Received: 5/8/2005 Accepted: 7/23/2005

Original Article

The Efficacy of Rational-Emotive-Behavioral versus Relaxation Group

Therapies in Treatment of Aggression of Offspring of Veterans with Post
Traumatic Stress Disorder

M. Barekatain MD*, T. Taghavi MD**, M. Salehi MD*, A. Hasanzadeh MS***

ABSTRACT
Background: Post traumatic stress disorder (PTSD) in war veterans has been linked with symptoms in their children,
including symptoms resembling those of the traumatized parents, especially aggression. This study aims to examine the
effectiveness of cognitive-behavioral group therapy in reducing aggressive behaviors of male adolescents whose fathers
have war related PTSD.
Method: 36 male children (aged 11 19 years) whose fathers had PTSD, were randomly assigned into three groups for
Rational-Emotive- Behavioral Therapy (REBT), Relaxation Therapy, and Wait-List control group. Each method had a
course of ten therapeutic group sessions of 60 minutes once a week. Rates of aggression were assessed by Aggression
Questionnaire (AGQ) at baseline, end of intervention, and two months later.
Results: The difference between AGQ scores of three groups was statistically significant. The behaviors of the three
groups were not homogenous across the time (group × time interaction) and showed a statistically significant difference.
Conclusion: This study revealed that the intervention groups were superior to control group in reduction of aggressive
behaviors in male adolescents of war veterans with PTSD. Further studies with greater sample size, prolonged duration
of follow up, and multiple assessment procedures may be needed for better conclusions.
Key words: Aggression, offspring, PTSD, Group Therapy

JRMS 2006; 11(1): 34-40

S
everal clinical and empirical studies have experiences from war veterans to their children
reported the adverse effects of Post is often referred as “secondary trauma” which
Traumatic Stress Disorder (PTSD) of hypothesized that previously nontraumatized
Holocaust survivors or Vietnam War veterans persons acquire characteristic trauma-like re-
on the second generation 1-6. Clinicians in the sponses by enduring contact with PTSD pa-
United States have reported that families of tients who have chronic stressful events. This
Vietnam veterans with PTSD had problems to effect is often seen when parents who are war
cope with the veterans ‘ hypersensitivity, ver- veterans pass on trauma like-like responses to
bal abuse, outburst of anger, and living in the their children 7. One explanation based on con-
atmosphere of fear, social isolation, and self temporary psychoanalytic approach using an
doubt 4. In one study the veterans’ children object relation framework which emphasis the
saw their family as being significantly higher interactional relation between parent and
in conflict and tending to be lower in cohesion 5. child, proposed that transmission of parental
In the literature, the transmission of war trauma may take place through the process of

*Assistant Professor, Department of Psychiatry, Isfahan University of Medical Sciences, Isfahan, Iran.
**Resident, Department of Psychiatry, Isfahan University of Medical Sciences, Isfahan, Iran.
***Department of Statistics, Department of Health, Isfahan University of Medical Sciences.
Correspondence to: Dr. Majid Barekatain, Noor Hospital, Behavioral Sciences Research Center, Isfahan, Iran.
E-mail: [email protected]

34 Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006
Group therapy for aggression of veterans’ offspring Barekatain et al

