Empirical comparison of three treatments for adolescent males with physical and sexual aggression: mode deactivation therapy, cognitive behavior therapy and social skills training.

This research study compared the efficacy of three treatment methodologies for adolescent males in residential treatment with conduct disorders and/or personality dysfunctions and documented problems with physical and sexual aggression. The results showed that Mode Deactivation Therapy, an advanced form of cognitive behavioral therapy based on Beck's theory of modes, was superior to traditional Cognitive Behavioral Therapy and Social Skills Therapy in reducing both physical and sexual aggression. At the same time, Mode Deactivation Therapy was the only treatment of the three that significantly reduced sexual aggression for these youth.

Keywords: Treatment Effectiveness, Conduct Disorders, Adolescent Sex Offenders, Cognitive Behavioral Therapy, Mode Deactivation Therapy, Personality Disorders

INTRODUCTION

Youth with conduct disorders and personality dysfunctions are extremely difficult to conceptualize and treat effectively. Such youth typically come from deprived environments with multiple stressors and often extensive histories of physical, emotional and sexual victimization and neglect. As a group, conduct disordered youth present with a complex array of recurrent behavioral problems, including aggression, bullying, violence, intimidation, delinquency, rule violations, recklessness, property destruction, callous disregard for others, substance abuse, sexual abuse and other disruptive and anti-social behaviors (Kazdin and Weisz, 2003). In fact, the prevalence rate for conduct disorder is 6% to 16% for males under age 18 and it is one of the most frequent problems diagnosed in outpatient and inpatient mental health programs. Moreover, 80% of these youth are likely to meet criteria for psychiatric disorders in the future (Kazdin and Weisz, 2003). For example, a longitudinal study by Johnson, Cohen, Brown, Smailes, and Bernstein (1999) showed a clear connection between childhood maltreatment and the development of cluster B personality disorders in later adolescence. Moreover, conduct disorder is by far the most frequent psychiatric diagnosis given to youth involved in the juvenile justice system with rates as high as 81% to 91% of incarcerated youth (Boesky, 2002).

Dodge, Lochman, Harnish, Bates and Petti (1997) have contributed a useful distinction between two types of conduct disordered youth: "Reactive aggressive" youth show extremely strong emotional responses to perceived threats and then react aggressively. The second type, "proactive aggressive" youth, initiate or use violence and aggression in an instrumental fashion to gain an objective or "pay-off." The former category appear to share a common characteristic pattern of "emotional dysregulation," in which the youth is overwhelmed by a sudden surges of intense emotions, sensations and irrational thoughts that are occur in combination and are disproportionate to the situation. Koenigsberg, Harvey, Mitropoulou, Antonia, Goodman, Silverman, Serby, Schopick and Siever (2001) found that many types of aggression, including self-destructive behavior, are linked to the personality disordered traits of affective instability and impulsivity (i.e., emotional dysregulation). Our research and clinical experience with violent and sexually aggressive youth suggests that this common phenomenon of "emotional dysregulation" is the same process that Aaron Beck (1996) has described as "modes" and that treatment must be modified to accommodate and address this process in order to be effective.

Need for Effective Treatment

Given the prevalence of conduct disorders and its major contribution to juvenile crime, societal violence, delinquency and sexual violence, there is a urgent need for effective treatment methods for such youth. While Kazdin and Weisz (2003) delineates some evidence-based treatment practices for children with Conduct Disorder, the same has been not achieved for adolescents over 14 years old. In recent years, Multisystemic Treatment has shown promise for antisocial youth (Henggeler, Schoenwald, Borduin, Rowland and Cunningham, 1998) and for adolescent sex offenders (Swenson, Henggeler, Schoenwald, Kaufman, and Randall, 1998), but it requires a resource-rich combination of services, one of which is psychotherapy, and it is not a realistic option for most such youth. Cognitive behavioral therapy (CBT) is widely employed in the treatment programs for behaviorally disordered youth across many settings and is frequently used with aggressive youth and adolescent sex offenders. But there are clear limits to the effectiveness of CBT in the treatment of personality disordered clients, especially borderline and narcissistic types (e.g., Young, Klosko and Weishaar, 2003).

