No mater what skills training that you undertake with individuals, groups, whether this is a residential program, individual, couples, you can not just train and hope. There is a whole set of guidelines that you need to follow in order to get generalization transfer, maintenance of this. And if those who are doing those interventions, whether it is in prisons, residential programs in schools, what have you, if they do not build into their treatment program these guidelines, it is unlikely to be effective. Let me give you one quick example: adolescents who are angry and aggressive rarely engage in anti-social behavior on their own. If you’re going to work with these children, these young people, whether they’re in gangs or not, if you do not change their peer affiliation, if you cannot find them a guardian angel, if you can not find them an area of competence that they can connect to, so that you can increase the likelihood of them finishing high school and the like, no matter how good you are in teaching skills…it is unlikely to be successful.

So when I talk about building in generalization guidelines, it talks about the social context by which aggressive behavior is employed.

Our goal is to help clients become collaborators. How do you develop a therapeutic alliance with people who’ve done, sometimes, rather nasty things? And how do you use the ‘glue,’ — that relationship — as the basis for getting them to be a partner in treatment?
So for instance in a handbook on treatment of individuals with anger control, that I have written, for instance, there is in the back of this an appendix on how to take an angry adolescent or adult and turn them into a social problem solver. So this is the kind of social discourse that can be used. We also try and teach them a variety of ways of breaking this kind of vicious cycle that they get into. Sometimes it is helping them re-appraise these kinds of triggers. Sometimes it’s dealing with the emotional dis-regulation in learning various skills like relaxation, how to take time out, how to use acceptance strategies. Sometimes it’s looking at the kinds of thinking processes that we know that you’re all too familiar with that contribute and escalate the nature of the anger and the aggression.So there are a number of rethinking… cognitive restructuring procedures, problem solving, and then at the behavioral level, we try to teach people how to engage in conflict resolution, communication skills, problem solving and the like. The thing that’s most encouraging is that while the data is preliminary, if you look at the outcome studies, and they’re still limited, you know, there aren’t that many truly good randomized studies with clinical populations, but of the studies that exist, this particular form of cognitive-behavioral intervention has the most promise. It can be done at an individual level, it can be done on a group basis, and it can also be done on couples and families. And in the handbook I review and summarize the state of the art.

There’s a high recidivism rate. It becomes a revolving door, so I recently put together what are guidelines on what prisons need to do. Before you release people what are the skills that they need to demonstrate, so you just don’t thrown them out. What are the transitional supports? What’s their job? So if we just put people back on the streets, given that they’ve spent hard time, then the key question of them turning around is highly likely. So in fact we’ve developed patient checklists that people can now fill out and share with you the therapist of what it is they’ve learned, what are the take home lessons, and not only that, what are the reasons why they should do it? Because it turns out that generating and getting people to self-generate the reasons is really a key element to getting them to employ it. So there are a lot of ways to improve that recidivism cycle data.
Dr. Firestone: The treatment works. I mean treatment is a much better option than just putting people back out on the streets.I think a punitive model has been found to be unproductive, cost-inefficient, and ineffective. Now people figure, you know, let’s take Florida, Florida where the Melissa Institute is, has one of the highest incidences of juveniles in adult prisons in the country. We know that putting juveniles in adult prisons is going to make things worse. Young children are now given more life prison sentences, right, because the Supreme Court just got rid of the death penalty, so one of the things that becomes really interesting is you’ll take a 13-year-old who did this and put him away fro the rest of your life? Or 3 strikes and you’re out, is that a good policy? It’s very expensive. So one of the things is that there are alternatives that are more evidence-based that should guide and influence our treatment decision making.

Stress inoculation and its variations has emerged as one of the key treatment modalities for people who have anger and aggressive problems. It’s now been employed with combat vets, with prisoners, with adolescent offenders, and there are a number of analog studies with college students, it’s been applied to people who have rage, driving rage and so on, and this is California, come on, where else is this kind of treatment needed?