overidentification with their parents 8-9. Re- cause of cultural limitations to arrange mixed-
flecting parents difficulties, children showed sex groups, only male adolescents were se-
symptoms in association with fathers’ disorder lected. After listing such PTSD patients, they
such as aggression, low self-esteem, and im- were called and invited, if they had sons in
paired social development 5. ages between 11-19 years old. Of total 68 invi-
Ahmadzdeh et al revealed that aggressive tations, 43 subjects responded positively and
behaviors were more prevalent in offspring of accepted the intervention. All subjects and
war veterans with chronic PTSD, 15 years after their parents were evaluated by Composite
termination of Iraq-Iran war, and psychiatrists, International Diagnostic Interview (CIDI) 20 to
psychologists or other mental health profes- confirm the diagnosis of PTSD in fathers and
sionals were often called on to intervene with rule out the presence of major psychiatric dis-
children who exhibit such behaviors 10. orders in the subjects and their Mothers. The
Considering the increased vulnerability to patients also were excluded from the study if
behavioral and emotional problems among they had low reading ability, or apparent cog-
offspring of PTSD patients, identifying effi- nitive deficits, or if their fathers had psychotic
cient strategies for reducing problems such as features. A minimum score of 42.5 in "Aggres-
aggressive behaviors and aggression-related sion Questionnaire" (AGQ) was needed at
stressful life events will be important. Several baseline assessment 21.
studies were found Cognitive-Behavioral
Group Therapy (CBT) effective in children and
Measures
Assessment of the effectiveness was carried by
adolescents with an acceptable effectiveness in
"Aggressive Questionnaire" (AGQ). This is a
different target problems 11-15. One study con-
30-item, self-report questionnaire in which
cluded that child-based CBT interventions
each item is rated from 0(never) to 3(always),
have a small to moderate effect on decreasing
so total score ranging from 0 to 90, with high
aggression, and were more effective for older
scores indicating higher aggressive behaviors.
elementary school-age children and adoles-
The standard and valid Persian version of the
cents than younger ones 16. In Iran, Sadeghi et
scale had been used in this study which its va-
al reported the effectiveness of REBT group
lidity was 0.85 21-22.
therapy in school referred adolescents with
Socioeconomic status was evaluated by a 4-
aggressive behaviors 17. The effectiveness of
item, self report scale in which the occupation
autogenic relaxation training on adolescents
of family head, monthly income of family,
with behavioral and emotional problems had
ownership of house, and quality of house were
also been shown 15, 18-19.
considered. Subjects assigned in four catego-
This study was designed to assess the effec-
ries based on their scores. Face and content va-
tiveness of group Rational Emotive Behavioral
lidity of the scale were approved by three ex-
Therapy (REBT) and Relaxation Therapy (RT)
on the aggressive behavior of male adolescents perts. Calculated Chronbach’s α score was
whose fathers had chronic PTSD after their ex- 0.71.
periences of catastrophic trauma in imposed Study design and procedure
Saddam’s war against Iran. The protocol of this study was approved by
the board review of Behavioral Sciences Re-
Subjects and Methods search Center, Isfahan University of Medical
Participants Sciences. After complete description of the
This 5-monthes, experimental study was de- study for all the eligible subjects and their par-
signed for male adolescents whose fathers ents, written informed consent was obtained.
have been treated for chronic war-related According to a previous study 17, a sample size
PTSD in out-patient clinic of Health Deputy of of 8 subjects/group, with power set at 90% and
War Veterans' Foundation, Isfahan, Iran. Be- α set at 0.05, was calculated. Thirty six male

Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006 35
Group therapy for aggression of veterans’ offspring Barekatain et al

adolescents, who met the above criteria, were tional believes for converting the irrational
randomized to Rational-Emotive- Behavioral consequences to rational ones was explained.
group Therapy (REBT group), Relaxation Assertiveness training and distinguish be-
group Therapy (RT group), or Wait-List con- tween assertion and aggression were taught at
trol group (WL group) using a block randomi- ninth session. Final session contained summa-
zation with six patients per block. Randomiza- tion and conclusion.
tion was conducted blinded to investigator of The RT group followed a modified protocol
the study. Each of the three groups had 12 for adolescents through ten group sessions of
members. 60 minutes with each group performing, once a
All subjects filled AGQ three times during week. Sessions 1-5 focused on the relaxation
the study: if First, before the beginning of in- units of about 10 minutes each were embedded
tervention (T1), second, immediately after the in an adolescent-centered framework of con-
end of group-therapies (T2), and finally, two versation. During these group sessions the six
months after the end of interventions (T3). basic exercises of RT were taught. The relaxa-
Two therapists conducted both type of tion training was done lying down with eyes
treatments. The main therapist was a M.S. de- closed. Within the group sessions, the text of
gree clinical psychologist and the co-therapist the (auto-) suggestions was spoken repeatedly
(second author) was a resident of psychiatry. by the therapist. The children were encouraged
Each treatment strategy consisted of one pre- to keep the short suggestions in mind and to
treatment group session during which thera- use them more and more automatically. The
pists explained a general introduction to the children’s experiences during the relaxation
program, a review of confidentiality issues, units were discussed afterwards. The follow-
and REBT or RT procedures. Ten therapeutic ing 6-9 sessions were devoted primarily to
group sessions of 60 minutes, once a week, helping subjects generalize these relaxation
were followed after. Wait-List control group skills across situations noted for producing ag-
did not give any treatment. gression. In session 10, a summary of the entire
The REBT group followed a protocol, using program was presented and subjects were en-
a modified version of this therapeutic method couraged to continue using their relaxation
or" ABC model" 23. During the first session, the skills in future aggression-producing situa-
concept of "irritability and aggression" and tions.
their emotive, cognitive, somatic, and behav- At the beginning of both group sessions, the
ioral aspects of them were explained. The A-B- participants reported about their experiences
C theory of "Accident-Belief-Consequence with the methods at home both orally and by
model" and the role of believes in the manifes- the remarks on their home protocols. The writ-
tation of aggression were taught at second ses- ten text was given to all children at the end of
sion. In the course of third session patients the each group session for at-home practice.
were learned how to configure belief systems. Parents were asked to support their children
During fourth session, Rational Be- by showing interest in their home practice but
lief/irrational Belief, Rational Conse- not to control them directly. All subjects in
quence/Irrational Consequence were ex- Waiting List control group were offered indi-
plained. In fifth session irrational belief was vidual psychotherapeutic intervention at the
discussed as a foundation of aggression. end of the study.
Maximization and dogmatism were explained
as cognitive distortions which lead to aggres-
Data analysis
The analysis was conducted using SPSS soft-
sive behaviors during sixth session. Self-
ware, version 11.5, for windows (SPSS Inc.,
acceptance was taught as an emotional tech-
Chicago, Illinois, USA). A two-way repeated
nique during seventh session for aggression
measure ANOVA (Time ×Treatment interac-
control. In eighth session, challenge to irra-
tion) was used. The three groups were consid-

