerment/responsibility Non-judgement
Normalisation by peers Priority of group Content not valued by facilitators
Off-loading Maturational influences on change
Blame
Control
Group 3, post focus group. Summary of identified codes. Highlighted = additional to groups 1 and 2.
Time to settle/warm up to group
More support wanted Lack of skills
Disengaging Engaging Metaphor Character Personalised content Relatable Role models Off-loading ConfidentialityTrust Embarrassment Group supportSupport from peers Intense/pressure People getting to know
youNon-judgement Influence of peers –
negativeChanging others perceptions
Easy option Safety BoundariesRelatable facilitator - negative
Relatable facilitator Between-session reflection
Content to include wider systemic issues
Control Frequency
Additional re-enforcers of group content/messages to increase salience
More detail Pace too fast/need more time
Interactive More strategies Transferability to different environments
School v group tension Valued content Thinking before actingChoices Keeping calm/relaxed ConsequencesThinking about future Less angry/negative
consequences of angerJudgement
Teacher preconceptions Un-relatable Consequences – to othersValid measure Helpful Fun Normalisation by peers Ambivalence Talking time valuedDuration Sitting with difficult
feelingsEmotion regulation
Condensed list of codesTerm listed above Condensed term Code
201
number
Control Control 1.Boring, repetitive, engaging, disengaging, generating concern/offence
Engaging/Disengaging 2.
Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation
Skill development/Lack of skills 3.
Group support, new ideas, support from peers, comfortable, embarrassment
Group support and help; benefits of group
4.
Trust, confidentiality Trust/Confidentiality 5.Frequency, duration, pace too fast/need more time
Pacing of group 6.
Unhelpful, helpful Helpfulness 7.Thinking before acting/less impulsive, not answering back
Thinking before acting 8.
Interactive, fun Interactive/fun 9.Influence of peers, influence of peers – negative, group distraction, normalisation by peers
Influence of peers 10.
School v group tension, lessons missed – good, lessons missed – bad, priority of group
Group priority (over school and other commitments)
11.
Boundaries, safety Boundaries/safety 12.Keeping calm/relaxed Keeping calm/relaxed 13.Characters, metaphor Character/metaphor 14.New friends New friends 15.Facilitator style, authority Facilitator style 16.Valued content, group planning important, group not valued
Valued/not valued 17.
Un-relatable, relatable Relatability of content 18.Personalised content Personalisation 19.Ambivalence Ambivalence 20.Clear messages, lack of clarity around purpose
Importance of clear, simple messages 21.
Consequences, consequences – to others
Thinking about consequences 22.
Interacting with people from other backgrounds, people getting to know you, changing others perceptions
Broader benefits of group 23.
202
Less angry/negative consequences of anger, no change, lack of awareness of change
Changes from group – proximal and distal
24.
Easy option Group as easy option 25.Making choices, choices Choices 26.Valid measure Valid measure 27.Judgement, non-judgement Judgement/Non-judgement 28.Intense/pressure, embarrassment
Intense/pressure 29.
Facilitator relatable, relatable facilitator - negative
Relatability of facilitator 30.
Additional re-enforcers of group content/messages to increase salience, between-session reflection
Reminders/re-enforcers 31.
Systemic influences on changes, maturational influences on change
External influences on change (maturation, systemic)
32.
Lack of awareness of cause of changes
Unclear why change has occurred 33.
Rewards, celebration, need for systemic approval
Rewards/celebration/acknowledgement 34.
Off-loading, talking time valued
Talking/expressing 35.
Fairness, no punishment Punishment/behaviour management 36.Goals/values, thinking about future
Consideration of things that are important
37.
Empowerment/responsibility Empowerment/responsibility 38.Content not valued by facilitators
Content not valued by facilitators 39.
Time to settle/warm up to group
Initial barriers to engagement 40.
Role models Role models 41.Content to include wider systemic issues, more detail, more strategies
Content too narrow 42.
Teacher preconceptions, blame
Teacher’s perceptions 43.
More support wanted More support from facilitator wanted 44.Transferability to different environments
Transferability to different environments
45.
203
Appendix 8c – Reference Document 3Theme Generation 22nd August 2016 - Supervisory discussion
Ideas for themes Ideas for themes: group content (personal relevance, accessibility, clear messages), group process (facilitator style, peers, boundaries/safety, confidentiality/trust), group organisation (workbook, lessons, facilitators), outcomes (think before act, broader skill development, consequences), choices, control, systemic influences on change
6 c’s Confidentiality, Content, Control, (group process – peers, facilitator style), Change, Choices, Consequences, Contextual factors, Communication23rd August 2016 - Further ideas for themesIdeas for themes: group content (relatability, engaging, clear messages), group process (facilitator style, peers, boundaries/safety, confidentiality/trust), group organisation (workbook, lessons, facilitators), outcomes (think before act, broader skill development, consequences), choices, control, systemic influences on change, positive experiences v negative experiences.
Overarching themes – content versus process; individual versus contextual factors
o Contento Culture of group – confidentiality, group process, etco Contextual considerationso Changes – choices, control, consequences
Initial attempts at organising codes into themes – see theme map 1, appendix 8dTerm listed above Condensed term Code
numberTheme
Control Control 46. ChangesBoring, repetitive, engaging, disengaging, generating concern/offence
Engaging/Disengaging 47. Content
Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation
Skill development/Lack of skills
48. Changes
Group support, new ideas, support from peers, comfortable, embarrassment
Group support and help; benefits of group
49. Culture of group
Trust, confidentiality Trust/Confidentiality 50. Culture of groupFrequency, duration, pace too fast/need more time
Pacing of group 51. Contextual considerations
Unhelpful, helpful Helpfulness 52.Thinking before acting/less impulsive, not answering back
Thinking before acting 53. Changes
Interactive, fun Interactive/fun 54. Content/ Culture of group
Influence of peers, influence of peers – negative, group
Influence of peers 55. Culture of group
204
distraction, normalisation by peersSchool v group tension, lessons missed – good, lessons missed – bad, priority of group
Group priority (over school and other commitments)
56. Contextual considerations
Boundaries, safety Boundaries/safety 57. Culture of groupKeeping calm/relaxed Keeping calm/relaxed 58. ChangesCharacters, metaphor Character/metaphor 59. ContentNew friends New friends 60. Changes / Culture
of groupFacilitator style, authority Facilitator style 61. Culture of groupValued content, group planning important, group not valued
Valued/not valued 62. Content
Un-relatable, relatable Relatability of content 63. ContentPersonalised content Personalisation 64. ContentAmbivalence Ambivalence 65.Clear messages, lack of clarity around purpose
Importance of clear, simple messages
66. Content
Consequences, consequences – to others
Thinking about consequences
67. Changes
Interacting with people from other backgrounds, people getting to know you, changing others perceptions
Broader benefits of group
68. Changes
Less angry/negative consequences of anger, no change, lack of awareness of change
Changes from group – proximal and distal
69. Changes
Easy option Group as easy option 70. Contextual considerations / Culture of group
Making choices, choices Choices 71. ChangesValid measure Valid measure 72.Judgement, non-judgement Judgement/Non-
judgement73. Culture of group /
Contextual considerations
Intense/pressure, embarrassment
Intense/pressure 74. Culture of group
Facilitator relatable, relatable facilitator - negative
Relatability of facilitator 75. Culture of group
Additional re-enforcers of group content/messages to increase salience, between-session reflection
Reminders/re-enforcers 76. Contextual considerations
205
Systemic influences on changes, maturational influences on change
External influences on change (maturation, systemic)
77. Contextual considerations / Change
Lack of awareness of cause of changes
Unclear why change has occurred
78. Change
Rewards, celebration, need for systemic approval
Rewards/celebration/acknowledgement
79. Content / Culture of group
Off-loading, talking time valued
Talking/expressing 80. Culture of group / Content
Fairness, no punishment Punishment/behaviour management
81. Culture of group / Contextual factors
Goals/values, thinking about future
Consideration of things that are important
82. Change / Contextual considerations/ Content
Empowerment / responsibility
Empowerment / responsibility
83. Change
Content not valued by facilitators
Content not valued by facilitators
84.