The stress inoculation has three components: The first component is to develop a therapeutic alliance and conduct psycho-education. It is to design, to develop a supportive relationship where you can do collaborative goal setting, where you can educate people about the triggers, the emotions, the cognitions, the thinking processes, the behaviors and how they get caught up in that. It isn’t like you do education and then you do treatment, these are highly intertwined. Not only that, the treatment tries to include both assessment and treatment together. So it’s not like you do assessment and then you do treatment. You’re going to have collaborative goals that you’re’ going to assess on a regular basis. So the first part of this stress inoculation training has to do with the education of the client and significant others. The second is the skills application. And sometimes people bring in skills, so you’re going to collaborate with them to learn a variety of skills to break this vicious cycle of how to appraise events, how to conduct some control, to develop control on emotional self-regulation, whether these are relaxation to dampen the arousal, whether it has to do with acceptance kinds of strategies, whether it’s cognitive restructuring. So we’re going to teach skills that focus in on emotionality, that focus in on cognition, and that focus in on behavioral elements.

The third phase, which is really critical, is application training. You want to make the training as similar to the real life situation as possible. So one of the things that becomes real interesting is that we can have rehearsal within the session, we can use imagery rehearsal, we can have graded in-vivo exposure, we can get you to perform personal experiments. In fact, if you stay with the concept of inoculation, like a medical inoculation, you can actually see the degree to which an individual can be exposed to lower doses of provocations and learn coping skills. This could be done both on a treatment basis and on a preventive basis. So if you go the Melissa Institute Website, you can read about how stress inoculation training has been used in the Israeli defense forces, with soldiers, with policemen.
So think about people who have to deal with this on a day-to-day basis. And what is it that you would like those individuals to do, both on an individual and group level, in order to notice, to catch, to interrupt that behavioral cycle.

Consider how do you make a suicide bomber. What do you think the steps are involved that leads them to justify that kind of behavior and it turns out that this same analysis could be applied to nation-to-nation conflicts. So if people are interested, they could go to the Website and read the papers I’ve written about that as well.

Dr. Firestone: And we’re doing this with our military before they go?

That’s exactly the project I’m working on. We’ve now developed an i-pod technology that you can go to called warfightersdiary.com on which you can download coping model films and you can access them when you’re in these high-risk situations and not only that, you are able to submit your own videos and become part of a social network. So we’re now using social media as a supplemental treatment augmentation. The way in which we do treatment is going to substantially change. We’re going to be able to use new technologies and that’s cutting edge.

Why is it so difficult to change human behavior? Part of it is that people are producing data that confirms their beliefs of themselves and of the world. How do you make people aware that they’re not just mere victims in how they perceive the world and the nature of their beliefs? Not only that, a number of these individuals have core concerns, schemas, if you call it. Of issues of personal control, of fairness and equity. This is the ”I am the king of the Castle,” so I’ve made a number of videotape films that are available that you can actually see people go through this process.

You have films like that, and the key question is how do you get them to attend to that inner voice, how do you get them to change it, but not only that, but how do you get them to learn coping skills and then use those coping skills when you’re no longer around?
So I think that the cognitive-behavioral stress inoculation training, and there are a number of people Ray Novaco, Jeff Deckenbacher, Ray Deinuscheppi, Detaf Raddi, there are a number of people who have now extended this model and the cautionary note is that if you look at outcomes of cognitive-behavioral interventions with anxiety disorders, with mood disorders, with anger, it is effective, but it has not as yet proven as effective as these other interventions. So I think we have a long way to go but we’re off to a good start. And I can think of no more important challenge for the health care professionals and for society in general.

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Order the Full DVD Interview:

A Cognitive-Behavioral Approach on Aggression

In this DVD, Dr. Donald Meichenbaum discusses violence and aggression, from origin to treatment. Dr. Meichenbaum draws upon his wealth of experience to articulate both how violent individuals are created and the thoughts that drive violent behavior. Dr. Meichenbaum advocates effective interventions with violence and explains the importance of Stress-Inoculation Training, which he describes as the “best evidence based intervention in working with angry and aggressive individuals.” He also defines key gender differences in aggression. “So our mission,” says Dr. Meichenbaum, “is not only to develop effective treatment programs for people who are angry and aggressive, the question is are we committed as a society to do that which we know to prevent violence in the first place? I think this film will go a long way in educating people to make that kind of passionate commitment.”

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Read More from Dr. Donald Meichenbaum

Donald Meichenbaum, Ph.D. is a founder of Cognitive Behavioral Modification and has been voted one of the 10 most influential psychotherapists of the Century by North American clinicians in a survey reported in the American Psychologist. Dr. Meichenbaum is Distinguished Professor Emeritus at the University of Waterloo, Ontario, Canada, and maintains a private practice as a clinical psychologist.

Tags: coping skills, inner voice, stress management, treatment, videos