Treating Alcohol-Related Violence - SAGE Journals

TREATING ALCOHOL-RELATED VIOLENCE Intermediate Outcomes in a Feasibility Study for a Randomized Controlled Trial in Prisons NICOLA BOWES Cardiff Metropolitan University

MARY MCMURRAN University of Nottingham

BRYN WILLIAMS Cardiff Metropolitan University

SIRIOL DAVID INGRID ZAMMIT National Offender Management Service Cymru

There is a lack of outcome evidence for alcohol interventions for offenders whose crime is alcohol related. In this study, the authors report the intermediate outcomes of a feasibility study for a randomized controlled trial of an alcohol-related violence intervention. Control of Violence for Angry Impulsive Drinkers (COVAID) was tested with sentenced prisoners in the United Kingdom. Participants were 115 adult men who were randomly allocated to COVAID or treatment as usual. Measures were the Alcohol-Related Aggression Questionnaire (ARAQ), the State-Trait Anger Expression Inventory (STAXI-2), the Eysenck Impulsivity, Venturesome, and Empathy Scale (IVE), and the Controlled Drinking Self-Efficacy Scale (CDSES). After the intervention, participants allocated to COVAID reported significantly greater improvement on the ARAQ Alcohol-Aggression subscale and all CDSES subscales. No significant differences were obtained for the STAXI-2 or the IVE. COVAID may have the potential to fill a gap in treatment provision for offenders whose crimes of violence are alcohol related. Keywords:  alcohol; violence; treatment; prisoners; COVAID; randomized controlled trial

A

lcohol-related violence is an issue of major concern to society. Around half of all crimes of violence are related to alcohol (Flatley, Kershaw, Smith, Chaplin, & Moon, 2010), and it is estimated that alcohol-related crime costs the economy of England and Wales £7.3 billion each year (Prime Minister’s Strategy Unit, 2004). Despite this knowledge, alcohol interventions for offenders are seriously underprovided and underdeveloped. Recent reports on alcohol services in U.K. prison and probation services present a picture of significant lack of provision (Fitzpatrick & Thorne, 2010; HM Inspectorate of Prisons, 2010; McSweeney, Webster, Turnbull, & Duffy, 2009). In addition, both of these reports comment on the lack of evidence-based alcohol interventions for offenders whose criminal behavior is related to their use of alcohol. A recent rapid evidence assessment of interventions

AUTHORS’ NOTE: Bryn Williams is now at Warwick Medical School, University of Warwick, UK. The research was supported by the National Offender Management Service Cymru (Wales). Our thanks to Samantha James, Karen Grove, Gemma Worgan, and staff of NOMS Cymru. All correspondence should be addressed to Nicola Bowes, Psychology Department, School of Health Sciences, Cardiff Metropolitan University, Cardiff CF5 2YB, UK; email: [email protected]. CRIMINAL JUSTICE AND BEHAVIOR, Vol. 39 No. 3, March 2012 333-344 DOI: 10.1177/0093854811433759 © 2012 International Association for Correctional and Forensic Psychology

