{"id":{"repo_id":"unsw","oai_identifier":"oai:unsworks.library.unsw.edu.au:1959.4/101474"},"canonical_url":"https://search.dev.ndltd.org/etd/unsw/oai:unsworks.library.unsw.edu.au:1959.4/101474","repository":{"repo_id":"unsw","name":"University of New South Wales","base_url":"https://unsworks.unsw.edu.au/oai/provider"},"display":{"title":"A Wait-List Controlled Study of a Culturally Adapted Trauma Focused-Adaptation and Development After Persecution and Trauma (ADAPT) Model-Based Anger Therapy (CTF-AAT) for Intermittent Explosive Disorder (IED) in Timor Leste","abstract":"Research background and context: The core focus of my dissertation is the development and assessment of a culturally adapted psychological intervention in response to my community observations during an extended United Nations (UN) assignment in the newly established independent country of Timor Leste. This was combined with an emerging body of research showing high rates of post-conflict chronic anger responses and inter-familial violence amongst trauma-affected communities in Timor-Leste. The structure of the dissertation includes a general introduction (Chapter 1), followed by eight focused research and clinical narrative review chapters that provide the context to the program of empirical research that forms the core of the second half of the dissertation comprising five chapters with a final integrative synthesis (Chapter 15). The review chapters commence with an overview of historical and contemporary approaches to anger and anger conditions including a review of culturally specific understandings of anger and pathological expression of some anger conditions reflected by the inclusion of intermittent explosive disorder (IED) within recent mental health diagnostic systems (Chapter 2). I then reviewed findings from mental health research within postconflict settings developed over the last 4 decades, with most of that research focused on posttraumatic stress disorder (PTSD) and depressive conditions (Chapter 3). Increasingly, posttrauma anger responses have also been documented as an outcome of trauma, initially amongst combat veterans but also amongst conflict exposed communities affected by war and mass violence (Chapter 4). This background narrative review of the key relevant mental health research allowed me to examine the Timor Leste postconflict environment and the particular importance of understanding the association and role of anger with past trauma exposures in the contemporary life of affected Timorese communities (Chapter 5). To identify a clinical framework to assist with understanding posttraumatic anger, I examine a number of prominent trauma models developed to understand the impact of mas conflict and persecution and review in detail the ADAPT theoretical framework proposed by Silove and colleagues, which focuses on five psychosocial pillars (Chapter 6). The pillar of justice in particular guided the conceptualization of the intervention that describes that exposure to injustices; particularly human rights violations (i.e., torture, murder, and rape) committed by state parties during conflicts, if unaddressed by relevant government entities in the postconflict era were bound to play a central role in triggering chronic anger reactions that may perpetuate pathological expressions of anger marked by aggression and violence. I then shift the focus to the role of psychological interventions including contemporary treatment responses for anger syndromes in other population groups, which were dominated by cognitive behavioural treatment (CBT) approaches and clinical trials examining clinical outcomes including the few IED treatment outcome studies (Chapter 7). A particular focus included research with combat veterans, the population with whom most trauma-focused anger studies had been undertaken. Chapter 8 includes a selective review of the efficacy of psychological interventions in treating PTSD and other CMDs in the literature followed by Chapter 9 that presents a literature overview on cultural competence, adaptation frameworks, models and guidelines that informed the creation and the testing of the culturally adapted trauma focused-adaptation and development after persecution and trauma (ADAPT) model based anger therapy (CTF-AAT) for intermittent explosive disorder (IED) in Timor Leste. Research Method and Results: The empirical chapters commence with a detailed description of the process that I used to develop CTF-AAT intervention linked to the experience of the Timor Leste communities. I drew on key developments in the postconflict mental health field particularly the research and conceptual framework of ADAPT of Silove and colleagues, linking postconflict anger and past experiences of injustice, in Timor Leste. This was combined with key informant and stakeholder consultation to assist and refine the CTF-AAT intervention (Chapter 10) and the selection of the key assessment tools to evaluate