Apsche developed an advanced form of cognitive behavioral treatment called "Mode Deactivation Therapy" (Apsche and Ward Bailey, 2004a) in order to simultaneously address the multiple problems issues of conduct- and personality-disordered youth, while also accommodating the particular defensive characteristics of the adolescent. Mode Deactivation Therapy (MDT) has been applied to adolescent sex offenders and mentally ill adolescents alike. MDT is an evidence-based treatment that blends key elements from Beck's theory of "modes" (Beck, 1996); traditional Cognitive Behavioral Therapy and Schema Therapy (Alford and Beck, 1997; Beck and Freeman, 1990); Dialectical Behavior Therapy (Linehan, 1993); and Functional Analytic Behavior Therapy (Kohlenberg and Tsai, 1993; Nezu, Nezu, Friedman and Haynes, 1998).

Beck's Theory of "Modes"

Recognizing that his earlier model of cognitive schemas was inadequate to explain a number of psychological problems, Beck (1996) introduced the concept of "modes" in his article, "Beyond belief: A theory of modes, personality and psychopathology." Beck conceives of "modes" as suborganizations of the personality, which are comprised of integrated networks of cognitive, affective, motivational and behavioral components, that have developed through experience as an "automatic" response to particular types of situations, notably perceived threats (Beck, 1996; Apsche, 2004). Thus, modes are consistent, coordinated, self-protective response systems for an individual, which are controlled by schema. Moreover, modes are charged (or "cathected") such that some schemas are more intensive and powerful than others in driving responses to perceived threat.

In Beck's theory, when an individual is faced with a perceived danger or potential threat, his orienting schema can activate a dysfunctional "mode" with all its simultaneous aspects--a particular conglomerate of beliefs, emotions, motivation, and behavior (Apsche, 2004). Dysfunctional modes are typically characterized by high levels of anxiety, fear, irrational thoughts and feelings, and aberrant behaviors. Further, "modes" are self-reinforcing and maintained by a group of fundamental beliefs. For this population, individuals have developed maladaptive orienting schemas and modes as protective strategies in response to their traumatic and abusive life experiences. Originally these modes were useful survival strategies that protected the individual from distress and threat, but they have become ingrained, virtually automatic, maladaptive responses.

As repeated victims of various trauma, neglect and abuse, these youth are ultra-sensitive to learned experiential cues, often unconscious, that signal danger and vulnerability. Alford and Beck (1997) refer to this phenomenon in describing how the schema that typify personality disorders operate on a more continuous basis and are more sensitive to triggering events. Hence, such individuals are always ready to defend and/or attack at the first sign of perceived danger. In short, when faced with a perceived risk of victimization/vulnerability, such individuals are unable to override the primal, automatic "mode" response by employing cognitive controls because they are instantaneously flooded with powerful feelings, sensations and fear.

Mode Deactivation Therapy

Mode Deactivation Therapy is designed to disrupt ("de-activate") the pre-established maladaptive cognitive/affective/motivational/behavioral response set ("mode") that is automatically triggered by the situational occurrence of the orienting schema. For example, a youth has the orienting schema that, "You can't trust anyone because you will be betrayed" and he is in the situation of developing more closeness with a peer or staff person in the treatment program. For this youth, his orienting schema would trigger a maladaptive "mode" in which the youth may become anxious, have intense physiological sensations, have paranoid thoughts that the person is "out to get me" and start to withdraw or act aggressively.

