Normal Grief Counseling

2004 Report on Bereavement & Grief Research

Twenty-three of the top researchers in the field concluded: “For participants experiencing uncomplicated bereavement [normal grief], there was essentially no measurable positive effect on any variable and nearly one in two clients suffered as a result of treatment.”

“Professional psychological intervention is generally neither justified nor effective for uncomplicated forms of grief.”

“Parkes, the leading expert on bereavement, stated, there is “no evidence that all bereaved people will benefit from counseling and research has shown no benefits to arise from the routine referral to counseling for no other reason than that they have suffered a bereavement.” (Stroebe, M., Schut H. & Stroebe, W., Health Outcomes of Bereavement, Lancet, 2007, p. 1969).

Researchers vehemently challenged the above findings, but in 2009 another meta-analysis was published on 75 outcome studies of grief therapies, spanning three decades of research and making it “the most comprehensive summary of the literature available.” What the researchers found was, “Consistent with the majority of smaller-scale reviews, our tests of overall effectiveness failed to yield an overly encouraging picture of grief therapies” and that “interventions failed to produce better outcomes than would be expected by the passage of time” (Current Directions in Psychological Science, Vol. 18, No. 6, Dec. 2009, pp. 352-365).

Complicated Grief Therapy-2005

A “break-through” treatment approach was reported by researchers in 2005. The technique involves 16-20 weeks of therapy (six of the 36 had treatments that lasted for more than 20 weeks) including repeated discussion of painful memories. Over twenty-five percent of the participants dropped out (13 out of 49). Fifty-one percent of the remaining 75% were rated as “much improved” or “very much improved,” but this amounted to only 37% since 25% dropped out. Forty-five percent were taking psychotropic medications. Five of the completers refused to participate in retelling the story of the death and having an imaginary conversation with the deceased person because they considered this too difficult.

Other Comments by Researchers

Psychologist Scott Lilienfeld of Emory University wrote an article entitled, “Psychological Treatments That Cause Harm,” (2007, Perspectives on Psychological Science, Vol 2, No. 1) in which he classified Grief Counseling for Normal Bereavement as a “Potentially harmful treatment” (PHT).

The Association for Death Educations and Counseling (ADEC) held its 30th Annual Conference in Montreal, Canada in 2008. Their conclusion was, “Psychotherapy is an effective way to help most people who are experiencing distress…For the subset of psychotherapy known as grief or bereavement counseling, however, the effectiveness of therapy is not as well established.”

Faith-based Grief Therapy

For the past fifteen years I have been using a simple prayer-based approach to grief counseling with both normal grief and with complicated grief cases. I have used this approach with hundreds of individuals and found that most individuals are able to find complete resolution of their grief in a single session. A few individuals have required several sessions in order to release all of the emotions connected to their grief.

This approach is offered only to those who express an interest in trying this approach and who are willing to sign an informed consent form. I make it policy to not offer this approach in the first therapy session, but only when patients return for a second session and specifically state their interest in trying a faith-based approach. Those who do not want faith-based therapy are provided standard cognitive therapy and are encouraged to talk about their feelings in an effort to decrease the intensity of their pain.

The Effectiveness of Current Treatments

By Jim Gardner, Ph.D.

Introduction

Posttraumatic Stress Disorder (PTSD) is defined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV-TR) as a mental disorder that occurs when, “The person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and (2) the person’s response involved intense fear, helplessness, or horror.” Several other symptoms are required before one can be diagnosed with PTSD but there are a wide range of events that can lead to this diagnosis including sexual abuse, physical abuse, witnessing violent actions, military combat, rape, and natural disasters such as earthquakes, tsunamis, tornadoes, hurricanes, and flooding.

Posttraumatic Stress Disorder was first recognized as a diagnostic category in 1980 with the development of the DSM III, largely as a result of the number of Vietnam Veterans who were found to have combat-related trauma. It is estimated that 3.1 million personnel served in Southeast Asia during the Vietnam War and that 15% to 30% experienced war-related PTSD in their lifetime (Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordan, B.K., Marmar, C.R., et al. (1990), Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.). For 20 years the Department of Veterans Affairs provided specialized programs for the treatment of PTSD for war veterans but after conducting studies of the efficacy of such treatments they began to withdraw their support for specialized PTSD programs around 2000 due to the cost of these treatments and their perceived lack of efficacy.

