Journal of the International Neuropsychological Society (2020), 26, 119–129

Copyright © INS. Published by Cambridge University Press, 2020.

doi:10.1017/S1355617719000833

Psychoeducational Interventions for Problematic Anger in

Chronic Moderate to Severe Traumatic Brain Injury:
A Study of Treatment Enactment

Tessa Hart1 Monica J. Vaccaro1, Jesse R. Fann2, Roland D. Maiuro3, Shira Neuberger1 and Steven Sinfield4
1
Moss Rehabilitation Research Institute, Elkins Park, PA 19027, USA
2
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA
3
Private Practice, Seattle, WA, USA
4
Drexel University College of Medicine, Philadelphia, PA 19129, USA

(RECEIVED February 27, 2019; ACCEPTED July 2, 2019; FINAL REVISION June 25, 2019)

Abstract

Objectives: Treatment enactment, a final stage of treatment implementation, refers to patients’ application of skills and
concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm,
multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic
brain injury and problematic anger. Methods: Seventy-one of 90 participants from the parent trial underwent a
telephone enactment interview at least 2 months (median 97 days, range 64–586 days) after cessation of treatment.
Enactment, quantified as average frequency of use across seven core treatment components, was compared across
treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally
equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment
were explored. Results: More than 80% of participants reported remembering all seven treatment components when
queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components
concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain
injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were
predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants
as a barrier to enactment, as was the reaction of other people to attempted use of strategies. Conclusions: Treatment
enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to
measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to
everyday life. (JINS, 2020, 26, 119–129)
Keywords: Traumatic brain injuries, Treatment enactment, Clinical trials, Anger management, Treatment fidelity,
Treatment implementation

INTRODUCTION Marlatt, 2015), refers to the extent to which a therapist has

delivered the treatment as intended. Both adherence to the
More than two decades ago, a seminal paper on psycho-
treatment protocol and skillfulness of the therapist in deliver-
therapy outcome research called attention to the concept of
ing its content may be examined (Faulkner, 2012). However,
treatment enactment (Lichstein, Riedel, & Grieve, 1994).
treatment fidelity refers to the behavior of the therapist;
The authors argued that the effects of an intervention studied
Lichstein et al. (1994) drew attention to the behavior of the
in a clinical trial could be interpreted only in the context of
patient as the “primary change agent” (p. 13). No matter
the rigor with which the treatment was implemented, and that
how faithfully the therapist renders the treatment, the desired
the examination of treatment implementation must go beyond
changes in patient behavior cannot occur unless the patient
the familiar evaluation of treatment fidelity. Fidelity, also
understands what to do (treatment receipt) and actually does
known as treatment integrity (Grow, Collins, Harrop, &
it in his or her daily life (treatment enactment).
Correspondence and reprint requests to: Tessa Hart, Moss Rehabilitation
Subsequent authors have elaborated the means by which
Research Institute, 50 Township Line Road, Elkins Park, PA 19027, USA. each of these phases of treatment implementation may be
E-mail: [email protected]

119
120 T. Hart et al.

