Testing a Novel Trauma-Informed Treatment for Anger and Aggression Following Military-Related Betrayal: Design and Methodology of a Clinical Trial

ABSTRACT

Introduction

Difficulty controlling anger is a common postdeployment problem in military personnel. Chronic and unregulated anger can lead to inappropriate aggression and is associated with behavioral health, legal, employment, and relationship problems for military service members. Military-related betrayal (e.g., military sexual assault, insider attacks) is experienced by over a quarter of combat service members and is associated with chronic anger and aggression. The high level of physical risk involved in military deployments make interconnectedness and trust in the military organization of utmost importance for survival during missions. While this has many protective functions, it also creates a vulnerability to experiencing military-related betrayal. Betrayal is related to chronic anger and aggression. Individuals with betrayal-related injuries express overgeneralized anger, irritability, blaming others, expectations of injustice, inability to forgive others, and ruminations of revenge. Current approaches to treating anger and aggression in military populations are inadequate. Standard anger treatment is not trauma-informed and does not consider the unique cultural context of anger and aggression in military populations, therefore is not well suited for anger stemming from military-related betrayal. While trauma-informed interventions targeting anger for military personnel exist, anger outcomes are mixed, and aggression and interpersonal functioning outcomes are poor. Also, these anger interventions are designed for patients with posttraumatic stress disorder. However, not all military-related betrayal meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 definition of trauma, though it may still lead to chronic anger and aggression. As a result, these patients lack access to treatment that appropriately targets the function of their anger and aggression.

Materials and Methods

This manuscript describes rationale, design, and methodology of a pilot clinical trial examining Countering Chronic Anger and Aggression Related to Trauma and Transgressions (CART). CART is a transdiagnostic, transgression-focused intervention for military personnel who have experienced military-related betrayal, targeting chronic anger and aggression, and improving interpersonal relationships. The pilot study will use an interrupted timeseries design, where participants are randomized to a 2-, 3-, or 4-week minimal contact waitlist before starting treatment. This design maximizes the sample size so that all participants receive the treatment and act as their own control, while maintaining a robust design via stepped randomization. This trial aims to (1) test the acceptability and feasibility of CART, (2) test whether CART reduces anger and aggression in military personnel with a history of military-related betrayal, and (3) test whether CART improves interpersonal functioning.

Results

The primary feasibility outcome will be the successful recruitment, enrollment, and initiation of 40 participants. Primary outcome measures include the Client Satisfaction Survey-8, the State Trait Anger Expression Inventory-2, Overt Aggression Scale-Modified, and the Inventory of Interpersonal Problems-Short Version.

Conclusion

If outcomes show feasibility, acceptability, and initial effectiveness, CART will demonstrate a culturally relevant treatment for chronic anger, the most frequent postdeployment problem, in a sample of active duty service members who have suffered a military betrayal. The DoD will also have an evidence-based treatment option focusing on interpersonal functioning, including relationships within the military and within families.

Difficulties controlling anger is the most reported postdeployment reintegration problem.¹ Anger problems are reported by over half (57%) of veterans using Veterans’ Affairs services with 39% of combat veterans reporting at least one act of aggression in the past 4 months following deployment.² Anger is a natural emotional response to unjust or harmful situations and can be adaptive if expressed and processed in a situationally appropriate way. Aggression, which is one behavioral response to anger, can also be adaptive in specific contexts such as when threatened or in military combat. However, chronic and unregulated anger can lead to inappropriate aggression³ and is associated with behavioral health, legal, employment, and relationship problems for military service members.⁴ High levels of anger are also associated with suicidal ideation even after controlling for posttraumatic stress disorder (PTSD), major depressive disorder, and traumatic brain injury.⁵

