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Development of Anger Management Strategies to Address

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Title: Development of Anger Management Strategies to Address


1
Development of Anger Management Strategies to
Address Domestic Violence
  • By Anna M Shepherd
  • Trainee Clinical Psychologist
  • Queens University Belfast

2
Overview of Presentation
  • Introduction
  • Literature Review
  • Case example David and Susan
  • Conclusions and Implications
  • Questions

3
Introduction
  • Anger and aggression are a heavy burden for the
    whole system concerned with the care and
    rehabilitation of incarcerated offenders with
    intellectual disabilities
  • ( Taylor et al 2002)
  • Anger management treatment seems effective for
    men with intellectual disabilities in the
    community who have committed socially and legally
    unacceptable acts
  • (Lindsay et al 2003)

4
Introduction cont.
  • An excess of anger, and its expression through
    aggression, has been a significant problem for
    some people with a learning disability
  • (Lindsay et al 1998)
  • Challenging behaviours have been a significant
    obstacle to resettlement in the community, and a
    frequent cause of requests for admission or
    readmission to hospital
  • (Mansell 1994)

5
Statistics
  • More than 60 of clients with a learning
    disability referred to a community based service
    for challenging or offending behaviour had
    clinically significant anger problems
  • (Lindsay Laws 1999)
  • Between 10-24 of offenders with intellectual
    disability have committed offences involving
    violence
  • (Day 1993)

6
  • Problems with anger management in this population
    can lead to
  • Poor community adjustment
  • Poor interpersonal relations
  • General health problems
  • Also is an important distinction between the
    individual being given the means to manage their
    own behaviour and those interventions that rely
    on medication and restraint.
  • (Black et al 1988)

7
Literature Review
  • Traditional methods of treating challenging
    behaviour include medication and behaviour
    programs using reinforcement principles.
  • Growing body of evidence in literature supporting
    the use of Cognitive/Cognitive Behavioural
    techniques with this client group.
  • Advantages empowering client and giving them
    enhanced life skills for their future in the
    community.
  • Disadvantages some clients may not be suitable
    for this type of approach for various reasons.

8
Anger Management Packages
  • Novaco (1977) Original article on cognitive
    approach to anger. Describes Stress Innoculation
    technique(cognitive appraisal, arousal reduction,
    and self monitoring)
  • Benson et al (1986) Adapted Novacos package
    for clients with a learning disability using
    various CBT components.
  • ONeill (1999) Manual specifically designed for
    clients with a learning disability. Provides
    session formats, photocopiable resources and
    activities.
  • Faupel et al (1998) Anger Management, A
    Practical Guide. Again provides visual material,
    worksheets and step by step guidance.Can also be
    modified to suit different client groups.

9
Lindsay et al (2003) Long term treatment and
management of violent tendencies of men with
intellectual disabilities convicted of assault.
  • N 6
  • Single case repeated measures design
  • Techniques modified anger management package
    including cognitive restructuring and arousal
    reduction
  • At follow up, 5 had not re-offended, 1
    re-offended within 6mths but had not for 4 yrs
    since then.

10
Taylor et al (2002) Cognitive behaviour
treatment of anger intensity among offenders with
intellectual disabilities.
  • Detained men with intellectual disability and
    history of offending
  • Used Taylor Novaco (1999) manual for anger
    management for the disabled offender
  • Advanced self monitoring
  • Focus on individuality of problems
  • Construction of personal anger provocation
    hierarchy
  • Arousal reduction and problem solving techniques
  • Stress innoculation (coping skills and role play)
  • Results reported anger significantly reduced
    following treatment compared to WLC.

11
Allen et al (2001)Treatment of women with
intellectual disabilities who have been involved
with the criminal justice system for reasons of
aggression
  • N5 women who had history of offending
  • Referred for problems with aggression
  • Duration 9 mths (40 sessions)
  • Techniques
  • Cognitive appraisal of anger provoking situations
  • Cognitive appraisals of personal arousal
  • Arousal reduction techniques
  • All made treatment gains, effects only seen
    however once cognitive aspects of treatment
    implemented.

12
Collins Kelly (2000) Cognitive behavioural
approach to anger management in forensic patients
with learning disability A Pilot Study
  • Group treatment on levels of aggression
  • 2 stages
  • 8 wk self control of anger and aggression
  • 8wk social skills training
  • Using
  • Cognitive strategies eg self talk
  • Behavioural eg role play, relaxation
  • Outcome the inclusion of this treatment
    approachhas a promising contribution to make
    towards a return to the wider community

13
Modification of CBT methods for Anger Management
in Learning Disability
  • Howells et al (2000) addition of teaching of
    basic skills eg recognising emotions in others
    and anger arousal cues at an early stage.
  • Lindsay et al (1998) personal characteristics
    and needs of clients should guide components of
    interventions.
  • Whitaker (2001) describes a number of
    strategies including using more visual aids,
    simpler language and a longer duration.
  • Issues
  • Kroese (1998) examines how deficits in self
    report, understanding of abstract concepts and
    deficits in self regulation can be overcome.

