Cogn itive Therapy and Research Vol. 22 No. 1 1998 pp.

63-74

Cogn itive-Behavioral Th erapy in the Treatm ent of An ger: A Meta-Analysis

Rich ard Beck1 an d Eph rem Fernan dez1 2

Anger has com e to be recognized as a significan t social problem worthy of clin ical attention an d systematic research. In the last two decades cognitive-behavioral therapy (CBT) has emerged as the m ost com m on approach to an ger m anagement. The overall efficacy of this treatm ent has not been ascertain ed and therefore it was decided to con du ct a m eta-an alysis of this literature. Based on 50 studies in corporatin g 1640 subjects it was fou nd that CBT produ ced a gran d m ean weighted effect size of .70 indicatin g that the average CBT recipient was better off than 76% of un treated subjects in terms of anger reduction . This effect was statistically significant robust and relatively hom ogen eou s across studies. These fin dings represent a quan titative integration of 20 years of research into a coherent pictu re of the efficacy of CBT for anger m an agement. The results also serve as an im petu s for con tinu ed research on the treatm ent of anger.
KEY WORDS: anger; cognitive-behavioral therapy; me ta-analysis.

INTRODUCTION With viole nt crime rising among adole scents wide spread familial abuse continuing racial discord and recent acts of te rrorism attention has turne d to ange r as a major proble m in human re lations (Koop & Lundbe rg 1992; Novello Shosky & Froehlke 1992) . Yet ange r disorde rs have bee n ne glected in diagnostic classifications and treatme nt programs (Eckhardt & Deffe nbache r 1995; Kassinove & Sukhodolsky 1995) . Incre asing re fe re nce s to ange r appe ar in PSYCINFO and othe r database s and practitione rs are increasingly cognizant of the ramifications of ange r in their clients (Abikoff & Kle in 1992; Fernande z & Turk 1993 1995; Koop & Lundbe rg 1992) but little is known about how best to treat ange r disorde rs. In a surve y of the lite rature on ange r it was found that the vast majority of ange r tre atment outcome studie s had utilize d a cognitive -behavioral approach. The pre sent study there fore e valuate d the e fficacy of cognitive -behavioral the rapy ( CBT)
1 Southern 2

Methodist University Dallas Te xas 75275. Address all correspondence to Ephrem Fe rnandez Ph.D. Departme nt of Psychology Southern Methodist University Dallas Texas 75275-0442. 63
0147-5916/98/0200-0063$15.00/0

1998 Plenum Publishing Corporation

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in the tre atment of ange r. Instead of a narrative re view a meta-analysis was conducte d to quantitative ly inte grate the re sults of individual studie s e mploying CBT for ange r control.

Cogn itive-Beh avior al Th erap y Applied to Anger Cognitive -be havioral therapy draws upon the rich traditions of be havior modification and rational-e motive or cognitive the rapy (Me ichenbaum 1976) paying attention to social cognition (Dodge 1993) as well as individual constructions of reality (Mahone y 1993) . It may combine a varie ty of technique s such as relaxation cognitive re structuring proble m-solving and stress inoculation but rathe r than being a mere form of technical e cle ctism it is theore tically unifie d by principle s of le arning theory and information processing. This approach has elicite d much interest in the treatme nt of affe ctive disorde rs such as anxie ty and depression as re ve aled in recent meta-analyse s by Dobson (1989) and Van Balkom (1994) . The status of CBT for ange r however re mains uncle ar. Yet the last 20 ye ars has see n an accumulation of research on the e fficacy of cognitive -behavioral the rapy in the tre atment of ange r proble ms. This re search has focused pre dominantly on Novaco s (1975) adaptation of Me iche nbaum s stre ss inoculation training (SIT) initially develope d for the tre atment of anxie ty (Me ichenbaum 1975). Using a coping skills approach stre ss inoculation inte rve ntions are typically structure d into three phase s: cognitive pre paration skill acquisition and application training. During this performance -base d intervention the client is e xposed to cognitive reframing re laxation training image ry modeling and role-playing to e nhance ability to cope with proble m situations. In SIT for ange r proble ms clie nts initially identify situational trigge rs which pre cipitate the onset of the ange r re sponse . Afte r ide ntifying environme ntal cue s the y re hearse self-state ments intende d to re frame the situation and facilitate healthy response s (example s of cognitive self-state ments include : Relax don t take things so personally or I can handle this. It isn t important enough to blow up over this ). The se cond phase of tre atment require s the acquisition of re laxation skills. The cognitive se lf-state ments can the n be couple d with relaxation as clie nts attempt afte r e xposure to the trigge r to mentally and physically soothe themselve s. Finally in the rehe arsal phase clie nts are expose d to ange r-provoking situations during the session utilizing image ry or role-plays. The y practice the cognitive and relaxation te chnique s until the mental and physical re sponse s can be achie ve d automatically and on cue . This basic outline of SIT can also be supple mented with alte rnative te chnique s such as proble m-solving conflict manage ment and social skills training as in the social cognitive model of Lochman and colle ague s (Lochman & Lenhart 1993) . The purpose of the present study was to e valuate the overall e ffective ne ss of such cognitive -be havioral treatme nts for ange r by using the methodology of metaanalysis. This e ntaile d computing various summary statistics of the stre ngth of treatment e ffect as well as infe rential tests of the specific re se arch hypothe sis that CBT statistically significantly re duce s ange r. Finally the se re sults were conve rted into