Chronic anger, hostility, and aggression are associated with betrayal-related transgressions in military populations.^6,7 Over one quarter of military service members and combat veterans report experiencing events involving military-related betrayal.^6,8 This may include being violated by a specific person, or an institution (i.e., institutional failure to prevent a betrayal act or respond supportively when a betrayal act happens).⁹ Examples of U.S. military-related betrayal that directly involve other U.S. or allied military personnel include military sexual assault and harassment, insider attacks, or delayed leadership response during time-sensitive combat missions resulting in injury or loss of personnel. Service members must also place high levels of trust in family and loved ones to manage life at home while they are away, or in case they are injured or killed in combat.¹⁰ Thus, military-related betrayals may also occur by family or loved ones while the service member is engaged in military operations overseas. Examples include partner infidelity, child abuse, or permanently leaving and taking the children from the home. The high level of stress and risk involved in military life make interconnectedness and trust in partners and family stateside of utmost importance for safety and survival during missions. While this extreme interconnectedness has many protective functions, it also creates a vulnerability to experiencing military-related betrayal.

Current anger and aggression treatments leave room for innovation. Anger management treatment is the most widely used approach to treating anger and aggression. However, standard anger management treatment is not trauma-informed and does not consider the unique function or the cultural context of anger and aggression in military populations. A review of meta-analyses of anger management treatment found only moderate effect sizes in reducing anger.¹¹ The authors also found a lack of studies that assessed aggression (separate from anger) in adults, interpersonal functioning following treatment was rarely assessed, and no studies in this extensive review focused on military personnel.

Another approach to addressing chronic anger and aggression in military personnel uses evidence-based trauma-focused treatments for PTSD, as anger is a frequent and often prominent symptom of PTSD.¹² However, research with military personnel show only small reductions in anger and aggression following gold-standard PTSD treatment.¹³ In fact, anger interferes with PTSD treatment outcomes in military personnel, diminishing treatment effectiveness.¹⁴

Given the above challenges, there have been efforts to adapt anger management treatment for military personnel to improve anger outcomes. Two pilot randomized controlled trials^15,16 (RCTs), 1 parallel-controlled trial of group treatment,¹⁷ and 2 noninferiority trials of group treatment^18,19 examined cognitive behavioral anger management treatment adapted for (almost exclusively male) veterans with PTSD symptoms. One additional clinical trial compared prolonged exposure therapy and affects regulation therapy for veterans with PTSD and anger problems.²⁰ Results of these studies show mixed findings, ranging from no differences from the comparison group,¹⁷ to small-to-medium effect sizes in reducing anger,^15,19,20 to large effect sizes in anger reduction.¹⁶ Only 3 of these studies^16–18 measured interpersonal functioning and only 2o^16,17 measured aggression separate from anger. Clearly, there is still a need to find effective treatments that can help service members and veterans decrease anger and aggression.

The current paper describes the design, methodology, and protocol of an initial pilot study testing Countering Chronic Anger and Aggression Related to Trauma and Transgressions (CART), a transdiagnostic, transgression-focused intervention for military personnel who have experienced betrayal. CART was adapted from Enright and Fitzgibbon’s Process Model of Forgiveness, which has extensive research supporting its use in multiple populations and several countries.²¹ Using a Community-Based Research Participatory approach, we have adapted the model and added additional components to meet the needs of military populations. CART directly targets reducing chronic anger and aggression as well as improving interpersonal relationships. This intervention combines evidence-based “here and now” anger regulation and interpersonal effectiveness skills with betrayal-focused processing such as making meaning of betrayal, letting go of ineffective resentment, and finding purpose after betrayal. The intervention places emphasis on the benefits of acceptance, forgiveness, and compassion for self and others as a mechanism to reduce anger and improve interpersonal functioning.

Evidence suggests that forgiveness is an important factor for psychological health for military personnel.^22,23 Difficulties reaching forgiveness are associated with higher levels of anger, depression,²² PTSD, and risk for suicide.²³ Two military-related, trauma-focused interventions, Adaptive Disclosure and the Impact of Killing in War, have recently emerged that utilize forgiveness and compassion as a component of treatment.^7,24 While there are limited controlled studies on these interventions, the findings are encouraging, with large reductions in PTSD symptoms.^24,25 However, neither of these studies assessed anger or aggression as an outcome.