optimized and measured in clinical research (Bellg et al., long-term habits, a call echoed by others in rehabilitation
2004). Therapist behavior, that is, fidelity, is often assessed (Dobkin, 2016; Whyte et al., 2018). For example, Taub
by evaluating audio or video recordings of treatment sessions. et al. (2013) have shown that the efficacy of Constraint-
A less labor-intensive strategy is to have therapists’ complete Induced Movement therapy for chronic stroke is magnified
checklists during each treatment contact, to help ensure that by inclusion of a “transfer package” of ingredients to enhance
important elements are not omitted, nor proscribed elements home practice, including behavioral contracts and problem-
accidentally included. Treatment receipt may be assessed and solving to overcome barriers to home enactment. It could
reinforced as needed during treatment sessions, using such be argued that assessment and promotion of treatment
methods as quizzing patients, asking them to repeat important enactment are particularly critical for the people served by
content in their own words, or observing them as they practice neuropsychological interventions, whose cognitive and
methods taught in session or engage in role plays. Patient behavioral impairments might pose special challenges to
satisfaction and engagement with treatment, and the “fit” development and maintenance of new routines.
of the intervention to cultural factors are also relevant to The current study was designed to assess treatment
treatment receipt (Rixon et al., 2016). As the intervention enactment of the concepts and skills presented in a multisite
is progressing, treatment enactment may be evaluated randomized controlled trial that compared two psychoeduca-
through patients’ completion of homework assignments, their tional treatments delivered to community-dwelling people
descriptions of relevant behaviors between therapy sessions, with chronic moderate to severe traumatic brain injury
or their self-reported attainment of therapy goals at each (TBI) and problematic anger/irritability (Hart et al., 2017).
treatment contact (Spillane et al., 2007). In this trial, we achieved a high level of treatment completion
But what about treatment enactment once the intervention and excellent treatment fidelity, as assessed through system-
is over? Typically, the ultimate goal of a behavioral interven- atic examination of audio-recorded sessions in both treatment
tion is long-lasting, if not permanent, change in behavior. arms, with feedback integrated into therapist supervision. For
Quantitative follow-up assessment, such as measuring the present study of enactment, we used a structured inter-
participant mood states several months after cessation of a view, conducted by phone several months after treatment ces-
treatment designed to improve mood, can speak to treatment sation, to examine the extent to which participants were using
efficacy overall, but does not show whether or not partici- learned material in daily life, and the degree to which they
pants are using specific strategies to achieve lasting outcomes found various treatment components to be currently helpful.
(Faulkner, 2012). Writing for the National Institutes of Health As described in more detail below, the parent trial com-
Behavior Change Consortium, Bellg et al. (2004) acknowl- pared an eight-session, one-on-one treatment called anger
edged that long-term enactment is the most challenging phase self-management training (ASMT) to a structurally equivalent
of fidelity assessment. They suggested strategies such as therapy designed to control for nonspecific therapeutic effects,
follow-up interviews, use of electronic monitoring when called personal readjustment and education (PRE). The
appropriate (e.g., movement sensors to record physical ASMT program provided education to normalize anger, par-
activity), or observation of in vivo interactions. The last of ticularly in the context of TBI, and training in the concept and
these methods might be used in self-contained settings such process of self-monitoring for physiological and psychologi-
as classrooms or residential facilities, but is less feasible for cal signals that could help participants both to use an expanded
trials with community-dwelling participants. emotional vocabulary to interpret their distress and to prevent
Given the practical and conceptual challenges of measur- maladaptive anger responses. ASMT participants also learned
ing real-world behavior, it is perhaps not surprising that the and practiced specific techniques such as taking time out to
literature contains relatively few examples of assessing treat- solve problems without anger, and using positive communica-
ment enactment. In one smoking cessation trial, investigators tion strategies. The PRE treatment provided education about
surveyed patients several months after treatment and also the effects of TBI, emphasizing the recovery process and the
tracked the number of logons and page views within the study concomitant changes and adjustments at the personal level as
website (Duffy et al., 2015). A study of resourcefulness well as in relationships and community roles. PRE therapists
training for caregivers of persons with dementia included also gave emotional support and opportunities to ventilate
an instruction for participants to maintain a journal, which feelings, without teaching specific ways of managing anger.
both reinforced the use of trained methods and allowed inves- Both treatment conditions were highly structured, with
tigators to assess which strategies were used most often in the detailed therapist manuals and printed exercises and work-
home setting (Zauszniewski, Lekhak, Burant, Underwood, & sheets for participants. In both treatment arms, participants
Morris, 2016). Grow et al. (2015), in a trial of mindfulness were invited but not required to include a significant other
meditation to reduce substance misuse, queried participants (SO), a friend or relative, in portions of three sessions.
as to the type, frequency, and duration of mindfulness prac- Although some outcomes were found to be superior for the
tice completed per week for up to 4 months after program ASMT arm, the differences between conditions were smaller
completion; the degree of treatment enactment was nega- than hypothesized (Hart et al., 2017). Partly for this reason,
tively associated with both substance use and craving. and to achieve a better understanding of nonspecific
Those authors also emphasized the importance of including treatment effects, we elected to examine treatment enactment
therapy ingredients that have the express purpose of building in both the experimental and active control arms of the parent
Hart-Treatment Enactment 121

