Costs of CBT for anger management tested against 'as usual' day service

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Last week we posted about the publication of a new manual for therapists engaged in providing cognitive behavioural therapy to people with learning disabilities . In that post, we drew attention to two randomised trials that had been done in the early 2000’s whose findings were m anger – encouraging.

This latest study adds a further RCT to the evidence base for the use of CBT in adults with learning disabilities.

The researchers were interested in looking at how CBT might help people with what is described as problem anger. Estimates of the prevalence for problem anger in people with learning disabilities varies in studies between 11% and 27% and aggression is a key reason for someone to be described as having severe challenging behaviour which can lead to exclusion from community services and on the well-being of the person and their family carers.

Current policy is to broaden access to psychological therapies like CBT, and recent positive practice guidelines have set out a range of ways in which therapists can engage appropriately with people with learning disabilities, although the most recent evidence suggests  that despite the fact that the Improving Access to Psychological Therapies service is now well established there are still barriers in relation to people with learning disabilities.

A recent Cochrane Review of interventions for aggressive behaviour in people with learning disabilities found only four studies suitable for inclusion and recommended more powerful randomised controlled trials be carried out


As a result of this recommendation the research team set up a multi-centre, cluster randomised controlled trial of a manualised group- based CBT anger management treatment on reported anger shown by people with mild-to-moderate learning disabilities. They set out to compare the treatment group, a small group, 12-session intervention in day services run by care as ‘lay therapists’ with training and supervision from a clinical psychologist with ‘treatment as usual’ (i.e. receipt of day care).

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The study was a multi centre cluster randomised trial involving across England Scotland and Wales

They used a range of measurements for clinical outcomes, including the
Provocation Index which was completed by the service user, along with the same index completed by a key worker as well as measures of anger coping skills, mental health and quality of life

In addition, they got reports from support workers at the participants’ homes, and also ran qualitative interviews with a sample of service users, lay therapists and service managers to get their perspectives on the intervention.

The research team set out to recruit an average of 6 service users in each of 30 participating centres ten in Scotland, England and Wales. To be involved, people had to be described as having mild to moderate learning disabilities, have problem anger and express a wish to improve their anger management. They also had to provide informed consent and complete the assessments.

The researchers describe the characteristics of the treatment and wait list control as well matched on demographic variables and on self-reported, key-worker-reported and carer-reported clinical outcome variables

All trial participants are accounted for as all losses to both groups are described and explained, with a loss to the final follow-up of 18 participants in the intervention and control arms of the trial.

Final data were available for comparison of costs in 67 participants in the intervention arm and 62 in the control arm.

In terms of measurement of costs, the costs of the intervention and its impact on health and social care resource use were assessed and incremental costs over treatment as usual were calculated.


This paper is concerned mainly with the impact of the intervention on costs. The researchers do summarise the some clinical outcomes however, including statistically significant improvements at follow-up in: self-reported anger on one of the two measures,
key worker-reported anger, self-reported and key worker-reported anger coping skills

There were also reports from key workers and home carers of statistically significant short-term reductions in challenging behaviour.

The qualitative data from the interviews with the samples of service users, key-workers and service managers showed a good deal of positive feedback about the intervention.

14 groups ran across the three countries, five in Scotland, five in Wales and four in England. Each group had 12 treatment sessions.

In terms of costs, the central regional costs of input from consultant and clinical psychologists, administrative support, running costs etc. averaged £726.67 per group in Scotland, £845.77 per group in England and £1229.05 per group in Wales.

Putting all these costs together provided a cost per service user hour for treatment. The mean cost per service user was £25.26, giving a cost per two hour session of £50.52.

The found the mean hourly excess cost of intervention compared with treatment as usual to be £25.26 − (£14.07 × 0.918) = £12.34 (where 14.07 is treatment as usual with the intervention replacing treatment as usual for 91.8% of service users.

Conclusion and comment

A well constructed trial adding to growing evidence base for effectiveness of CBT for people with mild to moderate learning disabilities

A well constructed trial adding to growing evidence base for effectiveness of CBT for people with mild to moderate learning disabilities

This appears to be a well constructed trial and the findings add to the growing evidence base for the effectiveness of CBT as an approach for people with mild to moderate learning disabilities.

In terms of costs, which was the main focus of the reporting in this paper, there were some difficulties published unit costs do not always accurately reflect all associated costs.

There were some difficulties that the authors point to in relation to the numbers of participants that could be included in the cost impact evaluation, which due to problems with data collection meant this was reduced to 71% of the original participants

The research team identified, unsurprisingly, that the cost of the intervention was higher than treatment as usual, but that the use of the intervention would increase the average total costs for a care package by 2.7%. They point out though that it was not possible to say whether this excess cost could be off-set by savings in health and social care resource usage as there was no statistically significant difference found in resource usage between the intervention and control groups.

They also point to the issue that staffing establishments tend not to be individualised and the practicalities of running a large trial meant that the allocation of staff time to individuals used was done in what they describe as a ‘crude’ measure. They suggest that “it remains a methodological challenge to assess changes in staffing given to an individual as a result of change in that individual’s behaviour and, hence, their needs for support.”

This means that whilst there appeared to be no major impact of the intervention on health and social care costs, the relationship may be much more complex.

The overall findings however appear promising and the additional costs of the intervention were small enough to suggest that they might be compensated for in savings on later health and social care costs.


Felce, D., Cohen, D., Willner, P., Rose, J., Kroese, B., Rose, N., Shead, J., Jahoda, A., MacMahon, P., Lammie, C., Stimpson, A., Woodgate, C., Gillespie, D., Townson, J., Nuttall, J. and Hood, K. (2014), Cognitive behavioural anger management intervention for people with intellectual disabilities: costs of intervention and impact on health and social care resource use., Journal of Intellectual Disability Research, [abstract]

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John Northfield

After qualifying as a social worker, John worked in community learning disability teams before getting involved in a number of long-stay hospital closure programmes, working to develop individual plans for people moving into their own homes. He worked for BILD, helping to develop the Quality Network and was editorial lead for the NHS electronic library learning disabilities specialist collection. This led him to found the Learning Disabilities Elf site with Andre Tomlin as a way of making the evidence accessible to practitioners in health and social care. Most recently he has worked as part of Mencap's national quality team and also been involved in a number of national website developments, including the General Medical Council's learning disabilities site.

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