Aggression is common among veterans with posttraumatic stress disorder (PTSD), one of the signature wounds affecting those who deployed post-9/11. Aggressive behavior can lead to devastating interpersonal and societal consequences, such as family violence and incarceration, and it can disrupt social support and other factors that can enhance therapy. The fear of an inability to control emotions may also prevent many veterans from ever seeking treatment for PTSD.

Veterans with PTSD primarily engage in impulsive aggression, which is emotional, reactive, and uncontrolled. An inability to manage one’s emotions, known as emotion dysregulation, is an underlying cause of impulsive aggression.

In this pilot study for the Consortium to Alleviate PTSD, Shannon Miles, PhD, of the James A. Haley Veterans’ Hospital in Tampa, Florida, and her study team will work with post-9/11 combat veterans with PTSD and impulsive aggression. The veterans will be identified as having impulsive aggression if they report having engaged in at least three episodes of aggression within the past month. The investigators will provide training in emotion regulation via an innovative three-session training called Managing Emotions to Reduce Aggression, or MERA.

The goal of the pilot study is to test the feasibility of MERA in reducing impulsive aggression. A secondary goal is to prepare veterans for psychotherapy for PTSD. One reason that too few veterans seek PTSD treatment may be that they fear that they will not be able to control their emotional responses when they begin treatment. The investigators for this study believe that equipping veterans with emotion regulation skills and knowledge about PTSD treatments may help them initiate, complete, and benefit from evidence-based psychotherapies.

MERA is provided in a three-session, condensed time frame to make it accessible to veterans whose careers, school, and families compete with treatment time. The training is delivered in a group format and incorporates emotion education, cognitive-behavioral and acceptance-based skills training, and information about what emotional experiences to expect from PTSD treatments. Study participants will undergo weekly assessments for emotion regulation and aggression. Following the MERA training, study participants will be followed by CAP investigators to monitor whether they seek out, receive, and complete evidence-based psychotherapies for PTSD.

Success of the program and the feasibility of later conducting a large-scale, randomized clinical trial will be evaluated by veterans’ judgments of MERA and if reductions are seen in impulsive aggression and/or emotion dysregulation. Investigators will also monitor the number of veterans who initiate PTSD psychotherapy, attend at least two sessions, and remain in treatment until the therapist indicates that they have improved sufficiently.

The researchers predict that those who complete MERA will:

• Have reductions in impulsive aggression and emotion dysregulation, and
• Initiate, engage in, and complete evidence-based PTSD psychotherapies at a greater rate than those who do not complete MERA.

Expected benefits

If successful, this study will demonstrate that teaching emotion regulation skills to veterans with impulsive aggression may be a feasible method to reduce aggression. This would help the large number of veterans suffering from posttraumatic stress to maintain productive careers and healthy relationships. It also would benefit their families and society overall by reducing interpersonal violence, injury, and incarceration. The study may have the added benefit of equipping veterans to initiate PTSD treatment. Successful outcomes would support the feasibility of larger studies examining emotion regulation training in reducing aggression among veterans with PTSD.