In 2010 I attended a workshop on PTSD and Grief that was conducted by a Board Certified Expert in Traumatic Stress who was described as a “national and internationally known author and speaker.” I was particularly interested in this seminar to hear what this expert would say about grief since I was very familiar with the research on this topic and knew that the leading experts agreed that therapy for normal grief was not effective. I spoke with this “expert” personally, who seemed to be a very nice person with Christian values, and found that she was unfamiliar with this research. She expressed her belief to me that grief therapy is effective, even though the research does not support this position.

When this “expert” spoke about treatments for PTSD she made the statement, “SSRIs are very effective in treating PTSD and can heal PTSD.” That statement was so inaccurate that it shocked me into interrupting her by saying, “Excuse me.” She paused and acknowledged me and I tried to carefully select my words so as not to sound offensive. “That statement that SSRIs can heal PTSD sounds a little strong to me. I have worked with many people with PTSD who are on SSRIs and I have never seen any of them “healed” of PTSD. Do you mean by using the term “heal” that they showed some improvement?” I asked. After a few moments to she reconsidered her statement and said, “Yes. That would be a better way of stating it. I should have said that SSRIs can help people with their PTSD symptoms. Thank you.”

The National Academy of Science Opinion

The Department of Veterans Affairs commissioned a committee through the National Academy of Sciences to study the research on the treatment of PTSD and assess the efficacy of current treatment approaches. Their lengthy written opinion was documented in April 2008 in the document, “Treatment of Posttraumatic Stress Disorder” and they summarized their findings before the U.S. House of Representatives on April 1, 2008. With regard to the efficacy of SSRIs one of the committee members stated, “The committee found the evidence for SSRIs inadequate to conclude efficacy.” This means that although there are many researchers who have concluded that some particular form of therapy is effective in treating PTSD, the examination of the major research projects conducted on PTSD over the last 40 years by this unbiased group of scientists led them to conclude that there is weak and “inadequate” evidence for the effectiveness of SSRIs in treating PTSD.

The same committee gave their opinion about the efficacy of psychotherapy treatments for PTSD. “The evidence for all but one of the remaining psychotherapy categories (including the broad “group therapy” category) was inadequate to conclude efficacy. The committee judged the evidence for exposure therapy sufficient to conclude efficacy."  In exposure therapy a patient is asked to vividly recall a traumatic event repeatedly until their emotional reaction decreases and they are able to encounter trauma-related stimuli without strong emotional reactions. The committee did not say how effective exposure therapy is but simply stated that it shows some level of efficacy.

I attended another seminar in 2010 that was conducted by three additional “experts” on childhood trauma and PTSD. One of the speakers deplored the “ready willingness among some to use… practices that have no evidence for their efficacy.” In contrast, she strongly advocated the use of “evidence-based practices” and particularly endorsed Trauma-Focused Cognitive-Behavioral Therapy because of its “high level of empirical support.” In the last ten years there has been a concerted effort made by some mental health professionals to require all mental health professional to use only “evidence-based practices,” implying that there are truly effective methods that everyone should be using. The professional opinion given above by the National Academy of Science study, however, was that any therapy that utilized a form of exposure therapy shows some efficacy and other therapies do not. The question that this raises, however, is just how effective are these “efficacious” PTSD treatments?

Definitions of “Effectiveness”

In August of 2006, researchers Agnes van Minnen and Edna B. Foa authored a study entitled, “The Effect of Imaginal Exposure Length on Outcome of Treatment for PTSD” (Journal of Traumatic Stress, Vol. 19, No.4, August 2006, pp. 427-438). They began their article with the statement, “Several controlled studies have demonstrated the efficacy of prolonged exposure (PE) in ameliorating posttraumatic stress disorder (PTSD) and related psychopathology.” What does it tell us about a treatment modality when researchers tell us it is effective? What measurements and standards are these researchers using and just how effective are the current recommended treatments for PTSD?

Using prolonged exposure techniques Minnen and Foa compared the use of 30-minute with 60-minute “Imaginal Exposure” sessions to determine whether there was a difference in effectiveness and conclude that both are equally effective. Sixty patients received 60-minute imaginal exposure sessions and 32 patients received 30-minute imaginal exposure sessions, for a total of 10 weekly sessions. Throughout the imaginal exposure process, anxiety levels were monitored using a 10-point likert scale called SUDS (Subjective Units of Distress) and all patients were assessed prior to each session and at the end of the study with the PTSD Symptom Scale Self-Report (PSS-SR). The PSS-SR provides a rating from 0-3 on each of the 17 DSM-IV criteria for PTSD with a total score ranging from 0 to 51. The findings were that patients from both groups showed a significant decrease in symptoms from the beginning to the end of treatment, but the two groups did not differ in the amount of decrease.

