Anger and violence prevention: enhancing treatment effects through booster sessions.

Anger and violence prevention: enhancing treatment effects through booster sessions. Abstract This study was designed to evaluate the effectiveness of booster Booster - A data-parallel language."The Booster Language", E. Paalvast, TR PL 89-ITI-B-18, Inst voor Toegepaste Informatica TNO, Delft, 1989. sessions on the maintenance of intervention gains following an angermanagement prevention program: Student Created Aggression ReplacementEducation Program (SCARE). Participants who had completed the SCAREprogram a year earlier were randomly assigned into either a boostertreatment or treatment as usual. Several scales focusing on anger(State-Trait Anger Expression Inventory-2/STAXI-2) and empathy(Interpersonal Reactivity Index/IRI) measured treatment effectivenesspre and post participation in booster sessions. The SCARE boosterprogram appears to have promise for maintaining and increasing treatmenteffects for the original fifteen-session program, particularly withregards to trait anger and empathy. Suggestions are made for theinclusion of booster sessions to enhance efficacy of interventionsdesigned to decrease youth violence and aggression and maintain schoolretention. KEY WORDS: Booster sessions, anger control, anger management,violence prevention, at-risk youth. Violence and aggression experienced by early adolescents havecreated an ongoing societal concern, faced daily by students, teachers,and mental health professionals. An increased need to address theongoing salient issues has inspired the development of a variety offield-based interventions designed to reduce violence in our schools andcommunity. One such program, the Student Created Aggression ReplacementEducation Program (SCARE; Herrmann & McWhirter, 2001) has been shownto decrease situational and dispositional anger (Herrmann, 1999;Herrmann & McWhirter, 2003) and aggression (Sipsas-Herrmann, 2001),while increasing a young person's ability to take the perspectiveof others (Bundy, 2001). The program is designed to provide support forearly adolescents, educating them with important skills and tools thatimprove their well-being and increase likelihood of school retention. Although the effectiveness of anger management programs isdemonstrated, long term maintenance effects are rarely known. Fewprograms are subjected to empirical verification. Among those that are,the majority fail to include follow-up data or maintenance effects. Itis even more unusual for program implementers to include additionalsessions after the intervention has been concluded even though it seemsreasonable and recommended by some researchers (Baggs & Spence n. 1. A place where provisions are kept; a buttery; a larder; a pantry.In . . . his spence, or "pantry" were hung the carcasses of a sheep or ewe, and two cows lately slaughtered.- Sir W. Scott. ,1990; Lochman, 1992; Whisman, 1990) that review sessions might serve tobooster the program's effects on participants. Booster sessions are proposed by some researchers (Baggs &Spence, 1990; Lochman, 1992; Whisman, 1990) as valuable in extendingpositive treatment gains over time, particularly for youth treatment andprevention. In this study, we intended to enhance the treatment effectson young adolescents previously exposed to an anger management program(i.e., SCARE) by implementing a five-week booster session and examiningits impact. In short, we were interested in determining how one group ofadolescents exposed to both the SCARE intervention and booster sessionsdiffers from another group of adolescents who received the SCAREintervention and no booster session on measures of anger and empathy. Method Participants Randomly selected students, age 11-13 years, participated in aninitial school-based SCARE prevention program the school year prior tothe current study. The elementary school elementary school:see school. district, where the originalSCARE and SCARE booster studies were conducted is in an inner-city poorneighborhood of a large southwestern city. Virtually all the students(over 90%) qualified for free or reduced lunches. The population washighly mobile, with many families maintaining connection with extendedfamilies in Mexico and Central America Central America,narrow, southernmost region (c.202,200 sq mi/523,698 sq km) of North America, linked to South America at Colombia. It separates the Caribbean from the Pacific. . Employed parents worked as daylaborers, hotel maids, fast food servers, and other minimum wage jobs.Out of the 80 