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measure s of practical significance . This is particularly informative in the curre nt climate of manage d health care where there is a pre mium on time-limite d interve ntions like CBT and growing demands for e mpirical evide nce to support the choice of tre atments. This quantitative synthe sis of the lite rature will also familiarize reade rs with the main parame ters of rese arch on this topic and gene rate considerations for furthe r rese arch in this area.

Meta-An alys is Me ta-analysis is a quantitative procedure for evaluating tre atment effe ctiveness by the calculation of e ffect size s (Fernande z & Boyle 1996; Glass McGaw & Smith 1981; Rosenthal 1991). The e ffect size e xpre sse s the magnitude of difference betwee n tre ated and untre ate d subje cts. Because e ffect size is e xpre sse d in standard deviation units it e nable s comparisons among studie s and the computation of summary statistics such as the grand ave rage effe ct size an inde x of overall effe ctiveness for the tre atment. Despite its advantage s over narrative and quasistatistical methods of re view (Fe rnande z & Turk 1989) meta-analysis has raised certain concerns which call for spe cific solutions (Fernande z & Boyle 1996) . For e xample it has bee n argue d that effe ct sizes obtaine d from studie s of varying quality may not be directly comparable ; conse que ntly it is now customary to weight e ffects sizes typically according to obje ctive crite ria such as sample size ( which de te rmine s statistical powe r). Concern has also be en raised about possible inflation in effe ct sizes due to sampling only publishe d studie s which are more like ly to re port significant re sults than are non-publishe d studie s (the file-drawe r proble m); this can be counte racted to some extent by including unpublishe d studie s and also by conducting te sts of robustne ss that provide a margin of tolerance for null results (Rosenthal 1995) . To date the only docume nted attempt to meta-analyze studie s of ange r manage ment was done by Tafrate (1995) . Howe ve r this revie w has certain methodological limitations. First stringe nt inclusion criteria restricte d the numbe r of CBT studie s re viewed to only nine . This small numbe r of studie s is unre pre sentative of the last 20 years of rese arch on CBT. Tafrate confine d his survey to adult sample s of mostly colle ge stude nts. No doubt stude nts have ange r proble ms too but the ne gle ct of nume rous studie s of CBT for oppositional childre n and adole scents (populations of primary conce rn) is proble matic. Only three of the studie s revie wed by Tafrate were base d on clinical sample s thus placing limits on the ecological significance of results. Unpublishe d results were ignore d and due to the small numbe r of studie s actually re viewed the conclusions re ache d were probably susceptible to sampling bias. Finally Tafrate ne glected tests of homoge neity te sts of significance or tests of robustne ss or weighing of effe ct size s based on any of the design feature s of the studie s; as e mphasize d earlie r the se statistics have now become standard practice in meta-analytic revie ws and they can significantly affe ct the conclusions reached. To improve upon Tafrate s (1995) initial revie w the pre se nt study e xpande d inclusion criteria incorporate d unpublishe d studie s and weighte d all e ffect size s. As de taile d below the scope of the revie w was broade ned to incorporate dive rse

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sample s re ceiving a combination of cognitive and be havioral technique s. In this way more than five time s the numbe r of CBT studie s re viewed by Tafrate were metaanalyze d here .