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specifically for alcohol-related violence has shown a dearth of evaluated interventions (McMurran, in press). Offenders in custody form one important target group for interventions addressing alcohol-related violence. Using the Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), 63% of male sentenced prisoners in England and Wales have been identified as hazardous drinkers (Singleton, Farrell, & Meltzer, 1999). Around half of prisoners who drink heavily admit to being violent when intoxicated (Bowes, Sutton, Jenkins, & McMurran, 2009). In England and Wales, the National Offender Management Service (NOMS) has a strategy for working with alcohol misusing offenders (NOMS, 2006), which endorses the treatment of offenders, and the Ministry of Justice has issued guidance to clinicians on what works to reduce alcohol-related offending (Ministry of Justice, 2010). This guideline suggests that cognitive-behavioral based interventions with motivational approaches are promising in treating both alcohol problems and violence. However, it is noted that, to date, there have been no outcome studies of the impact of these programs delivered in either prison or community settings in England and Wales (Ministry of Justice, 2010). The treatment program evaluated here is Control of Violence for Angry Impulsive Drinkers (COVAID; McMurran, 2007b; McMurran & Delight, 2010). COVAID is a structured cognitive-behavioral treatment program that aims to reduce the likelihood of alcoholrelated aggression and violence by targeting cognitions, emotions, and behavior known to be related to aggression and violence. This includes addressing alcohol intoxication, which may be considered a causal risk factor in relation to aggression, that is, “a risk factor that can change, and, when changed, cause(s) a change in risk for the outcome” (Murray, Farrington, & Eisner, 2009, p. 4). Alcohol intoxication has been shown to relate to violence in longitudinal studies. In a longitudinal study of a birth cohort in New Zealand, Fergusson and colleagues (Fergusson & Horwood, 2000; Fergusson, Lynskey, & Horwood, 1996) have shown that a substantial amount of the relationship between alcohol use and crime is related to shared factors, such as social disadvantage and deviant peer affiliations. Nevertheless, when these confounding variables are controlled for, a significant relationship remains between alcohol misuse and crime, particularly violent crime, with heavy drinkers being three times more likely to be violent than light drinkers. That is, the antecedent risk factors for alcohol misuse and violent offending are highly similar, but there is also a direct relationship between alcohol misuse and violent offending. In addition, alcohol intoxication has been shown to temporally precede violence. For example, in a casecrossover study of violent offenders, Hǻggard-Grann, Hallqvist, Lǻngström, and Möller (2006) showed that there was a thirteenfold increase in the risk of committing violence for those who had been drinking alcohol in the 24 hours before the event. Alcohol intoxication on its own does not explain violence. In a review of meta-analyses of experimental studies of alcohol on aggression, Exum (2006) reported overall effect sizes of around 0.50, showing that alcohol accounts for 25% of the variance in aggressive behavior. Therefore, the COVAID intervention addresses other contributory risk factors. These include context factors, such as drinking in high-risk venues (Graham, Bernards, Osgood, & Wells, 2006), and individual factors, such as hostile attributions (Dodge, Price, Bachorowski, & Newman, 1990), anger arousal (Novaco, 2011), alcohol outcome expectancies of both aggression (McMurran et al., 2006) and social confidence (McMurran, 2007c), and impulsive social problem solving (McMurran, Blair, & Egan, 2002; Ramadan & McMurran, 2005). To integrate the treatment targets into a coherent model, the COVAID

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intervention is based on Novaco’s angry aggression “system,” in which aggression is explained by the interaction of provocations, cognitive appraisals, physiological arousal, and learned behavioral responses (Robins & Novaco, 1999). Reducing angry aggression requires change in all parts of this system. In COVAID, the added risks of alcohol intoxication and drinking contexts are added to this system to identify the need to change drinking and related behaviors, and so reduce the risk of alcohol-related violence (McMurran, 2007b). The COVAID program consists of 10 group sessions, with individual support work as required. It is a fully manualized program, which adheres to the principles of what works in offender treatment. COVAID was accredited by the Ministry of Justice’s Correctional Services Accreditation Panel (CSAP) in 2010 for use in prisons in England and Wales. Small-scale evaluations have indicated that COVAID may be beneficial to offenders (McCulloch & McMurran, 2008; McMurran & Cusens, 2003), with positive changes on measures of alcohol-related violence expectancies and controlled drinking self-efficacy. However, there is a need to evaluate COVAID using more robust research methods with larger samples. Randomized controlled trials (RCTs) are widely viewed as the most robust method of outcome research (Farrington, 2003; Harper & Chitty, 2005). The current study is a feasibility study for an RCT, one purpose of which is to examine the effects of the COVAID intervention. The focus of this report is on intermediate measures of change in treatment; that is, the study investigates changes in treatment targets that are hypothesized to lead to a reduction in alcohol-related violent offending. Our hypotheses are that, compared to the treatment-as-usual group, participants in the COVAID treatment group will show greater positive changes in alcohol-related aggression expectancies, anger control, impulsivity, and controlled drinking self-efficacy. METHOD DESIGN

The design is a two-arm RCT comparing treatment for alcohol-related violence plus treatment as usual (TAU) to TAU only, exploring intermediate treatment targets of alcohol-related aggression expectancies, anger control, impulsivity, and controlled drinking self-efficacy. The research protocol was registered with the International Standard Randomized Controlled Trials Register (www.controlledtrials.com; ISRCTN reference CCT-NAPN-20281). PARTICIPANTS

