“Talk and Chalk”: An emotion regulation intervention for anger after acquired brain injury

Figures & data

Figure 1. Study overview.

Figure 2. Recruitment overview.

Table 1. Demographic and injury characteristics of the current sample (n = 24).

ID	Age (years)	Gender	Education (years)	Time since injury (years)	ABI etiology	ABI description
1	47	Male	19	1	MCA aneurysm	Rupture resulted in intracranial hemorrhage.
2	68	Male	14	10	TBI	Injury information obtained through self-report; no further information provided.
3	52	Female	14	1	TBI	Subarachnoid hemorrhage involving bilateral frontal and right temporal-occipital lobes. GCS of 12.
4	45	Male	17	7	TBI	Subdural hemorrhage in right frontoparietal region. GCS of 14.
5	28	Female	21	15	TBI	Involving frontal lobes.
6	24	Female	16	4	TBI	Severe diffuse axonal injury. GCS of 7.
7	24	Male	19	4	Hypoxia	Involving basal ganglia.
8	63	Female	11	6	Aneurysm	Rupture resulted in subarachnoid hemorrhage. GCS of 3.
9	53	Male	15	6	Tumor resection	Right frontotemporal meningioma.
10	36	Male	16	3	TBI	Diffuse axonal injury involving left postero-inferior temporal lobe and right superior frontal gyrus. GCS of 14.
11	51	Male	12	7	TBI	Involving frontal lobes.
12	85	Male	14	1	CVA	Injury information obtained through self-report; no further information provided.
13	37	Female	19	32	Tumor	Astrocytoma involving right side of brain stem; injury information obtained through self-report.
14	81	Male	14	15	CVA	Involving right frontal lobe; injury information obtained through self-report.
15	26	Male	15	5	TBI	Injury information obtained through self-report; no further information provided.
16	72	Male	12	11 Months	CVA	Injury information obtained through self-report; no further information provided.
17	59	Female	13	2	TBI	Right temporal hemorrhage.
18	51	Female	14	1	CVA	Involving left frontal lobe, posterior limb of left internal capsule, and pons.
19	66	Male	14	2	CVA	Hemorrhage involving right basal ganglia.
20	50	Male	10	14	TBI	Injury information obtained through self-report; no further information provided.
21	52	Female	10	1	CVA	Left frontal subarachnoid hemorrhage.
22	48	Female	10	4	Neurosurgery Post-operative CVA	Lesion resection in right anterior temporal lobe. Post-operative infarction resulting in atrophy of the right amygdala and anterior hippocampus.
23	36	Female	22	15	TBI	Diffuse axonal injury. Left anterior temporal and parietal lobe contusions. Parenchymal hemorrhage in right frontal and occipital lobes. GCS of 11.
24	48	Male	10	21	Neurotoxicity	Mefloquine prescribed for malaria prevention.

Note. ABI: acquired brain injury; CVA: cerebrovascular accident; GCS: Glasgow Coma Scale; MCA: middle cerebral artery; TBI: traumatic brain injury. Where possible, ABI information was confirmed through personal medical records provided by the participants.

Figure 3. Meeting content.

Figure 4. Example of a main trial for the “family” relationship category.

Figure 5. “Talk and Chalk” intervention process.

Table 2. Descriptive statistics for the sample’s emotional and cognitive functioning (n = 24).