14
Case Example David and Susan
  • Referral
  • David (26, FSIQ57)was referred by his Social
    Worker for anger management treatment following
    outbursts of temper and suspected domestic
    violence.
  • History
  • Early experiences of sexual abuse by both
    parents.
  • Parents described as having poor marital
    relationship, living in inadequate housing
    conditions, and displaying poor parenting skills.
  • David taken into foster care where further
    inappropriate sexual activity took place between
    David and his foster brother, and two younger
    girls. Foster placement broke down.

15
  • Police involved due to these and other public
    inappropriate behaviour including theft from
    local shops
  • Undertook therapeutic work with social worker and
    police for behaviour.
  • David and sister moved to residential care where
    further inappropriate sexual activity took place
    between the siblings and other residents.
  • Supervised meetings with parents continued, but
    relationships strained between David and both
    parents.

16
Previous Contact with Psychology Services
  • David met fiancé Susan (27yrs) in residential
    facility and were engaged shortly afterwards
  • Referred to psychology services for pre marital
    work surrounding their understanding of marriage
    and what it entails, their awareness of sexual
    and relationship issues and their plans for the
    future.
  • During this time Susan suffered visible injuries
    such as a black eye and injured limbs.
  • Was a sensitive issue for the couple at this
    time.

17
Current lifestyle
  • David and Susan live together in community
  • David was working but gave up his job due to
    feeling victimised by co workers
  • Continues to have strained relationship with his
    mother
  • Does not see father regularly
  • Sees his sister socially and appears to have a
    good relationship with her and her boyfriend
  • Has strained relationship with Susans family.

18
Assessment
  • Methods used
  • Existing information from case file and
    information from social work reports
  • Semi Structured interview (ONeill 1999)
  • Clients perspective of their own anger
  • Identification of triggers
  • Bodily sensations
  • Thought processes
  • Behavioural responses
  • Costs and benefits
  • Self report (diaries)
  • ABC charts

19
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20
Assessment Revealed
  • Davids ability to label his thoughts, feelings
    and behaviours very clearly
  • His motivation was genuine and focused, his goals
    were clear and realistic
  • Admission of one incident of domestic violence
    and suggestions of others
  • Co operative manner and honest about his
    difficulties
  • David accepted offer of having Susan coming to
    sessions with him to work together.

21
Formulation
  • Breakdown of contributing factors agreed with
    David and Susan.
  • Provided clear structured visual sequence of
    topics to be covered in sessions.
  • Main issues
  • Marital relationship and practical living
    situation
  • Misinterpretation of social cues/paranoia
  • Critical life events and relationships eg abuse,
    relationship with mother
  • Current lifestyle
  • Issues/topics to be covered placed in order of
    priority with David and Susan.

22
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23
Davids Self Report 1
  • At the moment I feel sad lonely hurt
  • I want to put things right but feel Im not
    being allowed to do so
  • I dont want the label as a wife beater for Im
    not proud of what Ive done
  • I do see it as a problem and Im getting help
  • I hopeI will gain control over my anger and be
    the person I have always wanted to be and also be
    more of a husband to Susan

24
Sequence of Topics
  • Marital relationship
  • Practical issues money and housekeeping
  • Aggression and Violence
  • Thought processes (CBT model)
  • Sleeping and relaxation
  • Coping skills
  • Past issues
  • Assertion
  • Daily activities and lifestyle

25
Evidence Based Components
  • Relaxation techniques
  • Diaries/Self report methods
  • Pleasant activities
  • Enhanced communication
  • Role play work
  • Problem solving skills
  • Assertiveness/Self esteem work
  • Cognitive appraisal
  • Practical living advice
  • Exploration of traumatic events
  • Psycho-education

26
Overview of Sessions
  • Clear structure used in every session
  • Open, Topic, Close
  • Opportunity to change agenda given
  • Offered individual session
  • Topics, themes and tasks overlapped
  • Visual aids used in every session
  • Fortnightly sessions of 1-1.5 hours duration
    each.

27
Sessions 1 2
  • Session 1
  • Interview about difficulties, background
    information taken
  • Introduction of anger diary and relaxation tape
  • Session 2
  • Discussed last week
  • Discussed use of anger diary and tape
  • Explored Susans perspective on Davids
    difficulties
  • Explored What is Anger?
  • Psycho-education sheet given about anger

28
The Ten Principles of Anger Control (Williams
Barlow 1998)
  • 1. Aggression is a learnt behaviour which can be
    changed.
  • 2. The beliefs that we develop influence the way
    we understand people and situations.
  • 3. Awareness and understanding of what we think
    affects the way we behave.
  • 4. What you feel affects the way you think and
    behave.
  • 5. Anger has a physiological component.
  • 6. Aggression almost always results in negative
    consequences for ourselves and others.
  • 7. Identification of all the specific factors
    which are likely to make you aggressive helps you
    to anticipate and cope with them as they arise.
  • 8. Loss of control is usually a result of a build
    up of small irritants that have not been dealt
    with.
  • 9. An imbalance of chores and pleasures in your
    general lifestyle increases the likelihood of
    your behaving aggressively.
  • 10. Anger can be a positive and empowering
    emotion if used constructively.

