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An Examination of Change in Anger and Depression
During Early Stages of Therapy
by
David Michael Tatera
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Counseling Psychology)
August 1995
Copyright 1995 David Michael Tatera
UMI Number: 9617145
UMI Microform 9617145
Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized
copying under Title 17, United States Code.
UMI
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Ann Arbor, MI 48103
UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90007
This dissertation, written by
T atera................................
under the direction of h±&....... Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillment of re
quirements for the degree of
DOCTOR OF PHILOSOPHY
^ /
Dean o f Graduate Studies
Date
DISSERTATION COMMITTEE
Chairperson
ACKNOWLEDGEMENTS
ii
I am deeply indebted to my dissertation chair, Dr. Frank Fox, for his
endless faith and patience. His guidance helped me to find hope when all
seemed lost.
I want to thank Dr. Rodney Goodyear and Dr. John Choma, Jr. for
serving on my committee and sharing with me their time and experience.
I am especially grateful to Dr. Bill Spradlin for his assistance and
supervision, and to the staff and clients of Glendale Family Service for their
cooperation in this project.
I would like to express my gratitude to Dr. Gregory J . Wheeler for his
early mentorship and allowing me to learn from someone who makes the
difficult look so easy.
Most of all, I want to thank my family and friends for their
encouragement and continued support throughout graduate school. Without
them, this academic endeavor would not have been possible. And, to my
mother, who told me when I was five years old that I was going to like school;
you were right.
Ill
TABLE OF CONTENTS..........................................................................................
CHAPTER 1 ............................................................................................................ 1
Introduction............................................................................................................ 1
The Problem and Its Explication............................................................................6
Statement of the Problem........................................................................................6
Purpose of the Study............................................................................................... 7
Significance of the Study.........................................................................................7
CHAPTER 2 ............................................................................................................ 9
Review of the Literature......................................................................................... 9
Time Limits in Psychotherapy.............................................................................. 9
Elements Within Time-Limited Therapy.............................................................. 14
Factors Affecting Outcome in Brief Psychotherapy.............................................16
Applications of Brief Therapy............................................................................... 18
Additional Applications......................................................................................... 21
Anger....................................................................................................................... 24
Definitions...............................................................................................................24
Theories of Anger................................................................................................... 25
Drive Theory of Anger and Aggression............................................................... 25
Social Learning Theory of Anger.......................................................................... 26
Cognitive Theory of Anger.................................................................................... 27
Measurement of Anger...........................................................................................27
Correlates of Anger................................................................................................ 28
Gender, Race and Age Differences........................................................................31
Treatment Applications..........................................................................................33
Depression...............................................................................................................36
Definitions...............................................................................................................36
Theories of Depression...........................................................................................37
Psychoanalytic Theory of Depression..................................................................37
Behavioral Theory of Depression......................................................................... 38
Cognitive Theory of Depression........................................................................... 38
Measurement of Depression..................................................................................39
Correlates of Depression..........................................................................................39
Anger and Depression............................................................................................. 40
The Study of Anger in Brief Therapy..................................................................... 43
The Study of Anger and Depression in Brief Therapy......................................... 44
Research Questions................................................................................................ 45
iv
CHAPTER 3 ............................................................................................................. 47
Method......................................................................................................................47
Subjects.....................................................................................................................47
Instrumentation....................................................................................................... 49
BDI............................................................................................................................. 49
STAXI........................................................................................................................ 50
Procedure................................................................................................................. 51
Research D esign.......................................................................................................53
Data Analysis........................................................................................................... 53
Limitations............................................................................................................... 54
Delimitations............................................................................................................ 55
CHAPTER 4 ............................................................................................................. 56
Results....................................................................................................................... 56
Participating Subjects..............................................................................................56
Hypothesis Testing..................................................................................................57
CHAPTERS............................................................................................................. 74
Discussion................................................................................................................ 74
General Findings......................................................................................................74
Specific Findings......................................................................................................75
Methodological Concerns....................................................................................... 81
Recommendations for Future Research................................................................. 83
References................................................................................................................. 85
V
LIST OF TABLES.....................................................................................................
Table 1. BDI and STAXI Pretest and Posttest Means and
Standard Deviations......................................................................57
Table 2. Pearson Product Moment Correlations between
Pretest Factors.................................................................................58
Table 3. Means and Standard Deviations for Trait Anger and
Anger-In Scores.............................................................................59
Table 4. Analysis of Variance for Pretest Trait Anger......................................60
Table 5. Means and Standard Deviations for Trait Anger and
Anger-Control Scores................................................................... 61
Table 6. Means and Standard Deviations for Trait Anger and
BDI Scores......................................... 62
Table 7. Analysis of Variance for Pretest Trait Anger by
Posttest BDI....................................................................................63
Table 8. Post Hoc Test of Main Effects..............................................................64
Table 9. Analysis of Variance for Pretest BDI by Posttest
Anger-Out...................................................................................... 65
Table 10. Means and Standard Deviations for BDI Scores and
Anger-Out..................................................................................... 65
Table 11. Analysis of Variance for Pretest State Anger..................................... 67
Table 12. Post Hoc Test of Main Effects.............................................................. 68
Table 13. Means and Standard Deviations for State Anger and
BDI Scores...................................................................................... 69
Table 14. Means and Standard Deviations for State Anger and
Anger Expression.................................................
Table 15. Analysis o f Variance for Pretest State Anger by
Posttest Anger-Control.........................................
Table 16. Means and Standard Deviations for State Anger and
Anger-Control........................................................
Table 17. Analysis o f Variance for Pretest BDI by Posttest
Anger-Expression................................................
Table 18. Means and Standard Deviations for BDI Scores and
Anger Expression.................................................
Abstract
An Examination of Change in Anger and Depression
During Early Stages of Therapy
This study examined change in depression and anger during
early stages of therapy. It was predicted that more change would
occur after a four session posttest than after an eight session posttest.
From new adult clients at a community mental health center, 60
subjects were randomly drawn. Subjects were divided into groups of
30 and received a pretest prior to the initial therapy session. One
group received posttests after four sessions of therapy and the other
after eight sessions. At the pretest and posttest each subject received
a Beck Depression Inventory and a State Trait Anger Expression
Inventory.
This sample contained 44 or 73.3% female and 16 or 26.7% male
subjects. Ages ranged from 21 to 63. Most subjects entered treatment
for depression, anxiety, or relationship difficulties. Clients exhibiting
severe pathology, such as Schizophrenia, were excluded from this
study.
The four session treatment group generally had more
significant changes than did the eight session treatment group,
supporting the hypotheses that psychotherapy is more effective
during the early stages.
High pretest trait-anger was positively correlated with pretest
anger-in and depression, and negatively correlated with pretest
anger-control, suggesting people with higher levels of anger tend to
suppress their anger and be more depressed.
Support found for:
1) four session group members high in pretest state-anger to
show lower posttest levels of depression and higher posttest anger-
expression.
2) high pretest trait-anger subjects in either group to show
lower posttest depression.
No support found for:
1) pretest subjects in either group high on pretest trait-anger to
show high posttest anger-in and anger-control.
2) high pretest state-anger subjects to show lower posttest
depression and higher posttest anger-expression for the eight session
group.
3) pretest subjects higher on state-anger to show higher
posttest anger-control.
4) pretest depression subjects and posttest anger-expression
and anger-out.
Results suggest anger suppression is related to depressive
symptomology, but not anger-expression.
Recommendations made for future research.
1
CHAPTER 1
Introduction
The field of psychology, and mental healthcare in general,
owe a great debt to a former president for insuring that there
would be sites where therapeutic services would be available to a
wide range of people. President John F. Kennedy restored the
community mental health system and supervised the creation of
many more centers through groundbreaking legislation (Patterson
& Sharfstein, 1992). This legislation also controlled how much
federal financial support each of the previous and new centers
would have for providing services.
Consequently, most agencies operate based on specific time
guidelines. Regardless of to where the therapeutic process leads,
clients are required to terminate after an agency set time limit.
Even without limits on treatment length, the average length of
treatment for outpatients is five to six sessions (Budman, 1992).
Traditionally, college counseling centers and community mental
health centers are overworked and understaffed. Consequently, an
increasing number of people are trying to use the limited services
that are available (Grob, 1994; Thompson, 1994). Community
mental health centers are particularly sensitive to local, state and
federal budgets for their financial stability and existence.
Since the emphasis on the time element limits
psychotherapeutic services, it seems imperative that both the client
and the therapist strive for the most or best results in the shortest
time. A greater sense of urgency now dictates how long mental
health services are provided. This is especially true considering
the recent interest in health care reform, which seems to ignore
the field of Psychology (Frank, Sullivan, & De Leon, 1994).
As the pace of our society intensifies, life itself can be
overwhelming, or as Gergen (1991) defines it, over-saturating.
Budgeting constraints become a prime focus on things from
automobile production to supermarkets to mental health
(Diamond, 1991).
Health Maintenance Organizations, or HMO's, try to offer
the best all-around care for their consumers. They also try to offer
their services at the most affordable rates possible for both
themselves and their patrons. Insurance companies are no longer
blindly accepting claims for services that their utilization review
representatives feel should have been resolved. Instead, they are
requiring justification for continued claims and are reducing the
amount they are willing to pay, leaving the consumer responsible
for an increasing portion of the fees for services rendered. Clearly,
financial aspects seem to dictate that less and less equals more;
that is, demanding less time for treatment with less finances that
they will pay equals more savings and bonuses for the insurance
company chairmen and stockholders. As Budman and Gurman
(1988) note, the consumers of mental health services have become
increasingly more informed; they, too, are desiring less expensive,
more efficient and quicker forms of treatment.
Not only is our society facing population booms and unstable
economic conditions, but the fiber of society itself seems to be less
3
tolerant of the people that form that society. Acts of violence
dominate newspapers and not only television news broadcasts, but
in prime-time television shows and movies as well. It seems that
the people in the world we live in are becoming less tolerant of one
another. In terms of extreme violence, the sanctity of public areas is
threatened. For example, Los Angeles has freeway shootings while
New York has commuter train and subway murders. The homicide
rate in Los Angeles County has continuously risen for the past 20
years (Hubler, 1993). In the United States, 12% of murders occur at
the hands of a friend, relative or family member (U. S. Department
of Justice, 1993).
It does not seem difficult to trace outside societal
contributions to the present atmosphere, considering the decline of
employment, increase of inflation along with less income and
insurance money to cover expenses. It is no wonder that more and
more people are getting angry, but it is also no excuse for the
violent and savage overtones that are becoming increasingly more
common in movies, television programs and in the experiences of
daily life. Argueably, violence has become one of America's most
pressing public health threats, and the topic for continued research
to find it's genetic roots (Stolberg, 1993).
Not only has the scenario gone from bad to worse financially,
but society seems to be taking on a seriousness that ends up being
deadly. Domestic violence, gang warfare and violent crimes are on
the rise. Disgruntled employees no longer fill out notes for the
suggestion box; they instead turn to weapons or other violent
means to retaliate. They are angry people expressing their rage
and frustration in detrimental and deleterious ways. Intuitively, it
seems reasonable that anger and/or depression would be on the
rise in society.
Depression, long suggested to be associated with anger, also
seems to be more visible in society. Psychotropic medications are
more commonplace in society, courtrooms and in best-selling books,
such as the recent Listening to Prozac (Kramer, 1993). In a sense,
the development of newer, faster-acting medications for
depression fulfill the managed care objective of quicker treatment in
a short period of time at an economic rate. As Poilano and Senra
(1991) suggest, undetected depression is a serious problem with
potentially devastating impacts. It remains a concern for clinicians
and a focus for researchers.
Within the profession of counseling, the need for efficient
mental health care continues to increase, in part due to increasing
environmental stressors. For example, poor economic conditions
have contributed to increased anger and depression among
unsuccessful job seekers in Southern California (Reed, 1993). One
way to approach this situation effectively (in both cost and relative
efficiency) is in Brief or Time-Limited Psychotherapy. As Manaster
(1989) points out, the concept of limiting the amount of time in the
therapeutic experience dates back to, among others, Adler more
than 75 years ago.
For example, Gelso and Johnson (1983) found that less severe
clients rated brief therapy more favorably than did therapists.
5
Therapist level of experience with brief therapy did not affect
outcome. Theoretical orientation, as measured in various
subscales, also found to have no relationship to effectiveness of
brief therapy. No relationship between expected length of therapy,
by either client or therapist, affected outcome. They also note that
clients and therapists ratings are possibly based on differing
response sets. Their research suggests that clients who perceive
their present difficulties as less severe, of a short-duration and
expect to return to their premorbid levels of functioning fairly soon
appear to be better candidates for time-limited therapy.