Time to settle/warm up to group
Initial barriers to engagement
85. Culture of group
Role models Role models 86. Culture of group / Content
Content to include wider systemic issues, more detail, more strategies
Content too narrow 87. Content / Contextual considerations
Teacher preconceptions, blame
Teacher’s perceptions 88. Contextual considerations
More support wanted More support from facilitator wanted
89. Culture of group
Transferability to different environments
Transferability to different environments
90. Contextual considerations
Codes without themes: Helpfulness – important, needs to be included, links with all 4 themes
identified above Valid measure – less important. Separate point, only really refers to computer
task? Content not valued by facilitators – less important, rare occurrence. Ambivalence – fairly rare.
Comments on themes - see theme map 1, appendix 8d Changes and Content = good. On initial viewing, appear to have internal
homogeneity. Some links with other themes. Culture = too heterogenous. Context = too heterogenous and too many links with other themes.
206
Resultant changes Culture subdivided: Culture of group – structural and content factors; Culture
of group – interpersonal factors Context subdivided: Contextual considerations – intra and interpersonal;
Contextual considerations – practical Helpfulness removed as a code as this was too broad and covering all themes,
and largely covered by existing codes, particularly valued/not valued (17) Interactive/fun (9) reviewed and re-categorised as referring only to content, as
this was largely the case and in other examples it was captured by other codes. This allowed greater internal homogeneity and external heterogeneity.
Role models (41) re-categorised to only include reference to role models in the content of the group. Reference to wanting facilitators who have had similar experiences has been solely included under “relatable facilitator”. Role models now categorised under content.
Rewards (34) redefined as “external acknowledgement of achievement”. Categorised under “contextual considerations: intra and interpersonal”
Overlap between 32 (external influences on change) and 37 (consideration of things that are important). 37 now includes only reference to goals, and is classified under “content”, 32 has incorporated “thinking about the future” and is classified under context: intra and interpersonal, and “change”.
New themes: - see theme map 2, appendix 8e Culture of group
Subthemes – Culture of group: Structural factorsCulture of group: Interpersonal
Contextual considerationsSubthemes - Contextual considerations: Intra and interpersonal
Contextual considerations: Practical Changes Content
Term listed above Condensed term Code number
Theme
Control Control 1. ChangesBoring, repetitive, engaging, disengaging, generating concern/offence
Engaging/Disengaging 2. Content
Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation
Skill development/Lack of skills
3. Changes
Group support, new Group support and help; 4. Culture of
207
ideas, support from peers, comfortable, embarrassment
benefits of group group: Interpersonal
Trust, confidentiality Trust/Confidentiality 5. Culture of group: Structural factors
Frequency, duration, pace too fast/need more time
Pacing of group 6. Contextual considerations: Practical
Unhelpful, helpful Helpfulness 7. Thinking before acting/less impulsive, not answering back
Thinking before acting 8. Changes
Interactive, fun Interactive/fun 9. Content Influence of peers, influence of peers – negative, group distraction, normalisation by peers
Influence of peers 10. Culture of group: Interpersonal
School v group tension, lessons missed – good, lessons missed – bad, priority of group
Group priority (over school and other commitments)
11. Contextual considerations: Practical
Boundaries, safety Boundaries/safety 12. Culture of group: Structural factors
Keeping calm/relaxed Keeping calm/relaxed 13. ChangesCharacters, metaphor Character/metaphor 14. ContentNew friends New friends 15. Changes /
Culture of group: Interpersonal
Facilitator style, authority
Facilitator style 16. Culture of group: Interpersonal
Valued content, group planning important, group not valued
Valued/not valued 17. Content
Un-relatable, relatable Relatability of content 18. ContentPersonalised content Personalisation 19. ContentAmbivalence Ambivalence 20.Clear messages, lack of clarity around purpose
Importance of clear, simple messages
21. Content
Consequences, consequences – to others
Thinking about consequences
22. Changes
208
Interacting with people from other backgrounds, people getting to know you, changing others perceptions
Broader benefits of group 23. Changes
Less angry/negative consequences of anger, no change, lack of awareness of change
Changes from group – proximal and distal
24. Changes
Easy option Group as easy option 25. Contextual considerations: Practical / Culture of group: Interpersonal
Making choices, choices Choices 26. ChangesValid measure Valid measure 27.Judgement, non-judgement
Judgement/Non-judgement 28. Culture of group: Interpersonal / Contextual considerations: Intra and interpersonal
Intense/pressure, embarrassment
Intense/pressure 29. Culture of group: Structural
Facilitator relatable, relatable facilitator – negative
Relatability of facilitator 30. Culture of group: Interpersonal
Additional re-enforcers of group content/messages to increase salience, between-session reflection
Reminders/re-enforcers 31. Contextual considerations: Practical
Systemic influences on changes, maturational influences on change, thinking about future
External influences on change (maturation, systemic)
32. Contextual considerations: Intra and interpersonal / Change
Lack of awareness of cause of changes
Unclear why change has occurred
33. Change
Need for systemic approval
External acknowledgement of achievement
34. Contextual considerations: Intra and interpersonal
209
Off-loading, talking time valued
Talking/expressing 35. Culture of group: Interpersonal / Content
Fairness, no punishment Punishment/behaviour management
36. Culture of group: Structural / Contextual considerations: Practical
Goals Goals 37. ContentEmpowerment / responsibility
Empowerment / responsibility
38. Change
Content not valued by facilitators
Content not valued by facilitators
39.
Time to settle/warm up to group
Initial barriers to engagement
40. Culture of group: Structural
Role models Role models 41. ContentContent to include wider systemic issues, more detail, more strategies
Content too narrow 42. Content
Teacher preconceptions, blame
Teacher’s perceptions 43. Contextual considerations: Intra and interpersonal
More support wanted More support from facilitator wanted
44. Culture of group: Interpersonal
Transferability to different environments
Transferability to different environments
45. Contextual considerations: Practical
5 th September 2016 - See theme map 3, appendix 8f
Review of above themes for internal homogeneity and external heterogeneity. Punishment/behaviour management (code 36). Transcripts reviewed and it
was felt that this was adequately covered by Culture: Structural and did not need additional classification under Context: Practical.
External influences on change reclassified solely under Context: Inter/Intrapersonal as, after reviewing transcripts and themes, it was felt that the change category referred largely to what changes had occurred, as opposed to influences on changes.