METHOD Inclu sion Criteria A compute r se arch of PSYCINFO and Dissertation Abstracts International from 1970 to 1995 was conducte d. Using keywords such as an ger control anger treatm ent and an ger m an agem ent and cross-re fe re nce s among article s a total of 58 re levant studie s of CBT were identifie d. Eight of these were single -case or small-sample studie s ( n < 4) and hence were e xclude d. The final sample consiste d of 50 nomothetic studie s incorporating a total of 1640 subje cts. All studie s provide d data on at le ast one ange r-relate d depe nde nt variable . In te rms of the inde pende nt variable only cognitive -behavioral tre atments for ange r were se lected. Studie s using pu rely cognitive or behavioral interventions alone were not include d nor were treatme nts aimed sole ly at re laxation. Typically the study include d was one in which some form of cognitive reappraisal or re structuring was com bined with some technique of promoting relaxation. The sample s were pre dominantly clinical such as prison inmate s abusive pare nts abusive spouse s juve nile de linque nts adole scents in re side ntial treatme nt childre n with aggre ssive classroom behavior and mentally handicappe d clie nts but also include d colle ge stude nts with re porte d ange r proble ms. Thirty-five studie s use d self-reporte d ange r as a de pe nde nt variable . Effe ct sizes for 28 of the 35 studie s were calculate d e xclusive ly from se lf re ports of ange r. The re maining se ven studie s combine d depe nde nt measure s of ange r and aggre ssion into e ffe ct size e stimate s. Fifte e n studie s of school childre n and adole scents in place ment (eithe r re side ntial or de tention facility) re fe rred to ange r but only re porte d be havioral ratings of aggre ssion. Since aggre ssive be havior has be en the focus in CBT inte rve ntions for childre n and adole scents aggre ssion ratings se rve d as the de pe nde nt variable for the se studie s. For younge r populations measure s of se lf-re porte d ange r are not always fe asible and behavioral ratings of aggre ssion be come a valid alte rnative just as se lf-re ports of depre ssion and anxie ty in childre n may be le ss acce ssible than the behaviors corre sponding to the se mood disturbance s.

Calcu lation of Effect Sizes Glass s d (e ffect size) was calculate d for each study whe re means and standard deviations were available for treatme nt and control groups (Glass e t al. 1981). For studie s utilizing single group pre- ve rsus postte st de signs and any othe r studie s not reporting means and standard deviations e ffect size was e stimate d from t- and F -value s. Whe re multiple depende nt variable s were reporte d e ffect sizes were av-

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erage d across variable s to yield one e ffect size per study thus minimizing nonindepende nce in the data. Adopting proce dures recommende d by Rosenthal (1991) e ach effe ct size was weighte d by sample size and ave rage d to yield a grand weighte d mean d base d on 50 studie s. Weighting e ffect size s by sample size is an unbiase d and obje ctive procedure for assigning different weights to studie s that vary in statistical powe r. The grand weighte d mean d was tested for significance ( d compare d to zero) using a one -sample t-test and 95% confide nce inte rvals were calculate d. A chi square was also calculate d to te st for heteroge ne ity of variance within the se t of e ffect size s. The heteroge ne ity te st is the basis for a de cision on whe ther or not to search for mode rator variable s; in case of significant heteroge ne ity it would be ne cessary to disaggre gate the e ffect sizes according to the variable s influe ncing e ffect size. Finally to addre ss the file-drawe r proble m a fail-safe N as re commende d by Rosenthal ( 1991) was calculate d to test for robustne ss. A robust finding indicate s that the probability of a Type I e rror arising from unpublishe d nonsignificant re sults is ne gligible . As strongly recomme nde d by Rosenthal (1995) a Binomial e ffect size display (BESD) was also constructe d to provide a more concrete impre ssion of the relative outcome s in tre atment and control groups.