Few positive changes have occurred in the 13 years since
Kovacs (1982) issued his foreboding account of the survival of the
profession of psychology. The socioeconomic strains that existed at
the time of his edict have only increased in terms of the impact on
society. Kovacs clearly documents the detrimental combination of
employers and insurance companies struggling to curtail somehow
the rapidly escalating premiums for health insurance, while the
reimbursement funds available for patients who desire therapy
decline with each fiscal quarter. Such actions leave professionals
re-evaluating therapeutic approaches and interventions, as well as
their applicability to a range of societal problems.
The present study investigated change in anger and
depression during early stages of therapy. The subjects were
drawn at random from new adult clients at a community mental
health center, Glendale Family Services. All subjects were divided
into two groups and received a pretest prior to the initial therapy
session. One group received the posttest after four sessions of
therapy and the other group received the posttest after eight
sessions of therapy. Each of the two research groups received the
same test materials at the pretest and at the posttest. The test
materials consisted of a Beck Depression Inventory (BDI) and a
State Trait Anger Expression Inventory (STAXI), and were
completed by each subject at the pretest and at the posttest.
The Problem and Its Explication
Statement of the Problem. Traditionally, college counseling
centers and community mental health centers operate based on
specific time guidelines. Regardless of the progress of the
therapeutic process, clients are required to terminate after an
agency-set time limit. As the increased emphasis on the length of
treatment limits the delivery of psychotherapeutic services. All
parties involved strive for the most or best results in the shortest
amount of time. Too often, clients in non-time-limited therapy
terminate because they do not see or feel results. As a practical
matter, most people only receive five to six sessions of therapy
(Bubman, 1992). Therefore, it is important to examine the early
stages of treatment. Brief or time-limited treatment is an example
of treatment that specifically focuses on a short time in treatment,
and serves as an excellent example of the early stages of treatment
for this research study. It was hoped that this study could be used
to highlight treatment areas where clients could receive the benefits
within a timited time in therapy.
Purpose of the Study. The purpose of this study was to
examine the efficacy of the early stages of therapy within a
community mental health center. Specifically, it investigated the
mediator effects of duration of time in psychotherapy on self-report
measures of depression and anger. The efficacy of brief treatm ent,
as an application of the early stages of therapy, was evaluated in
terms of its effect on the variables of depression and anger. All
subjects were given the pretests prior to their first sessions, and
then assigned to one of two treatment groups: posttests after four
sessions or posttests after eight sessions.
Significance of the Study. The results of this study may lead
to areas of focus to serve better the community and recipients of
either time-limited therapy or a limited amount of therapy.
Additionally, the areas of concern of this study may be shown to
hinder the efficacy of the early stages of therapy; which could then
be suggested to be a lesser focus by those responsible for the
conduction of therapeutic services. From this study, the field of
Psychology may receive new knowledge from which to base current
and future approaches to psychotherapy. The public, too, may
benefit from an increased level of efficiency in psychological
services resulting in less hesitation to procure such services.
Clearly, if the the public is seen as a consumer and the
therapist as a producer, then the insurance company or other
financially responsible party could be seen as the middleman, and
all three would reap the economic benefits of increased efficiency.
8
Overall, it was hoped that this study would significantly add to
the body of knowledge regarding the efficacy of treatment within
the early stages of treatment, and the efficacy of brief periods of
psychotherapy for the treatment of anger and depression.
9
CHAPTER 2
Rev iew of the l i terature
In this chapter, the relevant literature concerning short
duration psychotherapy, anger and depression is reviewed.
Time Limits in Psychotherapy
Among psychologists, there is a long held belief that there is a
direct correlation between client improvement and the length of
therapy: longer therapy produces better results (Fiester &
Rudestan, 1975). This myth does not hold under the scrutiny of
empirical research or when compared to client ratings of
improvement in a single session (Bloom, 1981,1992). In fact, the
literature suggests that shorter forms of therapy are, at the least, as
effective as longer versions. In some cases, brief therapy is more
effective (Perry, 1987; Smymios & Kirkby, 1993). Phillips (1985)
describes the mean treatment length as less than five sessions, with
the median number being only one session. Some therapists may
see this as personal failure, or as client resistance. Therefore, it is
important to examine the early stages of therapy. Time-limited or
brief therapy specifically operates in a limited number of treatment
sessions, and serves as an excellent example and model from which
to study the early stages of treatment.
Much of the research on shorter duration therapy focuses on
college counseling centers, with a lack of research focusing on other
settings such as community mental health centers. The literature
indicates that time-limited therapy is as good or better than time-
10
unlimited therapy in terms of level of change (Cartwright,
Robertson, Fishe & Kirtner, 1961; Muench, 1965; Munro & Bach,
1975; Shlien, Mosak, & Dreikers, 1962; Van Bragt & Hesselink,
1994) and duration of change (Kielson, Dworkin, & Gelso, 1979).
Conversely, Brodaty (1985) found no difference between brief
therapy, generic short term therapy and unfocused therapy
delivered as needed. His results indicated that there was no
demonstrative significant effects of therapy between patients in
these types of therapy. Overall, all patients improved appreciably
in a 15 month span.
Brief therapy, or therapy with a set time limit, is subjective.
Some versions have as few as one session or as many as 30. Hersh
(1988) contends that, perhaps, 40 sessions should be better used as
a maximum time limit and that less than 10 sessions should be
considered ultra-brief therapy. The area he suggests to
differentiate between approaches should be new learning versus
symptom relief. Despite the comparable results of brief approaches
to therapy, excepting Adlerian approaches, there is not a single
defining approach or strategy in this model of treatment (Sperry,
1987). The length of time in therapy, or duration, is one of the
variables to differentiate approaches to brief therapy (Sperry,
1989).
Sperry also identifies eight different approaches to short
duration therapy by different theorists and delineates between
diem in terms of outcome goals, length of treatment and
techniques. His listing divides the approaches into four categories
based on theorists: (1) Psychoanalytic orientation (Beliak, Mann
and Sifneos); (2) Cognitive/Behavioral orientation (Lazarus and
Beck); (3) Problem Solving orientation (Weakland and Klerman);
and, (4) Adlerian orientation. The range of sessions reflects the
fewest for Adlerian, one, and the highest for Klerman, 26. Both the
models of Beck and Lazarus are variable for session length, which
adds further ambiguity to this therapeutic method.
The present study used a limit of eight sessions as the
framework for the early stages of therapy and was based on results
from the meta-analytic study by Howard, Kopta, Krause, and
Orlinsky (1986). The eight session limit used in this research study
was not communicated to the therapists or subjects during their
treatment. Howard et al. examined the relationship between
length of treatment and patient benefit. After reviewing 15
different data sets consisting of over 2400 patients in 30 years of
outcome research, they found that 50% of patients were measurably
improved by eight sessions. Additionally, by 26 sessions, 75% of
patients showed improvement.
Brodaty (1983) defines the factors germane to brief
approaches as time, activity, focus, transference and termination.
12
A review of recent research on these areas reveals the same factors:
time (Flegenheimer & Pollack, 1989; Gibney, 1994; Pinkerton &
Rockwell, 1988,1990), activity (Duignan & Mitzman, 1994;
Shubeck, 1988), focus (De Shazer, 1986; De Shazer, Berg, Lipchick
& Nunnally, 1986; Macdonald, 1994), transference (Hoyt, 1987;
Joyce & Piper, 1993) and termination (Magnavita, 1994; Pinkerton
& Rockwell, 1988,1990).
The prime directive of therapy is the resolution of treatment
issues and the improved functioning of the client (Manaster, 1989).
Malan (1976) emphasized setting limits before starting treatment as
a way to aid clients in dealing with termination. Relatedly, Mann
(1973) rebuffed long term therapy and suggested that after a certain
number of sessions, continued treatment may only foster
dependence in clients towards the therapist.
The act of imposing time limits on therapy is an issue which
affects the clinical application of treatment. It has merits
regardless of whether or not the length is shortened or extended
(Gibney, 1994; Manaster, 1989). Adler (1972) echoes the notion that
the Adlerian approach accommodates client's needs and style.
Fitting the needs of the client above the approach of the therapist is
one of the basic tenants of MultiModal Therapy, created and still
advocated by Lazarus (1976,1981,1989). There seems to be a trend
of increasing interest in the area of brief forms of therapy as seen in
the number of recent books (Budman & Gurman, 1988; Cooper,
1995; Smith, Glass, & Miller, 1980), in recent research (Cummings,
Hallberg, & Slemon, 1994; Griswold, 1987; Reitav, 1991) and in
13
recent meta-analyses and reviews of the literature (Barber, 1994;
Budman & Stone, 1983; Howard et al., 1986; Johnson & Gelso,
1980; Shapiro & Shapiro, 1982; Steenbarger, 1994). Most tend to
show the effectiveness of time-limited therapy equal to or better
than longer therapy (Perry, 1987).
Recent literature suggests variations in methods for
establishing time limits as well as interpersonal rather than
intrapsychic concepts used to identify the focus (MacKenzie, 1988)
as well as different catalysts for change (Eckert, 1993). Rudolph
(1993) highlights the importance of a review at the midpoint of
treatment to guide the treatment focus.
Johnson and Gelso (1980) reviewed the literature on short
term therapy and offered a synopsis of what they found. They
compared 12 studies of time-limited versus time-unlimited therapy.
Rating methods included psychological tests, counselor ratings,
client ratings and ratings by an observer. One half of the studies
used some form of rating by the therapist on client improvement.
Of those, one half showed improvement with a time-limited
treatment approach, and the remaining 12 showed no difference
between a time-limited and time-unlimited approach.
14
Eight studies used client ratings of satisfaction, with seven
indicating more satisfaction with time-limited than with time-
unlimited therapy. The seven studies that employed psychological
tests showed time-limited therapy more favorable in four cases and
three with no difference from time-unlimited. Interestingly, the
only two studies that used ratings by observers both found time-
limited therapy rated higher than time-unlimited therapy.
Elements Within Time-Limited Therapy
Within a therapy setting that is time-limited, what is said
takes on more importance than in an unlimited therapy setting
simply because there is less time available for either the client of
therapist to exchange words. Burlingame (1984) could not find a
significant relationship between therapist content focus (what is
talked about) and specificity (stimulus value of what is said).
Essentially, he was not able to support with significance the idea
that specific content areas, like symptoms, precipitory event,
therapeutic relationship, history, support, and a miscellaneous
category, as therapist content or specificity was related to measures
of client change. His implications question the reliability of the
outcome measures used and reflect the need for further research.
However, his approach of forcing the client to focus on therapist
chosen topics goes against the nature of brief therapy, where the
clients concerns are the focus to the treatment.
Feldman (1983) looked at the role of the content of
interpretations and directives in encouraging change and
maintenance of change in brief therapy. Feldman had an
interesting variation of Burlingame's term of specificity.
Consistent and inconsistent combinations of paradoxical and
non-paradoxical interpretations and directives were given to 49
moderately depressed college students. The initial hypothesis was
that consistent paradoxical would be more effective than
inconsistent paradoxical and non-paradoxical interpretations,
which would be more effective than consistent non-paradoxical
interpretations. Counselors gave six interpretations and two
directives to the four intervention groups, while the control group
received nothing.
Paradoxical interpretations were associated with more
symptom remission than non-paradoxical. While the nature of the
directives made little difference on depressed symptoms, students
gave more favorable impressions of therapists when they were
consistent. These results seem to indicate that being reliable is as
important as what is said. Burlingame was unable to prove that
what was said by the therapist had any effect on change by the
client. As seen by other researchers, when clients are expected to be
active in their treatment, they tend to have longer lasting and more
meaningful change, which produces more satisfied clients. This can
be applied to Feldman's study in that the depressive symptoms
were lifted in clients due to the cognitive effort in determining the
relevance and applicability of the paradoxes, because it forces them
to be an active part of their treatment.
Guilfoyle (1987) also looked at paradoxical interventions in
brief therapy on procrastinators. This sample consisted of 42
16
undergraduates who were self-identified procrastinators with
failed attempts at stopping. No significant changes were noted in
respect to frequency and severity, but significant interactions
between treatment and time and reactance and time were noted.
Main effects were also noted between self-directive treatment and
paradoxical treatment on procrastination controllability and
expectations to change.
These results, in comparison to Feldman, reinforce the notion
that paradoxical interventions in brief therapy have an impact. No
attempts were made in this study to determine how lasting the
indicated results were. Like many of the studies that involve college
populations, the sample is biased or skewed simply because the
population from which it is drawn are higher functioning than
samples of less healthy in-patients, and are probably capable of
higher levels and qualities of change in less time.
Factors Affecting Outcome in Brief Psychotherapy
Wilson's (1987) results support counselor's level of experience
as a variable affecting the counselors focus on feeling, empathy
and communication of facilitative conditions in brief treatment.
Norville (1990) demonstrated that interpretation accuracy
correlates highly with outcome in brief psychodynamic
psychotherapy. The change in level of object relations correlates
significantly with outcome (Scheider, 1990).