anger syndromes and symptom change over time in Timor-Leste (Chapter 11). The resulting CTF-AAT intervention developed in partnership with Timorese consultants was examined for community acceptability and feasibility through a small consecutive series pilot study which confirmed the acceptability and perceived value of the psychological intervention (Chapter 12). This led to the formal examination of CTF-AAT (Chapter 13) through the implementation of an assessor-blinded waitlist controlled trial of a CTF-AAT amongst trauma survivors in postconflict Timor Leste. The intention-to-treat sample (n = 78) comprising Timorese nationals (women = 49; men = 29), ages 18 years and older, meeting Diagnostic and Statistical Manual of Mental Disorders (DSM; 4th ed.) criteria for IED, with equal numbers (n = 39 each) being randomized to the treatment group (TG) and waitlist (WL). Assessments were conducted 1 week prior to therapy, immediately at posttreatment, and at 1-month and 1-year follow-up. The study was designed in conformity with the Consolidated Standards of Reporting Trials (CONSORT) extension for nonpharmacologic treatment interventions. The primary measures included an IED diagnosis made according to the East Timor Explosive Anger Measure (ETAM) and the directionality of expression and control of anger assessed by four dimensions of the State-Trait Anger Expression Inventory (STAXI-2). Secondary measures included psychological distress assessed using the Kessler Psychological Distress Scale (K-10), and an index of PTSD assessed using the Harvard Trauma Questionnaire (HTQ). The results after the third assessment (at 1-month follow-up) in the TG demonstrated a decline in IED from 100% to zero. In the WL, more than 70% (of the 100% at baseline) demonstrated persisting IED at second and third assessments. The TG alone showed significant (p < .05) improvements on all STAXI-2 scales, the effect sizes for the intervention being uniformly large (> 0.80). Psychological distress and PTSD showed substantial reductions in the TG, but not the WL group. The fourth assessment was conducted among n = 26 TG participants after 1 year of the CTF-AAT intervention, where none met the criteria for IED. Improvements in the four anger dimensions of STAXI-2 observed in previous assessments were maintained at 1-year posttherapy. None of the 26 participants met the PTSD threshold of ≥ 2.2 or the K-10 threshold of K10 > 30, which indicates that the positive impacts of the CTF-AAT intervention are sustainable for at least 1-year posttherapy. Conclusion: The findings provide the first evidence in support of the efficacy of CTF-AAT for IED in a culturally diverse, postconflict setting and the first ADAPT-informed specialized mental health treatment outcome study in the world for IED. Considering the rising number of traumatized populations in the world due to war and conflict, IED rates are bound to escalate thus after further testing, the treatment protocol of CTF-AAT has the potential to be adapted and implemented by lay counselors in similar settings worldwide, the aim being to reduce anger, IED and aggression in post-conflict societies across different cultures.","abstract_html":"Research background and context: The core focus of my dissertation is the development and assessment of a culturally adapted psychological intervention in response to my community observations during an extended United Nations (UN) assignment in the newly established independent country of Timor Leste. This was combined with an emerging body of research showing high rates of post-conflict chronic anger responses and inter-familial violence amongst trauma-affected communities in Timor-Leste. The structure of the dissertation includes a general introduction (Chapter 1), followed by eight focused research and clinical narrative review chapters that provide the context to the program of empirical research that forms the core of the second half of the dissertation comprising five chapters with a final integrative synthesis (Chapter 15). The review chapters commence with an overview of historical and contemporary approaches to anger and anger conditions including a review of culturally specific understandings of anger and pathological expression of some anger conditions reflected by the inclusion of intermittent explosive disorder (IED) within recent mental health diagnostic systems (Chapter 2). I then reviewed findings from mental health research within postconflict settings developed over the last 4 decades, with most of that research focused on posttraumatic stress disorder (PTSD) and depressive conditions (Chapter 3). Increasingly, posttrauma anger responses have also been documented as an outcome of trauma, initially amongst combat veterans but also amongst conflict exposed communities affected by war and mass violence (Chapter 4). This background narrative review of the key relevant mental health research allowed me to examine the