Participants were convicted adult men recruited from two prisons in South Wales, United Kingdom. Inclusion criteria for the study required participants to be aged 18 or older, serving a determinate custodial sentence of 12 months or longer, have at least three incidents of alcohol-related violence in the past 2-year period in the community, have a moderate standard of literacy and comprehension, and have an Offender Group Reconviction Scale–3 (OGRS3; NOMS, 2008) risk score of 35 or greater (i.e., medium risk or above). Exclusion criteria were current diagnosis of mental illness, mental impairment, current alcohol dependence, abstinence from alcohol on medical grounds, having an indeterminate or life

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sentences, and serving a sentence for a sexual offense. COVAID is not designed to address sexual violence, and other exclusion criteria were agreed with the CSAP, whose view was that COVAID did not meet the needs of people with dual diagnosis or people who are alcohol dependent. Participants were referred to the study through the usual sentence planning processes at the sites. The aim was to recruit 100 men (50 in each arm) from consecutive referrals to the study. MEASURES

Alcohol-Related Aggression Questionnaire (ARAQ). The ARAQ (McMurran et al., 2006) is a 28-item self-report questionnaire that assesses the relationship between alcohol and aggression. Respondents rate their endorsement of items on a 4-point scale, from strongly disagree (score 0) to strongly agree (score 3), with the total score ranging from 0 to 84. The ARAQ has good internal consistency (a = .96) and good test–retest reliability (r = .79). As a single scale, the ARAQ discriminates among nonoffenders (M = 15.29, SD = 12.21), prisoners with no record of violence (M = 24.04, SD = 17.40) and prisoners with a record of non-alcohol-related violence (M = 24.05, SD = 19.18), and prisoners with a record of alcohol-related violence (M = 37.24, SD = 16.58). The ARAQ has four subscales—AlcoholRelated Aggression (outcome expectancies) (AA; 18 items; a = .96), Trait Aggression (TA; 4 items, a = .74); Drinking Contexts (DC; 3 items, a = .90), and Sensitivity to Pain and Anxiety (PA; 3 items a = .55). The AA subscale is the one measuring alcohol-aggression expectancies, for example, with items such as “I get aggressive if I drink too much” and “Drink makes me aggressive.” In this study, change is expected only on the AA subscale. State-Trait Anger Expression Inventory–2 (STAXI-2). The STAXI-2 (Spielberger, 1999) is a 57-item, 6-scale inventory which measures both state anger, that is, the intensity of anger as an emotional state, and trait anger, that is, the disposition to experience angry feelings as a personality trait. An overall Anger Expression Inventory can be calculated. Items are rated on a 4-point scale relating to the intensity and frequency of anger experience, expression, and control. In their review, Eckhardt, Norlander, and Deffenbacher (2004) concluded that this was the best existing measure for anger based on conceptual and theoretical validity and statistical reliability. Internal consistency of the scales ranges between .73 and .93 (Spielberger, 1999). Impulsivity, Venturesome, and Empathy Scale (IVE). The IVE (Eysenck & Eysenck, 1978) consists of 54 items with a yes–no response choice. The IVE has three subscales, Impulsivity (I), Venturesomeness (V), and Empathy (E). The IVE scales’ reliabilities for a male sample (N = 559) are I = .84, V = .85, and E = .69 (Eysenck, Pearson, Easting, & Allsopp, 1985). Controlled Drinking Self-Efficacy Scale (CDSES). The CDSES (Sitharthan, Job, Kavanagh, Sitharthan, & Hough, 2003) is a 20-item questionnaire that measures a person’s confidence in controlling alcohol use through confidence in controlling drinking in specific situations (15 items) and confidence in controlling the frequency and amount of alcohol consumed (5 items). The respondent is asked to rate how confident he or she is (0%–100%) that he or she can control his or her drinking, and the mean percentage is then calculated. The measure has two major scales: overall confidence (OC) and confidence controlling frequency of drinking and amount consumed (CCFC). It also has four minor scales, which relate to