Hanscom (1990) looked at client conceptual level and
supervisory style in supervision of brief therapy. With an unusual
design of only three sessions of feedback, no differences were found
between matching levels on either areas of measures of satisfaction
of supervision and the strength of the working alliance. In brief
therapy, supervision can be from a supervisor of differing
theoretical orientation and not affect the supervision experience.
However, Warren (1990) found that significant transference
enactments do occur even in brief therapy, and that the
interpretation of such has utility in brief settings. The
interpretation of transference appeared to advance the process of
therapy by contributing to the therapeutic efficacy of the treatment.
Failure to address the transference can have negative outcomes,
even in therapy lasting only a few sessions.
Polk (1987) found that when working with borderline patients
in brief therapy, therapists must modify their level of activity and
encourage less emotional expression from clients. Related,
Silverberg (1988) examined emotional discharge and catharsis and
their relation to brief therapy. Results are in agreement with the
idea that emotional discharge and improvement are unrelated,
especially true when considering that potential clients could be
severely depressed and unable to express deep emotions with a
cathartic benefit yet show improvements. Applicability of
Silverberg's data may apply to women only, as all 32 subjects in
that study were female.
18
Peake and Ball (1987) echo the financial constraints of the
present economy and consider the increase in therapists using brief
approaches to therapy. They emphasize careful planning and
consideration of all phases of treatment: beginning, middle and
end.
The above literature tends to reinforce the brief therapy
components advocated by Budman and Gurman (1983). They
include a high level of therapist activity, the maintenance of clear
and specific focus, flexible use of interventions and encouragement
of client activities outside of therapy. They point out that the
integration of differing approaches can make therapy beneficial
within a well planned limited amount of time.
Applications of Brief Therapy
Time-limited therapy has been applied to a variety of clients
in diverse locations. For example, Swetz (1983) studied single
versus twice weekly group therapy with incarcerated males, while
Day, Maddicks, and McMahon (1993) looked at individual therapy
in an incarcerated male population. Wiztum, Dasberg, and Shefler
(1989) used a community mental health center located in Jerusalem
for a follow up study. With a small sample size of six, the subjects
were followed up after two years. Their results indicate that a
modified version of Mann's (1973) approach to brief dynamic
psychotherapy has favorable and durable results, as in their
application to clients diagnosed with post traumatic stress disorder
(PTSD).
19
Time-limited therapy has been shown effective at reducing
some of the sexual dysfunction problems of sexually assaulted
women. Subjects were assigned to one of four groups: individual
or group therapy or delayed individual or delayed group therapy.
The group therapy treatment approach yielded the greatest
treatment gains that were maintained at a three month follow up
(Becker, Skinner, Abel, & Cinchon, 1984).
Rockwell (1987) urges more research on impotence for college
aged males, as a paucity of literature was detected. Snyder and
Berg (1983) link marital satisfaction index results as an indicator of
marital distress as a motivation to respond to brief directive sex
therapy. Weisstub and Shoenfeld (1987) also noted the importance
of a cooperative partner in their brief therapy w ith homosexual
couples.
Time-limited therapy has been applied to the treatment of
personality disorders. For example, Magnavita (1993) reviewed
the current approaches in treating passive-aggressive personality
disorder. He advocates cognitive, behavioral and psychodynamic
approaches within a brief therapy setting. Winston, Pollack,
McCullough, and Flegenheimer (1991) found short-term dynamic
and brief adaptational psychotherapy nearly equal in outcome but
different on subscale measures for subjects with personality
disorders.
20
The Winston et al. (1991) study used a wait list control group
and found significant differences when looking at different
treatment techniques. The expression of strong affect by subjects
was encouraged more in short-term dynamic approaches whereas
the brief adaptational approach dealt with subject resistance in
therapy more by clarifying than confronting.
Both approaches demonstrate that time-limited therapy is
effective, and as in other approaches, has better results in some
areas than in others. The study by Winston et. al. (1991) study did
not take into consideration variations in the different personality
types, pathological and non-pathological, which might affect the
validity of the results that they reported.
If their sample contained a high number of subjects with Antisocial
personality disorders, their results probably would not be as
favorable, since those types of subjects do not adapt to new
situations or accept confrontation well.
Chubb and Evans (1985) studied a family treatment approach
to personality disorders. Their focus was on the family's control of
the treatment outcome for an antisocial subject. The family had the
role of desensitizing the subject to tempting stimuli. Admittedly,
they state that their results are impossible to determine, but they
indicated at a five-year follow up their treatment seemed to be
"effective."
Free (1985) studied 53 outpatients with diagnoses of affective,
borderline and dependent personality disorders. The intention was
to study ratings of therapist empathy. The results indicated that the
21
importance of supervision and the accuracy of supervisors
assessment of the perceptions of the client were more important
than an extensive case conceptualization by the therapist. Polk
(1987) urges the modification of techniques when working with
borderline clients. Pinkerton and Rockwell (1990) consider the role
of termination in the brief setting, emphasizing its importance in
practice and in approach.
Taurke, Flegenheimer, McCullough, and Winston (1990)
found a negative correlation between good outcomes in brief
therapy and the ratio of defensive behaviors to total patient
activity. It appears that just as in younger patients, older patients
maintain gains versus relapse in brief treatment for depression.
Gallagher, Hanley-Peterson, and Thompson (1990) note that older
adults that were not depressed at 12 and 24 month follow-ups
remained depression free for longer periods than those who were
depressed at either follow up. This is in contrast to Winston,
Pollack, McCullough, and Flegenheimer (1991) who found no
significant differences when looking at response rates compared to
different treatment modalities.
Additional Applications
Time-limited therapy has been extended to medical and
related settings as well. The research is varied for applications in
Health Maintainance Organizations (HMO's). For example,
Wassenaar (1987) found a readmission rate of 0 for adolescent
parasuicides in this type of setting. Chubb (1982; Chubb and Evans,
1985; Chubb, Nauts, & Evans, 1984) has actively researched the
22
implications for HMO's in both family and individual settings.
Recent updates by Chubb and Evans (1990) indicate that the Mental
Health Research Institute (MRI) approach, which focuses on
problems and problem-maintaining behaviors, produced a rate of
hospitalization that was two-thirds lower than their region
average. Also, over a two year average, their HMO setting had an
average of 834 patients per therapist versus the regional average of
456.
Siddall, Haffey, and Feinman (1988) researched intermittent
treatment in an HMO setting. They looked at 70 cases of returnees
to therapy for additional service, which was 27% or roughly one-
fourth of their requests during a four month period. From this
sample, 77% found previous treatment helpful, while 26% returned
for the same problem 51% had a new difficulty. A transition from a
life-events developmental approach is advocated. Bennett (1984)
concurs, suggesting that humans continue to grow throughout
adult life and will seek to overcome obstacles that block
development.
Extensive literature has been found based on the research into
brief therapy on hypertensive and cardiac patients. Generally, a
combination of behavioral techniques (alterations in diet, level of
exercise and relaxation training) show improvements for clients on
health measures.
23
The main focus with medical patients is to increase their level of
involvement (Milton, 1989; Teitelbaum & Kettl, 1988). Bassett and
Pilowsy (1985) looked at chronic pain patients finding only an
increase in level of activity but no decrease in anxiety or depression
at six and 12 month follow-ups.
Sapp (1992) studied the effects of relaxation training and
hypnotherapy in reducing anxiety and stress. In this seven session
application of brief therapy, the study was designed assess for
maintainance of treatment gains after four weeks. The patients in
this study all were suffering from some form of neurogenic
immpairment, such as multiple sclerosis, strokes, traumatic brain
injury or Parkinson's disease. Sapp found that both anxiety and
stress were reduced, and also that self-esteem was improved, and
all were maintained at a four week follow-up. This offers direction
for continued research and treatment with diverse populations.
Bell (1983) determined within a study on biofeedback and brief
therapy on headaches, that more psychological gains occurred with
biofeedback. Bell reasoned that this was possibly due to therapy
explaining their illness as having a connection to their mental state,
which they had some degree of controll over, rather than their
illness being the result of their body. Again, it seems that the higher
the level of investment, the greater the gains.
Friedman and Taub (1985) looked at patients three years after
treatment for headaches and found that despite daily headache
record forms indicating otherwise, 78% rated themselves as feeling
better than at the one year follow up. They implicate repeated
24
yearly reinforcement of psychological intervention. Forman (1985)
indicates that with psychosomatic patients, clarifying behavioral
patterns in which problems are embedded should be the main thrust
of brief treatment. Patient self monitoring, cognitive restructuring
and relaxation training were taught to bulemic women in
psychoeducational groups by Connors, Johnson, and Stuckey (1984).
Results indicate a 70% reduction in binge-purge episodes.
Anger
Definitions
Affectual states regulate efficacy of daily functioning and
affect many different facets of living. Thomas (1990) historically
traces the concept of anger. At times it was considered a sin or a
sign of insanity; at other times it was a weakness that could be
strengthened or contained. Different theoretical schools within
psychology view anger differently, which is compounded by a lack
of a single type of anger. For example, Averill (1982) views anger
as a combination of feelings, behaviors, and physiological
reactions. Berkowitz (1990) approaches anger differently, and
views it as a perceptual experience while avoiding any attempt to
define or classify it as an emotion. The literature reflects that anger
may be composed of different subtypes of anger, which adds
difficulty to trying to predict or measure it with assessment tools.
Generally, anger has been studied along with aggression, a related
though different construct which is easily observed as a behavior.
Potential reasons for inconsistent, or possibly skewed data, in
research on anger are in part due to the low rate of self-reported
25
aggressive behavior (Unverzagt & Schill, 1989). At times, results
comparing measures provide only partial support for internal
consistency (Collins & Hailey, 1989). In part, Riley, Trieber, and
Woods (1989) feel this can be attributed to subjects tending to
suppress anger rather than expressing it when depressed.
The ories of Anger
There are several different theoretical approaches to anger,
of which the drive theory, social learning model and the cognitive
models will be reviewed.
Drive Theory of Anger and Aggression
Perhaps the oldest example of the Drive Theory was
originally offered by Dollard, Doob, Miller, Mowrer, and Sears
(1939). The general premise of a drive model is that excessive
negative stimulation, such as frustration, induce drive states that
lead to aggression. The negative stimulation interferes with an
expected attainment of a desired goal. It is the blocking, or
interference, that produces the frustration, which in turn produces
the aggression.
Dollard et al. (1939) defined frustration as any kind of
interference with goal-directed behavior and aggression as
behavior directed towards injuring the source of the source of the
offending frustration. Their approach assumes aggression is
always preceded by frustration, that frustration instigates
aggression, and that the aggression will persist as long as the
frustration continues. This approach contends that if the
aggressive behavior is inhibited, for example through fear of
26
reprimand, an increased instigation to aggression and increased
aggressive response would result. Conversely, Dollard et al.
posited that the enactment of aggressive acts towards the source of
the frustration would decrease the instigation to aggression.
Essentially, aggressive acts would be cathartic and allow a return
to a non-aggressive, non-angry state.
This approach, which Berkowitz renamed a Neo-
Associationistic Model, was later modified and refined several
times (Berkowitz, 1969,1978,1989,1990). In his approach,
individuals do not always attack others due to frustration. He
indicates that some aggression may be due to the belief that an
individual may obtain some personal benefits from the aggressive
action. Also, he points out that aggression can be hostile (with a
goal of doing harm) or instrumental (when the goal is the
achievement of other objectives such as power or wealth).
Berkowitz contends that anger mediates frustration and
aggression, and his theory maintains a cathartic view of
aggression.
Social Learning Theory of Anger
In this model, the reinforcement histories of the individuals
are the primary determinants of aggressive behavior (Bandura,
1973). According to Bandura, aggressive behavior is shaped by
previous associations of rewarding consequences and is influenced
by modeling. In this model, anger does not always follow
frustration, and less emphasis is placed on the interruption of goal-
27
directed behavior. He, too, views anger as a facilitator for
aggression.
Cognitiv^-Theory of Angei
Novaco (1979) conceptualizes anger as an affective stress
reaction which results from the perception of threats or demands.
In this model, it is the perception of an event as provocative which
is necessary in order for an individual to become angered. This
perception was based on appraisals of external events and
expectations regarding these events. Appraisals are defined as a
function of the expectations that individuals hold, and expectations
as resulting from previous appraisals of similar events. According
to Novaco, cognition and the experience of anger are interrelated.
Whether or not a person becomes angered is determined by their
appraisal of the event, and by their expectations regarding the
event. Essentially, events that would provoke anger are always
mediated by an individual's appraisals and expectations.