trial. Because treatments providing education and emotional (n = 4), or could not be reached thereafter (n = 2). The
support are commonly provided to people with TBI, we rea- Institutional Review Board at one treatment site did not per-
soned that information on more or less helpful concepts might mit remote consenting for the interview, which was added
be useful to both practicing clinicians and researchers seeking partway through the trial, resulting in the loss of that site’s
to develop similar interventions. With regard to the ASMT early participants (n = 7). Two additional participants
treatment, we considered information on the enactment of declined the interview. Participants gave informed consent
specific anger management techniques to be potentially use- and were compensated for interviews.
ful to professionals working in this area with persons who
have experienced TBI, since anger and irritability are impor-
tant clinical problems in this population. Measures
Given the paucity of prior work in this area, we considered
TBI-related variables included time postinjury, mechanism
this study to be largely descriptive and exploratory. We
of injury, and severity. Injury severity was confirmed for
wished to determine which treatment components within
inclusion using any one or more of the following indices
the ASMT and PRE programs continued to be used most
extracted from prospective medical records: postresuscitation
often by participants, and which were considered to be most
score on the Glasgow Coma Scale (GCS) <13 or GCS Motor
helpful in daily life. We were also interested in whether the
<6; loss of consciousness, unresponsiveness or coma attrib-
two treatment programs differed as to the overall degree of
utable to the TBI and persisting ≥1 hr; post-traumatic amne-
later enactment reported by participants. To enrich our under-
sia (PTA) attributable to the TBI and persisting ≥24 hr; or
standing of treatment enactment and to provide ideas for
neuro-imaging study positive for TBI-related findings.
improving the therapy protocols, we gathered qualitative
Because primary records were not consistent with respect
data, such as participants’ descriptions of how they had used
to the available severity indices, we also administered a
treatment principles or methods in daily life, and what bar-
structured interview (Hart et al., 2010, 2014) to provide
riers to enactment they had experienced. We also examined
a retrospective estimation of PTA duration. This afforded a
the predictive utility of participants’ pretreatment level of
severity index common to all trial participants. Baseline
anger and selected neuropsychological characteristics, with
neuropsychological measures included the Full Scale IQ
the expectation that both declarative memory and executive
(FSIQ) from the Wechsler Abbreviated Scale of
function might influence the ability of participants to imple-
Intelligence (WASI; Wechsler, 1999) and the sum of trials
ment learned concepts in daily life situations. Additionally,
1–5 on the Rey Auditory Verbal Learning Test (RAVLT),
we tested the hypotheses that degree of treatment enactment
with raw scores converted to Z-scores using age corrections
would be positively associated with (1) the participation of
by decade (Schmidt, 1996). Executive function was assessed
a relative or friend in the treatment program and (2) the mag-
using the Trail Making Test, Part B T-score (Reitan &
nitude of treatment response, as measured by change from
Wolfson, 1985), and the self-report Total T-score from the
baseline to posttreatment follow-up in the anger measures
Frontal Systems Behavior Scale (FrSBe; Grace & Malloy,
that were used as primary outcomes in the parent trial.
2001). Emotional status was measured using the Global
Severity Index (GSI) of the Brief Symptom Inventory
METHODS (BSI; Derogatis, 1993).
Self-reported anger was measured using the STAXI-2 TA
Participants and AX-O subscales administered at four time points
including pretreatment baseline (T1), interim (T2), 1 week
Participants in the current study were 71 of the 90 participants
posttreatment (T3), and 2-month follow-up (T4). TA is the
in the parent trial: 48 of 60 (80%) in the ASMT condition and
tendency to become angry, for example, by perceiving
23 of 30 (77%) in the PRE condition (sample sizes were
situations as hostile or unjust (Veenstra, Bushman, &
unequal due to the use of a 2:1 randomization scheme).
Koole, 2018); this predisposition is an important precursor
Inclusion/exclusion criteria are published elsewhere (Hart,
to the expression of anger, the outward manifestations of
Brockway, Fann, Maiuro, & Vaccaro, 2015, Hart et al.,
which are tapped by the AX-O scale. Thus, TA is a broader
2017). In brief, participants were aged 18–65, were at least
construct and is typically used to measure efficacy of main-
6 months post moderate/severe TBI, and acknowledged anger
stream anger management protocols (DiGuiseppe & Tafrate,
that was new, or worse, since injury. Problematic anger was
2003). In this study, treatment response was calculated as the
verified by a score ≥1 standard deviation above the demo-
change in T-scores between T1 and T4 on each of the STAXI-
graphically adjusted mean on the Trait Anger (TA) or
2 measures; T3 values were substituted for one participant
Anger Expression-Out (AX-O) subscales of the State-Trait
who had missed the T4.
Anger Expression Inventory-2 (STAXI-2; Spielberger,
2000), or a score of ≥9 on the Brief Anger-Aggression
Questionnaire (Maiuro, Vitaliano, & Cahn, 1987). Trial par-
Treatment Enactment Interview
ticipants were contacted for a treatment enactment interview
unless they had attended fewer than half of their treatment The enactment interview (available on request) was divided
sessions (n = 4), were lost to follow-up in the parent study into three parts. For Part 1, each of the treatment programs
122 T. Hart et al.

Table 1. Treatment components described to participants and abbreviated names used in text

Anger Self-Management Training condition: “You and your therapist : : : ” Abbreviated name
: : : talked about anger being a normal emotion that we all have. Anger is everyone’s natural, adaptive Anger Is Normal
response to feeling threatened in some way. So managing anger isn’t about getting rid of it, but rather
learning how to deal with it differently.
: : : talked about how common it is for people with brain injury to have problems with anger and irritability. Anger Reasons in TBI
There are lots of reasons for this, having to do with the brain injury itself (the brain reasons) and also
because of all the changes it creates in peoples’ lives (the life reasons).
: : : worked on some ways to self-monitor your anger and irritability. For example, picking up your anger Anger Self-Monitoring
cues and signals in your body and behavior; or recognizing the small a’s like being annoyed, before they
turn into large A’s like fury or rage.
: : : talked about your O’s, which are the Other Feelings wrapped up with anger, such as feeling Expanding Emotional
disrespected, anxious, or hurt. You worked on recognizing your O’s and giving voice to them, instead of Vocabulary
expressing yourself with anger.
: : : worked on a strategy called Time Out, which is a step-by-step way to slow down the action and take Taking Time-Out
time to cool off before dealing with a situation.
: : : worked on a skill called the Mirror Technique, which is where you take a negative statement like “Stop Positive Communication
making noise!!” and flip it over into a positive request like “I’d really like some quiet please.”
: : : worked on a technique called Active Listening, which is where you listen attentively to someone else Active Listening
without interrupting; restate carefully what you think they said (even if you disagree); and check to make
sure you understood correctly.
Personal Readjustment and Education condition: “You and your therapist talked about the idea Abbreviated name
that : : : ”
: : : people experience changes in themselves, and difficulties in life, after a brain injury (TBI). These TBI Change Is Normal
difficulties are normal and understandable because of what happens to the brain when it is injured.
: : : after TBI, there is a lot of potential for recovery, and recovery continues over a long period of time. Recovery Potential
: : : adjustment to major life changes, for example, moving, getting married or divorced, or going through a Adjustments Are Natural
serious illness, is a normal part of life. Everyone has the natural ability to adjust to life changes, even
after having a brain injury.
: : : experiencing changes in one’s relationships with other people over time is also a normal part of life. Relationship Changes
After a TBI there can be changes in relationships with family and friends. Sometimes there can be more
distance created between people, but sometimes people can grow closer together.
: : : after a TBI, there may also be changes in how you participate in the community and how you contribute Community Role Changes
to your community. Sometimes the person with TBI gives up some roles in the community. But
sometimes you might take on new roles and activities.
: : : even though there is a lot of change in the person after TBI, including changes in your cognitive Much Is Unchanged
abilities and in your emotions, it is important to remember that there are parts of you that have not
changed, and that some things may have changed in a positive way.
: : : thinking back about the changes that you have experienced, and putting them into words, can help with Expressing Feelings in
your personal readjustment. Words