students who completed the initial SCARE program, we wereable to locate only 38 (46% female; 54% male) to include in the currentstudy and analysis. Attrition AttritionThe reduction in staff and employees in a company through normal means, such as retirement and resignation. This is natural in any business and industry.Notes: was primarily due to the highly transientnature of our population and the presumed early school withdrawal ofsome students. The composition of the original group, with the boostersession population comprising essentially similar proportions, includedAfrican American African AmericanMulticulture A person having origins in any of the black racial groups of Africa.See Race. (12.3%), Latino (43.2%), Native American (9.9%),Caucasian (14.8%), and bi-racial or other (18.5%) students. Fifth gradestudents who completed the initial SCARE intervention advanced to thesixth grade; the original sixth grade students were promoted to theseventh grade at a middle school in another location. Participantsgained parental permission and were then randomly assigned to either thebooster group (n=20, 54%) or an alternative treatment as usual (TAU taun. Symbol The 19th letter of the Greek alphabet.tau (tou),n )condition (n=17, 46%). [FIGURE 1 OMITTED] The SCARE Program The SCARE curriculum is a fifteen-session anger and aggressionmanagement program targeting young adolescents. Sessions are clusteredinto three sections: (1) recognizing anger and violence in thecommunity, (2) managing and reducing one's own anger, and (3)defusing de��fuse?tr.v. de��fused, de��fus��ing, de��fus��es1. To remove the fuse from (an explosive device).2. To make less dangerous, tense, or hostile: anger and violence in others. The SCARE program focuses ondeveloping coping skills that help participants' control and manageanger and aggression. The instructional format of this program involvesbrief initial introduction of session theme followed by group activityand discussion. Activities varied and included role-playing,demonstrations, imagery exercises, and skill practice. The program isdesigned to encourage students to develop alternatives to violence, toincrease their ability to understand the perspectives of others, and tolearn skills appropriate to dealing with challenging situations. Prior to this current booster study, no significant differences onany of the previously impacted measures of anger and empathy were foundwith those students who participated in the SCARE program the yearbefore (Tarazon, 2003) although trends in the expected direction werenoted. Tarazon (2003) attributed nonsignificant non��sig��nif��i��cant?adj.1. Not significant.2. Having, producing, or being a value obtained from a statistical test that lies within the limits for being of random occurrence. results to a populationof young students, many of whom spoke English as a second language. SCARE Booster Sessions The SCARE booster sessions were developed from group facilitatorand teacher feedback of the initial SCARE program. After implementationof the 15-week program, group leaders and classroom teachers whoobserved all the sessions were asked to provide informal feedbackconcerning session appropriateness and impact. We asked about theirperceptions regarding the lessons, pertinence to the population, degreeof student involvement, and perceived legitimacy for the students. Abrief number of sessions were selected based on research indicating that60-65% of change within psychotherapy psychotherapy,treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. occurs within initial(first-seventh) sessions, with an additional increase in therapyoutcomes after 6 months (5-10%) and an subsequent increase after a yearof therapy (5-10%; Miller, Duncan, & Hubble, 2004). We identifiedfive of the original SCARE session themes as most engaging and impactfulamong students. Each of the original sessions' themes was continuedwith enhanced information, new activities and additional discussionitems to reinforce the content while limited any potential redundancywith the original SCARE program. For example, in the relaxation boostersession, students reviewed deep muscle and progressive relaxation andwere introduced to Benson's (2000) calming technique. One sessionof the booster program was taken from Part One and focused on defininganger and aggression; two sessions were taken from Part Two and dealtwith techniques to reduce anger in the self; and two lessons,recognizing and minimizing anger in others, were adapted from PartThree. This configuration of the SCARE booster