Measurement of Anger
In an attempt to help distinguish anger from hostility and
aggression, Spielberger (1991) created the State-Trait Anger
Expression Inventory (STAXI). This test provides concise
measurement of the experience and expression of anger. According
to Spielberger, the experience of anger contains two major
components: State-Anger and Trait-Anger. He views state-anger
as an emotional state of angry feelings at a particular time, and
trait-anger as a disposition to more easily perceive situations as
frustrating. Individuals with high trait-anger experience state-
anger more frequently and with a higher intensity than do
individuals with low trait-anger. The construct trait-anger has
two sub-factors: Angry-Temperament and Angry-Reaction. Angry-
temperament refers to the tendency to experience and express
anger without specific provocation, while angry-reaction refers to
individual differences in the disposition to express anger when
treated unfairly.
Spielberger (1991) conceptualized Anger-Expression as being
comprised of three components: Anger-In, Anger-Out, and Anger-
Control. Anger-Out (AX-OUT) refers to the expression of anger
towards people or things in the environment. Anger-In (AX-IN)
simply refers to anger that is directed inwards, or suppressed.
Anger-Control (AX-CON) represents the attempts of an individual
to control the expression of anger.
These constructs, as outlined and defined above, represent the
individual scales in the STAXI. There is, however, one additional
scale: Anger-Expression (AX-EX). This scale, which is based on the
responses in the scales Anger-In, Anger-Out, and Anger-Control,
measures the frequency of anger that expressed regardless of the
direction.
Correlates of Anger
Within the study of emotions, it is necessary to examine the
awareness of and control strategies of various affectual states.
McDougall, Venables, and Roger (1991) looked at 40 male offenders
with classifications as angry/non-angry, finding that the choice of
instrument affects results. Three fourths of the instruments they
29
utilized distinguished significantly between groups. Similar to the
work of Hart et al. (1991) with type A clients, Mizes, Morgan, and
Buder (1990) found that general cognitive distortions related to
anger distortions in undergraduate students. The goal of divorce
mediation is not the elimination of anger, but in preventing
adaptive anger from becoming maladaptive (Somary & Emery,
1991). Zwerdling and Thorpe (1987) concur that irrational beliefs
are connected to anger.
Houston and Vavak's (1991) findings indicate that hostile
clients tend to drink more alcohol, drive a car more frequently after
drinking and have greater relative weights. Also, highly hostile
subjects who avoid seeking or accepting social support experience
anger that is excessive and occurs in a wide variety of settings yet
suppress the expression of any anger. This seems to indicate that
the ability to control or regulate anger stems from perception and
affects functioning widely.
Cemey and Buskirk (1991) have demonstrated anger as a
hidden element of grief. Grief resolution depends on the
recognition, owning and resolution of feelings of anger. Renouf
and Harter (1990) found that 80% of subjects reported depression as
a mixture of anger and sadness. Gardner, Leibenluft, O'Leary, and
Cowdry (1991) looked at borderline personality subjects and found
significantly higher scores over normal subjects on a guilt-hostility
inventory. Their findings also suggest that a proneness to anger
and hostility are enduring characteristics of the borderline
personality.
30
Ben-Zur and Breznitz (1991) determined that anger was
affected by three basic aspects of a harmful event: extent of
damage, causes of damaging act and the likelihood of damage
occurrence. In a comparison of the MMPI-2 anger content scale
with other measures, Schill and Wang (1990) found significant
correlations with measures of anger awareness and anger
expression. They also found a negative correlation with measures
of anger control. Also found were significant correlations for
projections of anger for men. Fitzgibbons (1986) sees forgiveness
as one facet of releasing anger in treatment by allowing clients to
forget, reconcile and move forward.
Support for a link between anger and thought processes is
seen in the work by Torestad (1990) involving moral reasoning.
Even among substance abusers, anxiety and anger scores were seen
as higher compared to non-client samples (Walfish, Massey, &
Krone, 1990). Lohr, Hamberger, and Bonge (1988) concur that
irrational beliefs are related to anger processes.
Therapist's response to client anger has been reviewed to find
that trainees tend to avoid upsetting clients (Sharkin, 1989).
Reasoning includes fear of threatening implications and anxiety.
McCann and Biaggio (1987) indicate that narcissistic clients are
more likely to express their anger physically.
31
Additionally, the use of marijuana is associated with increased
aggressiveness in clients and more expressed anger towards other
persons or the environment (Stoner, 1988). Fremont and Anderson
(1986) concur with Sharkin, adding that some therapists do not
address some anger as it may be due to their issues rather than the
client's issues.
Anger, for example, may inhibit sexual desire and arousal
(Bozman & Beck, 1991). Global self-worth combines with affect to
produce anger or depression (Renouf & Harter, 1990). Irrational
belief systems can also combine with anger to produce additional
negative emotional distress (Hart, Turner, Hittner, & Cardozo,
1991). Mook, Van Der Ploeg, and Kleijn (1990) found that anxiety
moderates anger. Diodato, Pancoast, and Frey (1986) advocate
short term group counseling for both anger and stress.
Gender. Race and Age Differences
Thomas and Donnellan (1991) used women in adulthood
(aged 39-60) as a subject pool. Their results indicate significant
correlations of symptoms of anger contained in lower optimism,
higher occurrence and severity of everyday difficulties, lower
functional support and the loss of important relationships in the
past year. Also noted with anger symptomology was greater body
mass index, inadequate sleep, lack of exercise, higher rates of
drinking and over-the-counter drug use. Women who reported
more anger symptoms apparently did not suppress their anger but
directed it outward.
32
Women have been shown to have higher trait anxiety than
men (Stoner & Spencer, 1986), yet some women consistently
suppress anger while others are inconsistent, which also limits
treatment effectiveness (Hayles, 1986).
Kopper and Epperson (1991) compared sex and sex-role
identity in the expression of anger. Sex roles, but not sex,
maintained consistent relationships with anger proneness, outward
expression, control of anger expression and suppression of anger.
Cramer (1991) found that the projection and identification as
the predominant defenses to anger in late adolescents. The pattern
of cognitive distortion seems to intensify the expression of anger.
Harburg, Gleiberman, Russell, and Cooper (1991) found that when
compared to black males, younger adolescent white males have
higher rates of alcohol use and lower education related to higher
blood pressure levels in terms of a coping style to anger.
Johnson and Broman (1987) indicate that blacks who have
higher levels of outwardly expressed anger and more severe
intrapersonal difficulties have higher health related problems.
Tavris (1984) extends this further with implications stating that
added negative consequences include a hostile attitude, exclusion of
other emotions or the simultaneous expression of anger with other
emotions and the tendency to make others angrier.
Siegman, Anderson, and Berger (1990) detailed findings
regarding gender differences. They found that both male and
female subjects reported feeling significantly more angry and
showing significantly greater blood pressure and heart rate
33
reactivity when describing anger arousing events in fast-loud
voices when compared to normal voice conditions. With males,
significant effects were noted on anger self-ratings and
cardiovascular responses during the neutral communications as
well. Dimberg and Lundquist (1990) determined that females are
more facially reactive than males are to faces with or without
angry expressions.
Treatment Applications
Deffenbacher, McNamara, Stark, and Sabadell (1990, B)
compared cognitive-behavioral and process oriented group
counseling for general anger reduction. Both approaches yielded
significant reductions of: 1) general anger, 2) anger from diverse
provocations, 3) anger suppression, 4) anger related physiological
arousal and 5) poor coping tendencies in analog provocations. The
effectiveness in this area can be seen through similar studies in the
reports of maintenance of gains at one year followups
(Deffenbacher, 1988; Hazaleus and Deffenbacher,1986) and at 15
month follow-ups (Deffenbacher, Story, Brandon, & Hogg, 1988).
Combined training in relaxation, cognitive coping skills and
behavioral coping skills has also been shown to reduce general
anger (Deffenbacher, McNamara, Stark, & Sabadell, 1990, A).
Stermac (1986) demonstrated the efficacy of the short term
treatment of anger with forensic patients. As an application to
battering couples, 85% were free from further violence at 6-8 month
follow-ups, due to anger control training (Deschner & McNiel,
1986).
The connection between emotional mood and physical health
has been made concerning anger and somatization (Kellner,
Hernandez, & Pathak, 1992), and the research involving Type A
personalities is extensive (Hart, Turner, Hittner, & Cardozo, 1991).
In a rational emotive theoretical position, they looked at the role of
irrational beliefs moderating the impact of stressful events on
overall emotional distress. Their proposed idea was that the levels
of anger (and anxiety) would be highest for irrational individuals
who experience high levels of stress in their lives. The results
indicated interactional effects only for anger. Shibles (1991) points
out that the therapists use of humor can be useful to advance an
enlightened and humanistic approach.
In a recent review on the type A behavior pattern literature,
Lohr and Hamberger (1990) note that anger/hostility was the
primary factor in coronary heart disease for these subjects.
Cognitive-behavioral approaches appear to be the most promising
in this area. Sommers and Greenberg (1989) previously reviewed
the literature, finding an association between hypertension and the
expression and identification of anger. A possible genetic or
example of modeling is seen in the study of familial expressions of
emotions on the expression and experience of anger (Burrowes &
Halberstadt, 1987). Simon (1987) advocates the creation and
inclusion into the Diagnostic and Statistical Manual of Mental
Disorders of a Berserker/Blind Rage Syndrome. It focuses on the
violent overreaction to a harmless stimulus with an associated
amnesia for the reaction.
35
Promising prospects for reducing type A behaviors exist in
anxiety management and operant self-control (Nakano, 1990).
Siegel (1984) found that adolescents aged 13-18 are at risk of
cardiovascular disease due to the multidimensional nature of
anger.
Ford (1991) studied anger and irrational beliefs in
incarcerated males, finding a strong cognitive component which
could be addressed in Rational Emotive or other cognitive
approaches. Yuen and Kuiper (1991) used two studies to reinforce
their position that aberrant cognitions have an impact on the role of
anger in type A individuals. An increase of general hostile attitudes
and more frequent and hostile attitudes was an indicated result.
However, antidepressants and psychotherapy were not found to be
effective for controlling the suicidal depression, rage and cognitive
deficits of a 32 year old male diagnosed as having Organic Mood
Syndrome (Lowinger, 1990).
But, the role of the therapist is to facilitate growth in the
recognition of anger and choice of healthier responses (Alschuler &
Alschuler, 1984). Yet, gender differences remain in emotional norms
(Cancian & Gordon, 1988). The resulting application implications
need to consider the aspects of justified versus unjustified anger,
normative versus maladaptive anger and anger suppression, which
indicate more attention to and concern for appropriate treatment
planning (Biaggio, 1987). Carberry (1983) contends that a variety of
techniques, such as cognitive reframing, paradoxical intention and
general positive reinforcement have demonstrated usefulness.
36
Depression
The research on the area of depression is both overwhelming
and staggering. Therefore, this doctoral dissertation will reflect
only a portion of this body of literature, with a concentration on it's
relationship to anger.
Definitions
The large number of research studies focusing on depression
reinforces the prevalence of this affective disturbance in society.
This popularity is reflected in the wide variety of self-report
measures created to identify and assess the depth and severity of
depression. The nature of depression, namely that it consists of a
variety of symptoms, tends to add to the difficulty of assessment.
This is further compounded when general individual differences are
considered, because even though two people may both be
depressed, the symptoms they exhibit may be dramatically
different.
Boyle (1985) addresses the differences in the presenting
symptomology of depression, along with the questionable validity
and reliability of some depression scales. He notes the difficulties in
attempting to measure different symptoms in different people who
all have the same diagnosis of depression, and strongly suggests
continued refinement of assessment scales. The increased
refinement of assessment scales would decrease the rate of
misdiagnosis of depression (Upmanyu & Reen, 1990).
Depression, the most common psychological disorder, is a
frequent topic in both magazines and in clinical journals (Jarrett &
Rush, 1994). In lay person's terms, the term depression has been
applied to an occasional sad affect, prolonged disappointments, or
to a general state of feeling down or "blue." While this is an
unavoidable aspect of the human condition, a clinical depression
may be the result when symptomology remains over an extended
period of time. According to the Diagnostic and Statistical Manual
of Mental Disorders (4th ed.) (DSM-IV), depression can be an
episode or a disorder marked by varied disturbances in affect,
cognition, and behavior, and characterized by dysphoric mood,
lethargy and a lack of interest in activities. These definitions,
subjective and objective, are interpreted differently based on
different theories of depression.
Theories of Depression
Several different theoretical approaches to depression are
reviewed.
Psychoanalytic Theory of Depression
In this approach, the imagined or real loss of a desired or
loved "object" results in depression. The earlier this loss occurs in a
person's life, the greater the likelihood that a depression would
occur in adulthood when experiencing a loss or disappointment.
Freud (1917/1961) contended that the anger and disappointment at
the lost object are eventually internalized. Stated differently, Freud
viewed depression as anger turned inward.