Judgement/non judgement was reclassified to bridge the two subcategories of culture as, after reviewing transcripts, it was deemed to refer more to the way the group was set up as opposed to the context in which the group occurred.
210
Easy option code occurs solely with interactive/fun code, and pacing / group priority codes. After review of transcripts, it was felt that “group as an easy option” when referring to missed lessons etc could be adequately captured by the group priority code (11). Code 25 was thus used only to refer to content. Easy option moved to theme of “content” only. Group priority code renamed to “group v other options”
“New friends” was re-examined. Rather than bridging two themes, extracts were recoded into either “broader benefits of group” (under change theme) and /or “new friends”, which was moved to solely reside in “Culture of group: Interpersonal”.
Talking/expressing moved solely to “Culture of group: Interpersonal”.
11 th December 2016 – See final theme maps in main body of paperReviewed transcripts again after long break as a final check on coding and themes.
A couple of minor re-codes were made on transcripts (i.e. where a code had been missed, or where one was given which was not required as was covered by other codes)
“Intense/pressure” code was changed to “Intense/awkward” as it felt this would more accurately encapsulate the comments
Code 24 name was changed as this overlapped with the overall theme title and did not really highlight what it was referring to. Changed to “anger-related incidents”.
No change code was created to “mop up” the remainder of the previous code 24
NB: Table below incorporates 5th September and 11th December changes
Term listed above Condensed term Code number
Freq.
Theme
Control Control 1. 8 ChangesBoring, repetitive, engaging, disengaging, generating concern/offence
Engaging/Disengaging 2. 15 Content
Mindfulness, skill development, sitting with difficult feelings, lack of skills, emotion regulation
Skill development/Lack of skills
3. 7 Changes
Group support, new ideas, support from peers, comfortable, embarrassment
Group support and help; benefits of group
4. 9 Culture of group: Interpersonal
Trust, confidentiality Trust/Confidentiality 5. 9 Culture of group:
211
Structural factors
Frequency, duration, pace too fast/need more time
Pacing of group 6. 17 Contextual considerations: Practical
Unhelpful, helpful Helpfulness 7. Thinking before acting/less impulsive, not answering back
Thinking before acting 8. 4 Changes
Interactive, fun Interactive/fun 9. 13 Content Influence of peers, influence of peers – negative, group distraction, normalisation by peers
Influence of peers 10. 5 Culture of group: Interpersonal
School v group tension, lessons missed – good, lessons missed – bad, priority of group
Group v other options 11. 18 Contextual considerations: Practical
Boundaries, safety Boundaries/safety 12. 7 Culture of group: Structural factors
Keeping calm/relaxed Keeping calm/relaxed 13. 3 ChangesCharacters, metaphor Character/metaphor 14. 9 ContentNew friends New friends 15. 2 Culture of
group: Interpersonal
Facilitator style, authority Facilitator style 16. 8 Culture of group: Interpersonal
Valued content, group planning important, group not valued
Valued/not valued 17. 28 Content
Un-relatable, relatable Relatability of content 18. 11 ContentPersonalised content Personalisation 19. 5 ContentAmbivalence Ambivalence 20. 3Clear messages, lack of clarity around purpose
Importance of clear, simple messages
21. 5 Content
Consequences, consequences – to others
Thinking about consequences
22. 7 Changes
Interacting with people from other backgrounds, people getting to know you, changing others perceptions
Broader benefits of group
23. 6 Changes
Less angry/negative Changes from group – 24. 13 Changes
212
consequences of anger proximal and distalAnger-related incidents
Easy option Group as easy option 25. 4 ContentMaking choices, choices Choices 26. 7 ChangesValid measure Valid measure 27. 4Judgement, non-judgement
Judgement/Non-judgement
28. 3 Culture of group: Interpersonal / Culture of group: Structural
Intense/pressure, embarrassment
Intense/pressureIntense/awkward
29. 5 Culture of group: Structural
Facilitator relatable, relatable facilitator – negative
Relatability of facilitator 30. 8 Culture of group: Interpersonal
Additional re-enforcers of group content/messages to increase salience, between-session reflection
Reminders/re-enforcers 31. 8 Contextual considerations: Practical
Systemic influences on changes, maturational influences on change, thinking about future
External influences on change (maturation, systemic)
32. 5 Contextual considerations: Intra and interpersonal
Lack of awareness of cause of changes
Unclear why change has occurred
33. 2 Change
Need for systemic approval
External acknowledgement of achievement
34. 1 Contextual considerations: Intra and interpersonal
Off-loading, talking time valued
Talking/expressing 35. 8 Culture of group: Interpersonal
Fairness, no punishment Punishment/behaviour management
36. 6 Culture of group: Structural
Goals Goals 37. 2 ContentEmpowerment / responsibility
Empowerment / responsibility
38. 4 Change
Content not valued by facilitators
Content not valued by facilitators
39. 1
Time to settle/warm up to group
Initial barriers to engagement
40. 2 Culture of group: Structural
Role models Role models 41. 4 ContentContent to include wider Content too narrow 42. 3 Content
213
systemic issues, more detail, more strategiesTeacher preconceptions, blame
Teacher’s perceptions 43. 7 Contextual considerations: Intra and interpersonal
More support wanted More support from facilitator wanted
44. 2 Culture of group: Interpersonal
Transferability to different environments
Transferability to different environments
45. 3 Contextual considerations: Practical
No change, lack of awareness of change
No change 46. 1 Changes
214
Appendix 8d – Theme Map 1
215
Appendix 8e – Theme Map 2
216
Appendix 8f – Theme Map 3
217
Appendix 8g – Examples of Coded Extracts22
Pseudo-nym
Time Content First reading codes Second reading codes Draft code
Recoding after theme generation
Final codes after 11th Dec changes
Laura 4:10 Okay. Okay, we’ll go to Freddie next.Freddie 4:11 Umm, what I found helpful was, ummm,
the…the warrior and the mindless zombie (Laura: Mmhmm). Because, umm, if you…there’s like a (inaudible) about the mindless zombie...I mean not mindless zombie (Laura: Mmhmm), if you…the wise warrior, and, the mindless zombie, was it…it can help umm in which side you choose. You can choose like the road (Laura: Mmhmm). Yeh.
10 – characters helpful, choosing the road. Code: clear messages, consequences, content, characters/metaphors = good.
10 – mindless zombie/wise warrior = helpful, choosing the right path. Code: character/metaphor, choices, empowerment/responsibility?
7, 14, 26, 38, 21
17, 14, 26, 38, 21
17, 14, 26, 38, 21
Laura 4:40 So the two characters and choosing the road was helpful for you, yeh?Fantastic, thank you. Yes Gabriel?
Gabriel 4:46 What I learnt is that, what’s it called, when I’m angry I have a choice of different paths to take (Laura: Mmhmm)…whether to….carry on and get myself in more trouble, or calm down.
12 – choice of paths to take. Code: content, clear, simple messages, consequences, choice
12 – choice of different paths to take, carry on, getting in trouble or calm down: Code: choices, consequence, responsibility?
26, 21, 38, 22
26, 21, 38, 22
26, 21, 38, 22
Laura 4:56 Okay lovely, so thinking about the paths was helpful and how to choose what to do? (Gabriel Mmhmm) Great, okay.