Bowes et al. / ALCOHOL-RELATED VIOLENCE   337

confidence moderating alcohol use when the individual is experiencing negative affect (NA) or positive mood (PM), and whether the individual is confident controlling the quantity consumed (Quantity) and the frequency of drinking (Frequency). The CDSES total has good internal consistency (a = .95) and test–retest reliability (r = .90). For a sample of 652 problem drinkers, the mean CDSES score was 55.58 (SD = 21.04; Sitharthan et al., 2003). PROCEDURE

Ethical approval was obtained through the ethics panel of the School of Health Sciences, University of Wales Institute Cardiff. Participants were informed about the study and provided written consent to participate. They were then randomly allocated either to COVAID plus TAU or to TAU only using a Web-based system of random permuted blocks of varying size. Participants recruited to the study completed the psychometric measures in groups at two points in time 4 weeks apart, these being pretreatment and posttreatment or equivalent. The COVAID intervention was delivered to groups of between 8 and 10 participants by trained facilitators employed by the probation service. The 10 sessions covered the following topics: explaining alcohol-related aggression, crime harm reduction, managing anger and stress, modifying drinking, altering triggers, weakening the expectancies that contribute to alcohol-related violence, identifying and coping with high-risk situations, and enhancing problem solving skills. COVAID participants accessed approximately 20 hours of group treatment and at least 4 hours of individual support over a 4-week period. TAU consisted of access to all other interventions and services available in the prison. Of relevance here are the drugs Counselling Assessment Advice Referral and Throughcare service, which was accessed by 36 (64.29%) of the COVAID group and 34 (57.63%) of the TAU group; Prison Addressing Substance-Related Offending, which was accessed by 9 (16.07%) of the COVAID group and 12 (20.34%) of the TAU group; and the Violence Reduction Programme, which was accessed by 2 (3.57%) of the COVAID group and 2 (3.39%) of the TAU group. ANALYSIS

The aim was to examine whether there were significant differences between the groups after treatment or at the equivalent time for the control group. Repeated measures mixed ANOVAs were used to examine the Group × Time interaction for change (Time 1 to Time 2) scores. A Bonferroni correction was considered to correct for Type I error arising from multiple comparisons. However, this procedure substantially reduces statistical power, which increases the risk of Type II error (Perneger, 1998). Instead, effect sizes are reported as η2, where values of .01 are conventionally interpreted as small, .06 as medium, and .14 as large. Data were analyzed using SPSS Version 17. RESULTS PARTICIPANTS

The total number of referrals was 203, of whom 115 (57%) met inclusion criteria and were willing to participate in the study; 56 were allocated to COVAID plus TAU and 59 to TAU only. Recruitment details are presented in Figure 1. The mean age of participants was

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Enrollment

Assessed for eligibility (N=203) Excluded (N=88) Unable to recall 3 recent incidents of alcohol-related violence (N=30) Not meeting risk criterion (N=42) Other reasons (N=16) (e.g. transferred, not enough time left on sentence) Randomized (N=115) Allocation

Allocated to COVAID+TAU (N=56)

Allocated to TAU (N=59)

Follow-Up Lost to follow-up (refused to complete postintervention measures, ended sentence, transferred to open prison) (N=16)

Lost to follow-up (refused to complete postintervention measures, transferred to other prison, health reasons) (N=11)

Analysis Analyzed (N=40)

Analyzed (N=48)

Figure 1:  Recruitment Flow Chart

24.45 years (SD = 5.71). The majority of the sample was White (N = 107; 93.04%), 4 (3.48%) were mixed race, 2 (1.74%) were Black, and 2 (1.74%) were Indian-Asian. The groups were comparable in age (COVAID mean age 23.48, SD = 5.17; TAU mean age 25.37, SD = 6.08), t(111) = –1.776, p = .08). There were no significant differences between the groups on OGRS3 risk scores (COVAID M = 58.86, SD = 12.82; TAU M = 59.54, SD = 12.90), t(113) = –0.29, p = .78). Of the 56 participants in COVAID, 38 (67.8%) completed the full 20 hours of group treatment and 18 (32.1%) did not complete the full number of sessions. Complete data were available for 88 participants (COVAID N = 40, 71.42%; TAU N = 48, 81.36%). OUTCOMES