On the face of it, this study sounds conclusive but a closer examination reveals some significant limitations of the study. This study reported both 30-minute and 60-minute sessions to be equally “effective” in reducing PTSD symptoms using Imaginal Exposure in treating patients over a 10-week period. However, 21% of the initial patients dropped out, 63% of the patients had experienced a single traumatic event, PSS-SR scores dropped an average of 12 points on a 51-point scale, and about 41% of the patients achieved a PSS-SR score of 20 or less. SUDS scores dropped only 2 points on average, from initial ratings of 8 to final ratings of 6 on a 10-point scale of emotional distress. Most potential patients would not be enamored by such results but researchers call such treatments “effective” and urge all clinicians to use such“empirically-supported” methods.

Results of Other PTSD Studies

Other studies of “effective” PTSD treatments are similar. These studies indicate that they have good “efficacy” but this means that the patients show an “improvement” but nothing close to a complete remission or remediation of PTSD symptoms. In a study published in 1999 by seven researchers, both Cognitive Therapy and Imaginal Exposure were declared to be “equally effective” in treating chronic PTSD (Journal of Consulting and Clinical Psychology, V.67, 13-18, 1999). The treatment involved 16 weeks of treatment over 6 months, only 50% of all study participants “improved,” and researchers admitted that neither therapy was sufficient alone to completely remediate chronic PTSD.

In the October 2005 issue of the Journal of Traumatic Stress (Vol.18, No.5, pp. 425-436) authors Joseph Spinazzola, Margaret Laustein, and Bessel A. van der Kolk published an article entitled, “Posttraumatic Stress Disorder Treatment Outcome Research: The Study of Unrepresentative Samples?” In this article, the authors stated that “Several empirically supported.. interventions have been … tested.. and replication studies have established their efficacy in treatment of PTSD.” The authors examined 34 recent studies that met the Practice Guidelines for the Effective Treatment of PTSD established by the International Society for Traumatic Stress Studies (ISTSS) in 2000. Of these 34 studies, it was found that of the studies that reported pretreatment enrollment data, “21% of the participants dropped out prior to starting treatment, and an additional 16% were eliminated at baseline due to the presence of exclusionary criteria.” Thus, only 63% of the initial study participants were included in the study, and only 53% of the initial study participants actually completed treatment.

Recommendations for Efficacy Studies

The authors of the 2005 study cited above made a number of significant recommendations in their report. Four of their recommendations were as follows:

1. Studies should always include precise participant enrollment data and drop-out rates so that the actual number of participants are known.

2. PTSD efficacy studies should attempt to include diverse samples so that they can be better generalized to broad populations of persons with PTSD, and to better assess the ability of PTSD treatments to reduce symptoms of highly impaired trauma survivors.

3. “Investigators should develop and evaluate innovative treatments designed to address more complex symptom presentations.” Innovative treatments should receive higher prioritization by funding sources for development and evaluation, including those that attempt to treat PTSD symptoms in persons with addictive behaviors and disorders.

4. “Journals should publish negative findings,” so that “studies evaluating the efficacy of empirically untested psychotherapeutic interventions, or medications yet unapproved for PTSD” can be publicized for the benefit of other researchers who are searching for innovative approaches for treating PTSD.

Full-Remission Studies

The Journal of the American Medical Association (JAMA. 2007; 297:820-830) published an article entitled “Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women” in 2007. The authors reported that “prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD.” They included 284 female veterans in this study and 141 of them were randomly assigned to receive prolonged exposure therapy (PE), while 143 of them were randomly assigned to receive present-centered therapy (PCT) in 10 weekly 90-minute sessions. They reported that the prolonged exposure therapy was more effective, had more patients who no longer met PTSD diagnostic criteria, and more who achieved “total remission” which was defined as a CAPS score of less than 20 points.

A closer examination of the study reveals that 53 of the 141 women assigned to PE dropped out (38%) and 30 of the 143 women assigned to PCT dropped out (21%), 61% to 71% of the participants were taking psychotropic medications during the study, the average PTSD Checklist score at the end of the study was 41.6 for the women who received PE and 48.9 for those who received PCT (with a maximum score of 51). They reported that “total remission” was achieved (a CAPS score less than 20) by 15.2% of the 87 women receiving PE and 6.9% of the 112 women receiving PCT. Most of the women were treated for sexual trauma that had occurred 20 years earlier so these results are probably not generalizable to male PTSD patients. Although roughly two-thirds of the patients had a “clinically meaningful improvement, only 62% of the initial PE patients completed the treatment so 66% of 62% (41%) actually improved from the PE treatment.