Apsche repeatedly found that traditional cognitive behavioral therapy was not adequate to the instantaneous, primal and extremely powerful effects of maladaptive "modes" with conduct disordered and personality disordered adolescents. Similarly, in using CBT with Axis II disorders, Young, Klosko and Weishaar (2003) found that personality-disordered clients, especially borderline and narcissistic, continue to experience significant emotional distress following treatment. Apsche observed that most aggressive and sexually aggressive youth tend to lose control with such sudden primal intensity that they are unable to tolerate the traditional procedures of cognitive restructuring. Moreover, cognitive behavioral therapy itself needed to be modified to accommodate the adolescent's natural developmental sensitivities to resisting authority in the therapeutic relationship.

Consequently, Apsche and his colleagues blended methods from three proven treatment models--Cognitive Behavioral Therapy, Dialectical Behavior Therapy, and Functional Analytic Behavioral Therapy--to create an advanced form of cognitive behavioral therapy called "Mode Deactivation Therapy" (MDT).

Elements from Cognitive Behavioral Therapy: As described above, the term "mode de-activation" itself derives from Beck's (1996) term "modes" and uses his cognitive behavioral theoretical formulation of "modes." MDT shares the basic tenets of classic cognitive behavior therapy, including "Schema Therapy," which holds that internal schemas are at the core of the personality disorders (Young, Klosko and Weishaar, 2003). MDT agrees that aberrant behavior derives from dysfunctional schema that trigger "modes," but it takes a radically different approach to correcting such schema. Unlike cognitive therapy, MDT does not directly challenge the irrationality of the orienting schema by "arguing" the concepts of cognitive distortions. Even when the therapist has a good rapport, such youth are acutely sensitive to the power dynamic of being in a one-down position. Given their histories of victimization, they typically have serious difficulties with interpersonal trust. Challenging the reality of a youth's beliefs and perceptions is negatively experienced as an attack on his esteem, his world-view and his fragile sense of self. Developmentally, such youth perceive the cognitive therapist as another adult trying to impose their authority and force him to change. Adolescents bristle and respond poorly to direct cognitive corrections--even when such interventions seem to be delivered in the most gentle and collaborative fashion. Cognitive therapy then, as it is normally practiced, can trigger a negative response that undermines progress (Apsche and Ward Bailey, 2004a).

Elements from Dialectical Behavior Therapy: To accommodate this developmental and clinical barrier to traditional cognitive therapy, MDT uses two key principles from Dialectical Behavior Therapy (Linehan, 1993), which was originally developed to treat extremely unstable and volatile patients with severe personality disorders. Dialectical Behavior Therapy (DBT) uses the technique of radical acceptance in which the therapist elucidates and validates the unique "truth" in each individual's perceptions. Rather than directly challenging the validity or empirical support for the youth's beliefs and perceptions, MDT uses radical acceptance in fully validating the "grain of truth" of the individual adolescent's beliefs based on his life experiences and trauma history. The goal is to join with the youth in order to discover how the belief system is a legitimate reflection of the youth's life experience, relationships, sense of self and world view.

Subsequently, given radical acceptance and increased trust, the therapist can use the therapeutic relationship as well as the youth's direct experiences in the treatment program to show how beliefs can be modified based on corrective therapeutic experiences. MDT also adopts the technique of balancing from Dialectical Behavior Therapy. This is an interactive method of introducing increasing flexibility or balance in the individual's rigid and maladaptive dichotomous (either/or) beliefs by redirecting the person to considering a continuum of truth or a continuum of possibilities.

Elements from Functional Analytic Behavioral Therapy: MDT also incorporates principles from Functional Analytic Behavioral Therapy (Kohlenberg and Tsai, 1993). First, MDT aligns with FAB in affirming that perceptions of reality and unconscious motivations evolve from past contingencies of reinforcement, such as families of origin. Second, MDT uses an assessment and Case Conceptualization method that combines elements from Beck's (1996) case conceptualization and the Factor Analytic Behavior Therapy model of Nezu, Nezu, Friedman and Haynes (1998). The assessment and case conceptualization procedure concentrates on core beliefs, fears and avoidance behaviors that are reflective of the Post-Traumatic Stress Disorder and developing personality disorders (see Apsche and Ward Bailey, 2003, 2004b, 2004c).