was proportional to theoriginal SCARE package. Control conditions For this follow-up study, we were unable to standardize the TAUcondition treatment across grade level. Sixth grade students in the TAUcondition participated in an abstinence abstinence:see fasting; temperance movements. program for substance abusepresented by school personnel. Seventh grade students in the TAUcondition participated in regularly scheduled school activities. ThisTAU involvement served as the control condition. Group leaders Candidates from the Master of Counseling and Doctoral CounselingPsychology Counseling psychology as a psychological specialty facilitates personal and interpersonal functioning across the life span with a focus on emotional, social, vocational, educational, health-related, developmental, and organizational concerns. programs at Arizona State University Arizona State University,at Tempe; coeducational; opened 1886 as a normal school, became 1925 Tempe State Teachers College, renamed 1945 Arizona State College at Tempe. Its present name was adopted in 1958. participated as groupleaders (n=8). The group leaders, all women, were assigned in pairs andthe pairs were matched on the basis of their level of advancement intheir respective program, previous experience as group facilitators, andprevious experience as teachers to balance level of expertise effectsamong leader groups. Allowing for the contingencies of time, randomassignment of group leaders to groups and schools was accomplished. Design and Procedure A battery of pretest pre��test?n.1. a. A preliminary test administered to determine a student's baseline knowledge or preparedness for an educational experience or course of study.b. A test taken for practice.2. measures was collected from the students oneweek prior to implementing the booster program. All student participants(n=37) completed the battery of pretests. Pretest assessment wasadministered by teachers within the participating schools to decreasethe Hawthorne effect Hawthorne effectPsychology A beneficial effect that health care providers have on workers in most settings when an interest is shown in the workers' well-being. See Halo effect, Placebo effect, Placebo response. Cf Nocebo. . Teachers were provided detailed directions fortesting procedures and they read directions and test items aloud tostudents. Students who had previously participated in the SCAREprevention program were randomly assigned to the SCARE booster conditionor to the TAU condition and booster sessions were then implemented overa five-week period during regular school hours in a classroom setting.Due to school policy, a school employee was present duringimplementation of both the SCARE booster condition and the TAUcondition. Students, in the SCARE booster condition in groups offour-to-ten students, participated in the curriculum once a week forforty-five minute periods. After the completion of the five-week SCAREbooster sessions and the TAU condition, a complete battery of posttest post��test?n.A test given after a lesson or a period of instruction to determine what the students have learned. measures was collected from students in each condition. Measures Measures utilized in this study assessed anger and empathy. Twoscales were used to evaluate anger (State-Trait Anger Expressioninventory-2; STAXI-2) and the Interpersonal Reactivity Index (IRI Iri(ē`rē`), former city, North Jeolla (Cholla) prov., SW South Korea. An agricultural center and transportation hub, it was absorbed into Iksan. ) wasused to measure empathy. State-Trait Anger Expression Inventory - 2 (STAXI-2). The 57-itemSTAXI-2 is a self-report measure that assesses the experience,expression, and control of anger (Spielberger, 1999). Anger isconceptualized as having two major components: state anger and traitanger. State anger is defined as a relatively transitory emotionalcondition that includes subjective feelings of anger that may vary overtime. Trait anger is described as an extended stable condition similarto a personality characteristic. The STAXI-2 yields scores for a numberof sub-scales. However, for this study, we selected the State Anger andTrait Anger subscales because of their superior psychometric psy��cho��met��rics?n. (used with a sing. verb)The branch of psychology that deals with the design, administration, and interpretation of quantitative tests for the measurement of psychological variables such as intelligence, aptitude, and properties.Participants rate themselves on a four-point continuum that assesses theintensity of their