	Depression (HADS)	Anxiety (HADS)	Open to change (ARCQ)	Reappraisal (ERQ)	AD (ERQ)	Working memory	Verbal generativity	Inhibition
M (SD)	5.75 (4.18)	7.54 (4.86)		26.67 (9.42)	25.71 (9.40)	25.17 (5.64)	34.08 (9.15)	16.58 (2.57)
M (SD) scaled score						9.04 (2.79)	9.13 (2.64)	5.25 (1.07)
Borderline abnormal/Impaired
Score range [scaled score]	8–10	8–10				[6]	[4–6]	[3]
n Borderline [%]	4 [17%]	6 [25%]				3 [13%]	5 [21%]	2 [8%]
Clinical/Impaired
Score range [scaled score]	11–21	11–21				[1–5]	[1–3]	[1–2]
n Clinical/Impaired [%]	4 [17%]	8 [33%]				2 [8%]	0 [0%]	0 [0%]
Stage designation
n [%] Pre-contemplation			5 [21%]
n [%] Contemplation			9 [37%]
n [%] Action			10 [42%]

Note. AD: attentional deployment; ARCQ: Anger Readiness to Change Questionnaire (Rollnick et al., 1992; Williamson et al., 2003); ERQ: Emotion Regulation Questionnaire (Gross & John, 2003); HADS: Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983).

Working memory was measured using the Digit Span subtest from the Wechsler Adult Intelligence Scale – Fourth Edition (Wechsler, 2010).

Verbal generativity was measured using the Letter Fluency Subtest from the Delis-Kaplan Executive Function System (Delis et al., 2001).

Inhibition was measured using the Hayling Sentence Completion Test from the Hayling and Brixton Tests (Burgess & Shallice, 1997).

Table 3. Descriptive statistics for the anger outcome measures at three timepoints (n = 24).

	Baseline	Post-treatment	3MFU
Outcome Measure	M (SD), Range	M (SD), range	M (SD), range
STAXI-2 (T-scores)
Trait anger	56.33 (14.55), 34–80	49.00 (11.93), 34–80	47.00 (8.69), 36–72
Anger expression-in [AXI]	56.83 (13.03), 30–80	57.33 (9.79), 32–72	57.75 (11.64), 32–76
Anger expression-out [AXO]	55.83 (15.92), 26–80	49.50 (13.64), 26–76	47.67 (11.78), 26–68
Anger control-in [ACI]^a	44.50 (10.50), 24–60	46.92 (9.38), 28–64	51.42 (9.41), 30–66
Anger control-out [ACO]^a	40.42 (12.89), 20–64	44.33 (12.01), 24–64	46.83 (9.99), 26–64
AQ-12 (raw score)	30.38 (10.48), 12–50	27.54 (10.01), 12–51	23.50 (9.12), 13–43

Note. AQ-12: Aggression Questionnaire (Bryant & Smith, 2001; Buss & Perry, 1992); STAXI-2: State-Trait Anger Expression Inventory-2 (Spielberger, 1999); 3MFU: 3-month follow-up.

^aHigher scores represents better anger control.

Table 4. Relationship between participant characteristics and intervention gains (n = 24).

Variable	Outcome measure (r)
	Trait anger (STAXI-2)	AQ-12
Mental health (HADS)
Depression	0.29	0.34
Anxiety	0.42 (p = .04)	0.36
Readiness to change (ARCQ)	0.54 (p = .007)	0.46 (p = .03)
ER strategy use (ERQ)
Reappraisal	−0.05	0.18
Attentional deployment	−0.08	0.04
Cognitive functioning
Digit span (WAIS-IV)	−0.01	0.10
Letter fluency (DKEFS)	0.33	0.15
Hayling sentence completion	0.03	0.14

Note. AQ-12: Aggression Questionnaire (Bryant & Smith, 2001; Buss & Perry, 1992); ARCQ: Anger Readiness to Change Questionnaire (Rollnick et al., 1992; Williamson et al., 2003); DKEFS: Delis-Kaplan Executive Function System (Delis et al., 2001); ER: emotion regulation; ERQ: Emotion Regulation Questionnaire (Gross & John, 2003); HADS: Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983); STAXI-2: State-Trait Anger Expression Inventory-2 (Spielberger, 1999); WAIS-IV: Wechsler Adult Intelligence Scale (Wechsler, 2010).

Scores for the ARCQ ranged from −24 to +24; higher numbers indicated more readiness to change.

All p-values are two-tailed.

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Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.