The crucial difference between Mode Deactivation Therapy and Cognitive Behavioral Therapy is that the core beliefs (or schemas) of the individual are not seen and challenged as dysfunctional because this action necessarily invalidates the person's life experience. Instead, in MDT, core beliefs are consistently validated as legitimate creations from the person's life experience (no matter how irrational and even if they have little more than a tiny "grain of truth"), which are then "balanced" through the collaborative therapeutic process to deactivate the maladaptive mode responses.

The present study was designed to assess the effectiveness of Mode Deactivation Therapy (MDT) as compared to Cognitive Behavior Therapy (CBT) and Social Skills Training (SST) in the treatment of conduct disordered and personality-disorder youth with problems of aggression and sexual aggression.

METHOD

Sample Characteristics

A total of 60 male adolescents participated in the study. All subjects were referred to the same residential treatment facility for the treatment of aggression and/or sexual aggression. In this real world setting, subjects were randomly assigned to one of the three treatment conditions at the time of admission based on available openings in the caseload of the participating clinicians. The three treatment conditions showed similarity in terms of the frequency of Axis I and Axis II diagnoses, age, and racial background. To ensure consistency in the delivery of the three respective treatments, therapists were specifically trained in the one of the three treatment curriculums/methods. The average length of residential treatment across all conditions was roughly 11 months.

Condition one: Cognitive Behavioral Therapy (CBT): A total of nineteen male adolescents were assigned to the CBT condition. The group was comprised of 14 African Americans, 4 European Americans and 1 Hispanic American with an average age of 16.5. The principal Axis I diagnoses for this group included Conduct Disorder (14), Oppositional Defiant Disorder (4), and Post Traumatic Stress Disorder (7). Axis II diagnoses for the group included Mixed Personality Disorder (4), Borderline Personality Disorder (2), Narcissistic Personality Disorder (1) and Dependent Personality Disorder (1).

The particular CBT methodology used for this group employed a published treatment curriculum and workbook system for adolescent sex offenders called "Thought Change" (Apsche, 1999, Apsche, Evile and Murphy, 2004). This structured treatment program is specifically designed for personality disordered and conduct-ordered youth with psychosexual disturbances and high levels of aggression and violence. Components of this psycho-educational treatment curriculum included daily recording of negative thoughts, cognitive distortions, cognitive restructuring, sexual offense patterns and beliefs, aggressive patterns and beliefs, mood management, dysfunctional beliefs, taking responsibility, mental health maintenance, substance abuse issues, and victim empathy.

Condition two: Social Skills Training (SST): A total of twenty male adolescents were assigned to the SST condition. The group was comprised of 14 African Americans, 4 European Americans and 2 Hispanic American with an average age of 16.1. The principal Axis I diagnoses for this group included Conduct Disorder (17), Oppositional Defiant Disorder (3), and Post Traumatic Stress Disorder (5). Axis II diagnoses for the group included Mixed Personality Disorder (4), Borderline Personality Traits (1), Narcissistic Personality Traits (1), and Avoidant Personality Traits (1).

The Social Skills Training program included identification and reinforcement of appropriate behaviors, target skill identification, modeling, practicing skills, and role playing. The youth in this condition were encouraged to practice skills and were reinforced by shaping and fading procedures. All staff and therapists were trained and supervised in SST by a doctoral level psychologist. All skill training was performance based and evaluated for each individual (Henggeler, Schoenwald, Borduin, Rowland and Cunningham, 1998).

Condition three: Mode Deactivation Therapy (MDT): A total of twenty-one male adolescents were assigned to the MDT condition. The group was comprised of 15 African Americans, 5 European Americans and 1 Hispanic American with an average age of 16.5. The principal Axis I diagnoses for this group included Conduct Disorder (15), Oppositional Defiant Disorder (2), Post Traumatic Stress Disorder (7), and Major Depressive Disorder, primary or secondary (5). Axis II diagnoses for the group included Mixed Personality Disorder (6), Borderline Personality Traits (3), and Narcissistic Personality Traits (2). The MDT condition used the methodology described earlier in this paper.