Timor Leste postconflict environment and the particular importance of understanding the association and role of anger with past trauma exposures in the contemporary life of affected Timorese communities (Chapter 5). To identify a clinical framework to assist with understanding posttraumatic anger, I examine a number of prominent trauma models developed to understand the impact of mas conflict and persecution and review in detail the ADAPT theoretical framework proposed by Silove and colleagues, which focuses on five psychosocial pillars (Chapter 6). The pillar of justice in particular guided the conceptualization of the intervention that describes that exposure to injustices; particularly human rights violations (i.e., torture, murder, and rape) committed by state parties during conflicts, if unaddressed by relevant government entities in the postconflict era were bound to play a central role in triggering chronic anger reactions that may perpetuate pathological expressions of anger marked by aggression and violence. I then shift the focus to the role of psychological interventions including contemporary treatment responses for anger syndromes in other population groups, which were dominated by cognitive behavioural treatment (CBT) approaches and clinical trials examining clinical outcomes including the few IED treatment outcome studies (Chapter 7). A particular focus included research with combat veterans, the population with whom most trauma-focused anger studies had been undertaken. Chapter 8 includes a selective review of the efficacy of psychological interventions in treating PTSD and other CMDs in the literature followed by Chapter 9 that presents a literature overview on cultural competence, adaptation frameworks, models and guidelines that informed the creation and the testing of the culturally adapted trauma focused-adaptation and development after persecution and trauma (ADAPT) model based anger therapy (CTF-AAT) for intermittent explosive disorder (IED) in Timor Leste. Research Method and Results: The empirical chapters commence with a detailed description of the process that I used to develop CTF-AAT intervention linked to the experience of the Timor Leste communities. I drew on key developments in the postconflict mental health field particularly the research and conceptual framework of ADAPT of Silove and colleagues, linking postconflict anger and past experiences of injustice, in Timor Leste. This was combined with key informant and stakeholder consultation to assist and refine the CTF-AAT intervention (Chapter 10) and the selection of the key assessment tools to evaluate anger syndromes and symptom change over time in Timor-Leste (Chapter 11). The resulting CTF-AAT intervention developed in partnership with Timorese consultants was examined for community acceptability and feasibility through a small consecutive series pilot study which confirmed the acceptability and perceived value of the psychological intervention (Chapter 12). This led to the formal examination of CTF-AAT (Chapter 13) through the implementation of an assessor-blinded waitlist controlled trial of a CTF-AAT amongst trauma survivors in postconflict Timor Leste. The intention-to-treat sample (n = 78) comprising Timorese nationals (women = 49; men = 29), ages 18 years and older, meeting Diagnostic and Statistical Manual of Mental Disorders (DSM; 4th ed.) criteria for IED, with equal numbers (n = 39 each) being randomized to the treatment group (TG) and waitlist (WL). Assessments were conducted 1 week prior to therapy, immediately at posttreatment, and at 1-month and 1-year follow-up. The study was designed in conformity with the Consolidated Standards of Reporting Trials (CONSORT) extension for nonpharmacologic treatment interventions. The primary measures included an IED diagnosis made according to the East Timor Explosive Anger Measure (ETAM) and the directionality of expression and control of anger assessed by four dimensions of the State-Trait Anger Expression Inventory (STAXI-2). Secondary measures included psychological distress assessed using the Kessler Psychological Distress Scale (K-10), and an index of PTSD assessed using the Harvard Trauma Questionnaire (HTQ). The results after the third assessment (at 1-month follow-up) in the TG demonstrated a decline in IED from 100% to zero. In the WL, more than 70% (of the 100% at baseline) demonstrated persisting IED at second and third assessments. The TG alone showed significant (p &lt; .05) improvements on all STAXI-2 scales, the effect sizes for the intervention being uniformly large (&gt; 0.80). Psychological distress and PTSD showed substantial reductions in the TG, but not the WL group. The fourth assessment was conducted among n = 26 TG participants after 1 year of the CTF-AAT intervention, where none met the criteria for IED. Improvements in the four anger dimensions of STAXI-2 observed in previous assessments were maintained at 1-year