The Haumietiketike Anger Management Programme A New Zealand

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The Haumietiketike Anger Management Programme

• A New Zealand group-therapy programme for the
  treatment of emotion regulation difficulties in
  offenders with an intellectual disability.
• Paul Oxnam
• Clinical Psychologist
• Te Korowai Whariki Central Region Forensic
  Mental Health Service
• Wellington, New Zealand.

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• Boring....
• Unamusing....
• Monotonous....
• Waffling....

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Haumietiketike

• A secure facility for people with an intellectual
  disability who have committed an imprisonable
  offence and present with behavioural concerns
  that pose a serious risk to themselves or others.
• Eleven-bed inpatient unit
• Two four-bedroom step-down cottages
• Regional facility
• Clients come under orders from the Court

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Te Korowai Whariki

• The Central Region Forensic Mental Health,
  Rehabilitation and Intellectual Disability
  Service.

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Some more fun facts about New Zealand....
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Background to the Programme

• Most of the clients at Haumietiketike lack skills
  to effectively manage unpleasant emotions (e.g.,
  sadness, frustration, annoyance, anxiety, anger).
• This is in part related to the difficulty the
  clients have in understanding and tolerating
  ambiguous situations.
• Their attachment and developmental experiences
  were commonly traumatic and they failed to learn
  adaptive ways to self-soothe.
• They learned to develop ways of managing distress
  that that often included the use of violence
  towards people (themselves and others) and
  property.
• They have also learned how to get others to take
  responsibility for regulating their emotional
  states.

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• When I hit staff my anxiety stops and I can get
  out of stuff.
• When I smack people over it gets their attention
  and they give me what I want.
• I knew if I hurt someone they would finally
  listen to me.
• If I let my dad hit me it stopped my mum and
  sisters from getting hurt.

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• Despite the ingrained nature of learned coping
  strategies it is possible for all people to
  develop more effective ways of regulating
  emotion.
• ....but, I know if I smack people over I wont
  get to do my gardening course and I wont get to
  see my Granddad down South.

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Establishing the Programme

• Idea raised in early 2007 to address violent
  offending and significant behavioural management
  issues.
• Our approaches were inconsistent and
  anxiety-provoking for clients.
• Concerns about the capacity of our client group
  to understand the concepts.
• Lack of time, confidence, avoidance (?), too
  hard basket.
• Prof. Bill Lindsay - Forensic I.D Conference,
  Melbourne, September 2007.

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• Renewed confidence to give it a go...
• Promoting staff and client interest.
• Clients of all levels of functioning were invited
  to take part as long as they could adhere to the
  rules of the group. Four people accepted.
• Further planning and assessment (more
  procrastination and avoidance).
• First session finally took place in March 2008.

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Features of the Programme

• A 42-week manualised programme. Group meets once
  a week for up to two hours.
• Package developed by Murphy, Lindsay and Cox in
  Scotland. Shown through research to be highly
  effective.
• The programme includes pre- and post-treatment
  assessment to monitor progress and effectiveness.
• Homework tasks and key worker involvement
  encourages out of session use and development of
  skills.

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Key programme modules

• - What anger is.
• - Different things make different people
  experience different levels of anger.
• - Normalisation Its okay to get angry, its
  what you do with it that counts.
• - Disclosure of personal anger experiences and
  index offence.
• - Developing awareness of adaptive coping
  strategies.
• - Linking physical warning signs, wind up
  thinking, angry behaviour, consequences.
• - Guided imagery and coping well with angry
  situations.
• - Developing understanding of a range of
  emotions.
• - Developing confidence to express emotions
  appropriately.
• - Coping with provocation through role play.
• - Personal Anger Profiles - Frequent situations,
  danger signs, personal triggers and effective
  approaches.

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Additional Programme Features

• Certificates, games, quizzes, food, prizes!
• Emphasis on client leadership and staff support
  and follow up.
• Pictorial representation.

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Treatment Outcomes - 2008

• Through 2008, all four clients showed clear
  qualitative improvements
• Gradual improvement in clients ability to
  identify problem situations, triggers, warning
  signs and consequences of behaviour.
• More amenable to talking through problems and
  incidents and increasingly comfortable in
  utilising adaptive skills.
• Increased understanding of a range of emotions.
  Openness to share experiences of negative
  emotions, not just anger.
• Excellent attendance and commitment to the group.
• Improved self-esteem and quality of life
  outcomes.
• Improved staff awareness and confidence.
• All clients graduated to the Advanced Group for
  2009.

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Treatment Outcomes - 2009

• Six new clients formed a Beginners Group for
  2009.
• - More significant emotion regulation and
  offending histories. Traditionally resistant to
  therapeutic assistance.
• Generally higher functioning and more able to
  grasp concepts discussed.
• A different dynamic. More challenging of each
  other.
• Continued gains in domains of emotion
  recognition, emotion regulation, self-esteem,
  quality of life and progress through the
  rehabilitation pathway.
• Willingness to engage in additional therapeutic
  activities.
• The programme came to be embraced by staff and
  has become the ward flagship.

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Violent Incidents at Haumietiketike
Jan 06 Feb 08 Average 12 per
monthMar 08 Mar 10 Average 8 per
monthLast 12 Months Average 6 per
monthLast 6 Months Average 3 per month
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2010 The Haumietiketike Stepping Stones
Programme

• A broad emotion-regulation group therapy
  programme to address the wide range of
  difficulties that our clients present with.
• While not all clients present with anger and
  aggression concerns, they do all experience
  emotion regulation difficulties that impact on
  their lives.
• Greater emphasis on out-of-group learning and
  follow up.
• DBT-informed chain-analysis is a major focus.
• All 18 clients take part.

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Haumietiketike Stepping Stones Programme Chain
Analysis Name Staff Members Name Date


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Stepping Stones Skill Development

• Identifying a life worth living and the steps I
  need to take to get there.
• Identifying and understanding a range of emotions
  Anger, sadness, worry, disappointment,
  embarrassment, jealousy, frustration, happiness.
• Coping skill development with an increased
  emphasis on clients taking responsibility for
  their emotional responses.
• Sharing personal experiences of distress
• Using our five senses to get to know our emotions
• Arousal
• Recognising and understanding others emotions
• Stress inoculation and imaginal exposure
• Scenario planning
• Rumination and grudges
• Expressing ourselves
• Masculinity and the male role
• Passive, aggressive, assertive, and
  passive-aggressive communication
• Body language
• Winding up
• Role-play
• Personal strength profiles
• Audio and visual materials

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Process Issues Reflections

• The clients amaze us every week.
• Manualised approach keeps us moving forward.
• Readiness to engage and being prepared to take a
  chance at change are vital.
• The group process with individual follow-up is
  key.
• Different disciplines and personalities bringing
  different strengths.
• Learning to overcome our own anxieties and
  fears...and role-play anxieties...and public
  speaking phobias...

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Future Directions

• A therapeutic community?
• Quantitative research and writing up our
  experiences for publication.
• Encouraging others to have a go.
• Keeping the momentum going and continuing to meet
  the needs of our clients.
• Recognising the limitations of some clients.

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• Questions...
• or
• ...Lunch?

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• Still interested.....?(!!)
• paul.oxnam_at_ccdhb.org.nz