was divided into seven main components. Some of these were frequently (4)?” For each item rated >0, the interviewer
concepts or “take-home messages” that were emphasized asked, “And how helpful would you say that this (idea,
across sessions, while others (particularly in ASMT) were strategy, topic, etc.) is to you, in your daily life? Not at all
techniques introduced in a given session and practiced (0), slightly (1), somewhat (2), very (3), or extremely (4)?”
thereafter. During the enactment interviews, the interviewer Finally, the interviewer asked for examples of how and when
described each of these components to participants and asked the treatment component was used. To explain what was
if they recalled it. Table 1 lists the descriptions that were read meant by “using” an idea or concept, as opposed to a behav-
and/or paraphrased to participants, and a brief name used for ioral technique, the interviewer gave examples such as recall-
each component throughout the remainder of the manuscript ing an idea or concept to help manage emotions or their
and tables. expression, to shift perspective on or adjust to a situation,
For each component that the participant reported recogniz- or to understand and normalize experiences.
ing, the interviewer then asked, “How often, nowadays, do In Part 2, participants were asked whether they were still
you find yourself reminded of this (idea, strategy, topic, using the written tools they had used during the trial. In
etc.), or how often do you use it in some way? Not at all ASMT, these consisted of anger logs, which were used in
(0), rarely (1), occasionally (2), frequently (3), or very treatment sessions to promote discussion of triggers and
Hart-Treatment Enactment 123

emotional events surrounding anger episodes, and the treatment response, for the two anger scales separately. A
outcome of strategies employed. In PRE, the written record simple least squares regression with simultaneous variable
was a free-form “personal events diary” in which participants entry was conducted with treatment enactment score as the
were encouraged to record salient events and ventilate dependent variable and the following predictors, after ruling
feelings. All participants were also asked how often, if at out multicollinearity: pretreatment STAXI-2 TA T-score,
all, they were still reviewing the handouts they had received RAVLT Z-scores, Trails B T-score, FrSBe Total T-score,
during the trial. WASI FSIQ, and BSI GSI T-score. Alpha was set at .05.
Part 3 dealt with barriers to enactment: participants were
asked what, if anything, they thought had gotten in the way of
their being able to use the ideas and strategies discussed in RESULTS
treatment. Responses were recorded as free text. One author
Participant Characteristics
(TH) generated categories and sorted responses based on
barriers mentioned by two or more participants; another As shown in Table 2, participants were mostly male and
author (MV) independently verified the categories and sorted mostly white, although nearly one-third were from racial/
responses into them. Agreement exceeded 90% and discrep- ethnic minority groups. The values for PTA duration and time
ancies were resolved via discussion. between injury and treatment confirm that the sample was
composed of people with chronic, severe TBI. Baseline
values of the neuropsychological variables used to predict
Procedures treatment enactment are also displayed in Table 2. There were
no clinically significant differences between participants in
All enactment interviews were conducted via phone by one
the current study and those in the parent study who did not
author (SN), a Masters trained researcher with experience
receive an enactment interview with regard to age, sex,
in telephone interviewing and counseling. She was otherwise
education, race/ethnicity, PTA duration, time postinjury,
unconnected with the parent trial and had never interacted
involvement of an SO, or baseline anger scale scores (data
with any participants. Interviews were scheduled for a
not shown).
minimum of 2 months following the cessation of treat-
ment, although many occurred at a longer interval. Before
administering the questions, the interviewer presented a pre- Enactment Interview Findings
amble emphasizing the importance of knowing the true opin-
The interviews averaged 51 min (±12) for ASMT participants
ions and activities of each participant. Respondents were also
and 46 min (±16) for those in the PRE condition. The differ-
reassured that their responses were confidential and would
ence in interview duration was not significant (t = −1.31,
not be shared with their previous therapist. This was done
p = .20). Interviews occurred from 64 to 586 days (median
in an attempt to minimize the demand characteristics for pos-
97.5) posttreatment for ASMT participants and from 70 to
itive responses regarding the degree of treatment enactment.
274 days (median 94.0) for PRE participants; this difference
All interviews were audio-recorded. The interviewer took
was also not significant. In light of the wide range of intervals
detailed notes during the interview and listened to the record-
posttreatment, we examined the correlation between this time
ing immediately afterward to clarify or insert material.
span and the treatment enactment variable; there was no sig-
nificant relationship (Spearman r = .05).
The majority of participants in both conditions (43, or 89%
Data Analysis
of ASMT participants and 15, or 65% of PRE participants)
The number of concepts or techniques recognized by each reported that they recognized all seven treatment elements
participant was tallied. Descriptive statistics for each treat- described by the interviewer. Seven participants in the PRE
ment component included the proportion of participants condition did not recognize the “Expressing Feelings in
endorsing each frequency score and, for frequency scores Words” component (see Table 1). Only two participants in
>0, the proportion of participants endorsing each helpfulness each group recognized fewer than six elements from their
score. A treatment enactment score for each participant was treatment program.
calculated by averaging the frequency ratings across all seven Descriptive statistics for the frequency and helpfulness
treatment components. This score and an additional score ratings are displayed in Table 3. In the ASMT condition, there
comprised of each participant’s averaged helpfulness ratings were three items receiving frequent use by at least one-half of
were compared across treatment conditions using t-tests for participants: The idea that Anger Is Normal; Anger Self-
independent samples. T-tests were also used to compare Monitoring, which emphasized attention not only to bodily
enactment in those with and without SOs participating in signals of anger but also to low levels of irritation that could
treatment. The proportions of participants who had main- escalate; and Taking Time-Out, a key method of “stopping
tained the use of the written log/diary, and who were still the action” to engage in problem-solving when anger signals
using therapy handouts, were compared across conditions are perceived. These components also received high helpful-
with χ-square tests. Pearson correlations were used to ness ratings from the majority of participants using them (see
examine the association between treatment enactment and Table 3). Items used frequently by at least one-half of the PRE
124 T. Hart et al.