RESULTS A total of 50 effe ct size s was obtaine d for the 50 studie s (Table I). O f the se 40 utilize d control groups while 10 use d single -group repe ated-measure s de signs. The sample size and de sign feature s for each study are also tabulate d. As summarize d in Table II the effe ct size s range d from 0.32 to 1.57 SD = 0.43. With only one e xce ption all effe ct size s were positive in value . The grand mean unwe ighte d d was 0.81. The grand mean weighte d effe ct size was 0.70. This differe d significantly from zero t (49) = 13.28 p < .0001. The 95% confide nce inte rvals for the mean unweighte d e ffect size range d from 0.69 to 0.93. A ste m and le af plot is shown in Table III to display batche s of e ffect sizes. As can be see n the effe ct sizes approximate d a normal distribution. Most of the e ffect sizes were betwee n 0.5 and 0.99 and six e ffect sizes reache d about 1.2 thus making this the mode . A notable outlie r was the one negative value in the data set. Since any effe ct size is a standard de viation unit ( z-score ) it can be conve rted into a pe rcentile by asce rtaining the area unde r the normal curve that is bounde d betwee n that z-score and the tail e nd of the curve . Thus the grand weighte d mean effe ct size of 0.70 corresponds to an are a unde r the curve of 0.5 + 0.258 which in turn means that the average subje ct in the CBT treatme nt condition fared be tter than 76% of those not receiving CBT. To furthe r illustrate the practical importance of these re sults a binomial e ffect size display was adde d ( Table V I). This first e ntaile d conve rsion of the grand weighte d mean d to r which turne d out to be 0.33; as note d in the table half the value of r was the n adde d or subtracte d from 0.5 revealing that subje cts re ceiving CBT e xpe rienced a 67% treatme nt succe ss rate whe re as control subje cts had only a 33% succe ss rate .

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Beck and Fern an dez Table I. Effect Sizes and Sample Sizes for Individual Studies of CBT on Anger a Study Sample Abusive pare nts Abusive pare nts MR individuals School children Adult volunteers Clinical adolesce nts College students College students College students College students College students College students School children Abusive spouses Abusive spouses Clinical adolesce nts Adolescent (school) Inmates Juvenile delinquents School children Clinical adolesce nts Inmates School children School children School children School children School children School children Inmates Adolescent volunteers Juvenile delinquents College students Clinical adolesce nts Inmates College and adult Clinical adult School children Clinical adolesce nts Forensic in-patients Inmates Adolescent volunteers Clinical adolesce nts Juvenile delinquents Juvenile delinquents Inmates Juvenile delinquents DV SR SR SR BR SR SR BR SR SR SR SR SR SR SR SR BR SR BR BR BR SR BR BR SR SR BR SR BR BR BR BR BR SR SR BR BR SR BR SR SR SR BR SR BR BR SR SR SR SR SR BR SR BR De sign PP TC PP TC TC PP TC TC TC TC TC TC TC PP PP TC TC TC TC TC TC PP TC TC TC PP TC PP TC TC TC TC TC TC PP TC TC TC TC TC TC TC TC TC PP TC N 29 20 54 30 62 12 32 30 32 29 36 94 80 47 32 21 36 19 111 22 40 37 37 80 76 20 32 12 21 26 18 20 42 75 17 83 24 28 21 95 13 14 19 28 18 19 d 0.85 1.09 0.40 -0.32 0.83 0.92 1.04 1.27 0.59 0.45 1.43 0.82 1.32 0.32 1.57 1.16 0.68 1.33 0.72 1.29 0.32 1.29 0.21 0.38 0.28 0.36 0.24 0.65 1.28 0.53 0.64 1.52 0.22 0.68 1.03 0.76 0.84 0.56 0.91 0.69 1.00 1.13 1.20 0.22 0.55 0.57

Acton & During ( 1992) Barth Blythe Schinke & Schilling (1983) Benson Rice & Miranti ( 1986) Boswell (1984) Cain (1987) Dangle Deschner & Rasp ( 1989) Deffe nbache r Story Stark Hogg & Brandon (1987) Deffe nbache r Story Brandon Hogg & Hazaleus (1988) Deffe nbache r McNamara Stark & Sabadell (1990a) Deffe nbache r McNamara Stark & Sabadell (1990b) Deffe nbache r & Stark ( 1992) Deffe nbache r Thwaite s Wallace & Oetting (1994) Deffe nbache r Lynch Oetting & Kemper ( 1996) Deschne r & McNeil (1986) Faulkne r Stoltenbe rg Cogen Nolde r & Shooter (1992) Feindle r Ecton Kingsle y & Dubey (1986) Feindle r Marriott & Iwata (1984) Gaertner ( 1984) Glick & Goldstein ( 1987) Hinshaw Henke r & Whalen ( 1984) Jackson ( 1992) Ke nnedy ( 1992) Larson (1991) Lochman (1985) Lochman Burch Curry & Lampron (1984) Lochman & Curry ( 1986) Lochman Lampron Gemmer Harris & Wyckoff (1989) Lochman Ne lson & Sims ( 1981) Macphe rson ( 1986) Mandel ( 1991) McDougall Boddis Dawson & Haye s ( 1990) Moon & Eisler (1983) Moore & Shannon (1993) Napolitano (1992) Novaco ( 1975) Olson (1987) Omizo He rshberger & Omizo (1988) Pascucci (1991) Rhoades (1988) Rokach ( 1987) Rose ngren (1987) Saylor Benson & Einhaus (1985) Schlichter & Horan (1981) Shivrattan ( 1988) Smith & Beckner (1993) Steele (1991)