Measures

The key measures of physical and sexual aggression used in this study consisted of Daily Behavior Reports and Behavior Incident Reports. The Daily Behavior Reports were completed by all levels of staff, both professional and paraprofessional, across all settings of the residential treatment program (e.g., schoolroom, psychoeducational classes, treatment activities, residential dormitories, etc.). The Behavior Incident Reports were only completed by staff following the occurrence of serious or critical incidents, namely, acts of physical and sexual aggression. Inter-rater reliability in the use of the measures was determined by independently totaling the number of physical and sexual aggression incidents on both the Daily Behavior Report cards and the Behavior Incident Report forms and calculating the percentage of agreement. The agreement for this study was at the 98% level.

The baseline ("pre-treatment") measure of physical and sexual aggression consisted of the average number of incidents per week that occurred during the first 60 days following admission and the post-treatment measure was the rate of occurrence during the 60 day period prior to discharge.

RESULTS

This research study was initiated to compare the efficacy of three different treatment methods for male adolescents in residential treatment for physical and/or sexual aggression. We began the analysis by assessing weekly behavioral reports, which indicated a number of observed sexual or aggressive acts. Once reports were compiled, statistical analysis of the results ensued. It was found that all participants benefited from treatment regardless of theoretical orientation (see table one). The baseline average rate of aggression across all groups was 1.56 with a total standard deviation of .501 and standard error of .065. There was a 74% reduction in rate of aggression to the post treatment mean of .41, with a standard deviation of .495 and standard error of .065. An independent T test was performed on the difference in means. The T-test found a significant difference between the baseline and post-treatment measures T = 18, df = 59, p <.01.

[TABLE 3 OMITTED]

Further analysis was performed on the difference between baseline and post-treatment rates of sexual aggression. The baseline mean across all groups was 1.68 with a total standard deviation of .471 and standard error of .061. There was a 76% reduction in the rate of sexual aggression to the post-treatment mean of .41 with a standard deviation of .495 and standard error of .065. A One-way ANOVA was computed and indicated a significant difference, F(2,56) = 8.32, p < .01.

Thus, the first analysis suggests that all types of treatment--Mode Deactivation Therapy, Cognitive Behavioral Therapy and Social Skills Training--had a positive effect of reducing rates of physical and sexual aggression over the course of treatment (see Table 3).

behavior when treated with MDT as compared to CBT or SST. To test this hypothesis, a one way analysis of variance (ANOVA) was conducted on the baseline and post-treatment measures of physical and sexual aggression. Both post-treatment physical aggression and post-treatment sexual aggression were significantly affected by type of treatment, F(2, 56) = 8.32, p < .01 (post-treatment aggression); F(2, 56) = 10.02, p < .01 (post-treatment sexual aggression).

[GRAPHIC OMITTED]

To better elucidate between-group differences in magnitude of effect, independent factorial analyses on treatment model and variable were conducted.

With a overall percent reduction of 80.7% in rates of post-treatment physical aggression, Mode Deactivation Therapy was found to be superior to Cognitive Behavioral Therapy at 72.6% and Social Skills Training at 68.8%. The greater magnitude of effect for MDT was statistically significant compared to both CBT and SST, which were not significantly different from each other.

The most dramatic difference between treatment groups was found in reduction of post-treatment rates of sexual aggression. In this instance, only Mode Deactivation Therapy showed a statistically significant reduction in rates of sexual aggression from baseline to post-treatment. MDT showed a reduction of 84.5% in sexual aggression compared to CBT and SST at 72.0% and 70.6% respectively. Post-treatment rates of sexual aggression were .30 for MDT, .42 for CBT, and .43 for SST. The differences were significant using an independent T-test comparing, CBT, MDT and SST. The T test showed T = 2.21, df = 39, p =.01. The results clearly show that MDT produced significantly superior results when compared to CBT and SST. These differences in magnitude of effect are graphically represented in Table 6.