RESEARCH OBJECTIVES AND HYPOTHESES

This study is designed to pilot test CART. Our primary Aim (1) is to test the feasibility and acceptability of CART. We hypothesize that (1a) CART will be feasible, as measured by the successful recruitment, enrollment, and initiation of 40 participants across 1 year and (1b) participants will report being “mostly” or “completely” satisfied with CART as measured by the Client Satisfaction Survey-8.²⁶ Exploratory outcomes for Aim (1) will focus on tracking rate of completion and average sessions completed. Our secondary Aim (2) is to test whether CART reduces problematic anger and aggression in military personnel with a history of military-related betrayal. We hypothesize that (2a) participants will report statistically significant reductions in chronic anger from pretreatment to 1-month follow-up, as measured by the State-Trait Anger Expression Inventory-2,²⁷ after controlling for baseline to pretreatment changes that may occur during the variable wait period before starting treatment. We also hypothesize that (2b) participants will report statistically significant reductions in past month aggression from pre-treatment to 1-month follow-up, as measured by the Overt Aggression Scale—Modified,²⁸ after controlling for baseline to pretreatment changes. Our third Aim (3) is to test whether CART improves interpersonal functioning. We hypothesize that (3a) participants will exhibit statistically significant improvements in interpersonal functioning from pretreatment to 1-month follow-up, as measured by the Inventory of Interpersonal Problems²⁹ after controlling for baseline to pretreatment changes.

METHODS

Stakeholder Engagement

This study is being conducted under the leadership of South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR), a multidisciplinary, multi-institutional research consortium funded to develop and evaluate the most effective interventions of psychological health conditions in military personnel, veterans, and first responders. The study was informed by key stakeholders, military collaborators, and a Lived Experience Consultant throughout its development to ensure adaptations were culturally attuned to military populations. Our Lived Experience Consultant attends weekly study calls and has been involved in all stages of the research. Key stakeholder interviews of military-serving providers were conducted before finalizing the intervention. Additionally, STRONG STAR has a Community Advisory Board (CAB) who consults regularly on this project. The CAB is comprised of patients, military family members, military medical personnel, military researchers, and military leaders. Members on the Board have experiences related to military psychological health conditions such as PTSD, traumatic brain injury, sleep disorders, chronic pain, suicidal ideations, and anger and aggression. The CAB meets quarterly to provide guidance and feedback to STRONG STAR projects. Lastly, for this study, exit interviews will be conducted with a subset of participants to adapt and improve the acceptability of the intervention.

Research Design

This pilot study will use an interrupted timeseries design,³⁰ also known as non-concurrent multiple baseline across participants design,³¹ randomizing participants to 2-, 3-, or 4-week minimal contact waitlist before starting treatment. This design maximizes the sample size so that all participants receive the treatment and act as their own control, while maintaining a robust design via stepped randomization. Although randomized clinical trials (RCTs) are considered the gold standard when evaluating the causal effects of health care interventions, they are sometimes inappropriate for pilot studies evaluating the development of new clinical interventions.^32,33 RCTs require a wait-list comparison group, an inactive comparison control group, or an active comparison control group. When considering an RCT with a wait-list control arm or an inactive comparison control arm for the study, we determined that withholding treatment for the control arm or offering an inert comparison arm to participants might be considered unethical and could be difficult to obtain approval from a military Institutional Review Board (IRB). When considering the inclusion of an active comparison control arm, there are no other established treatments for military personnel who have experienced betrayal-related transgressions. When RCTs are infeasible or are ethically difficult, the interrupted timeseries design is an excellent alternative^30,33,34 and are arguably the strongest quasi-experimental designs.³⁵ Interrupted timeseries designs have been extensively employed in pilot studies evaluating novel treatments or new adaptations to interventions.^33,36