CBT for An ger Table I. ( continued ) Study Stermac (1986) Whiteman Fanshel & Grundy (1987) Wilcox & Dowrick (1992) Wu (1990)
a

69

Sample Forensic patie nts Abusive parents Clinical adolescents Divorced women

DV SR SR SR SR

Design TC TC PP TC

N 40 24 10 26

d 1.31 1.52 1.20 0.49

CBT = Cognitive-behavioral therapy; DV = de pendent variable; N = sample size; d = effect size; SR = self-reported anger BR = behavioral ratings of anger/aggre ssion TC = treatment ve rsus control de sign PP = pre/postdesign.

Total N = 1640 subjects Grand weighte d mean d : 0.70 95% confidence intervals for unweighted d : 0.69 to 0.93 d compare d with zero: t (49) = 13.28 p < .0001 2 Heteroge neity of ds: c (49) = 61.71 p > .10 Fail-safe N: 790; crite rion = 225
a

Table II. Meta-Analytic Summary Statistics for Studies of CBT on Ange ra

CBT = cognitive -behavioral therapy.

Table III. Stem and Le af Display of Effect Sizes from Studies of CBT on Ange ra Fre quency 1.00 12.00 18.00 16.00 3.00 Stem Leaf 3 222223333444 555556666677888899 0000112222223334 555

0. 0. 0. 1. 1.

Range = 0.32 to 1.57 Mean (unweighted) d = 0.81 Standard deviation = 0.43 Median = 1.75 Mode = 1.2
a

CBT = cognitive behavioral therapy; Each stem which represents the first digit of an effect size is attache d to several leave s each denoting the first decimal place of an effect size .

The fail-safe N of 790 was well above the minimal criterion of 225 indicating a robust finding. The te st of he teroge neity reve ale d a c 2 (49) = 61.71 p > .10. This indicate s homoge ne ity of e ffect size value s and the refore no ne ed to se arch for mode rator variable s.

70 Table IV . Binomial Effect Size Display of Treatment (CBT) Versus No Treatment of Anger a Condition Treatment Control Success 67 33 100 Failure 33 67 100

Beck and Fern an dez

100 100 200

CBT = cognitive -behavioral therapy. The numbers are in pe rcentages. To obtain them d must first be converted to r (cf. Rosenthal 1991) which is halved and then added to or subtracted from 0.5 (depe nding on the condition) before multiplication by 100.

DISCUSSION Effectiven ess of Cogn itive-Beh avior Th erap y in th e Treatm ent of An ger Re se arche rs have incre asingly focuse d the ir atte ntion on CB T as a tre atme nt for ange r disorde rs. O ve r the past 20 ye ars many individua l studie s have sugge ste d that CBT is an e ffe ctive time -limite d tre atme nt of ange r proble ms. O ur m e ta-analysis of 50 nom othe tic studie s of 1 640 subje cts re ve ale d a we ighte d me an e ffe ct size of 0.70 sugge stive of mod e rate tre atme nt gains. Since this is in standar d de viation units it can be infe rre d that the ave rage subje ct in the CBT condition was be tte r off than 76% of control subje cts. More ove r this e ffe ct was signific antly diffe re nt from what would be e xpe cted unde r chance . The grand e ffe ct size was also robust e nough to be unaffe cted by unpublishe d null re sults and it was re lative ly homoge ne ous across studie s. Since the populat ions inve stigate d consiste d large ly of abusive pare nts or spouse s viole nt and re sistant juve nile offe nde rs inmate s in de te ntion facilitie s and aggre ssive school childre n it is appare nt that CBT has ge ne ral utility in the clinical manage me nt of ange r. The se findings imply that the appare nt popularity of CBT in the treatme nt of ange r is justifie d by its e ffectivene ss in achie ving the de sire d treatme nt goals. The results are congrue nt with othe r meta-analyse s docume nting the effe ctiveness of CBT in the tre atme nt of othe r affe ctive disturbance s in particular de pre ssion (Dobson 1989) and anxie ty (Van Balkom e t al. 1994) . At the same time it may be note d that the grand weighte d e ffect size of 0.70 in this revie w is smalle r than Tafrate s ( 1995) reporte d effe ct size of 1.00 for CBT studie s (which were labe le d as multicompone nt ); this is probably because the latte r consiste d of only nine publishe d studie s none of which were weighte d according to statistical power. O n the othe r hand by sampling unpublishe d results revie wing studie s with clinical populations and weighing effe ct sizes by sample size the present study may have produce d a slight deflation of effe ct size but one that is probably more reliable .