38
Behavioral Theory of Depression
In this approach, underlying conflicts which in other
theoretical approaches would be viewed as causing psychological
disorders, are largely ignored. It is the behaviors of an individual
that are the focus of this model. Depression is the result when over
generalized responses, such as lack of appetite, are applied to a
particular stimulus, such as loss of a job. Essentially, depressive
behaviors are reinforced rather than healthier behaviors (Skinner,
1953).
As seen in the work of Ferster (1973), the depressive
symptomology can be affected by changing the schedules of
reinforcement, or changing what behaviors are given positive
reinforcement. He accounts for the generalization of responses as
an example of the chaining of behaviors associated with the
traumatic event. When an event changes the source of
reinforcement, as in the loss of a job, the behaviors associated with
that reinforcement (such as getting up early, showering, eating
meals, etc.) are reduced.
Ferster further noted the connection between anger and
depression, though the expression of anger is thwarted due to a
fear of the loss of positive reinforcement.
Cognitive Theory of Depression
Unlike behavioral theories on depression which highlight
overt behaviors, the cognitive approach emphasizes more covert
behaviors such as attitudes, beliefs and self-statements. In this
approach, depression is caused by maladaptive, faulty or irrational
cognitions, or cognitive distortions. The resulting depressive
behavior is the result of the errant thought processes. According to
Beck (1976), when a person processes information incorrectly or
distorts what they perceive, this can lead to a negative mind-set, or
schema. All additional information is then filtered through that
faulty schema, which only increases the faulty thought patterns.
Beck's theory focuses on what he refers to as the cognitive triad,
which is the individual's view of self, their world and their future.
Typically, the depression colors each of these views negatively and
are the result of the individual's misperceptions of their
environment.
Measurement of Depression
Based on Beck's (1976) views that the thought processes are
the cause of depression, he created the Beck Depression Inventory
(BDI). This measure, which is described in greater detail later in
this document, is one of the most frequently used self-report
measures of depression. It contains test items which represent the
affective, cognitive, motivational, and physiological symptoms of
depression. While it does not diagnose depression, it does measure
the severity of depressive symptomology.
Correlates of Depression
It seems generally accepted that depression, or the effects of a
depressive episode, can affect people in numerous ways. For
example, among suicide completers, depression is the most frequent
diagnosis, noted at 70% by Barraclough, Bunch, Nelson, and
Sainsbury (1974). Guze and Robins (1970) estimated that the suicide
40
risk experiencing an affectual disorder is 30 times greater than for a
normal population not experiencing an affectual disorder. Hovens,
Op den Velde, Falger, Schouten, De Groen, and Van Duijn (1992)
reinforce the idea that depression is linked to other emotions, and
they suggest a link between P.T.S.D., anxiety and depression.
Selby and Neimeyer (1986) suggest that anger and hostility
are linked, and with depression, there may be a significant amount
of self-denicil of hostility. Renouf and Harter (1990) report that 80%
of their adolescent sample population reported depression as a
mixture of sadness and anger. They also highlight the importance
of cognitions, in particular self-deprecating, as having a role in the
depressive experience.
Anger and Depression
There is increasing literature on the connection between
anger and depression. Kellner et al. (1992) found inhibited anger
related to depression. Carey, Finch, and Carey (1991) found that
depressed children and adolescents reported higher levels of anger.
Scherer and Tannenbaum (1986) noted that in the emotional
experiences found in daily life, anger is frequently mixed together
with sadness and depression. Berkowitz (1983,1990) noted that in
populations of depressed children and adults, both hostility and
anger were displayed.
Similarly, there is evidence for a relationship between mood
disorders and violence. Collins and Bailey (1990) found evidence
for both depression and dysthymia being related to a history for
robbery. Their work tried to separate out affectual disturbances by
41
diagnosis which, they contend, did not happen in previous studies
which usually produced inconsistent results. The authors also
indicate that they found a relationship between depressive
symptoms, whether or not a diagnosis was given, and an increased
frequency in fighting after age 18. Their sample utilized 1140
incarcerated male felons. It may be that with such a population,
depressive symptoms followed, not precipitated, illegal behaviors.
It also would be reasonable for an affective disturbance to follow
an incarceration, regardless of prior mental health history.
Mood disturbances and behavioral problems continue to be
an area of research. Teplin, Abram, and McClelland (1994)
conducted a six year longitudinal study to determine if psychiatric
disorders might predict violent crime. Their population were either
pretrial detainees or had been sentenced to one year or less. Their
research, however, found no significant relationship between
mental disorders as a predictor for violent crime.
They found that their population was highly recidivistic, yet found
no evidence that a psychiatric diagnosis increased the probability of
arrest for violent crime.
Finman and Berkowitz (1989) suggested that, in part, anger
and hostility are generated from a depressed mood. The
researchers induced a depressed mood in female subjects, who
reported higher anger ratings than did subjects who received a
"neutral" mood induction.
42
Maiuro, Cahn, Vitaliano, Wagner, and Zegree (1988) studied
anger, hostility and depression in domestically violent, generally
assaultive and control group men. They found that domestically
violent men as well as the generally assaultive men indicated
higher ratings of anger than did the control group men. In fact, the
scores of the domestically violent men and the generally assaultive
men were similar. Only the domestically violent men were more
likely to be significantly more depressed.
Implied from their research is that the elevated depression
scores of the domestically violent men could be higher than they
appear. They contend that this group of men has difficulty
expressing feeling and emotions, such as depression, so any slight
elevation should be viewed in this context.
Maiuro, O'Sullivan, Michael, and Vitaliano (1989) examined
hostility and depression in assaultive or suicide attempting male
psychiatric patients. They found that both of these two groups
were characterized by significantly higher levels of hostility and
depression.
The subjects who were suicide attempting tended to experience
anger and hostility more covertly, as well as higher levels of self
directed negative affect.
Studies by Biaggio and Godwin (1987) and Riley et al. (1989)
also strongly indicate a relationship between anger and depression.
Essentially, both research groups found that depressed individuals
experience a greater sense of hostility than do normals or control
groups. The Riley et al. study reflects the hypothesis that
43
depression is related to an inhibition in anger expression. More
anger is suppressed and less is expressed, leading to increased
levels of depression. They also found increased levels of trait anger
in their depressed population.
The Study of Anger in Brief Therapy
A recent study combining the brief therapy setting while
focusing on anger as a variable was conducted in an outpatient
mental health center by Rowe (1986). Rowe was interested in
determining if clients in time-limited therapy would attend more
frequently than clients in time-unlimited therapy. His results
indicate that clients do attend more frequently when there is a
specified limit on therapy sessions. Rowe expected to find
significant differences by session number four. He found that while
clients report no change in symptomology at session number four,
therapists rate clients to be improved.
Rowe (1986) also found interactional effects between
diagnosis and duration of problem on anger at p< .001. In his
sample, 43.7 % of subjects described their disturbance of less than
one year and the percentages of diagnoses were as follows:
adjustment disorders 26.7, anxiety disorders 20.0, major
depressions 26.7, dysthymic disorders 10.0, marital problemss 13.3
and panic disorders 3.3.
The generalizability of Rowe's study is hindered by a
treatment sample group of 86.7 % women. He found statistical
significance in the proportion of females in the treatment group to
the overall outpatient group.
44
The Study of Anger and Depression in Brief Therapy
Maloney (1988) looked at the duration of treatment on
patterns of change in anxiety, depression and anger. He predicted
that the most change would occur during the first four sessions as
compared to any other period during a 13 session therapy setting.
Ratings occurred between sessions 1-4,4-8, and 8-13. Ratings
methods used included the State Trait Anxiety Inventory, Profile of
Mood States, Beck Depression Inventory, the Brief Outpatient
Psychopathology Scale and the Multiple Affect Adjective Checklist.
Subjects were asked to complete self-report scales at the intake
session, and after sessions one, four, eight and 13. Ratings were
completed by the counselor, the client and by a significant other.
Overall, the therapy group experienced higher levels of anger,
anxiety and depression throughout the process than the control
group did.
Maloney found a trend of concordance between client and
therapist ratings via the Brief Outpatient Psychopathology scale,
but only for anxiety and depression. He did not take into
consideration the ephemeral quality of anger, and possible within
session fluctuations. Also, the treatment group probably ranked
higher on the above emotions because these factors were what
originally separated them from the control group. Another reason
is because the very process of therapy tends to stir up emotions.
I see a problem with Maloney's (1988) samples for both the
treatment and control groups. The control group sample size was
24, while the treatment sample contained 10 subjects. The larger
45
the size in a sample, the higher the tendency for the scores on any
scale to regress to the mean. Within the control group sample there
15 females and nine males, whereas the treatment group sample
contained six males and four females. The control group members
were not in therapy for any personal difficulties but the treatment
group members received diagnoses of affective disorders (3),
anxiety disorders (3), and adjustment disorders (4).
It is not surprising that ratings of depression and anxiety
would be consistent by clients and therapists, as seven out of 10
(70%) were anxious and depressed to begin with. A possible reason
for the low concordance rate for anger may be a bias or deficiency
in diagnoses, or due to male client apprehension because of a
(relatively) high female presence (nearly 50%) in the group.
Conversely, the lower male presence may have affected the honesty
of responses in women as well.
Research Questions
For the present study, the following research questions were
developed:
1) Will subjects higher on trait-anger on the pretest show higher
ratings on pretest anger-in and anger-control scales, regardless of
the number of therapy sessions?
2) Will subjects higher on trait-anger on the pretest show higher
ratings on pretest depression, regardless of the number of therapy
sessions?
46
3) In both treatment groups, will subjects higher on trait-anger on
the pretest show higher ratings on anger-in and anger-control
scales at the posttest?
4) In both treatment groups, will subjects higher on trait-anger on
the pretest show higher ratings on depression on the posttest?
5) In both treatment groups, will subjects higher on depression on
the pretest show lower ratings on the anger-out scale on the
posttest?
6) Will subjects higher on state-anger on the pretest show lower
levels of depression and higher levels of anger expression on the
posttest if they are in the eight session treatment group?
7) Will subjects with higher state-anger on the pretest will show
higher anger control at the posttest, with the eight session
treatment group showing higher scores than the four session
treatment group.
8) Subjects with lower scores of depression on the pretest show
higher scores on the anger expression scale on the posttest, w ith the
eight session treatment group showing higher scores than the four
session treatment group?
47
CHAPTER 3
Method
In this chapter the methodology, subjects, instrumentation
and design of the study are outlined.
This study used the revised Beck Depression Inventory (BDI)
to assess self-report levels of depression, and the State-Trait Anger
Inventory (STAXI) to measure self-reported anger.
Subjects
The subjects for this study were voluntary participants who
were seeking mental health treatment at a sliding-scale outpatient
treatment center (Glendale Family Service) located in Glendale,
California. All subjects were adults over 18 years of age, and all
children and adolescents were immediately excluded from
consideration in the present study. New clients at this facility are
routinely given paperwork at their initial intake session. The
consent form which explained the nature and purpose of the study,
a BDI and a STAXI were also included as a part of the initial
paperwork. These three items were placed in a separate envelope
so as not to confuse them with the standard insurance paperwork,
and to avoid the accidental misplacing of any of the research
inventories.
Prior to the start of the present study, it was decided that the
minimum number of subjects per group would be 30, for a total
sample size of 60 subjects.
48
The sample size (n=60) was drawn from new adult clients entering
treatment. These subjects were randomly assigned into one of two
groups: posttest after four sessions or posttest after eight sessions.
During a 10-month period, 320 subjects were given research
packets containing the two self-report measures as well as the
information/consent form. Of these subjects, 242 did not return
questionnaires, refused to participate in this study, or did not return
for treatment after the intake session. A total of 78 subjects
responded by completing the pretest, but 18 were not used due to
inappropriate age or attrition prior to either four or eight sessions.
The remaining 60 subjects participated in this research by
completing both the pretest and the posttest. This produced a
response rate of 19%. In this sample, the average number of weeks
needed to complete their treatment sessions was 7.67, SD=3.98.
In this sample, 44 or 73.3% of the subjects were female and 16
or 26.7% were male. Ages ranged from 21 to 63. Their education
levels ranged from completion of eighth grade to Master's degrees,
and occupations included unemployed to unskilled laborers to
skilled professionals. The socio-economic status of the subjects in
the present study ranged from low income to middle class, and
sliding-scale per-session fees ranged from $5 to $100. The subjects
were diverse racially and ethnically, and included Asians,
Hispanics, Blacks and Caucasions.
Most of the subjects lived in the local communities that
surround this treatment center. Client concerns or reasons for
seeking treatment were generally to alleviate symptoms of
49
depression or anxiety, or for distress due to relationship difficulties.
Typically, clients were relatively high functioning prior to seeking
treatm ent.
It should be noted that any client exhibiting severe pathology,
such as Schizophrenia, was referred to another nearby facility
better equipped to meet the increased needs associated with a more
severe diagnosis.