angry feelings or the frequency that anger isexperienced, expressed, or controlled. Raw scores are converted intostandard scores, with higher scores representing higher levels of anger.Adequate reliability and validity have been reported for the scale,including internal reliabilities ranging from .73 to .94. Evidence ofconcurrent validity concurrent validity,n the degree to which results from one test agree with results from other, different tests. is demonstrated with significant correlationsbetween the STAXI-2 and the Buss-Durkee Hostility Inventory, theMinnesota Multiphasic Inventory subscale Ho (Hostility), and theMinnesota Multiphasic Inventory subscale Hv (overt hostility) The STAXI STAXI State-Trait Anger Expression Inventory has been used extensively in the evaluation of anger-management programs(Bundy, 2001; Herrmann, 1999; Herrmann & McWhirter, 2003; Tarazon,2003). Interpersonal Reactivity Index (IRI). The 28-item IRI is aself-report measure developed as a multidimensional approach to empathy(Davis, 1983a). Items yield a seven-point Likert response format. TheIRI consists of four separate empathy scales: perspective taking,empathic em��path��ic?adj.Of, relating to, or characterized by empathy.Adj. 1. empathic - showing empathy or ready comprehension of others' states; "a sensitive and empathetic school counselor"empathetic concern, personal distress, and fantasy and a total score. Theperspective taking scale assesses the tendency of the subject to take inthe psychological perspective of others - to take another's pointof view. Empathic concern measures the tendency to experience warmth,compassion and concern for others. Personal distress taps into theability to respond to others with self-oriented feelings of personalanxiety and uneasiness. The fantasy scale involves the tendency totranspose trans��posev.To transfer one tissue, organ, or part to the place of another. oneself by means of the imagination into the role of fictionalcharacters. Both cognitive and affective affective/af��fec��tive/ (ah-fek��tiv) pertaining to affect. af��fec��tiveadj.1. Concerned with or arousing feelings or emotions; emotional.2. aspects of empathy areaddressed; the empathetic em��pa��thet��ic?adj.Empathic.empa��theti��cal��ly adv. concern and personal distress scale form theemotional reactions of empathy, and the fantasy and perspective scalesinvolves the cognitive components of empathy. Participants rate themselves on a seven-point response formatranging from 1 (never) to 7 (always). Some items are reverse scored.Total possible scores range from 28 to 96 with higher scoresrepresenting higher levels of anger. Adequate reliability and validityhave been reported for the scale, including internal reliabilitiesranging from .70 (males) to .78 (females) and test-retest reliabilitiesranging from .61 to .79 (for males) and .62 to .81 (for females) over a60 to 75 day interval. Relationships with the IRI and other measureshave been found in areas of social functioning social functioning,n the ability of the individual to interact in the normal or usual way in society; can be used as a measure of quality of care. , self-esteem,emotionality and sensitivity to others (Davis, 1983b). Treatment Integrity Several steps were taken to ensure the integrity and fidelity ofthe SCARE Booster program. The group leaders who implemented the boosterprogram were provided written training protocols for the fullcurriculum. All leaders participated in training designed to enhancetreatment integrity, which occurred on an ongoing weekly basis twomonths prior and continued throughout the program implementation.Training consisted of curriculum overviews and demonstrations, mocksessions with corrective feedback and discussions, and full preview oftreatment implementation and instruction. During implementation, weeklytwo-hour time slots were allotted al��lot?tr.v. al��lot��ted, al��lot��ting, al��lots1. To parcel out; distribute or apportion: allotting land to homesteaders; allot blame.2. for training purposes, programfacilitation FacilitationThe process of providing a market for a security. Normally, this refers to bids and offers made for large blocks of securities, such as those traded by institutions. meetings, and management of classroom procedures as relatedto the study intervention. Advanced counseling students and counselingsupervisors knowledgeable of procedures were available on an on-callbasis to address questions and concerns. In addition, spot-checks werecompleted during actual treatment implementation to ensure uniformity