Farouk 5:03 I was going to say that as well… 26, 38 26, 38Laura 5:05 That’s okay, you say it however you like to
22 All names in extracts are pseudonyms.
218
say it, it doesn’t matter if it’s already been said.
Farouk 5:08 Oh okay. So (inaudible)….I chose the path because, I can choose to…go with my anger, or stop it…from….from from….oh what’s the word? (Gabriel: Escalating). Yeh, stop it from escalating.
16 – choices. Code: choices
16 – choose to go with my anger or stop it from escalating: code: choices, outcomes, responsibility
26, 38
219
Pseudo-nym
Time Content First reading codes Second reading codes Draft code
Recoding after theme generation
Final codes after 11th Dec changes
Laura 13:40 […] Okay, umm, and what about the format of the groups? So obviously we had umm weekly sessions, with in-between practices with Poppy when you could get to them. How did you find that, was that about right (Callum: Yeh), not enough? Too much? (Callum: Yeh) You thought that was okay, Callum? Yeh? What about the rest of you?
Callum 14:17 Umm…cause, I think it’s good, ‘cause it gave us, like, time to think. And time to do the mindfulness session with Poppy.
84 – session format (Weekly) allows time to think and do mindfulness. Code: importance of in between session reflection?
84 – frequency of sessions gave us time to think and do mindfulness. Code: organisation promotes time for reflection
31, 6 31, 6 31, 6
Laura 14:25 Yep. So you liked having that time to practise it as well, yeh?
Callum 14:30 Yeh.Laura 14:30 Good. Finley?Finley 14:31 I think, yeh, you know on Monday’s with Poppy…
umm…’cause in *** we talk about a lot, like, about things that happen (Yep). We…we should do that, like, on Mondays…and then, talk about umm…umm, life and…and the streets and all that.
88 – wanting to time to talk about wider issues – life and the streets. Code: sharing wider systemic issues important – content not included? Content too narrow?
88 – would like to discuss broader issues. Code: opportunity for more systemic discussions? Anger too narrow?
42 42 42
Laura 14:50 Okay, so the sessions that you had with Poppy, on the Mondays, you would like to be able to just talk a little bit more about (Finley: Yeh) some of the stuff that’s going on? Yeh? Okay. Do you think you would’ve liked to have done that in the group as well? Talk a bit more about
220
what’s going on in your life?Finley 15:04 Mmhmm.Laura 15:05 Yeh? Okay, thanks Finley. Lemar, Fazal, would you like
to comment on, umm, how you found having the sessions weekly?
1, 31 1, 31
Lemar 15:24 Helpful in a way.Laura 15:26 Helpful in a way?Lemar 15:27 Yeh.Laura 15:28 Okay. In what way?Lemar 15:35 Umm, because, if we…because we have it on Monday…so
then yeh….it gives us, umm…it reminds us that we’re coming here after the weekend, because sometimes we…for the rest of the week, we should control our anger. And umm…’cause…yeh.
96 – reminder that we should control our anger. Code: control, frequency important, in between sessions a good reminder
96 – Monday reminds us to control our anger for the rest of the week. Code: control, organisation – need for reminders
1, 31
Pseudo-nym
Time Content First reading codes
Second reading codes
Draft code
Recoding after theme generation
Final codes after 11th
221
Dec changes
Laura 8.49 Okay. So it’s nice not to have all that pressure on you? (Gabriel: Mmhmm, yeh). Okay. Okay, and how did you find it…and again please be honest about this (just checking that’s recording, its fine). So obviously Jessica and I, umm, don’t work in the school…so we’ve come from outside the school to come into the group to run it…how did you find it having people from outside the school coming into the group to run it?
Gabriel 9:10 Easy peasy (laughter), lemon squeezy. Laura 9:15 Yes Gabriel?Gabriel 9:16 Oh what’s it called, yeh I think it helped, ‘cause it’s not someone…
it’s someone different from the school, someone that comes from another school
60/62/64 – helped having external facilitator as teacher might bring things up, feel more comfortable. Code: group boundaries important, non-judgment, safety
12, 5, 43
12, 5, 43 12, 5, 43
Taylor 9:22 Someone that knows you…Gabriel 9:23 Yeh because, like, yeh say it was another teacher in the school
(Laura: Mmhmm). You’ll be seeing that teacher every day (Laura: Mmhmm), and if you do something wrong, out of anger, the teacher might bring it up.
62/64 – good to have outside facilitators, teacher might bring up stuff, feel more comfortable. Code: trust, group boundaries, group process, safety in group? Feeling comfortable.
Laura 9:31 Right, okay.Gabriel 9:33 But if it was a teacher, that, what’s it called, doesn’t work in the
school, you only see them like only in that session, and you feel more comfortable, talking to them, and telling them…stuff, yeh.
Laura 9:41 Okay, good, thank you, Taylor?Taylor 9:44 Also, if it’s a teacher yeh, like, say you don’t actually like the teacher
(Freddie: Yeh). Or, if someone… a teacher, that you don’t really get 66 – teachers might have a
66- fear of being judged by teachers
43, 28 43, 28 43, 28
222
along with. (Laura: Mmhmm). Yeh, like, you’d be in a one-to-one with them, and like say you do one thing wrong, like, they know…they know who you are, so they’d be like ‘I’ve got things on you. Do anything bad you’re dead.’ But then, with, having like come outside the school, don’t really know you, so it’s like a new thing (Laura: Mmhmm)…yeh.
vendetta/not like you, external facilitators don’t know you. Code: not judged.
who already carry knowledge about them. Code: separation from school/prior knowledge = important
Laura 10:10 Okay, thank you Taylor. Yes, Farouk?Farouk 10:12 Well, you can trust you two, you two…because, yeh…yeh that’s all.
Yeh, that’s all.68 – can trust you two. Code: trust
68 – can trust you two. Code: trust/confidentiality
5 5 5
Laura 10:20 So able to trust someone? (Farouk: Yeh) Okay, lovely. Freddie did you want to add anything on that? (Freddie: No). Okay. Gabriel?
Gabriel 10:28 Another reason why I prefer teachers from another school because like, teachers, they gossip. (Laura: Okay). Cause like, you don’t want...don’t want them in the staff room, gossiping about your business (Laura: Okay) and…and what’s it called, another teacher just brings it up in the next lesson.
70 – teachers gossip. Code: trust, group boundaries, confidentiality.
70 – teachers, gossip, risk being brought up in next lesson code: confidentiality, boundaries
5, 12 5, 12 5, 12
Laura 10:43 So the confidentiality part of it (Gabriel: Mmhmm) is quite important. Yes, Freddie?
Freddie 10:47 Like, umm, if…if, if your…if one of your teachers were doing it with you…and if they tell your parents, umm, how badly…how badly you’ve behaved. Then...then…. (laughter; Laura instructs boys to settle down). Then…then umm...they might, then they might, they might umm, have a meeting.
72 – teachers might tell parents. Code: external facilitator important, trust/confidentiality
72 – might tell parents. Code: confidentiality, fear of other consequences, boundaries/safety/containment of group.
5, 12 5, 12 5, 12
Laura 11:10 Right okay. So you’d be worried about it going back to parents, if it was teachers? Yeh? Okay, that’s a helpful point. Please remember the group rules, about being respectful.