[TABLE 6 OMITTED]

DISCUSSION

The data indicates that Mode Deactivation Therapy (Apsche and Ward Bailey, 2004a) may achieve superior results to traditional Cognitive Behavioral Therapy (CBT) and Social Skills Training (SST) in reducing both physical aggression and sexual aggression in conduct-disordered and personality-disordered youth in a long-term residential treatment setting. Moreover, while all three treatments were effective in reducing physical aggression, only Mode Deactivation Therapy (MDT) demonstrated a significant reduction in rates of sexual aggression. This finding suggests that the technical modifications of cognitive behavioral treatment used in MDT may be better suited to the unique developmental and clinical presentation of these behaviorally disturbed adolescents and yield superior outcomes, especially with regard to sexual abuse issues.

[ILLUSTRATION OMMITED]

At the same time, several factors may limit the strength of the conclusions drawn from the outcomes. First, the results were derived in a long-term residential treatment program and may not find replication in less intensive outpatient treatment settings. Second, there are inherent difficulties in identifying "pure" diagnostic types for multiply-challenged youth such as these. While there was striking similarity in the distribution of diagnostic categories across treatment conditions (e.g. Conduct Disorder, Oppositional Defiant Disorder, Personality Disorders), exact matching by diagnosis could not be realistically achieved in this real world setting. Moreover, while all of the youth had documented histories of physical aggression and nearly all had histories of sexual aggression, it was not possible to definitively distinguish individual youth as primarily sex offenders or primarily aggressive youth nor match them accordingly across the three conditions.

As in any real world study, it is always difficult to control for the levels of competence of the participating therapists and their adherence to the "purity" of each of the three treatment methods. Best efforts were made to control for this common problem by ensuring that therapists shared the same professional degree and level of clinical experience in each of the three methodologies and by providing training in the delivery of each model prior to the study.

The strength of the outcomes could be further enhanced with the inclusion of additional outcome measures and, ideally, long-term follow-up of the youth who participated in the study. It is important to note that the authors do not purport that MDT will generalize to any groups other than youngsters with conduct and personality disorders.

The authors hope that future research may use randomized trials in outpatient clinics and attempt to replicate these findings in other residential treatment facilities and with other relevant adult and adolescent populations, particularly with those identified primarily as sexual offenders.

REFERENCES

Alford, B.A. and Beck, A.T. (1997). The integrative power of cognitive therapy. New York: Guilford Press.

Apsche, J.A. (2005). Beck's theory of modes. International Journal of Behavioral Consultation and Therapy, 1(1), in press.

Apsche, J.A. (1999). Thought Change Workbook. Portsmouth, VA: Alternative Behavioral services.

Apsche, J.A., Evile, M.M., and Murphy, C.J. (2004). The thought change system: An empirically based cognitive behavior therapy for male juvenile sex offenders. A pilot study. Behavior Analysis Today, 5(1), 101-107.

Apsche, J.A. and Ward Bailey, S.R. (2004a). Mode Deactivation Therapy: Cognitive-behavioural therapy for young people with reactive conduct disorders or personality disorders or traits who sexually abuse. In M.C. Calder (Ed.), Children and Young People who Sexually Abuse: New Theory, Research and Practice Developments, pp. 263-287. Lyme Regis, UK: Russell House Publishing.

Apsche, J.A. and Ward Bailey, S.R. (2003). Mode deactivation therapy: A theoretical case analysis (Part I). Behavior Analyst Today, 4(3), 342-353.

Apsche, J.A. and Ward Bailey, S.R. (2004b). Mode deactivation therapy: A theoretical case analysis (Part II). Behavior Analyst Today, 5(1), 395-434.