Table 2. Participant characteristics (N = 71)

Demographic variables
Age (M/SD/range) 39.0 11.3 18.7–63.9
Gender (no./% male) 61 86
Education (years; M/SD/range) 13.2 2.2 9–20
Race/Ethnicity (no./% white) 50 70
Neuropsychological variables (M/SD/range)
WASI FSIQ 95.2 14.9 64–130
Trails B T-score 41.1 13.3 11–68
RAVLT sum of five trials 39.3 10.6 11–59
RAVLT Z-score −1.6 1.3 −5.1 to .7
FrSBe T-score 63.5 17.0 34–107
BSI GSI T-score 67.9 9.2 47–80
TA T-score 64.8 10.8 42–80
Injury characteristics
Mechanism of injury (no./%)
Vehicular incident 49 69
Fall 8 11
Intentional injury 11 16
Sports 3 4
PTA, days (median/range) 30 2–365
Time from injury to treatment, months (median/range) 76 6–335

Notes: PTA = post-traumatic amnesia; WASI FSIQ = Wechsler Abbreviated Scale of Intelligence Full Scale IQ;
RAVLT = Rey Auditory Verbal Learning Test; FrSBe = Frontal Systems Behavior Scale; BSI GSI = Brief Symptom
Inventory Global Severity Index; TA = Trait Anger

Table 3. Frequency and helpfulness ratings of treatment components in the two conditions

% Ps reporting each level of frequency % Ps reporting each degree of helpfulness

Treatment component of use when used1
None Some Frequent None Some Very much
(score 0) (score 1–2) (score 3–4) (score 0) (score 1–2) (score 3–4)
ASMT treatment components
Anger Is Normal 2 48 50 2 42 56
Anger Reasons in TBI 9 51 40 5 58 37
Anger Self-Monitoring 8 36 56 0 32 68
Expanding Emotional Vocabulary 9 43 48 0 48 52
Taking Time-Out 10 40 50 2 23 75
Positive Communication 21 48 31 3 50 47
Active Listening 20 37 43 3 30 67
PRE treatment components
TBI Change Is Normal 0 57 43 9 35 56
Recovery Potential 5 43 52 0 40 60
Adjustments Are Natural 5 36 59 10 28 52
Relationship Changes 9 35 56 5 33 62
Community Role Changes 36 32 32 0 36 64
Much Is Unchanged 0 45 55 5 45 50
Expressing Feelings in Words 6 56 38 0 40 60

Notes: P = participant; ASMT = Anger Self-Management Training; PRE = Personal Readjustment and Education.
1
Proportions of helpfulness ratings are based on Ps who reported using each treatment component, that is, frequency score >0.

sample included Recovery Potential, Adjustments Are As noted above, an overall enactment score was calculated
Natural, Relationship Changes, and Much Is Unchanged; for each participant as the average of the seven frequency
these have to do with adjustments following a major life event ratings. This value was identical for the two conditions
such as a TBI being normal and achievable, and the idea that (2.3 ± .7); the groups were therefore combined for the regres-
TBI leaves many parts of the person intact. sion described below. An average helpfulness score was also
Hart-Treatment Enactment 125