Gabriel 11:17 We broke them already miss.Laura 11:19 Errm, that was a really helpful point, thank you. And was there…
would you prefer, umm, anyone else different facilitating the group? 30 30
223
Maybe a man facilitating, would that make it any better (Farouk: Yeah) or any worse?
Farouk 11:31 Like, they have experienced it…experienced this anger before, so like (Freddie: Communicate) Yeh, tell us… (another voice, inaudible)
Laura 11:40 Okay, so would that be about it being a man, or being someone who’s experienced anger before?
Taylor 11:45 Everyone experiences angerLaura 11:46 Well, yeh, good point.Taylor 11:48 But…(inaudible). I know what you’re saying, because like, if it was a
man yeh, we could be like “yeh yeh” and he could be like, “yeh I understand what happens”, ‘cause obviously he’s a male (Laura: Mmhmm) so he like, the same kinda anger thing happens
80 – male facilitator might be more helpful, can relate to how it feels. Code: relatable facilitator
80 – male facilitator good – experienced it. Code: relatable facilitator, experts by experience
30
Laura 11:57 Right, so that might be helpful, would it?Taylor 11:59 Yeh
224
Appendix 9 – Ethical Approval
225
Appendix 10 – Information and Consent Forms
226
227
228
229
230
Appendix 11 – Normality AnalysesDescriptive Statistics
N Minimum Maximum Mean Std. Deviation Skewness Kurtosis
Statistic Statistic Statistic Statistic Statistic Statistic Std. Error Statistic Std. Error
AARS instrumental anger, pre 17 21 49 28.76 9.801 1.267 .550 .055 1.063
AARS reactive anger, pre 17 10 32 19.65 5.852 .360 .550 -.250 1.063
AARS anger control, pre 17 23 48 31.88 7.381 1.041 .550 -.046 1.063
AARS total anger, pre 17 53 120 81.53 19.790 .369 .550 -.705 1.063
SDQ emotional symptoms, pre 17 .00 5.00 1.9559 1.42586 .681 .550 -.201 1.063
SDQ conduct problems, pre 17 2.00 7.00 3.5882 1.76985 .793 .550 -.577 1.063
SDQ hyperactivity/inattention, pre 17 3.00 7.00 4.5882 1.27764 .287 .550 -1.064 1.063
SDQ peer relationship problems, pre 17 .00 5.00 2.0588 1.34493 .579 .550 -.325 1.063
SDQ internalising difficulties, pre 17 1.00 8.00 4.0147 1.93744 .267 .550 -.100 1.063
SDQ externalising difficulties, pre 17 5.00 13.00 8.1765 2.42990 .271 .550 -.892 1.063
SDQ total difficulties, pre 17 6.00 17.00 12.1912 3.39062 -.555 .550 -.805 1.063
SDQ prosocial behaviour, pre 17 3.00 10.00 6.2941 2.20127 .174 .550 -1.160 1.063
Mean MAAS-A score, pre 17 3.43 5.64 3.9568 .62152 1.639 .550 2.309 1.063
AARS instrumental anger, post 15 21 35 25.87 4.926 1.114 .580 -.437 1.121
AARS reactive anger, post 15 10 26 18.07 4.803 .185 .580 -.957 1.121
AARS anger control, post 15 22 40 33.20 5.943 -.803 .580 -.405 1.121
AARS total anger, post 15 62 102 75.73 11.787 1.006 .580 .247 1.121
SDQ emotional symptoms, post 15 .00 5.00 2.1000 1.79483 .764 .580 -.879 1.121
SDQ conduct problems, post 15 .00 7.00 3.4667 1.72654 .113 .580 .393 1.121
SDQ hyperactivity/inattention, post 15 1.00 7.50 4.3667 1.81725 -.010 .580 -.449 1.121
SDQ peer relationship problems, post 15 .00 8.00 2.0667 2.46306 1.103 .580 .618 1.121
231
SDQ internalising difficulties, post 15 .00 13.00 4.1667 3.79693 1.037 .580 .504 1.121
SDQ externalising difficulties, post 15 3.00 13.00 7.8333 3.11486 .139 .580 -1.013 1.121
SDQ total difficulties, post 15 3.00 24.50 12.0000 6.00298 .436 .580 -.015 1.121
SDQ prosocial behaviour, post 15 2.00 9.00 5.9333 1.94447 -.498 .580 -.235 1.121
Mean MAAS-A score, post 15 2.64 5.38 4.1018 .74164 .043 .580 .075 1.121
AARS instrumental anger, follow up 14 20 31 24.50 3.937 .631 .597 -.948 1.154
AARS reactive anger, follow up 14 8 25 17.43 5.095 -.116 .597 -.727 1.154
AARS anger control, follow up 14 20 34 29.43 4.146 -1.043 .597 .691 1.154
AARS total anger, follow up 14 59 101 77.50 11.360 .404 .597 .040 1.154
SDQ emotional symptoms, follow up 13 .00 5.00 1.9038 1.57962 .725 .616 -.520 1.191
SDQ conduct problems, follow up 13 .00 8.00 2.9231 2.28989 .997 .616 .537 1.191
SDQ hyperactivity/inattention, follow up 13 1.00 9.00 4.6923 2.39390 .257 .616 -.590 1.191
SDQ peer relationship problems, follow up 13 .00 5.00 2.2692 1.64083 .419 .616 -.528 1.191
SDQ internalising difficulties, follow up 13 1.00 6.25 4.1731 1.97216 -.551 .616 -1.257 1.191
SDQ externalising difficulties, follow up 13 2.00 16.00 7.6154 4.25320 .492 .616 -.487 1.191
SDQ total difficulties, follow up 13 4.00 22.25 11.7885 5.09477 .506 .616 .338 1.191
SDQ prosocial behaviour, follow up 13 2.00 10.00 6.1538 1.90815 -.258 .616 1.824 1.191
Mean MAAS-A score, follow up 14 2.79 5.86 4.2957 .82621 -.025 .597 .100 1.154
Valid N (listwise) 13
232
Kolmogorov-Smirnova
Statistic df Sig.
AARS instrumental anger, pre .297 17 .000
AARS reactive anger, pre .081 17 .200*
AARS anger control, pre .248 17 .007
AARS total anger, pre .119 17 .200*
SDQ emotional symptoms, pre .194 17 .090
SDQ conduct problems, pre .227 17 .020
SDQ hyperactivity/inattention, pre .207 17 .052
SDQ peer relationship problems, pre .255 17 .004
SDQ internalising difficulties, pre .144 17 .200*
SDQ externalising difficulties, pre .156 17 .200*
SDQ total difficulties, pre .208 17 .049
SDQ prosocial behaviour, pre .192 17 .095
Mean MAAS-A score, pre .266 17 .002
AARS instrumental anger, post .381 15 .000
AARS reactive anger, post .188 15 .162
AARS anger control, post .215 15 .062
AARS total anger, post .191 15 .148
SDQ emotional symptoms, post .263 15 .006
SDQ conduct problems, post .207 15 .085
SDQ hyperactivity/inattention, post .113 15 .200*
SDQ peer relationship problems, post .268 15 .005
SDQ internalising difficulties, post .183 15 .191
SDQ externalising difficulties, post .145 15 .200*
SDQ total difficulties, post .170 15 .200*
SDQ prosocial behaviour, post .175 15 .200*
Mean MAAS-A score, post .173 15 .200*
AARS instrumental anger, follow up .220 14 .065
AARS reactive anger, follow up .116 14 .200*
AARS anger control, follow up .148 14 .200*
AARS total anger, follow up .160 14 .200*
SDQ emotional symptoms, follow up .255 13 .021
SDQ conduct problems, follow up .195 13 .189
SDQ hyperactivity/inattention, follow up .141 13 .200*
SDQ peer relationship problems, follow up .181 13 .200*
SDQ internalising difficulties, follow up .207 13 .130
SDQ externalising difficulties, follow up .156 13 .200*
SDQ total difficulties, follow up .178 13 .200*
SDQ prosocial behaviour, follow up .237 13 .044
Mean MAAS-A score, follow up .126 14 .200*
233
Example of normality graphs reviewed: SDQ total difficulties, post
234
235
Summary of normality analysesName of variable
Kolmogorov - Smirnov normal?