Apsche, J.A. and Ward Bailey, S.R. (2004c). Mode deactivation therapy: A theoretical case analysis (Part III). Behavior Analyst Today, 5(3), 314-332.

Beck, A.T. (1996). Beyond belief: A theory of modes, personality and psychopathology. In P.M. Salkovaskis (Ed.), Frontiers of cognitive therapy, (pp. 1-25). New York: Guilford Press.

Beck, A.T. and Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford Press.

Boesky, L.M. (2002). Juvenile offenders with mental health disorders: Who are they and what do we do with them? Lanham, MD: American Correctional Association.

Dodge, K.A., Lochman, J.E., Harnish, J.D., Petti, G.S. (1997). Reactive and proactive aggression in school children and psychiatrically impaired chronically assaultive youth. Journal of Abnormal Psychology, 106 (1), 37-51.

Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D. and Cunningham, P.B. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press.

Johnson, J.G., Cohen, P., Brown, J., Smailes, E.M., and Bernstein, D.P. (1999). Associations between four types of childhood neglect and personality disorder symptoms during adolescence and early adulthood: Findings of a community-based longitudinal study. Archives of General Psychiatry, 14, 171-120.

Kazdin, A.E. and Weisz, J.R. (2003). Evidenced based psychotherapies for children and adolescents. New York: Guilford Press.

Koenigsberg, H.W., Harvey, P.D., Mitropoulou, V., Antonia, N.S., Goodman, M., Silverman, J., Serby, M., Schopick, F. and Siever, L. (2001). Are the interpersonal and identity disturbances in the borderline personality disorder criteria linked to the traits of affective instability and impulsivity? Journal of Personality, 15(4), 358-370.

Kohlenberg, R.J. and Tsai, M. (1993). Functional Analytic Psychotherapy: A behavioral approach to intensive treatment. In W. O'Donahue and L. Krasner (Ed)., Theories of behavior therapy: Exploring behavior change (pp. 638-640). Washington, D.C.: American Psychological Association.

Linehan, M.M. (1993). Treating Borderline Personality disorder: The dialectical approach. New York: Guilford Press.

Nezu, A.M., Nezu, C.M., Friedman, S.H. and Haynes, S.N. (1998). Case formulation in behaviour therapy: Problem-solving and Functional Analytic strategies. In T.D. Eells (Ed.), Handbook of psychotherapy case formulation. New York: Guilford Press.

Swenson, C.C., Henggeler, S.W., Schoenwald, S.K., Kaufman, K.L., and Randall, J. (1998). Changing the social ecologies of adolescent sexual offenders: Implications of the success of multisystemic therapy in treating serious antisocial behavior in adolescents. Child Maltreatment, 3, 330-339.

Young, J.E., Klosko, J.S. and Weishaar, M.E. (2003). Schema therapy: A practitioner's guide. New York: Guilford Press.

Author Contact Information:

(1) Jack A Apsche, Ed.D., A.B.P.P. The Apsche Center 111 South Main Street Yardley, PA 19067 [phone] [e-mail] www.ApscheCenter.com

(2) Christopher K. Bass, Ph.D., Dept of Psychology, Clark Atlanta University, 207 Knowles Hall, Atlanta, GA 30313 [phone] [e-mail]

(3) Jerry L. Jennings, Ph.D., Liberty Behavioral Health Corporation, 401 E. City Ave., Suite 820 Bala Cynwyd, PA, 19004.