Recruitment and Enrollment

This project will recruit up to 57 active duty military service members and veterans with problematic anger and aggression who have experienced military-related betrayal with the goal of 40 participants completing the study. We anticipate up to 30% participant dropout. Pending approval, participants will be recruited from the Carl R. Darnall Army Medical Center Embedded Behavioral Health Clinics, the Fort Cavazos Family Advocacy Program, Military Family Life Counselors, and veteran-serving mental health clinics around the Killeen, Texas area. All treatment will be delivered on an individual basis.

Upon referral, participants will be prescreened over the phone for interest and eligibility into the study. Those determined ineligible in prescreening will be offered care through other STRONG STAR programs or will be provided referrals for other local behavioral health resources. Next, participants will be scheduled for an appointment to review the informed consent document. After consent, initial baseline assessment will be conducted to confirm eligibility, collecting baseline level of anger, aggression, interpersonal functioning, and other relevant psychological symptoms. Assessment to confirm eligibility will be separated from the administration of primary outcome measures, and participants will be informed whether they are eligible before completing additional baseline assessments. This strategy reduces risk of participant inflation of reported symptoms in order to be eligible to participate in the study.

Study Conditions

Upon enrollment, participants will complete the full baseline packet. They will then begin with a minimal contact wait condition, followed by the intervention condition. A pretreatment assessment packet will be completed following the wait period but before they begin the intervention. Because participants act as their own control, between-subject variability is reduced. To control for potential nonstationary trends (seasonal patterns), irrespective of an intervention, participants will be randomized to different wait times (2 weeks, 3 weeks, or 4 weeks). These wait groups will be used as a methodological tool; multiple baselines across participants reduce the validity threat of maturation in quasi-experimental research.^30,34 These time periods were considered long enough to obtain sufficient assessment during the wait period, but short enough to minimize drop-out before treatment initiation. See Figure 1 for an overview of the study design.

Figure 1.

Study design overview.

All participants will complete an assessment packet at baseline, pretreatment (following their wait condition), and 1-month follow-up. Additionally, during both the minimal contact wait condition and throughout the intervention condition, all participants will complete a 5 to 10-min assessment twice per week to assess their level of anger, aggression, and interpersonal functioning since their last assessment. These frequent assessments across conditions are a key component of the interrupted timeseries design.

Inclusion Criteria

Service members and veterans who meet the following criteria will be recruited into the study (1) military service members and veterans aged 18 or older, (2) with a history of military-related betrayal identified on the Modified Moral Injury Questionnaire-Military Version,³⁷ (3) with problematic anger in the past month, as measured by a score >11 on the Dimensions of Anger Reactions Questionnaire (DAR-5),³⁸ and (4) who report engaging in at least 1 act of aggression in the past month, measured by the Overt Aggression Scale-Modified.²⁸

Exclusion Criteria

Individuals will be excluded if they: (1) participated in an anger management or trauma-focused intervention in the past 3 months, (2) are currently experiencing acute suicidality requiring hospitalization, (3) report current homicidality with plans and intent to hurt a specific person, (4) have experienced a moderate to severe brain injury, (5) exhibit severe alcohol consumption patterns, or (6) are experiencing active psychosis or mania.

Intervention

CART is a transdiagnostic treatment for military personnel who have experienced betrayal trauma and transgressions. The intervention combines evidence-based present-focused anger regulation and interpersonal skills with betrayal-focused processing, such as making meaning of betrayal, letting go of ineffective resentment, and finding purpose after betrayal through building skills in acceptance, forgiveness and compassion for self and others. CART is heavily based on the Process Model of Forgiveness²¹ and the Stages of Change model,³⁹ beginning with the assumption that change does not happen quickly or decisively, and different intervention strategies are needed at different levels of readiness for change. The intervention is divided into 4 phases that guide patients through the process of forgiveness. The modules in each phase are based upon Enright & Fitzgibbon’s process model,²¹ while incorporating military-relevant content, emotion regulation skills, interpersonal skill building, and radical acceptance and commitment to action techniques. Enright and Fitzgibbon suggest journaling to facilitate the process of forgiveness,²¹ which is used for practice assignments throughout the protocol in addition to behavioral skills practice.