Other studies have begun using the term “full remission” as a measurement term but none of them refers to the total elimination of subjective emotional distress. They refer to a pre-established cutoff criteria or goal for the treatment, which is frequently a CAPS score of less than 20. In the Archives of General Psychiatry (Vo. 65, No. 6, June 2008) in a study titled, “Treatment of Acute Stress Disorder” the authors report in the abstract of the report that patients who underwent exposure therapy were more likely to “achieve full remission” (47% vs. 13%) but this term was never defined in the study. Based upon other studies that used this terminology it probably indicates that 47% of the patients received a CAPS score of less than 20 at the end of the study period. However, the use of such terminology is very misleading.

SUDS Scores

The 2006 study done by Minnen and Foa on, “The Effect of Imaginal Exposure Length on Outcome of Treatment for PTSD” (Journal of Traumatic Stress, Vol. 19, No.4, August 2006, pp. 427-438) used multiple measurement tools, including the PSS-SR and the SUDS measure of subjective distress given by patients who rated their distress on a 10-point scale. This is a common-sense measure that can be easily understood by the average person. Both the 30-minute and the 60-minute treatments showed a significant improvement in scores on the PSS-SR from pre- to post-treatment and a significant “effect size” for both treatments, but there were no significant differences between the two treatments. The SUDS measures likewise demonstrated a significant improvement in patient measures from pre- to post-treatment, but no differences between the two groups. The average improvement on SUDS scores from pre- to post- treatment was 2.2 units on the 60-minute group and 2.1 on the 30-minute treatment group.

Since the SUDS scores showed comparable results to the PSS-SR scores it is puzzling that researchers continue to prefer using instruments like the PSS-SR and CAPS rather than the more simple and intuitively understandable CAPS scores. When using an instrument like the PSS-SR or CAPS researchers can report “significant findings” and even report “full remission” when there is very little clinical significance to the findings. Likewise, when the results of the study are given in terms of effect size, this may sound impressive but may have no clinical significance and it is not easily understood by the lay person or the average mental health practitioner. On the other hand, use of the SUDS scoring technique makes the results easily understood to the lay person and to the typical therapist. A decrease in average SUDS scores from 10 to 8 means simply that their subjective distress when thinking about the traumatic event has decreased slightly but is certainly not “in full remission.”

Measures of Effectiveness

Two researchers from Emory University, Drew Westen and Rebekah Bradley, wrote a challenging critique of evidence-based practices in “Current Directions in Psychological Science” (2005, Vol.14, No.5, 266-271). While applauding the efforts of researchers to evaluate the empirical evidence for efficacy of treatments, they expose the limitations of the most common measures of effectiveness.

Effect Size. The standard measurements used by researchers to evaluate treatment efficacy leave a lot of room for confusion. The criteria used most frequently by researchers to determine treatment efficacy is the “effect size,” which numerically describes the magnitude of the effect that the average patient can expect to receive relative to a control group. These measurements are meaningless to the layperson, however, and may indicate a “large effect size” for a treatment when, in fact, there is not a clinically significant effect or the effect is obtained with just a small percentage of clients. Westen and Bradley stated that “On average, roughly half of patients who complete treatments in such trials improve” and they wrote, “We suspect most patients would be chagrined to learn that what is widely described in the research literature as the treatment of choice for their disorder gives them a 1 in 3 chance of recovery.”

Percent Improved. Westen and Bradley identified “percent recovered” and “percent improved” as two other measures that are often used and stated that these measures are helpful at times, but that it is important to know how many patients dropped out of the treatment and to include them in these statistics. Most studies have exclusion and inclusion criteria that can limit the effectiveness of the treatment, such as the exclusion of individuals who are thinking about suicide from studies of depression. This obviously provides over estimations of the efficacy of treatments for depression and these researchers recommend using only “those exclusion criteria in randomized controlled trials that a sensible clinician would impose in everyday practice (e.g., psychosis or severe brain damage in treating depression).

Post-treatment Symptomatology . In addition, they stated that a treatment may lead to some improvement but leave the patients with strong symptoms afterwards and so some researchers use “residual post-treatment symptomatology” measures. If a study indicates that a particular treatment has a strong effect size and 48% of the patients improved significantly after 16 weeks of therapy, it still does not tell us how many of the patients remain symptomatic and how many have achieved total remission. Some measure of post-treatment symptomatology would provide us this information.