inprocedures and adherence to the protocol. These spot checks werequalitative in nature and utilized to guide supervisory discussion andon-going training. Finally, in order to maintain a consistent treatmentdose effect, the student participants were required to attend at leastfour of the five sessions of the SCARE Booster program. Results Preliminary MANOVAs were conducted on all dependent variablesfollowing random assignment into condition (SCARE booster conditionversus TAU condition). No significant differences were revealed acrossmeasures at Time 1, providing evidence of pretreatment pretreatment,n the protocols required before beginning therapy, usually of a diagnostic nature; before treatment.pretreatment estimate,n See predetermination. equivalence:State Anger, F(l,36) = 2.04, p > .01, r = .24; Trait Anger, F(1,36) =0.53, p > .01, r = .12; Interpersonal Reactivity Index, F(1,36) =3.25, p > .05, r = .29. Assessing effects by treatment for the primary analyses, a seriesof repeated measures ANOVAs were employed for data meeting thetest's assumptions. Wilcoxon T or Kruskal-Wallis tests wereemployed for data that violated ANOVA anovasee analysis of variance.ANOVAAnalysis of variance, see there assumptions. Table 1 shows pretestand posttest dependent variable means for the SCARE booster sessions andTAU condition.Table 1Pretest and Posttest Dependent Variable Means for the SCARE BoosterSessions ConditionScales Experimental Group TAU GroupState Anger Pre 22.13 20.82 Post 22.64 22.56Trait Anger Pre 20.89 17.88 Post 18.17 16.69IRIPerspective Taking Pre 19.39 17.23 Post 15.99 12.34Fantasy Pre 16.61 16.47 Post 14.56 13.19Empathetic Concern Pre 17.87 15.47 Post 15.26 13.01Personal Distress Pre 16.51 15.41 Post 13.61 10.81Total Pre 70.38 64.58 Post 59.43 49.45 Anger measures State Anger. The Wilcoxon test Wilcoxon testa test used in statistics to compare paired data. Has the advantage of incorporating the size of the difference between the two sets of data in the comparison. was conducted to assess differencesbetween the pretest scores and the posttest scores on the State Angerand Trait Anger. Results for the State Anger indicated no significantchange for the SCARE Booster, [z.bar] = -.51, [p.bar] = 0.61, or the TAUcondition, [z.bar] = -.54, [p.bar] = .59. Specifically, for the SCAREBooster condition, the mean rank of subjects whose score decreased inState Anger upon posttest analysis was 10.20. The mean rank of subjectswho increased in State Anger upon posttest was 6.90. For the TAUcondition, the mean rank of subjects who decreased in State Anger atposttest was 6.29, while the mean rank for subjects who increased instate anger at posttest was 8.71. A non-significant number of SCAREBooster condition students (23%) and TAU condition students (41%)demonstrated a decrease in State Anger values from pre to posttest. Trait Anger. Results for Trait Anger indicated a significantdifference for the SCARE booster condition, [z.bar] = -2.01, [p.bar] =.044, and no significant findings for the TAU condition, [z.bar] =-.175, [p.bar] = .861. The SCARE booster condition's mean rank ofsubjects whose score decreased in Trait Anger upon posttest analysis was10.36, while the mean rank of subjects who increased in Trait Anger uponposttest was 9.00. For the TAU condition, the mean rank of subjects whodecreased in Trait Anger at posttest was 6.86, while the mean rank forsubjects who increased in Trait Anger at posttest was 7.17. The majorityof students (66%) in the SCARE booster condition, as compared to the TAUcondition (41%) demonstrated a decrease in Trait Anger values from preto posttest. Empathy Measures Empathic Concern and Fantasy scales. One-way ANOVAS were performedon two of the scales of the IRI, revealing no significant findings forthe Empathy concern scale, [F.bar] (1, 36) = 3.39, [p.bar] = .074, r =.30 and the Fantasy scale, [F.bar] (1, 36) = .829, [p.bar] =.37, r =.15. Personal Distress scale. A one-way ANOVA was performed on thePersonal Distress scale of the IRI, yielding significant results,[F.bar] (1, 36) = 5.71, [p.bar] = .022, r = .38. Estimated marginalmeans for the significant findings revealed a significantly higher SCAREBooster condition posttest mean (X=13.61), compared to the TAU conditionposttest mean (X=10.81). Perspective Taking scale. Because these data did not meet theassumptions of ANOVA, Kruskal-Wallis test was used and indicatedsignificant difference in the medians, 8.68, [p.bar] = .003. The SCAREBooster condition median 24.26 was significantly higher than the TAUcondition median of 