Instrumentation
BDI. As an assessment tool for depression, the Beck
Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock, &
Grbaugh, 1961) has been used extensively in both research and
clinical applications. It has gained wide acceptance as a valid and
reliable assessment tool for depression Edwards, Lambert, Moran,
McCully, Smith, & Ellington, 1984; Lambert, Hatch, Kingston, &
Edwards, 1986).
The revised scale is a 21 item inventory that allows subjects to
rate symptoms and attitudes on a 4-point scale, ranging from 0 to 3
increasing in severity. A total score is achieved by adding the scores
for all 21 items, with a higher total number indicating greater levels
of depression. Administration time for the BDI is approximately 5-
10 minutes, and a fifth-grade reading level is required.
Beck and Steer (1993) report reliability estimates from their
normative samples as follows: mixed diagnostic = .86, single
episode major depression = .80, recurrent-episode major
depression = .86, dysthymic = .79, alcoholic = .90 and heroin
addicted patients = .88.
50
Beck et al. (1988) report mean correlations of .72 between the
BDI and clinical measures of depression for psychiatric patients,
and a mean correlation of .60 between the BDI and clinical
measures of depression for nonpsychiatric patients.
Test-retest reliability ranges from .69 to .90 (Shaw, Vallis, &
McCabe, 1985). Beck and Steer (1993) indicate a range of .46 to .86
for test-retest reliability for psychiatric patients and a range of .60
to .90 for nonpsychiatric patients.
Beck, Steer, and Garbin (1988) report a mean correlation of
.73 between the BDI and the Hamilton Psychiatric Rating Scale for
Depression, which is in the range of .62 to .77 for concurrent
validity as reported by Shaw et al. (1985).
STAXI. The State-Trait Anger Expression Inventory (STAXI)
(Spielberger, 1991) is a 44 item Likert-type self-report measure of
the experience and expression of anger. It assesses anger along six
scales: State-Anger, Trait-Anger, Anger-in, Anger-Out, Anger-
Control, and Anger-Expression. It also assesses anger through two
subscales of Trait Anger: Angry Temperament and Angry Reaction.
Subjects respond to the items on a 4 point scale, 1 to 4, ranging from
"not at all" or "almost never" for 1 to "very much so" or "almost
alw ays" for 4. Scale raw scores are converted into percentiles in
order to compare the subjects in relation to a normative sample.
Administration time is approximately 10 to 12 minutes, and a fifth-
grade reading level is required.
Since the STAXI is relatively new, few studies of the reliability
have been conducted. Therefore, little data exists regarding the
51
reliability of this test. However, research has been conducted for
the separate scales that were revised to form the STAXI.
Spielberger, Jacobs, Russell, and Crane (1983) report an internal
consistancy of .81 to .92 for the Trait Anger scale. They also indicate
concurrent validity with the Buss-Durkee Hostility Inventory in the
range of .66 to .73. For the State-Anger scale, Spielberger et al.
(1983) report an internal consistancy of .93.
Jacobs, Latham, and Brown (1988) researched the anger
expression subscales (Anger-in, Anger-Out, Anger-Control, and
Anger-Expression) and indicate that coefficients range from .64 to
.81 for test-retest reliability.
In the STAXI manual, (Spielberger, 1991) reports the
following coefficient alphas for the 6 main scales: State Anger (.93),
Trait-Anger (.87), Anger-in (.82), Anger-Out (.74), and Anger-
Control (.84). Norms are available by sex for adolescents, adults,
college students, and for special populations such as general
medical and surgical patients, prison inmates and for military
recruits.
It appears that sufficient evidence exists to support the
validity (Fuqua, Leonard, Masters, Smith, Campbell, & Fischer,
1991) and the reliability (Spielberger, 1991) of the STAXI.
Procedure
The new adult clients were randomly assigned into two
groups: one group of 30 subjects who received a posttest after four
sessions and one group who received the posttest after eight
sessions. All subjects received the pretest prior to the initial intake
52
(first) session, and completed the pretest at Glendale Family
Services. Along with standard insurance and background forms,
the pretests were distributed to the subjects by the student
investigator or by the administrative staff at the front desk.
The student investigator monitored the frequency of sessions
for each subject in both the four and session groups, and distributed
the posttests to each subject when they checked in prior to their
fourth or eighth session. The subjects were reminded that the
posttest was to be completed following their treatment session.
Administrative staff assisted the student investigator in collecting
completed posttests from some subjects, and the subjects completed
the posttests at the facility whenever possible.
The confidentiality of the subjects was maintained throughout
the research. Subjects were asked not to use their name on the
envelope containing the research test forms, in an attempt to
conceal their identities. All envelopes and questionnaires were
coded with a number used by the researcher to identify the subjects.
This was the only visible means of identifying the subjects without
either looking for their name in the research envelope or cross
referencing their social security number in the computer to
determine their name.
Also, this allowed the student investigator to retrieve other
information, such as age and gender, from the billing computer
software without the possibility of the individual therapist possibly
seeing the subjects' name on the forms. All pretests and posttests
were dated and returned, either by the subject or by the
53
administrative staff at the front desk, to a locked file cabinet
established by the director of the facility. Only the student
investigator had knowledge of which subjects were assigned to
which group, and when the corresponding posttest was to be
administered.
All appointments were monitored by the student investigator
through weekly therapist appointment schedules and by facility-
required billing slips for each visit. The individual therapist for
each subject did not have access to the test information, neither the
pretest nor the posttest, in an attempt to minimize a possible
confound. However, both the clinical director and appropriate
therapist were notified of any client data which were suggestive of
suicidal ideation or potential suicidality.
Research Design
This study employed a variation of a time series design, in
which both groups are pretested at the same time but posttested at
different intervals (Isaac & Michaels, 1981, p. 73). These authors
indicated that this variation of this design does not have a control
group, yet is able to control for contemporary history, maturation,
regression and pretesting. The facility from which the sample
population was drawn does not maintain wait lists as they have
sufficient therapists to have all clients seen within one week of the
initial telephone contact.
Data Analysis
Each of the self-report instruments was analyzed using a
multivariate analysis of variance to determine the effects of time in
treatment and changes in self-report measures of anger and
depression. Research questions numbers one and two were
analyzed w ith a Pearson product-moment correlation coefficient to
assess any correlations. For research questions three through
eight, 2x2x2 ANOVAs were used with repeated measures on the
pre/post factor. For all research questions, an alpha level of .05
w as established for the rejection of the null hypothesis.
Limitations
This study faced the following limitations:
1) Sample size was limited.
2) The response rate obtained by subjects who agreed to
participate in this study was 19%.
3) The internal and external validity was limited to the
reliability of the instruments.
4) Subjects may have answered dishonestly.
5) Subjects received different types of treatment approaches.
6) The individual characteristics of the therapists, such as
therapeautic style and level of directiveness, were not
standardized.
7) Diagnoses of subjects did not affect length of treatment.
8) Sample population contained a disproportionately large
number of female subjects.
55
Delimitations
This study faced the following delimitations which limit the
generalizability of the results:
1) Any changes from pretest to posttest may be the result of
reactive effects of the experimental procedure.
2) Subjects at this clinic may not be representative of all
clients in therapy.
3) Data were reported in raw scores rather than in normed
scores, which affects the generalizability of the results to external
populations.
4. The present study utilized only adult subjects over 18 years
of age.
CHAPTER 4
Results
In this chapter, the results of the statistical analyses are
reported.
Participating Subjects
Dining a 10-month period, 320 subjects were given research
packets containing the two self-report measures as well as the
information/consent form. Of these subjects, 242 did not return
questionnaires or refused to participate in this study. A total of 78
subjects responded by completing die pretest, but 18 were not used
due to attrition or inappropriate age. The remaining 60 subjects
participated in this research by completing both the pretest and the
posttest. This produced a response rate of 19%.
In this sample, 44 or 73.3% of die subjects were female and 16
or 26.7% were male. Ages ranged from 21 to 63. In this sample, the
average number of weeks needed to complete their treatment
sessions was 7.67, SD=3.98.
Table 1 shows the pretest and posttest means and standard
deviations for the BDI and each of the STAXI scales and subscales.
Scores were divided into low and high categories with the
median used as the cutoff point, with that number being included in
the low group. This produced BDI categories of low (0-16) and high
(17-63). It should be noted that the recent BDI manual offers
revised general scoring guidelines for depressed populations: 0-9 =
minimal: 10-16 = mild depression; 17-29 = moderate depression;
and 30-63 = severe depression (Beck & Steer, 1993).
57
Table 1.
BDI and STAXI Pretest and Posttest Means and Standard Deviations
Pretest Pretest Posttest Posttest
Scale_______________Mean_Std.Dev______ Mean Std.Dev
BDI 15.88 10.75 13.42 10.15
STAXI
State-Anger 15.67 7.75 14.95 7.58
STAXI
Trait-Anger 19.88 6.09 18.90 6.02
STAXI Angry-
Temper ament 6.92 2.78 6.63 2.65
STAXI
Angry-Reaction 9.68 3.15 8.90 2.94
STAXI
Anger-in 18.43 4.82 11.73 4.88
STAXI
Anger-Out 15.63 3.94 15.57 3.90
STAXI
Anger-Control 22.22 4.84 22.2 5.64
STAXI
Anger-Expression 27.85 9.23 27.37 8.98
Hypothesis Testing
Research question 1 investigated subjects higher on pretest
trait anger. It was predicted that, regardless of the number of
treatment sessions, these subjects would show higher ratings on
58
pretest anger-in and anger-control scales. Pearsons product-
moment correlation coefficients indicated significant relationships
on ttie pretest regarding subjects high on trait anger. These results
indicated that regardless of the number of treatment sessions,
pretest subjects high on trait anger showed high pretest ratings on
anger-in (r= .4474, p < .0005) and on anger-control (r= -.4533, p <
.0005). Table 2 shows the Pearson product moment correlation
coefficients for these factors. Thus, research question 1 was
supported.
Table 2.
Pearson Product Moment Correlations between Pretest Factors
Pretest
Trait Anger
Pretest
Anger-in .4474 * * *
Pretest
Anger-Control -.4533 * * *
Pretest
BDI .3402 * *
*p < .05. -*p < .01. ***p < .001.
Research question 2 investigated subjects higher on pretest
trait anger. It was predicted that, regardless of the number of
treatment sessions, these subjects would show higher ratings on the
pretest depression scale. Pearsons product-moment correlation
coefficients indicated significant relationships on the pretest
59
regarding subjects high on trait anger. These results indicated that
regardless of the number of treatment sessions, pretest subjects
high on trait anger showed high pretest ratings on depression (r=
.3402, p < .004).
Table 2 shows the Pearson product moment correlation coefficients
for these factors. Thus, research question 2 was supported.
Research question 3 investigated subjects in both treatment
groups higher on pretest trait anger. It was predicted that these
subjects would also show higher ratings on anger-in and anger-
control at the posttest. In terms of the variable anger-in, there was
no support for research question 3, F(l, 56) = .12, p > .05. Table 3
depicts the means and standard deviations for trait-anger and
anger-in for both treatment groups. The F ratios and the levels of
significance for each combination are seen in Table 4.
Table 3.
Means and Standard Deviations for Trait-Anger and Anger-in Scores
Pretest
Trait
Anger
Tx
Group
Pretest
Ax-In
Mean
Std.
Dev
Posttest
Ax-In
Mean
Std.
Dev
low 4session 15.53 5.66 14.88 5.46
high 4session 22.31 3.15 19.77 4.83
low 8session 17.50 3.01 18.19 3.54
high 8session 19.43 4.29 18.79 4.35
*p < .05. **p <, .01. * * * p S .001.
60
Table 4.
Analysis of Variance Jor Pretest Trait Anger
Positest Anger-in
Source SS DF MS F
Within &
Residual
Within-Subjects
281.88 56 5.03
Pretest-Posttest 18.21 1 18.21 3.63
Group by
Pretest-Posttest 19.35 1 19.35 3.84
Trait Anger by
Pretest-Postest 19.24 1 19.24 3.82
Within &
Residual
Positest .Anger-control
Within-Subjects
439.51 56 7.85
Pretest-Posttest .13 1 .13 .02
Group by
Pretest-Posttest .18 1 .18 .02
Trait Anger by
Pretest-Postest 12.69 1 12.69 1.62
Group by
Trait Anger by
Pretest-Posttest 7.75 1 7.75 .99
*p £ .05. **p £ .01. ***p £ .001.
61
For the variable anger-control, no significant sources of
variation were noted and thus, for anger-control, research question
3 was not supported, F(l, 56) = .99, p> .05. Table 5 depicts the
means and standard deviations for trait-anger and anger-control
for both treatment groups. Table 4 shows the F ratio and the levels
of significance for each combination.
Table 5.