So, in order to understand how effective a treatment is in a particular study it is important to identify many factors. We should know the number and types of people who were excluded from the study initially, the number of people who dropped out of the study, the length of the treatment involved in the study, the number who experienced clinically significant improvement, and the number who achieved true remission of symptoms and not just “total remission” by an arbitrarily established cut-off point. Measurement tools that are understood only by researchers should be avoided and tools such as SUDS scores should be used that are relatively simple and intuitively meaningful to patients, therapists, and researchers.

The authors point out that psychotherapy treatments emerge from clinical practice, not from a laboratory as with pharmaceutical trials. Eliminating the use of all clinical practices other than “evidence-based practices” would prevent the development of more effective techniques when the current practices are still very ineffective for the majority of patients. They recommend identifying promising treatment approaches by using clinical practice as a natural laboratory and looking at the “results obtained by experienced clinicians, some percent of whom, either by chance, trial and error, or creativity, experimentation, and experience, are likely to have happened upon something more effective” (p. 270). This corroborates the opinion of researchers Spinazzolla, Laustein, and Kolk (2005) cited earlier that, “Investigators should develop and evaluate innovative treatments designed to address more complex symptom presentations” and that “ Innovative treatments should receive higher prioritization by funding sources for development and evaluation, including those that attempt to treat PTSD symptoms in persons with addictive behaviors and disorders.”

Best Current Treatment Efficacy Facts

The current “evidence-based treatments” recommended to clinicians are only partially effective and their limitations should be clearly stated when being recommended for use. The following are examples of some of the best-available current “evidence-based treatments.”

A. Depression: One in four depressed patients treated with cognitive behavior therapy for 16 weeks recovers and remains recovered two years later, when individuals who are having suicidal thoughts are excluded from treatment (Westen & Bradley, 2005, p. 270).

B. Bulimia Nervosa: Forty percent of patients who enter treatment, and 50% who complete it, no longer binge and purge at the end of 20 weeks of treatment, while the remaining 60% binge once or twice per week and purge two or three times per week on average (Westen & Bradley, 2005, p. 270).

C. Imaginal Exposure for Posttraumatic Stress Disorder: Patients who completed 10 weeks of 30-minute or 60-minute Imaginal Exposure sessions achieved an average symptom reduction of 12 points on a 51-point PTSD scale (41% achieved a final score of 20 or less) and rated their distress 2 points lower on a 10-point SUDS scale. 63% of these patients had experienced a single traumatic event and 21% of the initial patients dropped out of the study due to finding it too stressful (Minnen & Foa, 2006, p. 427-438).

D. Prolonged Exposure Therapy for Posttraumatic Stress Disorder: Women who were treated with 90-minute sessions for 10 weeks lowered their average score from 48 to 41 on a 51-point PTSD scale and 15% of them achieved a final score less than 20. 38% of the initial patients dropped out of the study due to finding it too stressful and 61% of them remained on psychotropic drugs during the study.

Most of the women were treated for sexual trauma that had occurred 20 years earlier (JAMA. 2007; 297:820-830, “Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women.”

E. Complicated Grief Therapy for Complicated Grief: Half of the patients who completed 16 weeks of therapy indicated that they felt much better after treatment, while 25% of them dropped out of the study.

Although these are “evidence-based” treatments, there is much room for improvement and it is important that therapist have the freedom to continue searching for more effective treatments. This is why many researchers are recommending that “Innovative treatments should receive higher prioritization by funding sources for development and evaluation” until the mental health profession discovers truly effective ways of helping those with serious mental health disorders. Such “innovative treatments” should include faith-based approaches that may be far more effective than the current treatments being used by mental health professionals.

Jim Gardner, Ph.D.

May 26, 2011

       The judicial system in the United States is increasingly referring individuals to anger management classes as an alternative to incarceration when cases involving domestic disputes or violent acts are brought before the courts. High profile cases involving sports figures and movie stars being court-ordered to participate in anger management are common, such as when Ron Artest, the center of the NBA Indiana Pacers was involved in a fight during a basketball game in 2004. He had been previously ordered to have anger management classes in 2002 after he was accused of striking a former girlfriend.

       Dr. Ray DiGiuseppe, a psychologist at St. John’s University, is one of the leading researchers in the area of anger management. Regarding anger management classes he said, “Anger management classes, I think, are a Band-Aid; they allow people to feel they’ve done something, but they haven’t had any kind of real treatment. We have no organized treatment, no idea whether counselors doing the teaching have training in mental health. We’re operating under this delusion that we’re helping people when we may be just continuing the violence” (Benedict Carey, New York Times, Nov. 24, 2004).