Phase 1 is composed for 5 modules which focus on enhancing motivation for change through building awareness of how psychologically holding on to past transgressions has negatively impacted the patient’s health and psychosocial functioning. During this phase, the patient will learn about the process and explore the potential benefits of forgiveness for self and others but are not yet asked to make a commitment to change.

Phase 2, completed in a single module, focuses on making the decision to work towards forgiveness. This phase is designed to facilitate movement from the Contemplation or Preparation stages of change into the Action Stage of change. The patient is guided to weigh the short- and long-term costs and benefits of working toward forgiveness vs. continuing on their current path. Here, the patient may decide to continue and work toward forgiveness or not to work toward forgiveness, but skip to Phase 4 to work on interpersonal skill building.

Phase 3 is dedicated to working toward acceptance, forgiveness, and compassion through the use of cognitive restructuring and acceptance and commitment techniques. Empathy and compassion are conceptualized as skills that can be improved with cognitive practice coupled with a willingness to work toward change. The skills of understanding another’s perspective and feeling compassion for self and others are practiced first with “lower stakes” situations and builds to practicing these skills with the transgressor in mind.

In Phase 4, the participant explores the emotional freedom they now have as they put down the burden of chronic anger and commit to new value-driven behaviors. The concepts of meaning and purpose are explored, and the participant is guided to contemplate the meaning and purpose of the pain they have endured. The participant will also practice interpersonal skills they are still struggling with as they interact with others. See Table 1 for a list of all CART Phases and Modules.

Table 1.

CART phases and modules.

Phase 1: Exploring the impact of holding on to betrayal

Program Overview: Understanding Betrayal, Acceptance, and Forgiveness Examining Anger Examining other Betrayal-Related Emotions Examining Physical Health Examining Your Worldview

Phase 2: Deciding to Work toward Forgiveness and Compassion

Deciding whether to work on Forgiveness

Phase 3: Working toward Forgiveness

Working toward Understanding Working toward Empathy and Compassion Working toward Acceptance Giving Yourself and others the Gift of Forgiveness

Phase 4: Discovering a new way of life

The Meaning and Purpose of Suffering Discovering your Community: Building Trust and Intimacy Interpersonal Effectiveness: Boundaries, Assertiveness, and Emotion Regulation Commitment to Forgiveness, Compassion, and Continued Growth

Outcome Measures

The primary feasibility outcome for Aim 1 will be the successful recruitment (eligible referrals), enrollment (participants screened eligible versus enrolled), and initiation of treatment (attendance of one session) of 40 participants across 1 year. The primary acceptability outcome for Aim 1 will be the Client Satisfaction Survey-8 (CSQ-8)²⁶ administered at post-treatment, regardless of intervention completion. The CSQ-8 is a well-established 8-item self-report measure designed to assess client satisfaction with treatment. The intervention will be determined to be acceptable if, on average, participants “mostly” or “completely” satisfied with the CART intervention. The primary anger outcome for Aim 2 will be measured by the STAXI-2.²⁷ The STAXI-2 is a 57-item inventory which measures frequency and intensity of anger as an emotional state, the disposition to experience anger as a personality trait, the expression of anger, and self-control of anger. The primary aggression outcome for Aim 2 will be the OAS-M.²⁸ The OAS-M is a 17-item measure that assesses frequency of different aggressive acts in an outpatient setting, including verbal and physical aggression against self, other, and objects. The primary outcome for Aim 3 will be measured by the Inventory of Interpersonal Problems-Short Version (IIP-32).²⁹ The IIP-32 is a 32-item self-report assessment designed to measure interpersonal functioning.