Means and Standard Deviations for Trait Anger and Anger-Control Scores
Pretest
Trait
Anger
Tx
Group
Pretest
Ax-Con
Mean
Std.
Dev
Posttest
Ax-Con
Mean
Std.
Dev
low 4session 22.82 5.27 21.65 5.41
high 4session 21.00 4.06 22.15 4.67
low 8session 24.63 3.85 24.63 5.77
high 8session 19.86 4.96 20.14 6.15
*p ; £ .05. **p < .01. ***p < .001.
Research question 4 investigated subjects higher on prettest
trait anger. It was predicted that, in both treatment groups, these
subjects would also show higher ratings on depression at the
posttest. Table 6 shows the means and standard deviations for
trait-anger and BDI scores for both treatment groups.
62
Table 6.
Means and Standard Deviations for Trait Anger and BDI Scores
Pretest
Trait
Anger
Tx
Group
Pretest
BDI
Mean
Std.
Dev
Posttest
BDI
Mean
Std.
Dev
low 4session 10.94 11.21 8.77 9.56
high 4session 20.08 11.90 13.77 11.00
low 8session 15.63 8.74 13.75 8.81
high 8session 18.27 9.75 18.36 9.96
Significant differences were found when only looking at
pretest to posttest score changes, F(l, 56) = 12.16, p < .001, with
mean changes from 15.88 to 13.42. Significant differences were
found when looking at the change from pretest to posttest score by
treatment group, F(l, 56) = 5.13, p < .027, with mean posttest
changes for the four session group from 14.90 to 10.93, and from
16.87 to 15.90 for the eight session group. This research question
was supported, F(l, 56) = 4.24, p < .044, indicating that statistically
significant differences exist in the BDI score from pretest to posttest
for high pretest trait anger subjects. Table 7 shows the F ratio and
the levels of significance for each combination.
63
Table 7.
Analysis of Variance for Pretest Trait Anger by Posttest BDI
Source SS DF MS F
Within &
Residual
W ithin-Subjects
903.96 56 16.14
Pretest-Posttest 196.23 1 196.23 12.16**
Group by
Pretest-Posttest 82.75 1 82.75 5.13*
Trait Anger by
Pretest-Postest 8.85 1 8.85 .55
Group by
Trait Anger by
Pretest-Posttest 68.49 1 68.49 4.24*
*p < .05. **p < .01. ***p < .001.
Post hoc tests for main effects determined significant
differences, F(l, 56) = 16.02, p < .0005, for the four session
treatment group members that were high in pretest trait anger. In
this group, the mean BDI scores decreased from 20.08 on the pretest
to 13.77 on the posttest. Table 8 shows the F ratio and the levels of
significance for each combination in the post hoc analysis.
Table 8.
Post Hoc Test of Main Effects
64
Source SS DF MS F
Within-Subjects
Group 1 by
Traitgrp 1 40.26 1 40.26 2.49
Group 1 by
Traitgrp 2 258.62 1 258.62 16.02***
Group 2 by
Traitgrp 1 28.13 1 28.13 1.74
Group 2 by
Traitgrp 2 .04 1 .04 .00
Note. Group 1 = 4 session treatment group
Group 2 = 8 session treatment group
Traitgrp 1 = low trait anger
Traitgrp 2 = high trait anger
*p < .05. **p £ .01. * * * p < .001.
Research question 5 investigated subjects in both treatment
groups who were higher on pretest depression and predicted that
these subjects would show lower ratings on the anger-out posttest.
For these factors, Table 9 represents the F level and levels of
significance, and Table 10 represents the means and standard
deviations. No statistical differences were found, F(l, 56) = .00,
p= .988, and this research question was not supported.
Table 9.
Analysis of Variance, for Eretesl BDIJbyJosttestAnger-Out
Source SS DF MS F
Within-Subjects
Within &
Residual 359.36 56 6.42
Pretest-Posttest .44 1 .44 .07
Group by
Pretest-Posttest .00 1 .00 .00
BDIby
Pretest-Postest 19.37 1 19.37 3.02
Group by BDI by
Pretest-Posttest .00 1 .00 .00
*p < .05. **p < .01. ***p < .001.
Table 10.
Means and Standard Deviations for BDI Scores and Anger-
Pretest Posttest
Pretest Tx Ax-Out Std. Ax-Out Std.
BDI Group Mean Dev Mean Dev
low 4session 14.35 3.59 15.06 2.93
high 4session 17.23 4.80 16.30 2.93
low 8session 15.07 3.41 15.73 4.45
high 8session 16.27 3.77 15.33 5.12
66
Research question 6 predicted that the subjects higher on
pretest state anger would show lower posttest levels of depression
and higher posttest levels of anger expression if they were in the
eight session treatment group. Statistically significant interactions
were found, but for the four session groups and not for the eight
session group as predicted. There was a significant interaction
between group membership, high state anger pretest scores and
lower levels of depression on the posttest, F(l, 56) = 8.67, p < .005.
Table 11 shows the F ratios, and levels of significance for these
factors. Thus, for the variable depression, research question 6 was
supported.
Significant differences were found when only looking at
pretest to posttest score changes, F(l, 56) = 14.29, p < .0005, with
mean changes from 15.88 to 13.42. Significant differences were
found when looking at the change from pretest to posttest score by
treatment group membership, F(l, 56) = 5.92, p < .018, with mean
posttest changes for the four session group from 14.90 to 10.93, and
from 16.87 to 15.90 for the eight session group.
Post hoc tests for inain effects determined significant
differences, F(l, 56) = 18.98, p < .0005, found on the postest BDI
scores for the four session treatment group members that were high
in pretest state anger. Table 12 shows the F ratios and the levels of
significance for each combination in the post hoc analysis. Their
mean BDI scores dropped from 23.75 at the pretest by
approximately 6.5 points to 16.83 at the posttest.
67
Table 11.
Analysis o f Variance for Pretest State Anger
PDSttfiStBDI
Source SS DF MS F
Within-Subjects
Within &
Residual 847.13 56 15.13
Pretest-Posttest 216.22 1 216.22 14.29***
Group by
Pretest-Posttest 89.57 1 89.57 5.92*
State Anger
by Pretest-Postest 3.51 1 3.51 .23
Group by
State Anger by
Pretest-Posttest 131.15 1 131.15 8.67**
Anger-Expression
Within-Subjects
Within &
Residual 1291.54 56 23.06
Pretest-Posttest 17.15 1 17.15 .74
Group by
Pretest-Posttest 35.38 1 35.38 1.53
Staitgrp by
Pretest-Postest 18.94 1 18.94 .82
Group by Staitgrp
by Pretest-Posttest 117.88 1 117.88 5.11*
*p £ .05. **p £ .01. ***p <, .001.
Table 12.
Post Hoc Test of Main Effects
Pretest State Aneer bv Posttest BDI
Source SS DF MS F
Within-Subjects
Within & Residual 847.13 56 15.13
Group 1 by Staitgrp 1
by Pretest-Posttest 36.00 1 36.00 2.38
Group 1 by Staitgrp 2
by Pretest-Posttest 287.04 1 287.04 18.98***
Group 2 by Staitgrp 1
by Pretest-Posttest 56.03 1 56.03 3.70
Group 2 by Staitgrp 2
by Pretest-Posttest 4.80 1 4.80 .32
Pretest State Aneer bv Posttest Aneer-Exoression
Within-Subjects
Within & Residual 1291.54 56 23.06
Group 1 by Staitgrp 1
by Pretest-Posttest 8.03 1 8.03 .35
Group 1 by Staitgrp 2
by Pretest-Posttest 130.67 1 130.67 5.67*
Group 2 by Staitgrp 1
by Pretest-Posttest 5.63 1 5.63 .24
Group 2 by Staitgrp 2
by Pretest-Posttest 17.63 1 17.63 .76
Note. Group 1 = 4 session treatment group
Group 2 = 8 session treatment group
Staitgrp 1 = low state anger
Staitgrp 2 = high state anger
*p £ .05. **p £ .01. ***p < .001.
Table 13.
Means and Standard Deviations for State Anger and BDI Scores
69
Pretest
State
Anger
Tx
Group
Pretest
BDI
Mean
Std.
Dev
Posttest
BDI
Mean
Std.
Dev
low 4session 9.00 9.94 7.00 8.51
high 4session 23.75 9.90 16.83 10.32
low 8session 13.27 5.39 10.53 6.90
high 8session 20.47 10.82 21.27 8.80
Table 13 shows the mean and standard deviations for these factors.
Significant differences were noted for the variable posttest
anger-expression. There was a significant interaction between
group membership, high state anger pretest scores and higher
levels of anger expression on the posttest, F(l, 56) =5.11, p<.028.
Table 11 shows the F levels and levels of significance for these
factors. However, this proved to be statistically significant not for
the eight session group, as predicted, but for the four session group.
Post hoc tests for main effects were consistant with previous
results and determined significant differences, F(l, 56) =5.67, p<
.021, found for posttest anger expression for the four-session
treatment group members that were high in pretest state anger.
Table 12 shows the F ratio and the levels of significance for each
combination in the post hoc analysis.
70
Their mean anger expression scores decreased from 33.25 at the
pretest by approximately 4.5 points to 28.58 at the posttest. Table
14 shows the means and standard deviations for these factors.
Table 14.
Means and Standard Deviations for State Anger and Anger Expression
Pretest
State
Anger
Tx
Group
Pretest
BDI
Mean
Std.
Dev
Posttest
BDI
Mean
Std.
Dev
low 4session 24.56 9.77 25.50 9.10
high 4session 33.25 8.18 28.58 8.97
low 8session 28.07 7.08 27.20 9.22
high 8session 27.27 10.05 28.80 9.10
Research question 7 predicted that subjects higher on pretest
state anger would show higher posttest anger-control, with the
eight session treatment group scoring higher than the four session
group. No significant differences or interactive effects existed
between the four and eight session groups for subjects higher on
pretest state anger and posttest anger control, F(l, 56) = .01, p=
.923. Table 15 shows the F levels and levels of significance for these
factors. Table 16 shows the mean and standard deviations for these
factors. Thus, this research question was not supported.
71
Table 15.
Analysis o f Variance for Pretest State Anger by Posttest Anger-Control
Source SS DF MS F
Within-Subjects
Within &
Residual 441.75 56 7.89
Pretest-Posttest .13 1 .13 .02
Group by
Pretest-Posttest .13 1 .13 .02
State Anger
by Pretest-Postest 18.03 1 18.03 2.29
Group by Staitgrp
by Pretest-Posttest .07 1 .07 .01
*p < .05. **p £ .01. ***p < .001.
Table 16.
Means and Standard Deviations for State Anger and Anger-
Pretest
State
Anger
Tx
Group
Pretest
BDI
Mean
Std.
Dev
Posttest
BDI
Mean
Std.
Dev
low 4session 22.28 5.38 21.44 5.32
high 4session 21.66 3.96 22.50 4.70
low 8session 22.33 5.08 21.73 7.03
high 8session 22.47 5.00 23.33 5.55
72
Research question 8 predicted that subjects lower on pretest
depression would show higher posttest anger expression scores,
with the eight session treatment group showing higher scores than
the four session group. This research question was not supported.
However, a statistically significant difference was found, F(l, 56)
= 4.89, p < .031, for the depression scores by pretest- posttest
scores. Table 17 shows the F levels and levels of significance for
these factors. The mean four session group BDI scores increased
from 24.81 at the pretest to 26.09 at the posttest, while the mean
scores for the eight session group decreased from 31.32 at the
pretest to 28.82 at the posttest. Table 18 shows the mean and
standard deviations for these factors.
Table 17.
Analysis of Variance for Pretest BDI by Posttest Anger-Expression
Source SS DF MS F
Within-Subjects
Within &
Residual 1305.76 56 23.32
Pretest-Posttest 12.43 1 12.43 .53
Group by
Pretest-Posttest 28.55 1 28.55 1.22
BDIgrp
by Pretest-Postest 114.03 1 114.03 4.89*
Group by BDIgrp
by Pretest-Posttest 7.19 1 7.19 .31
*p < .05. **p < .01,, ***p £ .001.
73
Table 18.
Means and Standard Deviations for BDI Scores and Anger Expression
Pretest
State
Anger
Tx
Group
Pretest
BDI
Mean
Std.
Dev
Posttest
BDI
Mean
Std.
Dev
low 4session 24.24 9.93 25.06 9.05
high 4session 33.00 7.96 28.92 8.56
low 8session 25.47 6.20 27.27 8.61
high 8session 29.87 10.13 28.73 9.70
CHAPTER 5
Discussion
In this chapter, the implications of the statistical analyses in
relation to the research questions are discussed.
General Findings
The results found in this research were generally consistant
with the prior research concerning the correlation between anger
and depression, with increased support for different levels and
types of anger. Also, the results found in this research are
consistant with previous research which documents the
effectiveness of brief therapy and change within the early stages of
therapy.