13-62. Total IRI. A one-way ANOVA performed on the Total score of the IRIrevealed significant findings, [F.bar] (1, 36) = 10.36, [p.bar] = .003,r = .48, with a posttest IRI total score significantly higher in theSCARE Booster condition (M = 59.43) compared to the TAU condition (M =49.45). Overall, the SCARE Booster program appears to have promising impactfor maintaining and increasing treatment effects for the originalfifteen-session program, particularly with regards to trait anger and toempathy. A summary of results is presented on Table 2.Table 2Summary of Results on Univariate Analysis of Measures Pre to Posttestfor Each Dependent VariableScale Analysis Utilized ResultsSTAXI-2 State Anger Wilcoxon No significance Trait Anger Wilcoxon Significant for Booster groupIRI Perspective Taking Kruskal-Wallis Significant Wilcoxon Significant for Booster and TAU group Fantasy ANOVA No significance Empathetic Concern ANOVA No significance Personal Distress ANOVA Significant for Booster group Total ANOVA Significant for Booster group Discussion Youth advocates, particularly counselors, social workers,psychologists and other mental health professionals, struggle totranslate theoretically and scientifically grounded treatment intofield-centered policy and practice. This study was designed to evaluatethe effectiveness of a five-week booster curriculum on the maintenanceof treatment impact from an anger management program, Student CreatedAggression Replacement Education Program (SCARE). The current study hasdemonstrated some useful findings in comparing the effects of a boosterprogram for the SCARE anger management program with a TAU conditionwithout the booster program. In sum, students who received the SCARE Booster sessions,contrasted to TAU condition students, demonstrated significantlydecreased levels of trait (dispositional) anger from pre- topost-booster participation. Participants who received the SCARE Boostersessions demonstrated significant improvement on levels of cognitive andemotional empathy contrasted to the TAU condition participants. This isespecially important because these students did not demonstratesignificant gains in the original intervention (Tarazon, 2003). It maybe that younger students need a longer period of time to show treatmentgains. Such a delay allows the students to practice what they havelearned and incorporate skills into daily life tasks. The boostersessions may be especially beneficial in refreshing coping skills aftera delay. In conclusion, the SCARE Booster program appears to havepromise for maintaining and increasing the treatment effects of theoriginal fifteen-session program. The school-based, collaborative nature of the investigation wasimportant in yielding meaningful, contextual findings in response to theresearch question; yet, it precluded random assignment of trainers toschool site and, in this case, also limited measurement to self-report.It is recommended that future investigations incorporate a greatervariety and type of measurement and randomly assign trainers acrossschools. As anticipated, the transient nature of the population andsetting in an investigation of this type resulted in a reduction ofthose eligible to participate in the present investigation (from 80participants in the original SCARE intervention to 38). As previouslymentioned, attrition was due to early school withdrawal of some studentsand highly mobile families moving out of district. Although all 38eligible students were recruited and ultimately engaged in the research,it is likely that power was adversely affected. More to the point, the38 students returned to the same district the following year, and wereavailable to participate in the SCARE booster sessions. These studentswere likely from more stable families, less likely to have erraticbehaviors, and more likely to respond in a positive way to the boostersessions. Unfortunately, those students who might have been even moreat-risk for the negative consequences of anger were unavailable toparticipate in the booster sessions. Booster interventions have been important in both maintaining gainsachieved during initial treatment, as well as enhancing initialtreatment effects (Tolan, Gorman-Smith, & Schoeny, 2009). In fact,several studies have found overall treatment effects only for thoseconditions exposed to booster sessions (Botvin, 2000; Metropolitan AreaChild Study Research Group, 2002; Tolan et al., 2009). In spite of thepromise of booster sessions on maintaining or improving gains in thelonger term, few studies on booster effects