This project has several planned secondary outcomes focusing on additional assessment of the main outcomes. A secondary acceptability and feasibility outcome for Aim 1 will be completion rates. Average number of modules completed and rate of protocol completion will be examined. A secondary anger outcome for Aim 2 will be the DAR-5.³⁸ A secondary interpersonal functioning outcome for Aim 3 will be the Brief Inventory of Psychosocial Functioning (B-IPF).⁴⁰ Lastly, exploratory outcomes include PTSD, depression, anxiety, insomnia, guilt, and suicidal ideation.

Statistical Model and Data Analytic Plan

To address Aim 1, descriptive statistics will be calculated to examine the number of participants referred, recruited (scheduled baseline appointment vs. opted out at prescreening), enrolled (consented to participate vs. opted out during informed consent process), and initiated (attended at least 1 treatment session). Feasibility will be based on successful initiation of 40 participants, average number of sessions completed, and rate of completing each phase of the intervention. Acceptability of the intervention will be based on the overall satisfaction rating and the proportion of participants who report satisfaction (item score of ≥3 or greater on CSQ). Additionally, participants will complete a qualitative interview at 1-month follow-up to provide feedback on the intervention (acceptability). Feasibility and acceptability results will be used to inform planning for future studies.

Regression-based interrupted timeseries analyses (ITSA) will be used to examine the preliminary benefit of CART to reduce anger and aggression (DAR-5; OAS-M) and improve interpersonal functioning (B-IPF). The two effects of interest in ITSA are change in level (or intercept) and change in slope upon initiation of the intervention. For this study, the primary effect of interest will be the difference in slope over time before and following the initiation of CART. However, we will also investigate immediate changes in level (or intercept) upon initiation of CART. Models will include the effects of time, intervention point coded as a dummy variable (pre = 0, post = 1), their interaction, and respective outcome of interest (e.g., DAR-5). A common concern with ITSA (and timeseries analyses) is time-varying confounders that impact outcomes irrespective of an intervention. To control for time confounds, models will include the waitlist randomization group (2, 3, or 4 weeks). ITSA will also employ autoregressive integrated moving average (ARIMA) methods to control for autocorrelation. The combination of ARIMA and staggered CART initiation will reduce concerns that observed effects are due to variables other than the intervention. Analyses will be intent-to-treat using all available data, regardless of the extent of participation. Alpha will be set at unadjusted P = .05 for all analyses.

Statistical Power

Statistical power analyses were obtained from Power Analysis & Sample Size (PASS) for a population-averaged regression mixed-effects model with repeated measures. The primary effect of interest to address Aims 2 and 3 is the slope difference over time before and after initiation of the intervention. Power was calculated based on a range of plausible effect sizes (d = 0.20-0.80, considered small to large effect by conventional standards, Supplementary Material 1) and within-subject correlation coefficients (r = 0.10-0.50, small to large effects). Power calculations assumed a conservative average of 8 assessment time points captured over the course of the study (we anticipate a larger number of assessment time points), a total N = 40, and alpha = 0.05. Based on these parameters, if the within-subject correlation is equal to 0.30 and a medium effect size (d = 0.50) slope difference is detected power is good (70%). Power rises to >90% if the within-subject correlation remains constant (r = 0.30) and the effect size slope difference increases to greater than or equal to d = 0.65. Assuming a within-subject correlation of r = 0.50, power improves to 83% if a medium effect is detected and rises above 95% if the effect size is d = 0.65 or greater.