posttherapy. None of the 26 participants met the PTSD threshold of ≥ 2.2 or the K-10 threshold of K10 &gt; 30, which indicates that the positive impacts of the CTF-AAT intervention are sustainable for at least 1-year posttherapy. Conclusion: The findings provide the first evidence in support of the efficacy of CTF-AAT for IED in a culturally diverse, postconflict setting and the first ADAPT-informed specialized mental health treatment outcome study in the world for IED. Considering the rising number of traumatized populations in the world due to war and conflict, IED rates are bound to escalate thus after further testing, the treatment protocol of CTF-AAT has the potential to be adapted and implemented by lay counselors in similar settings worldwide, the aim being to reduce anger, IED and aggression in post-conflict societies across different cultures.","abstract_has_math":false,"creators":["Hewage, Madhubhashini"],"institution":"UNSW, Sydney","degree_name":null,"degree_level":null,"degree_discipline":null,"degree_department":null,"school":null,"contributors":[],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2023,"date_issued":"2023","date_published":"2023","updated_at":"2026-07-24T05:33:06Z","subjects":["Anger","Intermittent Explosive Disorder","ADAPT","Culturally adapted -Trauma Focused - Anger Therapy","Postconflict","Timor Leste","anzsrc-for: 320221 Psychiatry (incl. psychotherapy)","anzsrc-for: 520302 Clinical psychology"],"languages":["en"],"rights":["open access","CC BY 4.0","free_to_read"],"rights_urls":["https://purl.org/coar/access_right/c_abf2","https://creativecommons.org/licenses/by/4.0/"],"identifier_entries":[{"key":"dc:identifier","label":"Identifier","values":["https://doi.org/10.26190/unsworks/25181"],"render_values":[{"text":"https://doi.org/10.26190/unsworks/25181","href":"https://doi.org/10.26190/unsworks/25181","code":true}]}]},"links":{"outbound_url":"http://hdl.handle.net/1959.4/101474","outbound_label":"Handle","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:creator","label":"Author","values":["Hewage, Madhubhashini"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date","label":"Dc Date","values":["2023"]},{"key":"dc:publisher","label":"Institution","values":["UNSW, Sydney"]},{"key":"dc:type","label":"Dc Type","values":["doctoral thesis","http://purl.org/coar/resource_type/c_db06"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Anger","Intermittent Explosive Disorder","ADAPT","Culturally adapted -Trauma Focused - Anger Therapy","Postconflict","Timor Leste","anzsrc-for: 320221 Psychiatry (incl. psychotherapy)","anzsrc-for: 520302 Clinical psychology"]}]},{"id":"language_rights","label":"Language and Rights","entries":[{"key":"dc:language","label":"Dc Language","values":["en"]},{"key":"dc:rights","label":"Dc Rights","values":["open access","https://purl.org/coar/access_right/c_abf2","CC BY 4.0","https://creativecommons.org/licenses/by/4.0/","free_to_read"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["http://hdl.handle.net/1959.4/101474","https://unsworks.unsw.edu.au/bitstreams/6f58d38a-9c24-4cef-b6d6-051455abeffb/download","https://doi.org/10.26190/unsworks/25181"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description","label":"Description","values":["Research background and context: The core focus of my dissertation is the development and assessment of a culturally adapted psychological intervention in response to my community observations during an extended United Nations (UN) assignment in the newly established independent country of Timor Leste. This was combined with an emerging body of research showing high rates of post-conflict chronic anger responses and inter-familial violence amongst trauma-affected communities in Timor-Leste. The structure of the dissertation includes a general introduction (Chapter 1), followed by eight focused research and clinical narrative review chapters that provide the context to the program of empirical research that forms the core of the second half of the dissertation comprising five chapters with a final integrative synthesis (Chapter 15). The review chapters commence with an overview of historical and contemporary approaches to anger and anger conditions including a review of culturally specific understandings of anger and pathological expression of some anger conditions reflected by the inclusion of intermittent explosive disorder (IED) within recent mental health diagnostic systems (Chapter 2). I then reviewed findings from mental health research within postconflict settings developed over the last 4 decades, with most of that research focused on posttraumatic stress disorder (PTSD) and depressive conditions (Chapter 3). Increasingly, posttrauma anger responses have also been documented as an outcome of trauma, initially amongst combat veterans but also amongst conflict exposed communities affected by war and mass violence (Chapter 4). This background narrative review of the key relevant