have been conducted (Eyberg,Edwards, Boggs, & Foote, 1998; Tolan et al, 2009). Similar to someof the issues encountered in this study, the study of booster effectsoverall is challenged by differential levels of exposure to treatment(dosage dosage/dos��age/ (do��saj) the determination and regulation of the size, frequency, and number of doses. dos��agen.1. Administration of a therapeutic agent in prescribed amounts. effects), selection effects related to attrition, and retentionaffecting sample size and power needed for comparative analyses. Forexample, age, curriculum, and other prevention/intervention exposurevariables are possible confounds not controlled for in this study.Future investigations may seek to impose a matched-sample procedure sothat these criteria may be evenly distributed across conditions. Studiesthat address these and related methodological issues morecomprehensively to test booster effects within a variety of treatmentand prevention programs are needed and represent the next wave ofinvestigation in this area. Addressing the effects of boosters in terms of participantcharacteristics is another potential for further study. For example, theamount, timing, and duration of the booster following initial treatmentmay differ according to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. participant risk Participant riskThe risk associated with the credit of the participants and possibility of non-performance. or developmental level. Resultsfrom several prevention trials have revealed more extensive and broadbenefits among high-risk as contrasted to general populations for bothmain and booster treatment effects (Stoolmiller, Eddy, & Reid, 2000;Tolan, Gorman-Smith, & Henry, 2004; Tolan et al., 2009). Of course,it is probable that relatively greater gains are likely achievable amongthe higher risk groups with lower initial scores. Other interventionprograms have found that stronger long term effects are mediated byparticipant age, with benefits limited to those with earlier exposure(Tolan et al., 2009). In one study, for example, benefits were apparentonly among participants exposed to a 2-year intervention beginning insecond grade, as compared to exposure beginning in the fifth grade(Metropolitan Area Child Study Research Group, 2002). Together withfindings of the current investigation, these studies point to thepromise of booster effects and suggest the importance of exploring thecomplexities of successful youth prevention programs in the context ofmaintaining and enhancing initial preventative and therapeutic benefits. References Baggs, K. & Spence, S.H. (1990). Effectiveness of boostersessions in the maintenance and enhancement of treatment gains followingassertion training. Journal of Consulting and Clinical Psychology The Journal of Consulting and Clinical Psychology (JCCP) is a bimonthly psychology journal of the American Psychological Association. Its focus is on treatment and prevention in all areas of clinical and clinical-health psychology and especially on topics that appeal to a broad , 58,845-854. doi:10.1037/0022-006X.58.6.845. Benson, H. (2000). 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Supportingfamilies in a high-risk setting: Proximal proximal/prox��i��mal/ (-mil) nearest to a point of reference, as to a center or median line or to the point of attachment or origin. prox��i��maladj. effects of the SAFEChildrenpreventive intervention. Journal of Consulting and Clinical Psychology,72, 855-869. doi:10.1037/0022-006X.72.5.855. Tolan, PH., Gorman-Smith, D., & Schoeny, M. (2009). Thebenefits of booster interventions: Evidence from a family-focusedprevention program. Prevention Science, 10, 287-297. doi:10.1007/s11121-009-0139-8. Whisman, M.A. (1990). The efficacy of booster maintenance sessionsin behavior therapy behavior therapyor behavior modification,in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior. : Review and methodological critique. ClinicalPsychology Review, 10, 155-170. doi: 10.1016/0272-7358(90)90055-F. Alysha Bundy Arizona State University Paula T. McWhirter University of Oklahoma University of Oklahoma, abbreviated OU, is a coeducational public research university located in the U.S. state of Oklahoma. Founded in 1890, it existed in Oklahoma Territory near Indian Territory 17 years before the two became the state of Oklahoma. J. Jeffries McWhirter Arizona State University Paula McWhirter, Assoc. Professor, Counseling Psychology Program,University of Oklahoma, 820 Van Vleet Oval, Norman, OK 73019-20411;email: PaulaMcWhirter@ou.edu.