       Anger problems are not even considered a mental disorder by the American Psychiatric Association, whose Diagnostic and Statistical Manual of Mental Disorders specifies what is and is not considered a mental disorder. Individuals with anger problems were sometimes given a diagnosis of depression by mental health professionals seeking insurance reimbursement for their services in the past, but are now being given a diagnosis of a bipolar disorder, posttraumatic stress disorder, or an intermittent explosive disorder for some individuals. But many people have a consistent pattern of anger problems that interferes with their marriage or their job that do not qualify as having any form of mental disorder and these people are being referred to anger management classes that are being conducted by persons with no particular qualifications and without any established standards.

Effectiveness of Anger Management

       Studies of anger management classes have suggested that these classes can be helpful for some people, but often have no measurable effect. Dr. DiGiuseppe and Dr. Raymond Tafrate, from Central Connecticut State University, conducted a 2003 review of 92 anger-management treatments, including 1841 participants. They concluded that classes can reduce angry outbursts in some people who are motivated to change. These classes typically involve group counseling sessions that educate the students about the causes of anger, provide training in relaxation techniques and distraction techniques, and teach the students assertiveness skills so they can express their feelings in more socially appropriate ways.

       A survey of men and women in the New York area who sought help with anger management found that about 60% of them had substance abuse problems and early childhood traumas as well. This supports the view that many people with anger problems have deep-seated emotional issues that require more than anger management classes to change. Additionally, when groups of 10 to 12 individuals with anger problems are placed in group setting they tend to support one another’s reactions and authenticate each other’s anger rather than serve to serve as a deterrent to their anger. New York Times writer, Benedict Carey, wrote that “In a review of 22 studies of state programs, a team of psychologists in Texas and New York reported in January that the courses had little positive effect” in curbing domestic violence (Benedict Carey, New York Times, Nov. 24, 2004).

       In June of 2002, the Australian Institute of Criminology reported on a study conducted on anger management programs used with offenders in their department of corrections. Their treatment consisted of ten two-hour sessions of classes with incarcerated offenders. They used violent offenders rather than university students for this study so they could determine the impact of anger management with individuals with well-documented anger problems, and they recommended the use of outcome measures such as behavioral observations and recidivism rates rather than simple written tests. A summary of their results was that, “the overall impact of the anger management interventions was small” and “the changes were not large enough to be of real clinical significance.” The study confirmed that “high levels of anger exist in the prison population” but it was also found, “that anger management programs have only a very modest impact in general” (Howells, K., Day, A., Bubner, S, Jauncey, S., Williamson, P., Parker, A., and Heseltine, K., Anger Management and Violence Prevention: Improving Effectiveness, June 2002, In Australian Institute of Criminology).

       Using 1,841 subjects involved in 92 psychosocial treatments for anger, DiGuiseppe and Tafrate (2003. Anger treatment for adults: A meta-analytic review. Clinical Psychology: Science & Practice, 10, 70-84)) found an overall effect size of 0.71. “Effect size” is the criteria used most frequently by researchers to determine treatment efficacy and is a measure which numerically describes the magnitude of the effect that the average patient can expect to receive relative to a control group. These measurements are meaningless to the lay person, however, and may indicate a “large effect size” for a treatment when, in fact, there is not a clinically significant effect or the effect is obtained with just a small percentage of clients.

        Of more significance is the fact that “most of the evidence for the efficacy of psychosocial treatments for anger derives from self-report measures” (Olantuji, B.O. & Lohr, J.M., 2005, “Nonspecific Factors and the Efficacy of Psychosocial Treatments for Anger”, In The Scientific Review of Mental health Practice, p.17). These researchers go on to observe that, “The few studies that have incorporated behavioral and physiological assessment have found limited evidence for the specific efficacy of psychosocial treatments of anger.”

Summary

       Although a large number of studies have been conducted on the effectiveness of anger management classes, most studies report a small or modest effect at best. Those that do report moderate effectiveness do so based upon self-report measures and not upon behavioral measures and the reports that use behavior measures such as recidivism rates have very poor success rates. In spite of the growing practice of courts to require offenders to attend anger management classes, there is very little support from research to suggest that anger management classes are truly effective in helping those with serious anger problems or to reduce the occurrence of domestic violence or violent criminal behavior. In view of the fact that anger affects marriages, leads to substance abuse, antisocial behavior, and to criminal activities, other forms of intervention are greatly needed to assist those with serious anger problems. Faith-based interventions that can significantly reduce anger in clients should be closely examined and welcomed by mental health professionals due to the very poor effectiveness of the traditional treatment approaches for reducing anger in clients that are currently available to them.