mental health research allowed me to examine the Timor Leste postconflict environment and the particular importance of understanding the association and role of anger with past trauma exposures in the contemporary life of affected Timorese communities (Chapter 5). To identify a clinical framework to assist with understanding posttraumatic anger, I examine a number of prominent trauma models developed to understand the impact of mas conflict and persecution and review in detail the ADAPT theoretical framework proposed by Silove and colleagues, which focuses on five psychosocial pillars (Chapter 6). The pillar of justice in particular guided the conceptualization of the intervention that describes that exposure to injustices; particularly human rights violations (i.e., torture, murder, and rape) committed by state parties during conflicts, if unaddressed by relevant government entities in the postconflict era were bound to play a central role in triggering chronic anger reactions that may perpetuate pathological expressions of anger marked by aggression and violence. I then shift the focus to the role of psychological interventions including contemporary treatment responses for anger syndromes in other population groups, which were dominated by cognitive behavioural treatment (CBT) approaches and clinical trials examining clinical outcomes including the few IED treatment outcome studies (Chapter 7). A particular focus included research with combat veterans, the population with whom most trauma-focused anger studies had been undertaken. Chapter 8 includes a selective review of the efficacy of psychological interventions in treating PTSD and other CMDs in the literature followed by Chapter 9 that presents a literature overview on cultural competence, adaptation frameworks, models and guidelines that informed the creation and the testing of the culturally adapted trauma focused-adaptation and development after persecution and trauma (ADAPT) model based anger therapy (CTF-AAT) for intermittent explosive disorder (IED) in Timor Leste. Research Method and Results: The empirical chapters commence with a detailed description of the process that I used to develop CTF-AAT intervention linked to the experience of the Timor Leste communities. I drew on key developments in the postconflict mental health field particularly the research and conceptual framework of ADAPT of Silove and colleagues, linking postconflict anger and past experiences of injustice, in Timor Leste. This was combined with key informant and stakeholder consultation to assist and refine the CTF-AAT intervention (Chapter 10) and the selection of the key assessment tools to evaluate anger syndromes and symptom change over time in Timor-Leste (Chapter 11). The resulting CTF-AAT intervention developed in partnership with Timorese consultants was examined for community acceptability and feasibility through a small consecutive series pilot study which confirmed the acceptability and perceived value of the psychological intervention (Chapter 12). This led to the formal examination of CTF-AAT (Chapter 13) through the implementation of an assessor-blinded waitlist controlled trial of a CTF-AAT amongst trauma survivors in postconflict Timor Leste. The intention-to-treat sample (n = 78) comprising Timorese nationals (women = 49; men = 29), ages 18 years and older, meeting Diagnostic and Statistical Manual of Mental Disorders (DSM; 4th ed.) criteria for IED, with equal numbers (n = 39 each) being randomized to the treatment group (TG) and waitlist (WL). Assessments were conducted 1 week prior to therapy, immediately at posttreatment, and at 1-month and 1-year follow-up. The study was designed in conformity with the Consolidated Standards of Reporting Trials (CONSORT) extension for nonpharmacologic treatment interventions. The primary measures included an IED diagnosis made according to the East Timor Explosive Anger Measure (ETAM) and the directionality of expression and control of anger assessed by four dimensions of the State-Trait Anger Expression Inventory (STAXI-2). Secondary measures included psychological distress assessed using the Kessler Psychological Distress Scale (K-10), and an index of PTSD assessed using the Harvard Trauma Questionnaire (HTQ). The results after the third assessment (at 1-month follow-up) in the TG demonstrated a decline in IED from 100% to zero. In the WL, more than 70% (of the 100% at baseline) demonstrated persisting IED at second and third assessments. The TG alone showed significant (p < .05) improvements on all STAXI-2 scales, the effect sizes for the intervention being uniformly large (> 0.80). Psychological distress and PTSD showed substantial reductions in the TG, but not the WL group. The fourth assessment was conducted among n = 26 TG participants after 1 year of the CTF-AAT intervention, where none met the criteria for IED. Improvements in the four anger dimensions of STAXI-2 observed in previous