Means and standard deviations on all psychometric tests for both groups before and after treatment are presented in Table 1. The groups were significantly different at baseline on the CDSES CCFC and Frequency scales, and the STAXI-2 Anger Control (In) scale, with the TAU group scoring higher in all cases. There were significant main effects of time, with lower scores at Time 2 for the following measures: ARAQ AA, F(1, 87) = 4.81, p = .03, η2 = .05, CDSES OC, F(1, 87) = 15.78, p < .001, η2 = .15, CDSES CCFC, F(1, 86) = 20.88, p < .001, η2 = .20, CDSES NA, F(1, 87) = 20.16, p < .001, η2 = .19, CDSES PM, F(1, 87) = 5.92, p = .01, η2 = .06, CDSES quantity, F(1, 86) = 4.81, p < .001, η2 = .15, CDSES frequency, F(1, 87) = 11.37, p = .001,

Bowes et al. / ALCOHOL-RELATED VIOLENCE   339 TABLE 1:  Psychometric Test Mean Scores and Standard Deviations Before and After Treatment or Equivalent for Both Groups COVAID Time 1 (n = 53) Measure Subscale ARAQ

M

SD

Baseline Differences

TAU Time 2 (n = 41)

M

SD

AA 31.98 9.77 27.93 10.64 TA 3.01 2.76 2.66 2.23 DC 5.23 2.44 5.05 2.31 PA 2.89 1.93 2.78 1.82 Total 43.12 13.77 38.41 14.44 STAXI-2 State Anger 17.96 6.65 18.00 6.79 Trait Anger 22.55 6.27 22.22 7.14 Anger Exp. (Out) 17.68 4.26 16.88 4.87 Anger Exp. (In) 17.77 4.13 16.15 4.22 Anger Con. (Out) 17.73 4.03 18.65 5.11 Anger Con. (In) 17.59 4.50 18.93 5.95 AXI 48.06 8.91 43.45 12.29 IVE Impulsivity 13.55 3.42 13.22 4.32 Venturesomeness 11.47 2.83 11.63 2.52 Empathy 10.15 4.19 11.51 3.54 CDSES OC 48.94 19.47 65.41 22.13 CCFC 52.70 25.60 75.07 21.59 NA 49.22 22.32 69.57 22.14 PM 48.28 24.15 60.80 25.34 Quantity 33.32 27.80 60.10 29.36 Frequency 65.91 32.86 84.00 27.39 Total 295.75 111.21 415.96 119.47

Time 1 (n = 53) M 30.01 2.72 4.81 2.45 40.06 20.09 22.15 19.45 18.34 19.04 19.57 47.14 13.91 11.92 9.88 55.18 64.98 57.01 53.67 42.45 80.00 353.29

Time 2 (n = 51) SD

M

11.97 29.88 2.30 2.80 2.35 5.26 2.26 2.39 15.80 40.33 10.79 18.71 7.28 21.26 5.60 16.69 4.68 17.02 5.04 19.72 5.08 19.26 13.57 42.73 4.33 13.16 2.67 11.69 3.55 9.51 21.85 58.92 21.59 68.24 24.26 61.52 22.97 55.97 27.94 46.77 27.42 82.48 113.96 373.90

SD 13.71 2.34 2.41 2.06 17.95 7.85 6.90 4.41 4.17 5.53 5.00 13.60 4.46 3.25 3.71 23.60 23.09 25.39 24.74 29.96 26.02 133.72

t(104)

p

0.90 .37 0.76 .45 0.89 .37 1.06 .29 1.09 .28 1.22 .22 0.30 .76 1.83 .07 0.66 .51 1.46 .15 2.13 .04 0.41 0.68 0.47 .64 0.85 .40 0.35 .73 1.55 .12 2.65 .01 1.72 .09 1.18 .24 1.68 .10 2.40 .02 2.62 .01

Note. COVAID = Control of Violence for Angry Impulsive Drinkers; TAU = treatment as usual; ARAQ = AlcoholRelated Aggression Questionnaire; AA = Alcohol-Related Aggression; TA = Trait Aggression; DC = Drinking Contexts; PA = Sensitivity to Pain and Anxiety; STAXI-2 = State-Trait Anger Expression Inventory–2; Anger Exp. = Anger Expression; Anger Con. = Anger Control; AXI = Anger Expression Index; IVE = Impulsivity, Venturesome, and Empathy Scale; CDSES = Controlled Drinking Self-Efficacy Scale; OC = Overall Confidence; CCFC = Confidence Controlling Frequency and Consumption; NA = Negative Affect; PM = Positive Mood.