Table 4. Summary of regression analysis for predicting treatment mentioned by 17 (35%) of ASMT participants and 9 (39%) of
enactment (N = 70) those in PRE, was lack of memory for the material, either
altogether or at the time it was needed. For ASMT partici-
Variable B SE B β pants, the reactions of other people to the attempted use of
RAVLT Z-score .15 .08 .28 strategies were cited as a barrier by 13 participants (27%);
Trails B T-score −.03 .01 −.47* 4 PRE participants (17%) also cited others’ reactions as bar-
FrSBe Total T-score −.01 .01 −.13 riers. Several in the ASMT condition mentioned that using
WASI FSIQ .01 .01 .31** the strategies to remain calm made them look weak in the eyes
TA T-score .00 .01 .07 of other people; another problem mentioned was that some
BSI GSI .00 .01 .04 family members simply continued to argue instead of
R2 .22 cooperating with a more reasoned approach. Five participants
F 2.97* in the ASMT condition stated that it was sometimes hard to
enact treatment techniques in the constraints of the “real
*p < .01, **p < .05.
Notes: WASI FSIQ = Wechsler Abbreviated Scale of Intelligence Full Scale world,” particularly in work settings, and two in that condi-
IQ; RAVLT = Rey Auditory Verbal Learning Test; BSI GSI = Brief tion, as well as one in PRE, said that they sometimes became
Symptom Inventory Global Severity Index; FrSBe = Frontal Systems angry “too fast” to make good use of the strategies they had
Behavior Scale; TA = Trait Anger.
learned. Two participants in ASMT and one in PRE stated
that not all of the treatment content had applied to their
calculated per participant, across treatment components; this problems, which interfered with enactment in daily life.
score was slightly, but not significantly higher for ASMT Despite the barriers, participants in both conditions gave
(2.7 ± .7) versus PRE (2.5 ± .9); t = −.66, p = .50. There numerous examples of how each of the treatment components
was also no significant difference between conditions in had been applied in daily life. These are illustrated, with one
the proportions of participants who were still using the anger participant comment per component, in Table 5.
logs/personal events diary (21% for ASMT, 39% for PRE;
χ-square = 2.66, p = .10) or were still referring to study hand-
outs (48% for ASMT, 39% for PRE; χ-square = .48, p = .49).
DISCUSSION
The purpose of this study was to explore the concept of
Predictors and Correlates of Treatment treatment enactment in a clinical trial that compared two
Enactment 8-week psychoeducational interventions: one, a program
designed to provide education and skill development toward
Table 4 shows the results of the regression analysis predicting
more effective self-management of anger following TBI and
the enactment score from baseline anger and neuropsycho-
the other, developed as an educational/supportive therapy to
logical characteristics, collapsing across treatment groups.
control for nonspecific effects. In addition to the specific find-
The overall model was significant; the contribution of memory
ings discussed below, we hope that this paper serves as an
did not quite reach significance at p = .06. However, FSIQ
example that may prompt others to consider examining the
contributed significantly to the model such that higher IQ
sustained use of treatment concepts and techniques in daily
was associated with greater enactment, as was a higher level
life, so as to further our understanding of how to enhance
of executive function when measured objectively (Trails
treatment enactment and prevent relapse in the longer term.
B T-score) but not when self-reported (FrSBe score). Levels
The majority of our participants with moderate to severe
of anger and emotional distress at baseline were also
TBI stated that they recognized all of the main concepts
nonsignificant.
and strategies presented in their program more than 2 months
The enactment scores for participants who had an SO
after cessation of treatment. We used a recognition format,
involved in treatment were slightly higher than those who
with the interviewer describing each treatment element,
did not (2.35 vs. 2.13), but this did not approach significance
deliberately to maximize recollection since we were inter-
(t = −1.32, p = .19). Enactment was, however, significantly
ested in enactment as opposed to verbal recall. Despite our
and positively related to treatment response as measured
explicit instructions to respondents, we cannot rule out the
by the STAXI-2 TA score (r = .25, p < .05) but not the
impact of social desirability, that is, claiming to recognize
AX-O score (r = .13, ns).
a concept that was actually not remembered. Still, we were
encouraged by the number of concepts endorsed as recalled,
by the number of examples offered when participants were
Qualitative Findings asked how they had used each treatment component in daily
Barriers to enactment were mentioned by the majority of life, and by the distribution of frequency and helpfulness rat-
participants in both conditions: 14 (29%) of ASMT and 9 ings for each component: all but one of the components in
(39%) of PRE participants said that nothing had interfered each treatment condition were used “frequently” or “very
with their ability to use the techniques and concepts learned frequently” by more than one-third of the participants who
in treatment. The most frequently cited barrier to enactment, had been exposed to them.
126 T. Hart et al.