assessments were maintained at 1-year posttherapy. None of the 26 participants met the PTSD threshold of ≥ 2.2 or the K-10 threshold of K10 > 30, which indicates that the positive impacts of the CTF-AAT intervention are sustainable for at least 1-year posttherapy. Conclusion: The findings provide the first evidence in support of the efficacy of CTF-AAT for IED in a culturally diverse, postconflict setting and the first ADAPT-informed specialized mental health treatment outcome study in the world for IED. Considering the rising number of traumatized populations in the world due to war and conflict, IED rates are bound to escalate thus after further testing, the treatment protocol of CTF-AAT has the potential to be adapted and implemented by lay counselors in similar settings worldwide, the aim being to reduce anger, IED and aggression in post-conflict societies across different cultures."]},{"key":"dc:format","label":"Dc Format","values":["application/pdf"]},{"key":"dc:title","label":"Title","values":["A Wait-List Controlled Study of a Culturally Adapted Trauma Focused-Adaptation and Development After Persecution and Trauma (ADAPT) Model-Based Anger Therapy (CTF-AAT) for Intermittent Explosive Disorder (IED) in Timor Leste"]}]}],"canonical_facts":{"dc:creator":["Hewage, Madhubhashini"],"dc:date":["2023"],"dc:description":["Research background and context: The core focus of my dissertation is the development and assessment of a culturally adapted psychological intervention in response to my community observations during an extended United Nations (UN) assignment in the newly established independent country of Timor Leste. This was combined with an emerging body of research showing high rates of post-conflict chronic anger responses and inter-familial violence amongst trauma-affected communities in Timor-Leste. The structure of the dissertation includes a general introduction (Chapter 1), followed by eight focused research and clinical narrative review chapters that provide the context to the program of empirical research that forms the core of the second half of the dissertation comprising five chapters with a final integrative synthesis (Chapter 15). The review chapters commence with an overview of historical and contemporary approaches to anger and anger conditions including a review of culturally specific understandings of anger and pathological expression of some anger conditions reflected by the inclusion of intermittent explosive disorder (IED) within recent mental health diagnostic systems (Chapter 2). I then reviewed findings from mental health research within postconflict settings developed over the last 4 decades, with most of that research focused on posttraumatic stress disorder (PTSD) and depressive conditions (Chapter 3). Increasingly, posttrauma anger responses have also been documented as an outcome of trauma, initially amongst combat veterans but also amongst conflict exposed communities affected by war and mass violence (Chapter 4). This background narrative review of the key relevant mental health research allowed me to examine the Timor Leste postconflict environment and the particular importance of understanding the association and role of anger with past trauma exposures in the contemporary life of affected Timorese communities (Chapter 5). To identify a clinical framework to assist with understanding posttraumatic anger, I examine a number of prominent trauma models developed to understand the impact of mas conflict and persecution and review in detail the ADAPT theoretical framework proposed by Silove and colleagues, which focuses on five psychosocial pillars (Chapter 6). The pillar of justice in particular guided the conceptualization of the intervention that describes that exposure to injustices; particularly human rights violations (i.e., torture, murder, and rape) committed by state parties during conflicts, if unaddressed by relevant government entities in the postconflict era were bound to play a central role in triggering chronic anger reactions that may perpetuate pathological expressions of anger marked by aggression and violence. I then shift the focus to the role of psychological interventions including contemporary treatment responses for anger syndromes in other population groups, which were dominated by cognitive behavioural treatment (CBT) approaches and clinical trials examining clinical outcomes including the few IED treatment outcome studies (Chapter 7). A particular focus included research with combat veterans, the population with whom most trauma-focused anger studies had been undertaken. Chapter 8 includes a selective review of the efficacy of psychological interventions in treating PTSD and other CMDs in the literature followed by Chapter 9 that presents a literature overview on cultural competence, adaptation frameworks, models and guidelines that informed the creation and the testing of the culturally adapted trauma focused-adaptation