Histogram visual inspection normal?
Normal Q-Q plots, visual inspection normal?
Skewness Z score normal?
Kurtosis Z score normal?
Overall summary normal?
Outlier (as identified via box plot)?
AARS ins pre No No – positive skew
No 2.30 - no 0.05 - yes No Present
AARS reac pre Yes Yes Yes 0.65 - yes -0.23 – yes YesAARS control pre
No No – positive skew
Yes/No 1.89 - yes -0.04 - yes Yes/No Present
AARS total pre Yes Yes Yes 0.67 - yes -0.66 – yes YesSDQ Emo pre Yes Yes/No - slight
positive skewYes 1.23 – yes -0.19 - yes Yes
SDQ con pre No No – positive skew
Yes 1.44 – yes -0.54 – yes Yes
SDQ hyp pre Yes (marginal)
Yes Yes 0.52 - yes -1.00 – yes Yes
SDQ peer pre No Yes/No – slight positive skew
Yes 1.05 - yes -0.31 – yes Yes
SDQ int pre Yes Yes Yes 0.49 – yes -0.09 - yes YesSDQ ext pre Yes Yes Yes 0.49 - yes -0.84 - yes YesSDQ total diff pre
No (marginal)
Yes Yes -1.01 - yes -0.76 – yes Yes
SDQ prosocial pre
Yes Yes Yes 0.31 - yes -1.09 – yes Yes
Mean MAAS- No No – positive Yes/No 2.98 - no 2.17 – no No Present
236
A pre skewAARS ins post No Yes Yes/No 1.92 - yes -0.39 - yes Yes PresentAARS reac post
Yes Yes Yes 0.32 - yes -0.85 - yes Yes
AARS control post
Yes No – negative skew
Yes -1.38 – yes -0.36 – yes Yes
AARS total post
Yes No – positive skew
Yes 1.73 - yes 0.22 – yes Yes Present
SDQ Emo post No No – positive skew
Yes 1.32 - yes -0.78 – yes Yes
SDQ con post Yes Yes Yes 0.19 - yes 0.35 – yes YesSDQ hyp post Yes Yes Yes -0.02 - yes -0.40 – yes YesSDQ peer post No No – positive
skewYes/No 1.90 - yes 0.55 – yes Yes/No
SDQ int post Yes No – positive skew
Yes/No 1.79 - yes 0.45 – yes Yes Present
SDQ ext post Yes Yes Yes 0.24 - yes -0.90 – yes YesSDQ total diff post
Yes Yes Yes 0.75 - yes -0.01 – yes Yes Present
SDQ prosocial post
Yes Yes – slight negative skew
Yes -0.86 - yes -0.21 - yes Yes
Mean MAAS-A post
Yes Yes – slight negative skew?
Yes 0.07 - yes 0.07 – yes Yes Present
AARS ins follow up
Yes Yes Yes 1.06 - yes -0.82 – yes Yes
AARS reac Yes Yes Yes -0.19 - yes -0.63 – yes Yes
237
follow upAARS control follow up
Yes No - negative skew
Yes -1.75 - yes 0.60 – yes Yes
AARS total follow up
No Yes Yes 0.68 - yes 0.03 - yes Yes
SDQ Emo follow up
Yes Yes – slight positive skew
Yes 1.18 - yes -0.44 - yes Yes
SDQ con follow up
Yes No – positive skew
Yes 1.62 - yes 0.45 – yes Yes
SDQ hyp follow up
Yes Yes Yes 0.41 – yes -0.50 - yes Yes
SDQ peer follow up
Yes Yes Yes 0.68 - yes -0.44 - yes Yes
SDQ int follow up
Yes Yes – slight negative skew
Yes -0.89 - yes -1.06 - yes Yes
SDQ ext follow up
Yes Yes Yes 0.80 - yes -0.41 – yes Yes
SDQ total diff follow up
Yes Yes Yes 0.82 - yes 0.28 - yes Yes Present
SDQ prosocial follow up
No Yes Yes -0.42 - yes 1.53 – yes Yes Present
Mean MAAS-A follow up
Yes Yes Yes -0.04 - yes 0.09 - yes Yes
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Appendix 12 – Additional reliability analyses
Several of the questionnaires had a substantial proportion of negative inter-item correlations, casting doubt over the internal
consistency of the scale for this client group.
Scale Pre-group no. of -ve correlations
largest -ve corre-lation
% of total number of item correlations that are negative23
Post-group no. of -ve correlations
largest -ve corre-lation
% of total number of item correlations that are negative
Follow-up group no. of -ve correlations
largest -ve corre-lation
% of total number of item correlations that are negative
AARS control (13 qu’s)
7 -0.186 (7/78)*100 =8.97%
25 -0.357 (25/78)*10 0 =32.05%
28 -0.519 (28/78)*100 =35.9%
AARS instrumental (18 qu’s pre; 17 qu’s post; 15 qu’s follow-up)
22 (16 of which were qu22)
-0.24 (22/153)*100 =14.38%
42 -0.464 (42/136)*100 =30.88%
29 -0.284 (29/105)*100 =27.62%
AARS reactive (8 qu’s)
2 -0.091 (2/28)*100 =7.14%
4 -0.255 (4/28)*100 =14.28%
5 -0.315 (5/28)*100=17.86%
MAAS-A (14 qu’s)
31 (10 of which were
-0.448 (31/91)*100 =34.07%
27 -0.608 (27/91)*100 =29.67%
9 -0.334 (9/91)*100 =9.89%
23 Using AARS control as an example, “total number of item correlations” figure derived as follows. Total number of questions = 13. Therefore, total number of unique item correlations (excluding item-self perfect correlations) = ([13*13] – 13)/2 = 78.
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question 1)
SDQ prosocial (5 qu’s)
2 -0.205 (2/10)*100 =20%
2 -0.208 (2/10)*100 =20%
0 - -
SDQ hyper-activity (5 qu’s)
8 -0.203 (8/10)*100 =80%
1 -0.228 (1/10)*100 =10%
0 - -
SDQ emotional (5 qu’s)
2 -0.224 (2/10)*100 =20%
0 - - 5 -0.368 (5/10)*100 =50%
SDQ conduct (5 qu’s)
2 -0.163 (2/10)*100 =20%
2 -0.206 (2/10)*100 =20%
1 -0.022 (1/10)*100 =10%
SDQ peer (5 qu’s)
6 -0.291 (6/10)*100 =60%
0 - - 6 -0.463 (6/10)*100 =60%
SDQ total difficulties (5 qu’s)
82 ? (82/190)*100 =43.16%
55 -0.507 (55/190)*100 =28.95%
72 ? (72/190)*100 =37.89%
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Given the small number of items that make up the SDQ subscales (n=5) and
the reactive anger scale of the AARS (n=8), mean inter-item correlations were also
considered for these subscales as advised by Pallant (2010). Briggs and Cheek (1986)
suggest an optimal inter-item correlation range of 0.2-0.4. As can be seen below, the
SDQ scales regularly fall outside of this range, casting doubt over the internal
consistency of this scale for this client group, whilst the AARS reactive scale falls
within this range.