From the data, it seems clear that a consistent pattern
emerged in relation to the members of the four-session treatment
group. Their posttest scores generally had more significant
changes than did the posttest scores of the eight session treatment
group. This would support the research that the initial
effectiveness of psychotherapy is more apparent in the beginning
stages than in the later stages (Budman et al., 1988; Howard et al.,
1986; Smith et al., 1980.) It would seem that after there has been
some cursory symptom relief from entering treatment, that the
more substantive changes needed to also produce statistically
significant changes may not appear until after the eight session
limit this study employed.
Also found were several correlations involving high levels of
trait-anger. This variable was found to be positively correlated
75
with the variables anger-in and depression, and negatively
correlated with the variable anger-control. As seen in prior
research by Biaggio and Godwin (1987), Finman and Berkowitz
(1989), Kellner et al. (1992), and Riley et al. (1989), this suggests that
people who typically have higher levels of anger tend to suppress
their anger and tend to also be more depressed.
The findings in the present study that significant differences
exist in relation to levels of anger is impressive considering that the
treatment goals for the subjects was not specified to involve the
reduction of anger. Stiles, Shapiro & Elliot (1986) report that
larger effect sizes are obtained when the outcome measures are
matched to the treatment goals. The subjects in the present study,
as well as their therapists, were made aware that the presence of
anger and/or depression was not a prerequisite to participate and
would not necessarily be a specific treatment focus. The results
obtained in the present study reinforce the validity of the measures
used to discern the awareness and expression of anger as well as
depressive symptoms in a high functioning outpatient population.
Specific Findings
Research question 1 investigated subjects higher on pretest
trait anger, and was supported. It was predicted that, regardless of
the number of treatment sessions, these subjects would show higher
ratings on pretest anger-in and anger-control scales.
76
The results indicated that regardless of the number of treatment
sessions, pretest subjects high on trait-anger showed high pretest
ratings on anger-in (r= .4474, p < .0005) and on anger-control (r=
-.4533, p < .0005).
The correlation with the variable anger-in is consistant with
results obtained by Biaggio and Godwin (1987), Finman and
Berkowitz (1989), and Riley et al. (1989), and reinforces the link
between persons with characteristic anger (trait anger) and the
suppression of anger. The negative correlation for anger-control
was an unexpected result. The STAXI manual (Spielberger, 1991)
offers an interpretation of this correlation as possibly indicating an
over-control of anger and indicative of passivity. In light of the
large number of female subjects in the present study, this
correlation may be an example of the stereotyped sex-based
tendencies to repress anger as noted by Fischer, Smith, Leonard,
Fuqua, Campbell, and Masters (1993). It should be noted that their
results did not indicate a significant difference between men and
women on this variable.
Research question 2 investigated subjects higher on pretest
trait anger, and was supported. It was predicted that, regardless of
the number of treatment sessions, these subjects would show higher
ratings on the pretest depression scale. The results indicated that
regardless of the number of treatment sessions, pretest subjects
high on trait anger showed high pretest ratings on depression (r=
.3402, p < .004).
77
These results are consistant with prior research (Biaggio &
Godwin, 1987; Finman & Berkowitz, 1989; Moreno, Fuhriman, &
Selby, 1993; Riley et al., 1989; Thomas & Atakan, 1993).
Research question 3 investigated subjects in both treatment
groups higher on pretest trait anger. It was predicted that these
subjects would also show higher ratings on anger-in and anger-
control at the posttest. No significant sources of variation were
noted for the variable anger-in, F(l, 56) = .12, p> .05, or for the
variable anger-control, F(l, 56) = .99, p> .05. Previous research
(Biaggio & Godwin, 1987; Finman & Berkowitz, 1989; Riley et al.,
1989) demonstrated significant differences for the variable anger-
in, and with a larger sample the present study may have also
produced significant results.
Research question 4 investigated subjects higher on prettest
trait anger, and was supported. It was predicted that, in both
treatment groups, these subjects would also show higher ratings on
depression at the posttest. These results are consistant with prior
research (Biaggio & Godwin, 1987; Finman & Berkowitz, 1989;
Moreno et al., 1993; Riley et al., 1989; Thomas & Atakan, 1993).
Significant differences were found when only looking at
pretest to posttest score changes, F(l, 56) = 12.16, p < .001, with
mean changes from 15.88 to 13.42. Significant differences were
found when looking at the change from pretest to posttest score by
treatment group, F(l, 56) = 5.13, p < .027, with mean posttest
changes for the four session group from 14.90 to 10.93, and from
16.87 to 15.90 for the eight session group.
78
This research question was supported, F(l, 56) =4.24, p $
.044, indicating that statistically significant differences exist in the
BDI score from pretest to posttest for high pretest trait anger
subjects.
Post hoc tests for main effects determined significant
differences, F(l, 56) = 16.02, p < .0005, for the four session
treatment group members that were high in pretest trait anger. In
this group, the mean BDI scores decreased from 20.08 on the pretest
to 13.77 on the posttest. This can be interpreted as further evidence
that changes in psychotherapy are more evident in the beginning
stages than in the later stages (Budman & Gurman, 1988; Howard
et al., 1986; Smith et al., 1980.)
Research question 5 investigated subjects in both treatment
groups who were higher on pretest depression and predicted that
these subjects would show lower ratings on the anger-out posttest.
No statistical differences were observed, F(l, 56) = .00, p= .988,
and this research question was not supported. This is consistant
with the results obtained by Riley et al. (1989), who also were
unable to show significant differences on the variable anger-out for
subjects who were depressed.
Research question 6 predicted that the subjects higher on
pretest state anger would show lower posttest levels of depression
and higher posttest levels of anger expression if they were in the
eight session treatment group. Statistically significant interactions
were found, but for the four-session group and not for the eight-
session group as predicted and this research question was not
79
supported. There was a significant interaction between group
membership, high state anger pretest scores and lower levels of
depression on the posttest, F(l, 56) =8.67, p<.005.
Significant differences were found when only looking at
pretest to posttest score changes, F(l, 56) = 14.29, p < .0005, with
mean changes from 15.88 to 13.42. Significant differences were
found when looking at the change from pretest to posttest score by
treatment group membership, F(l, 56) = 5.92, p < .018, with mean
posttest changes for the four session group from 14.90 to 10.93, and
from 16.87 to 15.90 for the eight session group.
Post hoc tests for main effects indicated significant
differences, F(l, 56) = 18.98, p < .0005, on the postest BDI scores
for the four session treatment group members that were high in
pretest state anger. Their mean BDI scores dropped from 23.75 at
the pretest to 16.83 at the posttest. Again, this can be interpreted as
further evidence that changes in psychotherapy are more evident in
the beginning stages than in the later stages (Budman & Gurman,
1988; Howard et al., 1986; Smith et al., 1980).
Significant differences were noted for the variable posttest
anger-expression. There was a significant interaction between
group membership, high state anger pretest scores and higher
levels of anger expression on the posttest, F(l, 56) = 5.11, p < .028.
However, this proved to be statistically significant not for the eight
session group, as predicted, but for the four session group.
Post hoc tests for main effects were consistant with previous
results and determined significant differences, F(l, 56) =5.67, p <
.021, found for posttest anger expression for the four-session
treatment group members that were high in pretest state anger.
Their mean anger expression scores decreased from 33.25 at the
pretest by approximately 4.5 points to 28.58 at the posttest. This,
too, can be interpreted as contributing to the research that suggests
that changes in psychotherapy are more apparent in the beginning
stages than in the later stages (Budman & Gurman, 1988; Howard
et al., 1986; Smith et al., 1980.)
Research question 7 predicted that subjects higher on pretest
state-anger would show higher posttest anger-control, with the
eight session treatment group scoring higher than the four session
group. Thus, this research question was not supported, F(l, 56) =
.01, p = .923. The results for the variable anger-control are
consistant with Fischer et al., (1993), who were unable to find a
significant difference between men and women on this variable.
Research question 8 predicted that subjects lower on pretest
depression would show higher posttest anger expression scores,
with the eight session treatment group showing higher scores than
the four session group. Although this research question was not
supported, a significant difference was found, F(l, 56) =4.89, p<
.031, for the depression groups by pretest-posttest scores. The
mean four session group BDI scores increased from 24.81 at the
pretest to 26.09 at the posttest, while die mean scores for the eight
session group decreased from 31.21 at the pretest to 28.82 at the
81
posttest. As in the research by Riley et al. (1989), the present study
could not find a relationship between depression and anger-
expression. This is suggestive of the idea that the suppression of
anger is related to depressive symptomology, but not the
expression of anger.
Methodological Concerns
Additional statistically significant results may not have been
found due to several potential confounds. This study utilized a
small sample size in relation to many other research studies. Of the
320 subjects given research packets during a 10-month period, 242
did not return questionnaires, refused to participate in this study, or
did not return for treatment after the intake session. A total of 78
subjects responded by completing the pretest, but 18 were not used
due to inappropriate age or attrition prior to either four or eight
sessions. The remaining 60 subjects participated in this research by
completing both the pretest and the posttest, which produced a
response rate of 19% and may reflect.
The low response rate of 19% may indicate that the present
study may be better used as indicating a direction for future
research. It is probable that the sheer lack of size in this study
hindered more significant results from being obtained. It is possible
that the subjects who responded by completing both the pretest and
posttest may differ from the subjects who did not complete both
tests. An example of this would be that the subjects who did not
complete the pretest and posttest may, in fact, be too angry or too
depressed to respond. Therefore, an increased sample size (or,
82
more importantly, an increased response rate) might more
accurately reflect the population at large.
A potential flaw exists in the lack of standardization of
treatment technique. Therapists in both groups treated each subject
without any methodological attempts to equalize their techniques.
Without this control, it is difficult to determine specifically what
accounted for the changes that were observed. It is not known if
the therapists in one group used techniques or had a therapeutic
style that was more conducive to treatment change. This is
especially important considering the work of Luborsky, Crits-
Christoph, McLellan, Woody, Piper, Liberman, Imber, and Pilkonis
(1986) and Lambert (1989). Both indicated that the rate of treatment
success and and variations of this rate had more to do with the
therapist than the type of treatment.
This study utilized subjects from a limited geographic area.
This sample pool may not have been sufficiently diverse to allow for
changes to be observed. Most subjects were generally from the
local area surrounding the clinic used for data collection, which
means they may not be reflective of other people in treatment at
other clinics or settings in other locations.
Another potential flaw with the sample was the bias in favor
of females. Nearly three-quarters of the sample were female. It is
not known if this affected the validity of the results. It is also not
known how a more equal gender sample, or even a complete one
gender sample, would have affected the results.
83
Recommendations for Future Research
The significant results produced in this study are suggestive of
the impact the early stages of therapy can have to reduce symptoms
of depression and anger. Despite obtaining varied statistically
significant results in this study with a small sample (n=60), a larger
sample population is recommended for future research. Increasing
the sample size may yield additional results not obtained in this
study due to the low response rate of 19% that was obtained.
From a clinical perspective, the reduction of initial
symptomology and the continued cessation or the return of
symptoms over an extended period of time is an important
direction for future research, as this study did not address it. It may
be necessary to increase the treatment window from the area
between four and eight sessions as used in this study.
Extending the length of time in treatment to a much larger
duration may yield more substantive changes between comparison
groups. Prior research suggests that approximately 75% of patients
in therapy show improvement by the end of 26 sessions (Howard et
al., 1986). Therefore, a suggested increase would be to 26 sessions,
roughly equal to six months, rather than the eight sessions (or two
months) used in this study. Thus, future research consideration
should include a series of follow-up studies along with longer
treatment periods to evaluate these aspects.
The present study did not attempt to monitor subjects that
dropped out of treatment. It is possible that these may return to
treatment at a later date, or even left treatment at Glendale Family
84
Service to begin treatment elsewhere. This suggests that some of
the subjects may be engaging in intermittant treatment, as their
needs for treatment arise. The area of intermittant treatment and
evaluating it's efficacy would be a direction for future research.
The present study made no attempt to treat subjects with the
same or similar type of treatment techniques. Each therapist was
solely responsible for the deliverance of the treatment and not
subject to any comparison by the researcher. A standardized or
consistent approach to treatment would allow for better
differentiation between techniques as well as possibly identifying
more productive techniques.
This study utilized subjects from only one source. It would
also be beneficial to examine the effectiveness of brief therapy and
change within the early stages of therapy for anger and depression
in different populations, such as correctional, inpatient and
additional private practice settings.
Since the sample in this study was heavily biased towards
women, consideration should be given to the Fischer et al. (1993)
suggestion that the nature of depression may be different for men
and women. It would be recommended that continued research,
with a more equal gender sample, be conducted to produce
additional findings. Future research is suggested in the area of
single gender studies, both male and female, to evaluate the
consistency of results with those obtained in the present study.
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