η2 = .12, total CDSES, F(1, 86) = 25.14, p < .001, η2 = .23, STAXI-2 Anger Expression Out, F(1, 86) = 10.69, p = .002, η2 = .11, STAXI-2 Anger Expression In, F(1, 86) = 4.04, p = .05, η2 = .05, STAXI-2 Anger Control Out, F(1, 86) = 4.42, p = .04, η2 = .05, STAXI-2 Anger Expression Index, F(1, 86) = 12.57, p = .001, η2 = .13, and IVE I, F(1, 87) = 16.77, p < .001, η2 = .16. Results of the ANOVAs are presented in Table 2. There were significant Group × Time interactions, with the COVAID group reporting significantly greater change scores in the desired directions on ARAQ AA (η2 = .05), ARAQ Total (η2 = .05), CDSES OC (η2 = .09), CDSES CCFC (η2 = .11), CDSES NA (η2 = .12), CDSES PM (η2 = .04), CDES Frequency (η2 = .07), CDSES Quantity (η2 = .07), CDSES Total (η2 = .14), and the IVE empathy subscale (η2 = .04). There were no significant Group × Time interactions on any of the STAXI-2 scales.

340   Criminal Justice and Behavior TABLE 2:  Results of Repeated Measures Mixed ANOVA COVAID

TAU

Measure

Subscale

n

n

F(1, 86)

p

ARAQ

AA TA DC PA Total State Anger Trait Anger Anger Expression (Out) Anger Expression (In) Anger Control (Out) Anger Control (In) AXI Impulsivity Venturesomeness Empathy OC CCFC NA PM Quantity Frequency Total

41 41 41 41 41 41 41 40 40 40 40 40 41 41 41 41 40 41 41 40 41 40

48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48 48

4.73 1.12 3.48 0.94 4.68 0.00 0.37 1.90 0.12 0.02 1.54 0.04 0.01 0.15 3.85 8.83 10.56 11.44 3.99 6.81 6.57 13.53

.03 .30 .07 .34 .03 .96 .55 .17 .73 .88 .22 .84 .91 .70 .05 .00 .00 .00 .02 .01 .01 .00

STAXI-2

IVE

CDSES

Note. COVAID = Control of Violence for Angry Impulsive Drinkers; TAU = treatment as usual; ARAQ = AlcoholRelated Aggression Questionnaire; AA = Alcohol-Related Aggression; TA = Trait Aggression; DC = Drinking Contexts; PA = Sensitivity to Pain and Anxiety; STAXI-2 = State-Trait Anger Expression Inventory–2; AXI = Anger Expression Index; IVE = Impulsivity, Venturesome, and Empathy Scale; CDSES = Controlled Drinking Self-Efficacy Scale; OC = Overall Confidence; CCFC = Confidence Controlling Frequency and Consumption; NA = Negative Affect; PM = Positive Mood.

DISCUSSION

The COVAID intervention aims to reduce alcohol-related violence by tackling the mediators of anger, impulsivity, and drinking. Our findings indicate that, compared to TAU only, COVAID benefits participants by reducing their alcohol-aggression outcome expectancies (i.e., ARAQ AA scale). Alcohol outcome expectancies are the effects one expects to experience as a result of drinking (Goldman, Del Boca, & Darkes, 1999). Alcoholaggression outcome expectancies, as measured by the ARAQ AA scale, include items such as “The more I drink, the more aggressive I get” and “The more I drink, the less able I am to control my temper.” The role of these expectancies in explaining drunken aggression is equivocal. Some studies indicate that the belief that alcohol leads to aggression personally are associated with alcohol-related violence (Quigley, Corbett, & Tedeschi, 2002; Zhang, Welte, & Wieczorek, 2002) and others do not (Giancola, 2006). Targeting alcohol-related aggression outcome expectancies may be useful as one component in interventions to tackle alcohol-related aggression in dispositionally aggressive men (McMurran, 2007a). Our findings also indicate that, compared to TAU only, COVAID benefits participants by increasing their confidence in controlling both the quantity and frequency of alcohol consumption and in response to both negative and positive moods (i.e., CDSES scales). Since alcohol