Scale Pre-group mean inter-item correlation
Post-group mean inter-item correlation
Follow-up mean inter-item correlation
AARS reactive 0.390 0.267 0.285SDQ prosocial 0.238 0.190 0.261SDQ hyperactivity -0.044 0.086 0.425SDQ emotional 0.115 0.273 0.059SDQ conduct 0.151 0.110 0.389SDQ peer -0.035 0.480 0.044
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Appendix 13 – Informal Process Notes Discussion
Interviews and journal notes were reviewed. Reading and reviewing this informal data
revealed that the facilitators observed several positive aspects of holding the groups in the
school, including the boys all being in the same building which facilitated attendance, and the
school being familiar with running additional groups. The facilitators also commented on
aspects of the group they would change in the future. This included having a greater number
of sessions to allow a slower pace, and having group sizes of less than seven as group one
was experienced as too large.
The facilitators reported several logistical challenges of running the group in the
school. They found it difficult to balance the dual role of group facilitator and assisting the
school-based co-facilitator with ensuring the boys adhered to school behaviour policies,
noting that they lacked authority due to unfamiliarity with school processes. The need for a
firm school facilitator was commented on. In addition, the participants did not always arrive
on time for groups and/or facilitators had to collect them from lessons, resulting in lost
session time. Last minute room changes and timetable clashes occurred on several occasions,
resulting in disorganised starts to some sessions. The facilitators suggested that embedding
future groups into the school timetable may overcome these issues, as well as the facilitators
raising the profile of the group with all school staff. The facilitators also experienced some
difficulty getting hold of parents at the start of each group to gain consent to participate,
requiring multiple attempts to contact them.
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Appendix 14 – Reflexive Account of Qualitative Analysis Process
This account summarises the processes through which I engaged with the qualitative
data throughout all stages of the research. It aims to highlight the obstacles and challenges I
faced to maintain an objective, honest and credible account of the data, and how I attempted
to overcome these.
I approached the qualitative aspect of my project from a position of “critical-realism”.
Given the mixed-methods nature of the project, a critical-realist epistemological position
provided a coherent framework for the project. Adopting a more social-constructionist
interpretation of the data (for example) would not have allowed coherent integration with the
quantitative data, whilst adopting a purely realist approach would have lost some of the
subtleties of the focus group. The critical-realist position enabled integration of the two types
of data, whilst still allowing some interpretation of the nuances within the qualitative data.
I was very aware of the multitude of roles I was managing through the qualitative
data collection and analysis processes. On the one hand, I was a “scientist-practitioner” and
“researcher”, keen to establish the “facts” of the data, and aiming to minimise bias in
interpretation. However, I was simultaneously acknowledging my role as the developer and
facilitator of the group, and the inherent bias that this could introduce. The group was, after
all, an innovative and creative product which engaged intellectual effort and many hours of
work. Furthermore, I also held the role of trainee clinical psychologist, with the natural
curiosity of “reading between the lines” that this role can bring. Finally, I brought my own
humanness, including my own values, biases and history. I was conscious that the “hat” I
needed to be wearing for this task was that of “researcher”, but acknowledged that my other
roles would carry some influence.
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Elliott, Fischer and Rennie (1999) suggest guidelines against which qualitative
research should be evaluated. These include 1) Owning one’s perspective; 2) Situating the
sample; 3) Grounding in examples; 4) Providing credibility checks; 5) Coherence (of
analyses); 6) Accomplishing general versus specific research tasks; and 7) Resonating with
readers. Whilst my approach to analysis falls in line with each of the criteria, Elliott et al.
(1999) observe that these are only suggested to be guidelines, as opposed to a rigid checklist
to adhere to. In addition, Willig (2008) emphasises the relevance of the epistemological
position and associated evaluation; i.e. it would not make sense to adopt evaluation centred
on “objectivity” and “reliability” for a social constructionist informed analysis, however this
does fit better with a critical-realist analysis. Given this, the analysis process and audit trail
evidences my attempt to retain objectivity and reliability. A detailed breakdown of the audit
process is available in appendix 8 and is described in brief below.
In an attempt to allow the “researcher” position to take a dominant role, during the
focus groups themselves I was aware that there would be a temptation to explore things that I
personally thought were interesting and/or helpful, and that I had hoped the boys would have
found interesting and/or helpful too (e.g. specific ACT-related exercises). I attempted to
guard against this by devising a relatively structured interview format with the assistance of a
colleague and supervisor, to broaden my perspective on what would be helpful to ask the
boys. The relatively structured format of the focus group also allowed me to summarise and
reflect back to the boys to seek clarification, in reference to the questions posed rather than
avenues I wished to explore, and curtailed my curiosity. However this clarification and
reflection process brought my language to the transcripts, not just the boys, potentially
introducing a different perspective, given our obvious diverse differences of age / ethnicity /
gender / culture.
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During the transcription and analysis phases, I paid meticulous attention to detail,
transcribing all the utterances and nuances of the boys’ discussions, with the only exception
being when we were completely off-topic because a behavioural incident occurred that
required managing. However, there were certain occasions when I actively permitted my lens
as a trainee clinical psychologist to influence the interpretation process. The boys were
discussing when to schedule the groups, and it became apparent through some of their
language, as well as my knowledge of the school, and the boys themselves, that what they
explicitly said was different to what they meant. They gave “reasons” why it was helpful to
have the intervention on specific days, but their side conversations, comments from other
boys, and some individuals’ direct admissions, clearly inferred that it was to avoid
traditionally disliked subjects (maths, humanities). To ignore this “other” information would
have portrayed the data in a misrepresentative way, hence why I considered this added layer
of interpretation was relevant. This was checked with my colleague and co-facilitator who
agreed with this interpretation. In addition, the boys discussed wanting more games and food
as something they would change about the group; my interpretation of this was that they
viewed the group as potentially an “easy option”, and coded this as such, in addition to
coding the explicit content where appropriate.
Throughout all stages of interacting with the qualitative data, I was acutely aware of
my lens as the “facilitator” and “co-creator” of the group, as this had potential to introduce
the bias of wanting to find a “good” result. To guard against this, I followed a systematic
process of interacting with the data, detailed in appendix 8. I coded the data thoroughly and
repeatedly line-by-line, to ensure all data was coded as opposed to just the sections that were
important to me as the “facilitator” and “co-creator”. I then re-read transcripts and re-
generated ideas for codes without having the initial codes present, in an attempt to promote
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“fresh” readings of the transcripts, and to promote reliability of the codes. Codes were then
organised and re-organised into themes several times, and included consultation from the
research supervisor on initial theme generation. Transcripts were re-read two months after
tentative final themes were generated, and minor further tweaks to codes and themes were
made. The research supervisor also reviewed samples of the transcripts, and all audit
documents to add an additional reliability check on the process. Willig (2008) suggests
“triangulation” may be helpful for more positivist results, including the use of second coders.