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Fu ture Con sid eration s This study was an attempt to summarize and docume nt the progre ss made ove r the last two decades of rese arch on CBT for ange r tre atment rese arch. The clinical implications of the meta-analysis are e ncouraging. Clinicians treating clie nts with ange r control proble ms can now substantiate the ir choice of CBT in the treatment of ange r and expe ct at least mode rate improve ments in the ir clie nts. Moreove r the pre sent findings may se rve as a benchmark against which to evaluate othe r psychological and pharmacological treatme nts for ange r. O utcome efficacy aside future re search might also addre ss the cost-e ffectivene ss of the se treatme nts an issue of growing interest in the curre nt era of manage d care. New variations of CBT might also be explore d. Deffe nbache r and colle ague s have alre ady take n a step in this dire ction with the developme nt of a package calle d cognitive relaxation. O n the othe r hand Lochman and colle ague s have emphasized training pe ople in e ncoding of social stimuli and proble m-solving within a social context. With additional studie s in these areas it is forsee able that the most active ingre die nts of CBT may be ide ntifie d and integrate d to produce an e ven more e ffective regimen for managing ange r. Anothe r viable frontie r of re search might be client variable s relate d to treatment outcome . These may center around se lf-e fficacy locus of control impulsivity versus refle ctivity and a host of traits predisposing individuals to respond to treatment in se le ct ways. Clarification of these variable s may enable the careful matching of clie nts to spe cific treatme nt re gime ns. Finally ecological validity re mains a goal for most tre atment outcome research. In ange r manage ment well-controlle d laboratory studie s have re ve aled e ncouraging tre atment e ffects. But the generalizability of these findings to various clinical and multicultural populations ofte n nee ds to be establishe d. Ultimate ly the ability to pre dict and control ange r as it occurs spontane ously in differe nt groups of pe ople within the ir own naturalistic se ttings is a challe nge worth addre ssing.

REFERENCES
Reference s marke d with an asterisk indicate studies included in the me ta-analysis. Abikoff H. & Klein R. G. (1992) . Attention-deficit hype ractivity and conduct disorder: Comorbidity and implications for tre atment. Journal of Consulting and Clinical Psychology 60 881-892. *Actor R. G. & During S. M. (1992) . Pre liminary results of aggression manageme nt training for aggressive pare nts. Journal of Interpersonal Violence. 7 410-417. *Barth R. P. Blythe B. J. Schinke S. P. & Schilling R. F. (1983). Self-control training with maltreating parents. Child Welfare. 62 313-324. *Benson B. A. Rice C. J. & Miranti S. V. (1986) . Effects of anger manageme nt training with mentally re tarde d adults in group tre atment. Journal of Counseling and Clinical Psychology 54 728-729. *Boswell J. W. ( 1984) . Effects of a multimodal counse ling program and of a cognitive -behavioral counseling program on the ange r management skills of pre-adolesce nt boys within an eleme ntary school setting (Doctoral dissertation Pennsylvania State Unive rsity 1984). Dissertation Abstracts International 45 372. *Cain J. A. (1987) . Anger control: A comparison of cognitive-behavioral and relaxation training with post-treatment follow-up (Doctoral dissertation United States International University 1987). Dissertation Abstracts International 48 1804-1805.

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