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intoxication is a major contributory risk factor for aggression (Fergusson et al., 1996; Fergusson & Horwood, 2000; Hǻggard-Grann et al., 2006), this is an important positive outcome. However, the effect of COVAID on actual alcohol consumption remains to be tested. There were no significant Group × Time interactions on any scales of the STAXI-2. This suggests that more attention needs to be paid to the role of anger in alcohol-related violence. There are different motivations for aggression while intoxicated, as there are for aggression while sober, and not all motivations are associated with anger (McMurran, Jinks, Howells, & Howard, 2010, 2011). Those whose violence is in the pursuit of material goals have been found to be high on trait aggression, trait anger, trait anxiety, and anger suppression; those who use violence in the pursuit of social dominance show high trait aggression and trait anger; and those whose violence is a defensive response to threat show lower trait aggression and trait anger (McMurran et al., 2011). Norström and Pape (2010) found a stronger relationship between alcohol and violence in those with high levels of anger suppression. A more individual approach to motivations for violence and the role of anger would potentially be a positive development in COVAID. There was no Group × Time interaction on the impulsivity subscale of the IVE. McDougall, Perry, Clarbour, Bowles, & Worthy (2009) found significantly different changes in impulsivity, as measured by the Eysenck Impulsivity scale, for prisoners in the Enhanced Thinking Skills (ETS) program (Clarke, 2000) compared to a wait-list control. COVAID may benefit from revision to incorporate more of the effective components of ETS, or alternatively COVAID could be delivered in conjunction with ETS. There was, however, an observed difference on the empathy subscale of the IVE. Although this difference was not hypothesized, it may be that those components of COVAID that focus on the effects of violence enhance empathic concern for others. LIMITATIONS

The study reported here is a feasibility study for a full-scale RCT, and the degree of change is part of the information required to calculate sample sizes. The sample size was too small to produce complete equivalence of groups at baseline, and the study was not adequately powered to detect a reliable effect. Therefore, the changes reported here should be interpreted with caution. Although significant improvement in participant ratings of confidence across all the scales on the CDSES is positive, it should be acknowledged that participants were in prison where no alcohol is available and where confidence about change may run high. At present, there is no information about whether changes in the mediating variables measured here predict changes in drinking or alcohol-related violence. Follow-up data are necessary to examine effects of COVAID on actual behavior. The results were also affected by attrition at follow-up, with missing or incomplete data for 27 participants (23% of the total sample). A further problem is that the level of attrition was slightly higher in the TAU group. This may be surprising given that the sample was incarcerated but is consistent with other evaluations of offending behavior programs in U.K. prisons (McDougall et al., 2009). CONCLUSIONS

The study indicates that it is feasible to implement an RCT to evaluate the COVAID intervention within custodial settings, at least with the specific group of nondependent

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Nicola Bowes is a senior lecturer at Cardiff Metropolitan University (formerly University of Wales Institute Cardiff), where she is program director for the master’s degree in forensic psychology. She is also a practicing forensic psychologist who is registered with the Health Professions Council in the United Kingdom and chartered with the British Psychological Society. Mary McMurran, PhD, is professor of personality disorder research at the Institute of Mental Health, University of Nottingham. The assessment and treatment of alcohol-related violence is one of her main research interests.

344   Criminal Justice and Behavior Bryn Williams has a master’s in abnormal and clinical psychology as well as a postgraduate qualification in forensic psychology. He was employed as a research assistant on the project reported in this article. He is currently studying medicine at the University of Warwick. Siriol David, PhD, is the regional psychologist for the National Offender Management Service Cymru. She leads the forensic psychological services across prison and probation teams in Wales. Ingrid Zammit is the commissioning manager for NOMS Cymru and is responsible for commissioning services for prison and probation teams in Wales.