36 Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006
Group therapy for aggression of veterans’ offspring Barekatain et al

ered as the between-subjects factor (group) and groups did not continue the trial after first
three times AGQ measurements during trial as group session and therefore were omitted from
the within-subjects factor (time). In addition, a the study, thus the REBT group had 10 mem-
repeated measure ANOVA test was performed bers, and RT group had 8 members. There were
for finding the main effect of time on AGQ no statistically significant differences between
scores in each group. Correlation analysis was baseline characteristics of participants randomly
used to detect relation between reduction of assigned into the three groups (table 1). The pre-
AGQ scores and number of patients’ participa- test, post-test, and follow up AGQ scores of
tion in each session. A one way ANOVA was three groups shown in table 2. There was no
used to compare changes of AGQ scores from significant difference between pre-test AGQ
T1 to T3 between three groups. Demographic scores of three groups. A two-way repeated
data, baseline, and end point AGQ scores were measure ANOVA revealed a statistically sig-
compared between two groups by one-way nificant difference between three groups as in-
ANOVA and fishers’ exact test as appropri- dicated by the main effect of group or the be-
ated. Results are presented as means (SD). All tween-subjects factor (F=9.13, P=0.001). Post
statistical tests were two-tailed with a signifi- Hoc Duncan test showed a significant differ-
cance level of 0.05 (P-value < 0.05). ence between REBT and WL groups (P<0.05),
RT and WL groups (P<0.05), but not REBT and
Results RT groups (P>0.05).
Two subjects in REBT and four in the RT

Table 1. Baseline characteristics of participants (N= 30)

Rational Emotive Relaxation Waiting List

Groups Behavioral Therapy Training Control
(n = 10) (n = 8) (n = 12)
Measures
Age in years mean (SD) 14.6(2.36) 13.5(2.92) 14.41(2.90)
Education in years mean (SD) 8.60(1.95) 8.37(4.30) 8.25(2.76)
Socioeconomic 20% Level 2 25% Level 2 58.33% Level 2
level (%) 80% Level 3 62.5% Level 3 41.67% Level 3
12.5% Level 4
No statistically significant differences were found between groups (P > 0.05).

Table 2. Means (Standard Deviations) for outcome Measures.

Rational Emotive Relaxation Waiting

Groups Behavioral Intervention Training List
(n = 10) (n = 8) (n = 12)
AGQ* Measures
Pre-test (T1) 53.50 (7.05) 50.63 (10.04) 57.92 (13.32)

Post-test (T2) 37.80 (14.77) 28.87 (13.45) 53.67 (15.61)

Follow up (T3) 34.30 (8.02) 26.75 (7.57) 52.42 (17.68)

*Aggression Questionnaire

Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006 37
Group therapy for aggression of veterans’ offspring Barekatain et al