By Jim Gardner, Ph.D.

June 2011

     I am not a medically trained person and this article should not be construed as an attempt on my part to practice medicine but to share the view of some well-qualified physicians whose opinions are not generally found in the popular media. When doctors disagree about matters, it is the right and responsibility of each individual to weigh the opinions of those who are medically qualified and to make an informed decision about what treatments are best for them.

Causes of Mental Health Disorders

    Due to the efforts of pharmaceutical companies to market their medications through television commercials many individuals, including physicians, have become convinced that mental disorders are the result of genetic or chemical problems and their solution is to prescribe medications to alter the brain chemistry of the affected individuals. This concept, however, is not universally accepted by physicians and some of them have conducted research that seriously challenges this assumption.

     Vincent J. Felitti, M.D. was the director of the “Adverse Childhood Experiences” study conducted between 1995 and 1997 which assessed the relationship between eight traumatic childhood experiences and the rates of prescription usage for psychotropic medications throughout adulthood. The prescription data were drawn from 1997 to 2004 and this was compared to the ACE score of each of the 15,033 patients included in this portion of the study. ACE scores were calculated by adding the number of different types of traumatic experiences that the individual experienced (with a maximum score of 8).

     Prescription rate usage increased each year during the follow-up period of the study in a graded manner as the ACE score increased. The higher the ACE score of the individual, the greater the prescription rates were for antidepressant, anti-anxiety, antipsychotic, and mood-stabilizing medications. The authors of the study concluded, “The strong relationship of the ACE Score to increased utilization of psychotropic medications underscores the contribution of childhood experience to the burden of adult mental illness. Moreover, the huge economic costs associated with the use of psychotropic medications provide additional incentive to address the high prevalence and consequences of childhood traumatic stressors.” (Reference: American Journal of Preventive Medicine, 2007, May; 32(5): 389-94).

     In other journal articles written about this research project, Dr. Felitti addresses the relationship between early childhood experiences and the later abuse of alcohol, attempted suicides, smoking, sexually risky behaviors, depressive disorders, hallucinations, and premature mortality. In each case, the researchers found a direct and strong relationship between early childhood experiences and the risk of experiencing these social and mental conditions in adolescence or adulthood. In each case Dr. Felitti rejected genetic and chemical explanations of these disorders in favor of environmental explanations. With regard, specifically, to addictions he wrote, “We find that addiction overwhelmingly implies prior adverse life experiences” and stated, “Addiction is not a brain disease, nor is it caused by chemical imbalance or genetics.”

(Reference: Felitti, FJ, The Origins of Addiction: Evidence from the Adverse Childhood Experience Study, 2004, Online). Those who wish to examine more articles on this project are encouraged to examine articles available online under the Adverse Childhood Experiences study.

     In another definitive study, Kenneth Kendler, MD, and Carol Prescott, Ph.D. conducted a study of over 9,000 twins in Virginia to assess the role of genetic and environmental factors in mental disorder. This study was documented in a book released in 2006 by the Guilford Press entitled, “Genes, Environment, and Psychopathology: Understanding the Causes of Psychiatric and Substance Use Disorders.” The study, known as the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (ATSPSUD) examined twin pairs in order to differentiate the genetic and environmental influences on mental disorders that developed in adulthood.

     In this “twin study” the researchers calculated the heritability factor for twenty-four mental health disorders and found heritability estimates to range from a low of .16 for social phobias and .75 for any type of drug dependence. Most mental health disorders included in this study had a heritability estimate that was below .50, meaning that if one twin had the disorder, the other twin was likely to have it 50% of the time. This can be compared with other inherited physical conditions such as asthma, lung cancer, and breast cancer that fall in the “moderate heritability range” (20-40%), whereas weight and intelligence fall in the “Moderately high heritability range” (60-80%). Drug dependence fell in the “high heritability range” between 60-80%, which is the range in which weight and intelligence fall, but none of the mental disorders examined in this study fell in the “very high heritability” range of between 80-100%. Although several mental disorders have been postulated to fall in this range, more recent studies have shown them to fall in the 40-60% heritability range.