(4) Christopher J Murphy, MA Regent University 1000 Regent University Drive, Virginia Beach, VA 757-226-4488 [e-mail]

(5) Linda A. Hunter, Regent University 1000 Regent University Drive, Virginia Beach, VA 757-226-4488 [e-mail]

(6) Alexander M. Siv, MA. Brightside for Families and Children 2112 Riverdale Street West Springfield, MA 01089. 413-827-4327 [e-mail]

Table 1. Diagnostic and Demographic Similarity
of Subjects Across Treatment Conditions

Axis I                              CBT    SST    MDT

  Conduct Disorder                   14     17     15
  Oppositional Defiant Disorder       4      3      2
  Post Traumatic Stress Disorder      7      5      7
  Major Depression                    0      0      5

Axis II

  Mixed Personality Disorder          4      4      6
  Borderline Personality Traits       2      1      3
  Narcissistic Personality Traits     2      1      2
  Dependent Personality Traits        1      0      0
  Avoidant Personality Traits         0      1      0

Race

  African American                   14     14     15
  European American                   4      4      5
  Hispanic/Latino American            1      2      1
  Total                              19     20     21

Average Age                        16.5   16.1   16.5

TABLE 2 Descriptive Statistics
                                                        95%
                                                     confidence
                                                       Interval
                 Tx                  Std.   Std.    Lower   Upper
Measure          Type     N   Mean   Dev.   Error   bound   Bound

Baseline         CBT     19   1.53   .513    .118    1.28    1.77
Physical         MDT     20   1.55   .510    .114    1.31    1.79
Aggression       SST     20   1.60   .503    .112    1.36    1.84
                 Total   59   1.56   .501    .065    1.43    1.69
Baseline         CBT     19   1.68   .478    .110    1.45    1.91
Sexual           MDT     20   1.65   .489    .109    1.42    1.88
Aggression       SST     20   1.70   .470    .105    1.48    1.92
                 Total   59   1.68   .471    .061    1.56    1.80

Post-Treatment   CBT     19    .42   .507    .116     .18     .67
Physical         MDT     20    .30   .470    .105     .08     .52
Aggression       SST     20    .50   .513    .115     .26     .74
                 Total   59    .41   .495    .065     .28     .54

Post-Treatment   CBT     19    .47   .513    .118     .23     .72
Sexual           MDT     20    .25   .444    .099     .04     .46
Aggression       SST     20    .50   .513    .115     .26     .74
                 Total   59    .41   .495    .065     .28     .54

                 Tx
Measure          Type    Mi   Max
                          n

Baseline         CBT      1     2
Physical         MDT      1     2
Aggression       SST      1     2
                 Total    1     2

Baseline         CBT      1     2
Sexual           MDT      1     2
Aggression       SST      1     2
                 Total    1     2

Post-Treatment   CBT      0     1
Physical         MDT      0     1
Aggression       SST      0     1
                 Total    0     1

Post-Treatment   CBT      0     1
Sexual           MDT      0     1
Aggression       SST      0     1
                 Total    0     1

Table 4. ANOVA--Difference in Outcomes
Between MDT, CBT and SST Treatment Groups

                             Sum of          Mean
Measure                     Squares   df   Square      F     Signif.

Baseline          Between      .707    2     .353
                  Groups
Physical          Within     14.005   56     .250    1.413      .252
                  Groups
Aggression        Total      14.712   58

Post-Treatment    Between     3.299    2    1.649
                  Groups
Physical          Within     11.108   56     .198    8.316      .001
                  Groups
Aggression        Total      14.407   58

Baseline Sexual   Between      .537    2     .269    1.074      .349
                  Groups
Aggression        Within     14.005   56     .250
                  Groups
                  Total      14.542   58

Post-Treatment    Between     3.483    2    1.742   10.017      .000
                  Groups
Sexual            Within      9.737   56     .174
                  Groups
Aggression        Total      13.220   58

Table 5. Post-Treatment  Scores and Percent Reduction
in Types of Aggression Across Treatments

                       MDT                      CBT
                 Post-     Percent       Post-     Percent
             Treatment   reduction   Treatment   reduction
                 Score                   Score

Physical           .30       80.7%         .42       72.6%
Aggression
Sexual             .25       84.5%         .47       72.0%
Aggression

                       SST
                 Post-     Percent
             Treatment   reduction
                 Score

Physical           .43       68.8%
Aggression
Sexual             .50       70.6%
Aggression