and development after persecution and trauma (ADAPT) model based anger therapy (CTF-AAT) for intermittent explosive disorder (IED) in Timor Leste. Research Method and Results: The empirical chapters commence with a detailed description of the process that I used to develop CTF-AAT intervention linked to the experience of the Timor Leste communities. I drew on key developments in the postconflict mental health field particularly the research and conceptual framework of ADAPT of Silove and colleagues, linking postconflict anger and past experiences of injustice, in Timor Leste. This was combined with key informant and stakeholder consultation to assist and refine the CTF-AAT intervention (Chapter 10) and the selection of the key assessment tools to evaluate anger syndromes and symptom change over time in Timor-Leste (Chapter 11). The resulting CTF-AAT intervention developed in partnership with Timorese consultants was examined for community acceptability and feasibility through a small consecutive series pilot study which confirmed the acceptability and perceived value of the psychological intervention (Chapter 12). This led to the formal examination of CTF-AAT (Chapter 13) through the implementation of an assessor-blinded waitlist controlled trial of a CTF-AAT amongst trauma survivors in postconflict Timor Leste. The intention-to-treat sample (n = 78) comprising Timorese nationals (women = 49; men = 29), ages 18 years and older, meeting Diagnostic and Statistical Manual of Mental Disorders (DSM; 4th ed.) criteria for IED, with equal numbers (n = 39 each) being randomized to the treatment group (TG) and waitlist (WL). Assessments were conducted 1 week prior to therapy, immediately at posttreatment, and at 1-month and 1-year follow-up. The study was designed in conformity with the Consolidated Standards of Reporting Trials (CONSORT) extension for nonpharmacologic treatment interventions. The primary measures included an IED diagnosis made according to the East Timor Explosive Anger Measure (ETAM) and the directionality of expression and control of anger assessed by four dimensions of the State-Trait Anger Expression Inventory (STAXI-2). Secondary measures included psychological distress assessed using the Kessler Psychological Distress Scale (K-10), and an index of PTSD assessed using the Harvard Trauma Questionnaire (HTQ). The results after the third assessment (at 1-month follow-up) in the TG demonstrated a decline in IED from 100% to zero. In the WL, more than 70% (of the 100% at baseline) demonstrated persisting IED at second and third assessments. The TG alone showed significant (p < .05) improvements on all STAXI-2 scales, the effect sizes for the intervention being uniformly large (> 0.80). Psychological distress and PTSD showed substantial reductions in the TG, but not the WL group. The fourth assessment was conducted among n = 26 TG participants after 1 year of the CTF-AAT intervention, where none met the criteria for IED. Improvements in the four anger dimensions of STAXI-2 observed in previous assessments were maintained at 1-year posttherapy. None of the 26 participants met the PTSD threshold of ≥ 2.2 or the K-10 threshold of K10 > 30, which indicates that the positive impacts of the CTF-AAT intervention are sustainable for at least 1-year posttherapy. Conclusion: The findings provide the first evidence in support of the efficacy of CTF-AAT for IED in a culturally diverse, postconflict setting and the first ADAPT-informed specialized mental health treatment outcome study in the world for IED. Considering the rising number of traumatized populations in the world due to war and conflict, IED rates are bound to escalate thus after further testing, the treatment protocol of CTF-AAT has the potential to be adapted and implemented by lay counselors in similar settings worldwide, the aim being to reduce anger, IED and aggression in post-conflict societies across different cultures."],"dc:format":["application/pdf"],"dc:identifier":["http://hdl.handle.net/1959.4/101474","https://unsworks.unsw.edu.au/bitstreams/6f58d38a-9c24-4cef-b6d6-051455abeffb/download","https://doi.org/10.26190/unsworks/25181"],"dc:language":["en"],"dc:publisher":["UNSW, Sydney"],"dc:rights":["open access","https://purl.org/coar/access_right/c_abf2","CC BY 4.0","https://creativecommons.org/licenses/by/4.0/","free_to_read"],"dc:subject":["Anger","Intermittent Explosive Disorder","ADAPT","Culturally adapted -Trauma Focused - Anger Therapy","Postconflict","Timor Leste","anzsrc-for: 320221 Psychiatry (incl. psychotherapy)","anzsrc-for: 520302 Clinical psychology"],"dc:title":["A Wait-List Controlled Study of a Culturally Adapted Trauma Focused-Adaptation and Development After Persecution and Trauma (ADAPT) Model-Based Anger Therapy (CTF-AAT) for Intermittent Explosive Disorder (IED) in Timor Leste"],"dc:type":["doctoral thesis","http://purl.org/coar/resource_type/c_db06"]},"updated_at":"2026-07-24T05:33:06Z"}