     Some of the conclusions made by the researchers include a very significant role of environmental factors such as sexual abuse, parental death, and parental divorce in the later development of mental disorders. Childhood abuse was found to be causally related to alcoholism and substance abuse and seven other forms of psychiatric disorders. Childhood parental death was found to be specifically related to the later development of major depressive disorder, but also increased the risk of developing a generalize anxiety disorder, panic disorder, and drug dependence. Parental divorce was found to increase the risk for major depressive disorders, general anxiety disorders, panic disorders, and substance use disorders. The risk for developing major depression, general anxiety disorders, and panic disorders lasted for 20-35 years, and the risk for drug abuse or dependence lasted for 55 years, but the risk for alcohol dependence risk never ended. Thus, this study demonstrated a powerful connection between childhood traumas and the development of mental disorders in adulthood.

     The ACE study and the Virginia Twin Study are two very definitive studies that raise serious questions about the genetic and biological explanations of mental disorders and strongly suggest the importance of environmental factors in the development of mental disorders. This should lead us to revise our understand, then, of the role of psychotropic medications in the treatment of mental disorders.

The Impact of Psychotropic Medications

     Dr. Peter Breggin is a psychiatrist and expert in clinical psychopharmacology who has been studying the impact of psychotropic medications for over 40 years. He has written dozens of scientific articles and more than 20 books, but most recently wrote the book, “Medication Madness” in 2008, to expose some of the potential problems that he has witnessed with the use of these brain-altering medications. He has served as a medical expert in many criminal and civil cases against the pharmaceutical companies who manufacture psychiatric drugs. In this book he documents the potential dangers of mood-altering medications and he exposes the pharmaceutical industry’s attempts to hide these dangers in order to increase their sales and profits. The following are some of the statements and conclusions that Dr. Breggin makes in this book.

• “In forty years of psychiatric practice, I have never started a patient on an antidepressant, although I do prescribe them during the withdrawal process or if the patient is unable to go through withdrawal.” (p.54).

• “In my own private practice of psychiatry conducted since 1968, I have always worked with the most disturbed patients without resorting to psychiatric drugs. Most of my extensive hands-on experience with psychiatric drugs comes from taking patients off their medications, often after years of exposure to multiple drugs.” (p. 102)

• “If you are wondering if you can trust your doctors to tell you the truth about psychiatric drugs, the answer is, you can trust your doctors only to the degree that you can trust the drug companies who provide them with most of their drug information.” (p. 246)

• “If you have a biochemical imbalance in the brain, the odds are overwhelming that your doctor put it there with a psychiatric drug. In fact, these are the only known biochemical imbalances in the brains of psychiatric patients—the biochemical imbalances caused by drug treatments and electroshock.” (p. 269-270)

• “Mounting laboratory evidence –indicates that psychiatric drugs can cause permanent brain dysfunction and damage.” (p 274)

• “Despite how often doctors tell their patients, ‘Don’t worry, it’s a small dose,’ many people have serious adverse effects from one or two doses of a drug, often in relatively small amounts.” (p. 277)

• “Drug companies and their paid researchers have tried for years to show that these drugs reduce the suicide rate, but no compelling evidence has been forth-coming. The opposite has been proven—that they cause suicidal behavior. As a result, no drugs are FDA-approved for treating suicidal feelings or behavior.” (p. 279).

• “Comparing ‘mental disorders’ like anxiety, depression, and mania to diabetes, as is often done, is false and misleading.” (p. 280)

• “When a psychiatrist tells you, ‘You will have to take medication for the rest of your life.’ He’s making a pernicious speculation that’s bound to do you much more harm than good.” (p. 282)

• “As avidly as they push drugs, physicians tend to know very little about them…They are listening to drug company salespersons. They are listening to drug-company advertising.” (p. 282)

• “Doctors who prescribe medication too often feel slighted or disrespected when patients ask to stop taking their drugs. Don’t accept one physician’s opinion, especially the original prescribing doctor, about whether or not you should spend ‘the rest of your life’ on a drug. Get second opinions. Research the drugs for yourself. Ultimately, make up your own mind.” (p. 295)

• “The best measure for preventing medication madness is not to start taking psychiatric drugs; if you decide to take them, then take as few as possible at the smallest possible dose, and stop taking them as soon as you can.” (p. 321)

• “Historically, religion as well as less-formalized spiritual approaches have offered solutions to human suffering. In recent time, however, when confronted with depressed or anxious persons, even the minister, priest, or rabbi is likely to refer them to someone who gives drugs.” (p. 329)