Controlled Evaluation of a Computerized Anger-reduction Treatment for Suicide Prevention

Problematic anger is often found among returning military veterans, especially those exposed
to combat. Anger control problems are associated with difficulties with reintegration. One
study of Iraq-Afghanistan combat veterans who used VA medical services (N = 754) found that
difficulty controlling anger was the most commonly reported problem experienced since
homecoming, occurring among 57% of the sample (Sayer et al., 2010). Problematic anger and
hostility have also been linked to risk for suicide (Daniel et al., 2009; Lehnert,
Overholser, & Spirito, 1994; Maiuro, O'Sullivan, Michael, & Vitaliano, 1989). From the
perspective of the interpersonal-psychological theory of suicide (Joiner, 2005), individuals
with problematic anger may be at increased risk for suicide because they engage in impulsive
behaviors (e.g., aggression, substance abuse) intended to manage anger. Such behaviors may
lead to exposure to painful and provocative events, which increase their acquired capability
for engaging in suicidal behavior. Additionally, anger problems often lead to social
isolation, which may contribute to greater perceived burdensomeness and a failed sense of
belonging, established risk factors for suicide (Van Orden et al., 2010).

Anger prone individuals are likely to hold the hostile attribution bias, which reflects the
tendency to interpret the ambiguous actions of others as reflecting hostile intent
(Wilkowski & Robinson, 2008). Recently, researchers have developed computerized
interpretation bias modification (IBM) protocols intended to efficiently reduce interpretive
biases. These treatments have shown efficacy in reducing anxiety and depression (Beard &
Amir, 2008; Holmes, Lang, & Shah, 2009; Mathews et al., 2007). We have conducted studies
using similar procedures that focus on hostile interpretation biases and found our program
to successfully reduce anger and hostility.

To evaluate the efficacy of the IBM protocol we have developed in reducing anger and suicide
risk, we will conduct a three-arm randomized controlled trial over the internet. Military
veterans and non-veteran community participants reporting elevated trait anger (N = 120)
will be randomized to one of three conditions: 1) IBM; 2) progressive muscle relaxation
(PMR); or 3) healthy education videos (control). Each condition will consist of eight
15-minute treatment sessions. Participants will complete two sessions per week for four
weeks and will be administered assessments at pre- and post-treatment. IBM and PMR
conditions will also complete 3-month and 6-month follow-up assessments. To ensure an
adequate test of the effects of this intervention on suicide risk, we will oversample for
individuals with current suicidal ideation. We hypothesize that: 1) IBM will lead to greater
reductions in anger than PMR and control conditions in a sample with problematic anger; 2)
IBM will lead to greater reductions in suicidal ideation, perceived burdensomeness, and
thwarted belongingness than PMR and control conditions; 3) efficacy of the IBM condition in
reducing suicidal ideation will be mediated by reductions in perceived burdensomeness and
thwarted belongingness; 4) group differences between IBM and PMR will be maintained at the
3-month and 6-month follow-up assessments.

Inclusion Criteria:

- elevated levels of trait anger (scoring 19 or higher, or the top 25% of the general
population)

- must have access to a computer with an internet connection

- must also be English speakers

Exclusion Criteria:

- currently receiving therapy for problematic anger

- evidence of serious suicidal intent requiring hospitalization or immediate treatment

- evidence of psychotic-spectrum disorders