There was a statistically significant differ- Although several studies have found Cogni-
ence between AGQ scores as indicated by the tive-Behavioral Group Therapy with an ac-
main effect of time, the within-subjects factor ceptable effectiveness in children and adoles-
(F=25.27, P<0.001). The behavior of the three cents 11-19, some limitations had been reported
groups were not homogenous across time about use of cognitive behavioral group thera-
(group × time interaction) and showed a statis- pies in adolescents. These limitations were
tically significant difference (F=3.3, P=0.019). high attrition rate of severely stressed families,
A repeated measure ANOVA which per- scheduling difficulties, reluctance to partici-
formed for finding the main effect of time on pate in a treatment intervention, group intoler-
AGQ scores in each group showed a signifi- ance, and challenge to obtain motivation to
cant effect of time in REBT group (F=13.9, change when aggressive behaviors were ego-
P=0.001), and in RT group (F=16.36, P<0.0001), syntonic 24-25. Nevertheless, this study revealed
but not in WL group (F=0.98, P=0.37). the effectiveness of both REBT and RT tech-
Comparison of AGQ score changes from T1 niques in reducing aggressive behaviors of
to T3 by one-way ANOVA revealed a statisti- male adolescent offspring of war veterans
cally significant difference between the three which was comparable to the other studies 11-19.
groups (F=4.75, P=0.017) which Post Hoc Dun- One probable cause of good efficacy was selec-
can test revealed a significant difference be- tion of subjects from 11-19 ages, who are more
tween REBT and WL groups (P<0.05), RT and cognitively sophisticated 15, 24-25.
WL groups (P<0.05), but not REBT and RT Although children in both treatment condi-
groups (P>0.05). tions improved, because the mean number of
The average number of participants attend- participants in REBT group sessions were sig-
ing in each group session, by treatment op- nificantly greater than in RT group, we consid-
tions, were 9.1 (SD: 1.19) for REBT group and ered the effect of this factor by means of corre-
6.37 (SD: 2.38) for RT group, which revealed a lation analysis. It revealed that when the num-
significant difference between groups ber of participants in treatment sessions in-
(P=0.006). Correlation analysis showed statis- creased, in RT group, the efficacy decreased,
tically significant positive relation between but in REBT group, the more participation in
reduction of AGQ scores in REBT group and the group sessions for each patient led to the
number of patients’ participation in each greater reduction in AGQ scores. One expla-
group sessions (r = 0.82, P=0.02), but for RT nation may focus on deficits and distortions in
group, the decrease of AGQ scores was nega- nonadaptive cognitive processes in REBT in-
tively related to number of patients’ participa- stead of merely focusing on excitement and
tion in consecutive group sessions (r =-0.78, anger in RT.
P=0.01). The present study had several limitations,
including small sample sizes, selection of sub-
Discussion jects only from male sex, short duration of fol-
Aggressive behaviors were more prevalent, in low up, and assessment procedure restricted to
offspring of war veterans with chronic PTSD 1-6. AGQ. This study may limit the ability to gen-
Descriptive data of the psychometric instru- eralize its findings to the broader population,
ment of this experimental study at T1 also but strengthens their specific relevance to
demonstrated increased scores of aggressive trans-generational PTSD. We can not exclude a
behaviors in this sample (Table 2) which was placebo effect on subjects who were not blind
comparable with previous Iranian survey 10. to the intervention, especially in Waiting List
Number of final participants in each group group.
was equal or greater than the calculated sam- By considering the high prevalence of ag-
ple size, so results of the study seem not to be gressive behaviors and effectiveness of the
affected by subjects who dropped out. therapeutic methods, it seems desirable to ar-

38 Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006
Group therapy for aggression of veterans’ offspring Barekatain et al

range programs containing these techniques Acknowledgment

(especially REBT) for this population to pre- We are extremely grateful to the deputy of
vent consequences of aggression on family co- health of Bonyade Janbazan, Isfahan, Iran, be-
hesion, social adaptation, and educational cause of their co-ordination and support.
achievement.

