Table 2.

Treatment components of the ASMT and PRE treatment arms.

Treatment Component	Anger Self-Management Training	Personal Readjustment and Education
Core Philosophy	Anger is a normal, adaptive emotion that becomes harder to manage after TBI. Self-management may be strengthened by learning strategies to bolster key executive functions: self-awareness and problem-solving. These skills help P to recognize when anger is triggered, and to choose a reasoned response from an enhanced behavioral repertoire.	People with TBI do not receive adequate education or emotional support, leading to inhibition of natural coping mechanisms. Receiving information, emotional support, and opportunities to ventilate feelings in a warm, permissive atmosphere can help restore P’s ability to cope with problems.
Session 1	Introduction to program content; education about anger (normalization); discussion of specifics of P’s anger responses; introduction of Balance Sheet, listing “reasons” for P’s anger in (−) column and existing Calming Strategies/supports in the (+) column (as techniques are learned throughout program, they are successively added to (+) column).	Introduction to program content; education about TBI and the changes it may lead to; reassurance that recovery may continue over a long period of time. Explanation of “ripple effects” of TBI through 3 circles of life, each of which requires its own adjustment process: the Inner Circle (self, including emotional changes), Middle Circle (relationships with others), and Outer Circle (functioning in the wider community).
Session 2	Education about self-monitoring; reformulation of anger as a cue, not a solution; discussion of P’s characteristic anger cues in body/behavior; introduction of Other Feelings that accompany threats leading to anger, e.g., shame, fear, confusion.	Inner Circle I: Education about cognitive changes: Attention, memory, and executive function. T leads p in exercise to prompt discussion of cognitive changes experienced by P as well as areas that are more intact.
Session 3	Practice in identifying Other Feelings as signals of anger and using them to communicate more effectively (versus communicating with anger).	Inner Circle II: Education about emotional changes and why there may be under- or over-reaction to events. T invites P to ventilate feelings in supportive environment and reinforces value of putting feelings into words.
Session 4	Training and practice in how to read anger signals as a cue to initiate the Time Out technique, a key problem-solving algorithm allowing P to “slow down the action” and formulate a reasoned response.	Middle Circle I: Education about TBI and how it changes family relationships, for better or worse (and sometimes both). Discussion of role changes, guilt, and communication issues, and process of “normal” family adjustments to life changes..
Session 5	Training and practice in use of Mirror Technique, a method of replacing negative with positive communication to defuse anger situations.	Middle Circle II: Friendships, their normal cycle, and how they can be affected by TBI. P completes sociogram analyzing changes in social relationships, including positive ones.
Session 6	Training and practice in Active Listening, a technique to enhance understanding of the viewpoints of others and to avoid non-constructive argument.	Outer Circle I: Discussion of meaning of “community” and how P sees his/her belongingness, participation, and contribution as having changed, and not changed, since TBI. Discussion of changes in roles, if any.
Session 7	Self-assessment and consolidation of skills: P completes self-assessment of progress, evaluates own strengths and weaknesses related to program content, and reviews/practices techniques felt to be most in need f shoring up.	Outer Circle II: P completes self-assessment of progress to date; T prompts discussion of activities out in the community and how these may have been affected by TBI, as well as self-assessment of most fulfilling activities.
Session 8	Review and relapse prevention: Final review of skills and concepts covered in program; discussion of likely pitfalls for future and how they might be handled or circumvented; planning for generalization of learned skills to various situations.	Review of information and topics discussed in program, with emphasis on how P’s situation has not changed (or changed for the better) since TBI and affirmation of ways in which P and SO have been able to adjust and cope with changes.
Weekly assignments	Completion of Anger Logs (introduced in Session 1) to record key triggers, bodily/behavioral responses, other key data on incidents occurring between sessions; reviewed at start of Sessions 2–7	Completion of Personal Events Diary (introduced in Session 1) to record any (not necessarily related to anger) salient events and associated thoughts/feelings between sessions; reviewed at start of Sessions 2–7
Involvement of SO, if any	SO participates in portions of Sessions 1, 4, and 8, and provides brief telephone feedback privately to the T between Sessions 6 and 7, to complete a brief progress assessment parallel to the P’s self-assessment.	SO participates in portions of Sessions 1, 4, and 8, and provides brief telephone feedback privately to the T between Sessions 6 and 7, to complete a brief progress assessment parallel to the P’s self-assessment.
Proscribed elements	Topics or concerns not covered in treatment manual; T reminds P that program is focused on anger-related issues and encourages P to seek other help for different issues.	Directive counseling or giving of advice; T must not suggest specific strategies but may encourage P to create and try things on his/her own using his/her own best ways to adjust.

P= participant; T = therapist; SO= significant other