This was attempted via the research supervisor’s aforementioned involvement, as well as my
repeated readings of the transcripts and codes, particularly the “blind” second stage coding.
Salience of themes was decided upon in reference to those that enabled the greatest
understanding of the research questions posed. This reduced the opportunity for my personal
biases to influence the decisions over what were the most important themes. Whilst certain
codes and associated themes occurred more frequently in transcripts (e.g. “pacing of group”),
they did not significantly assist in the understanding of the research questions, and therefore
were not provided the same status as other themes. For example, the “Changes” theme was
particularly useful for research question 1, and the “Content” theme for questions 1 and 3.
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Appendix 15 – Anger Control Subscale Questions – Removed for E-thesis
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Part 3 – Summary of Clinical Experience
1st year – Secondary Care Adult Mental Health (CMHRS) – 1 year.
My first-year clinical placement took place in a mental health team for adults with
severe and enduring mental health difficulties. The clients had received a range of diagnoses
such as bipolar disorder, borderline personality disorder, schizophrenia, depression, and a
variety of anxiety disorders. I worked with adults in acute distress, particularly for those
individuals where there was a history of trauma. My role entailed delivering individual and
group therapy, completing cognitive assessments (including using the WAIS-IV and WMS-
IV), and completing a service evaluation. My primary theoretical models were CBT and
ACT. My service evaluation looked at a new referral pathway that had been implemented and
provided the team with useful data and recommendations with regard to waiting lists.
2nd year – Community Adult Learning Disability – 6 months.
I completed six months in a multi-disciplinary community team for adults with
learning disability. This required both independent and joint work / liaison with other
professionals in the team. Responsibilities included individual therapy and family-based
intervention (CBT, narrative, systemic), indirect work with family and staff, dementia
assessments, assessment for learning disability diagnosis, sexual knowledge assessments, and
providing consultation to day centres. I also completed a piece of service development work,
by designing and delivering "ACT for staff"; a series of lunchtime workshops aimed at
promoting staff wellbeing.
2nd year – Tier 3 CAMHS / CAMHS learning disability – 6 months.
My core six-month child placement was split between a tier 3 child and adolescent
(CAMHS) mental health service, and a specialist CAMHS learning disability team. I was
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thus able to work with children and young people who were experiencing mental health
difficulties across a spectrum of developmental pathways, including those with a diagnosis of
learning disability, autism, and indeed those children who were “typically” developing.
My responsibilities included individual therapy (informed by CBT, narrative, and systemic
theories), indirect interventions (informed by attachment, neurodevelopment, and positive
behaviour support theories), and half a day per week in a family therapy team in both
reflecting team and lead therapist roles. In addition, I undertook cognitive assessments using
the WISC-IV and BADS-C and completed a stage 1 ASC assessment. The placement
involved joint work with other professionals (e.g. occupational therapist), as well as
providing consultation to other professionals (e.g. to schools). In addition, I took a lead role
in designing and co-facilitating an emotion regulation group for children with anxiety and
learning disabilities.
3rd year – Older Adults Community Mental Health Team and Memory
Assessment Service - 6 months.
I completed a six-month placement working with older adults (aged 65 +) with mental
health needs and / or cognitive difficulties. My role required individual therapy, facilitation of
a cognitive stimulation therapy group, providing consultation to other staff members, and
completing memory assessments for the purposes of diagnosing dementia and other
neurodegenerative conditions. The therapeutic work adopted an integrative framework,
incorporating elements of CBT, narrative therapy, and compassion-focused therapy.
3rd year – Specialist Placement in Paediatrics – 6 months.
My specialist placement involved working with children and adolescents who were
experiencing a range of physical health problems and had associated psychological needs.
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Physical health problems included diabetes, cancer, procedural anxiety, brain injury,
medically unexplained symptoms, and pain. I also completed a formal developmental
assessment with a pre-school child with suspected developmental delay. I worked with both
the individual and their families. In addition, I provided consultation to medical teams when
psychological issues were identified in clinic appointments. The majority of children were
seen as outpatients, although some inpatient consultation also occurred. I also completed
service development work, including developing resources, and designing a new workshop
for helping parents to communicate with their teenagers.
Additional general experiences over the course of all placements
All placements required me to complete some form of formal psychometric
assessment. Tests completed over the course of placements include the following: WAIS-IV,
WMS, ToPF, CAMDEX-DS, RBANS, ToMM, WISC-IV, BADS-C, NAID, Hayling and
Brixton, Boston Naming Test, and subtests of several other tests. I have also completed
functional skills assessments (e.g. HALO, ABAS, etc), and a developmental assessment
(Bayley’s).
I have typically evaluated my therapeutic work using a range of formal and informal
outcomes measures, including questionnaires (e.g. SDQ, RCADS, PHQ-9, GAD-7, etc),
qualitative feedback (e.g. experience of service questionnaire), and person-specific goal-
based measures.
I have delivered presentations and teaching workshops to a variety of audiences
including staff teams, parents and carers of clients, and assistant psychologists. These have
been on a variety of topics including ACT, executive functioning, emotion regulation,
communication, and boundaries.
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Part 4 – Table of Assessments Completed During Training
Year I AssessmentsASSESSMENT TITLE
WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity
Summary of assessment and formulation with a male in his early 20s presenting with anxiety difficulties
Audio Recording of Clinical Activity with Critical Appraisal
Cognitive behavioural therapy for anxiety: Exposure therapy session with “Kate”
Report of Clinical Activity N=1
Cognitive behavioural therapy with “Kate”: A female in her early 20s presenting with a range of anxiety difficulties
Major Research Project Literature Survey
Anger and aggression in adolescent males
Major Research Project Proposal
A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males.
Service-Related Project Evaluation of the efficiency of the newly implemented referral pathway for clients with borderline personality disorder
Year II AssessmentsASSESSMENT TITLE
Report of Clinical Activity – Formal Assessment
Does “John” have an intellectual disability and/or autism? What are “John’s” strengths and weaknesses in relation to his cognitive skills and his functional, adaptive skills? A report of the assessment process carried out with “John”, a White-British male in his early 60s, to establish diagnosis, ascertain strengths and weaknesses, and to recommend appropriate ongoing support.
PPLD Process Account
Team PPD: A reflective account of individual and group development through participation in PPD groups
Presentation of Clinical Activity
Extended assessment, formulation, and indirect intervention with “Georgie”
Year III Assessments ASSESSMENT TITLE
Major Research Project Literature Review
Psychological interventions for anger and aggression in adolescent males: A systematic review of 21st Century interventions
Major Research Project Empirical Paper
Taking ACTion on Anger: A feasibility study investigating the effectiveness and acceptability of an ACT-based anger intervention for adolescent males in a school-context.
Final Reflective Account
From “thinking”, to “feeling”, to reflecting, to formulating: My ongoing journey towards becoming a bio-psycho-socially-informed, reflective-scientist-practitioner
Report of An integrative assessment, formulation and intervention with “Ruby”: A
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Clinical Activity female in her late 70s presenting with low mood and adjustment difficulties.
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