References
1. Yehuda R, Schmeidler J, Wainberg M, Binder-Brynes K, Duvdevani T. Vulnerability to posttraumatic stress dis-
order in adult offspring of Holocaust survivors. Am J Psychiatry. 1998;155(9):1163-71.
2. Sigal JJ, Weinfeld G. Control of aggression in adult children of survivors of the Nazi persecution. J Abnorm Psy-
chol. 1985;94(4):556-64.
3. Rosenheck R, Nathan P. Secondary traumatization in children of Vietnam veterans. Hosp Community Psychiatry.
1985;36(5):538-9.
4. Jordan BK, Manner CR, Fairbank JA . Problems in families of male Vietnam veterans with posttraumatic stress
disorder. J Consult Clin Psychol. 1992;60(6):916-26.
5. Davidson AC, Mellor DJ. The adjustment of children of Australian Vietnam veterans: is there evidence for the
transgenerational transmission of the effects of war-related trauma? Aust N Z J Psychiatry. 2001;35(3):345-51.
6. Westerink J, Giarratano L. The impact of posttraumatic stress disorder on partners and children of Australian
Vietnam veterans. Aust N Z J Psychiatry. 1999;33(6):841-7.
7. Motta RW, Joseph J M, Rose RD, Suozzi JM, Leiderman LJ. Secondary trauma: assessing inter-generational
transmission of war experiences with a modified Stroop procedure. J Clin Psychol. 1997;53(8):895-903.
8. Abrams MS. Intergenerational transmission of trauma: recent contributions from the literature of family systems
approaches to treatment. Am J Psychother. 1999;53(2):225-31.
9. Rowland-Kline D, Dunlop R. The transmission of trauma across generations: identification with parental trauma
in children of Holocaust survivors. Aust N Z J Psychiatry. 1998;32(3):358-69.
10. Ahmadzadeh GH, Malekian A. Aggression, anxiety, and social development in adolescent children of war vet-
erans with PTSD versus those of non-veterans. Journal of Research in Medical Sciences 2004; 9(5): 33-6.
11. Snyder KV, Kymissis P, Kessler K. Anger management for adolescents: efficacy of brief group therapy. J Am
Acad Child Adolesc Psychiatry. 1999;38(11):1409-16.
12. Feindler EL, Marriott SA, Iwata M. Group anger control for junior high school delinquents. Cognit Ther Res.
1984;8(3):299-311.
13. Hoag MJ, Burlingame GM. Evaluating the effectiveness of child and adolescent group treatment: a meta-
analytic review. J Clin Child Psychol. 1997;26(3):234-46.
14. van Manen T G, Prins P J M, Emmelkamp PMG. Reducing aggressive behavior in boys with a social cognitive
group treatment: results of a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry.
2004;43(12):1478-87.
15. Biabangard E. Effectiveness of Lazarus Multimodal Therapy, Ellis Rational Emotive Therapy, and Relaxation
Therapy on Decreasing Student Test Anxiety. Andeesheh Va Raftar 2003;8(3):36-42.
16. Bennett D, Gibbons T. Efficacy of child-behavioral interventions for antisocial behavior: a meta-analysis. Child
Fam Behav Ther. 2000;22(1):1-15.
17. Sadeghi A, Ahmadi A, Abedi M. A study of the effectiveness of group training in anger management in Rational-
Emotive-Behavioral therapy. Journal of Psychology 2002; 6(1):52-62.
18. Reynolds WM, Coat KI. A comparison of cognitive-behavioral therapy and relaxation training for the treatment
of depression in adolescents. J Consult Clin Psychol. 1986;54(5):653-60.
19. Goldbeck L, Schmid K. Effectiveness of autogenic relaxation training on children and adolescents with behav-
ioral and emotional problems. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1046-54.
20. World Health Organization. Composite International Diagnostic Interview: Persian translation. I.R. Iran Min-
istry of Health Publishing Center; 2000.
21. Allahyari A. Evaluation of juvenile aggression based on personality parameters and effectiveness of stress man-
agement on aggression. [Dissertation]. Tehran: School of Psychology, Tarbiat Modares University; 1997.
22. Najjarian B. Constructing and validating an instrument for measuring Aggression in Iranian adolescents. [Dis-
sertation]. Ahvaz: School of Psychology & Educational Sciences, Shahid Chamran University; 1996.

Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006 39
Group therapy for aggression of veterans’ offspring Barekatain et al

23. Ellis A. Anger: How To Live With And Without It. 1st ed. New York: Citadel Press; 2003.
24. Kazdin A E, Wassell G. Therapeutic changes in children, parents, and families resulting from treatment of chil-
dren with conduct problems. J Am Acad Child Adolesc Psychiatry. 2000;39(4):414-20.
25. Webster-Stratton C, Hammond M. Treating children with early-onset conduct problems: a comparison of child
and parent training interventions. J Consult Clin Psychol. 1997;65(1):93-109.

40 Journal of Research in Medical Sciences; Vol. 11, No. 1; Jan. & Feb. 2006