DISCUSSION

The military is built upon interconnected and cohesive teams. According to the Army Holistic Health and Fitness Manual, an important aspect of Mental Readiness includes social cohesiveness, or the motivation to develop and maintain social relationships within the military unit. However, in 2020, the U.S. Army Third Armored Division & Fort Hood (now Fort Cavazos) Command Team identified that decades of sustained combat operations have contributed to the harmful behaviors of sexual assault/harassment, racism/extremism, suicide, and a resulting deficit of trust between leaders and the led (Supplementary Material 2). Military sexual assault, harassment, and transgressions involving racism/extremism are exemplary of military-related betrayal. For service members struggling after these betrayals, problems with anger and aggression, distrust, and interpersonal dysfunction make effective teamwork an insurmountable task.

If successful, the long-term impact of this project is 3-fold. First, the widespread availability of an effective treatment for the chronic anger and aggression will promote military readiness by helping service members rebuild trust with those who play a critical role in their life (when appropriate), including fellow service members and the military leadership. Second, the widespread availability of such treatment could contribute to the prevention of interpersonal violence and suicide. Military-related betrayal⁷ and problems with anger are⁴ associated with elevated suicide risk. If effective, CART could provide an approach for healing from these betrayals, reducing the burden of chronic anger and the impact of that burden on aggressive urges and urges for self-harm. Finally, the CART intervention targets the improvement in meaningful relationships and rebuilding of emotional intimacy among families. Thus, this approach may improve quality of life and wellbeing for service members, veterans, and whole military families impacted by betrayal.

Limitations

The primary limitation of this study is the quasi-experimental design and length of the waiting period. Two to four weeks may not be an adequate pretreatment window to fully account for the maturation threat to validity. However, in collaboration with our Community Advisors, we believe it important to balance methodological control with the ethical considerations of withholding treatment from participants suffering from the difficulties for which they are seeking treatment. If this initial pilot study is successful, the next step will be to conduct a full RCT with enhanced methodological control. A second potential limitation is the length of treatment. Because of the daily demands of military service and the frequency of transitions (e.g., temporary duty travel, deployments), completing multi-month treatment can be challenging. A massed (i.e., daily) approach to CART was discussed with our Lived Experience Consultant and pros and cons were evaluated. We ultimately decided on a bi-weekly schedule because no studies, to our knowledge, have evaluated a forgiveness-focused intervention for military personnel with a history of military-related betrayal. Therefore, the first appropriate step in the development of CART is to examine the intervention in a standard format.

ACKNOWLEDGMENTS

The authors have no acknowledgments to declare.

INSTITUTIONAL REVIEW BOARD

The study has been approved by The University of Texas Health Science Center at San Antonio.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

V.J. and A.L.P. designed the study and developed the original manuscript. C.P. and P.F. provided military key stakeholder consultation to the design of the study. S.Y.M. provides regulatory expert guidance throughout the course of the study. C.S. developed the data analytic strategy. S.M. provided content expert guidance regarding anger and aggression in military populations. All authors reviewed, edited, and approved the manuscript.

INSTITUTIONAL CLEARANCE

The 2023 poster presentation on this study was approved through Carl R. Darnall Army Medical Center, Fort Cavazos, Texas. This manuscript has been approved.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Military Medicine online.

FUNDING

This work was supported by research grants (W81XWH2220085 to V.M.J.) and (W81XWH2220086 to A.L.P.) by the U.S. DoD through the Office of Congressionally Directed Medical Research Programs’ Traumatic Brain Injury and Psychological Health Research Program.

SUPPLEMENT SPONSORSHIP

This article appears as part of the supplement “Proceedings of the 2023 Military Health System Research Symposium,” sponsored by Assistant Secretary of Defense for Health Affairs.

CONFLICT OF INTEREST STATEMENT

None declared.

Author notes

Presented as a poster at the 2023 Military Health System Research Symposium, Kissimmee, FL; MHSRS-23-09292.

The views expressed here are solely those of the authors and do not represent an endorsement by or the official policy or position of the U.S. Army, the DoD, the Department of Veterans Affairs, or the U.S. Government.