Table 5. Examples of treatment enactment for each treatment component

Component
(abbreviated name) Participant example
ASMT components
Anger Is Normal I used to get angry and I was ashamed about being angry : : : But now I realize that everyone gets angry;
it’s just learning how to deal with it : : : The therapy has put me in a different place and I have a different
perspective about it.
Anger Reasons in TBI I deal with the public on a daily basis and the public can be very frustrating and so I use the brain reasons
and life reasons to help me understand why I am feeling a certain way and give me pause, to give me a
chance to handle situations in a different way or a better way : : : It helps me understand the “why” of how
I am feeling.
Anger Self-Monitoring I was doing homework online; it was math, and it is very frustrating : : : I could feel myself getting hot,
which is one of my physical cues, so I left the computer and took a walk around the halls of my dorm to
cool down.
Expanding Emotional I got in an argument with a friend, and instead of just saying that I was angry at him, I tried to express what
Vocabulary exactly was making me angry, using words like, “disrespected” and “being lied to” instead of just saying,
“I’m angry.” [This] causes me to slow down and think about it and stops me from just losing it and
throwing myself around in a rage.
Taking Time-Out I work in customer service : : : I use this technique every day, all the time, to mentally step away (not
literally) from what they are telling me, while I let them vent : : : and I think about how to solve it. Then I
come back and we find a strategy : : : [I’m] trying to find ways to solve the problem, and not getting
angry and being mean.
Positive Communication My mom asks me to do things now that I don’t want to do, and I usually give her a nasty answer. So I
always try to say– instead of, “Not now, Mom. Ugh, Mom,”– I try to give her more positive responses.
Even if it’s something I don’t want to do, I’ll try to say, “Mom, I understand and I’ll try and do it later.
Now’s not a good time.”
Active Listening At work : : : I got in trouble for being 5 minutes late. I really just listened and put myself in her shoes and
the situation worked out a lot better than it could have. I think because I listened and agreed with her
instead of arguing, she didn’t write me up and she felt that I understood.
PRE Components
TBI Change Is Normal This helped me start thinking about stuff differently. It was enlightening. I started thinking, “If you accept
that you have a brain injury, then you understand why your emotions might be this way.”
Recovery Potential When I get frustrated or struggling with stuff, I realize that I’m doing a lot better than I did even last year,
or the year before. It helps me understand : : : there’s the possibility for future improvement. Something
might bug me a certain way today, and tomorrow it might be different.
Adjustments Are Natural I think about what I have been through in the last 3 years on a daily basis and going through the therapy
program made me more aware of what I am going through and it has been helpful. Yesterday, when my
grandkids came here for the week, I just sat back and was thankful for everything I have been through.
Relationship Changes My friends’ attitudes toward me have changed : : : [this] idea helps me know who my true friends are. My
old friends who I have had my whole life are still my friends; a few of my newer friends aren’t really
there for me, just there for themselves.
Community Role Changes Yesterday, it was helpful to me because it helps me evaluate and analyze what I will do in the community
in the future. As a result of my experiences since my injury, I am starting to think about using my
personal experiences, my injury, combined with my professional background, to become an advocate for
other individuals and families : : :
Much Is Unchanged I just feel that I am the same person inside. I am not bitter since the injury, and I don’t have a lot of guilt.
Life is too short for that : : : Some people who do not have TBIs do half the stuff that I do, and I am not
even at 100%. So I feel OK.
Expressing Feelings in I started writing stuff down when I started getting angry. Sometimes I still get angry, but when I start to
Words write to it down, it kind of takes the anger out.

A striking finding was the close similarity in both fre- what we have termed the “dilemma” of the control condition
quency and helpfulness ratings across the two treatment arms, for behavioral treatment trials (Hart, Fann, & Novack, 2008).
one of which was designed as a control condition. This gen- Ideally, an active control contains all of the ingredients in the
erally comports with the results of the parent trial (Hart et al., experimental condition save the active ones responsible for
2017), which found a stronger than the expected response on change in the target behavior(s). But such ingredients are
anger measures in the PRE condition, and serves to highlight difficult to isolate and operationalize, let alone remove, in
Hart-Treatment Enactment 127

novel, complex interpersonal interventions (Hart, 2009). The that persons with more cognitive flexibility and problem-
so-called nonspecific factors such as warmth and therapist solving ability would find more ways to generalize treated
attention may be necessary delivery vehicles for the active skills and concepts to everyday situations. The integrity of
ingredients within specific, theoretically motivated treatment pretreatment episodic memory was a weaker predictor, just
protocols; to render an interpersonal treatment without such missing statistical significance. However, this trend was
factors, or containing material that is completely irrelevant consistent with the number of participants who cited memory
to the target problem, could bias a trial in favor of the exper- for treatment content as a barrier to enactment. A clear direc-
imental treatment by alienating participants. Experts in main- tion for future research would be including booster sessions to
stream anger management programs have expressed concern reinforce the material and to help prevent relapse, or a
about the lack of evidence for the superiority of specific over software application that could be used “just-in-time,” that
nonspecific factors as well (Olatunji & Lohr, 2004). is, at the first sign of an imminent anger response, to remind
While we cannot offer a solution to this dilemma, our people of their preferred strategies.
findings may help to illuminate some of the concepts most The hypothesis that the involvement of an SO in treatment
engaging to participants receiving brain injury psychoeduca- would be reflected in greater treatment enactment was not
tional interventions, which are often provided in clinical as confirmed. In fact, a substantial number of participants cited
well as research settings. Specifically, our PRE participants other people as a barrier to enactment, even when they had
seemed to find the most value in ideas that normalized their relatives involved in treatment sessions. Our enactment
experiences and provided perspective about positive as well interviews did not include questions about whether the “other
as negative changes, as well as the perspective of long-term people” cited as barriers were the SOs involved in treatment
recovery. Regarding this last concept, we did not imply that or different people; future trials should consider including
there would be complete recovery following moderate to such questions. In this study, the barriers involving other
severe TBI, only that recent research has shown that positive people were described as others belittling or not cooperating
changes may occur for longer than previously expected with participants’ attempts to express feelings other than
(Corrigan & Hammond, 2013). anger, or concerns that participants would appear weak if they
Participants in the ASMT program also valued the normal- used strategies that obviated anger responses. This serves as a
izing concepts used in that treatment. In ASMT, the emphasis reminder that anger expression is at least in part culturally
was on normalizing anger as an essential, protective response determined, and that future efforts in this direction need to
to threat, which could be managed to one’s advantage, and on take cultural and familial factors into account.
validating the many reasons for exacerbation of anger follow- In this study, treatment enactment was significantly
ing TBI. The first step in learning to manage anger is learning associated with treatment response as measured by change
to better recognize when one is becoming angry via self- in TA. Although the causal direction of this association
monitoring, a skill that more than half of participants reported cannot be firmly established in this study, it may be that
using frequently. After anger is recognized, one needs a the use of learned strategies by the participants in daily life
method for managing the situation; the Time-Out technique, maximizes the impact of the treatment by helping to diminish
which was also among the most frequently enacted of the the tendency to perceive situations as hostile or threatening.
treatment components, provides the basis for selecting a rea- Limitations of this study include a relatively small sample
soned response rather than the knee-jerk reaction of acting out and a reliance on self-report, which could introduce significant
(or passive aggression). It was not surprising that relatively distortions from cognitive limitations as well as demand char-
fewer participants reported using the specific communication acteristics of the research. Future enactment research would
techniques (Positive Communication, Active Listening), as benefit from exploring ways of improving or confirming
these may be used only in interpersonal situations and are self-report. For instance, participants’ examples of enactment
therefore less “all-purpose” than the Time-Out strategy. might be formally evaluated for accuracy, a process not under-
During the treatment sessions, ASMT participants developed taken in the current study due to resource limitations. A two-
a list of what we termed Calming Strategies, which were step process in which participants are first asked for free recall
personal methods for dealing constructively with anger- of components, followed by a recognition procedure, might
provoking situations. A main purpose of the Time-Out also help to improve confidence in the validity of the data.
technique is to allow the person time to decide which strategy In addition, collateral respondents close to the participant
will be most effective in dealing with a given situation. The might be interviewed, or participants might be asked to keep
fact that several participants cited becoming angry “too fast” logs of enactment; this type of activity might also serve as an
for the strategies to be effectively used implies that programs additional reminder to keep using the treatment material
such as ASMT might be more effective if important strategies (Zauszniewski et al., 2016). It would also be helpful for future
are practiced to a criterion of automaticity, so that they can be studies to compare treatment enactment during treatment with
enacted with less effort under stress. enactment following treatment, to learn more about changes
Regardless of the treatment to which participants were over time. In the current study, therapists assessed and rein-
assigned, the predictors of greater treatment enactment forced enactment during the treatment phase via review of
included executive function and general intelligence, but homework, response to practice exercises, etc., but this was
not baseline anger or emotional distress. It is not surprising not measured in a formal way. Where appropriate to the
128 T. Hart et al.

intervention, such as treatments to improve sleep quality or Grace, J. & Malloy, P.F. (2001). Frontal Systems Behavior Scale
increase physical activity, future studies might also assess (FrSBe): Professional manual. Lutz, FL: Psychological
enactment using passive activity monitoring systems (e.g., Assessment Resources, Inc.
Fitbits), as suggested by previous authors (Bellg et al., 2004). Grow, J.C. Collins, S.E. Harrop, E.N., & Marlatt, G.A. (2015).
Enactment of home practice following mindfulness-based relapse
prevention and its association with substance-use outcomes.
CONCLUSION Addictive Behaviors, 40, 16–20.
Hart, T. (2009). Treatment definition in complex rehabilitation inter-
While treatment enactment is difficult to measure, the effort to ventions. Neuropsychological Rehabilitation, 19(6), 824–840.
do so is worthwhile if we are to understand the factors that Hart, T., Benn, E.K., Bagiella, E., Arenth, P., Dikmen, S.,
affect our patients’ ability to maintain benefit from treatments Hesdorffer, D.C., Novack, T.A., Ricker, J.H., & Zafonte, R.
provided in the clinic or in intervention trials. Some treatments (2014). Early trajectory of psychiatric symptoms after traumatic
may effect their changes during the interval in which the thera- brain injury: Relationship to patient and injury characteristics.
pist and patient are working together, but many, if not most, Journal of Neurotrauma, 31(7), 610–617.
neuropsychological treatments depend for their long-term Hart, T., Brockway, J.A., Fann, J.R., Maiuro, R.D., & Vaccaro, M.J.
(2015). Anger self-management in chronic traumatic brain injury:
effects on the adoption of new strategies and habits.
Protocol for a psycho-educational treatment with a structurally
Measuring the individual differences and treatment compo-
equivalent control and an evaluation of treatment enactment.
nents that support these long-term changes will help to advance Contemporary Clinical Trials, 40, 180–192.
the efficacy and effectiveness of treatments in our field. Hart, T., Brockway, J.A., Maiuro, R.D., Vaccaro, M., Fann, J.R.,
Mellick, D., Harrison-Felix, C., Barber, J., &Temkin, N.
(2017). Anger self-management training for chronic moderate
ACKNOWLEDGEMENTS to severe traumatic brain injury: Results of a randomized
This work was supported by the National Institutes of Health controlled trial. The Journal of Head Trauma Rehabilitation,
(R01HD042738) and the Peer Review Committee of Moss 32(5), 319–331.
Rehabilitation Research Institute. The authors express deep Hart, T., Dijkers, M., Whyte, J., Braden, C., Trott, C., & Fraser, R.
(2010). Vocational interventions and supports following job
appreciation to Jo Ann Brockway, PhD for her contributions
placement for persons with traumatic brain injury. Journal of
to this work.
Vocational Rehabilitation, 32(3), 135–150.
Hart, T., Fann, J., & Novack, T. (2008). The dilemma of the
CONFLICT OF INTEREST control condition in experience-based cognitive and behavioral
The authors have nothing to disclose. treatment research. Neuropsychological Rehabilitation, 18(1),
1–21.
Lichstein, K.L., Riedel, B.W., & Grieve, R. (1994). Fair test of
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