29
Session 3 Marital Relationship
  • Open mood check, diary review
  • Topic work
  • Description of good and bad sides of their
    marriage
  • Description of good and bad points about each
    other
  • If marriage meets their expectations
  • Reflection of what has changed in their
    relationship over time
  • How they treat each other on day to day basis
  • Important aspects of relationships love, trust,
    honesty, respect
  • Communication and teamwork in the relationship
  • External pressures on relationship
  • Close Review, homework set

30
Session 4 Practical issues
  • Open mood check, diary review
  • Topic work
  • Finances current problems and how these could
    be solved
  • Housework current problems and how these could
    be solved
  • The contract of marriage and living together
  • How and why practical issues can affect
    relationship
  • How they feel about the current situation and
    each other
  • In the future what will affect this eg children
  • Made a contract / plan for teamwork and shared
    responsibility
  • Budget for finance and rota for housework
  • Close review and homework task

31
Session 5 Violence
  • Open mood check, diary review
  • Anger and aggression need not always go together
  • Discussion of the control factor
  • Goal reduce anger and remove aggression
  • Start focus on safe target eg punchbag
  • Developing coping strategies as alternatives
  • Discussed experience of aggression in past
  • Use of thermometer or hulk imagery
  • Understanding of physiology behind anger and
    recognition of triggers
  • Close review and homework task

32
Davids Self Report 2
  • Things between me and Susan have been a lot
    better for Im talking more to Susan if there is
    anything bothering me
  • Today Susan and I done the housework as a team
    and now we are listening to music together
  • I feel like a huge weight has been lifted off
    my chest
  • I know what (we) are going to do over the next
    appointments and what things I can do to keep me
    calm and to deal with my anger in a more rational
    way

33
Session 6 Introduction of CBT model
  • Open mood check, diary review
  • Topic work
  • Differentiating between a thought, an emotion
    and a behaviour
  • Explanation of how these interact using diagram
    of specific situation
  • Relation of physiological feedback to thoughts
    and emotions
  • Introduction of negative automatic thought
    patterns
  • Seeking alternative explanations for situations
  • Close review, homework task

34
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35
Session 7 Sleeping and relaxation
  • Open mood check and diary review
  • Topic work
  • Effects of sleep withdrawal on thoughts,
    emotions, behaviour and physical symptoms
  • Reasons for not sleeping attributed to circular
    and distressing thoughts
  • Importance of routine relaxation music, hot
    drink, baths etc
  • Increasing physical activities to increase
    tiredness
  • Use of thought diary to express worries before
    going to bed
  • Introduction of OSTAR relaxation technique (On
    The Spot Arousal Reduction)
  • Close review, homework task

36
Session 8 Coping Skills
  • Open mood check, diary review
  • Topic work
  • Discussion of what coping skills are and how they
    could be used
  • What his current ones are and what works best for
    him
  • In which situations would he need alternative
    ways of coping
  • Relaxation techniques
  • Cognitive skills eg positive self statements
  • Use of routines
  • Practise plan for imagined situations, and role
    play exercise
  • Developing a solution worksheets
  • Close review, homework task

37
Session 9 Past Issues
  • Open mood check, diary review
  • Topic work
  • Introduction of concept of past experience and
    its influence on current behaviour
  • Past experience of anger and aggression discussed
  • Discussed how he bottles things up and used
    diagram to explain how this may be expressed as
    pressure is released
  • Discussed that he has had bad things happen to
    him
  • Discussion of whether a leopard can change its
    spots
  • Optimism for future and trying to move on from
    bad memories
  • Close review and homework task

38
Session 10 Assertiveness
  • Open mood check, review diary
  • Topic work
  • Role of self esteem and assertiveness in anger
  • Perceived self image
  • Difference between aggression, assertion and
    passivity
  • How he would like to come across to others
  • How to express your emotions appropriately
  • How to express your hurt, anger or confusion
    assertively not aggressively
  • Role plays and imaginary situations
  • Close review and homework task

39
Session 11 Changes in lifestyle
  • Open mood check, review diary
  • Topic work
  • Changes in daily activities
  • Developing new interests and widening social
    circle
  • Increased physical activity
  • Seeing friends separately and time alone
  • Review of topics covered
  • Map of influences on anger made together
  • Discussed changes made in each area
  • Close review, and plans made for last session

40
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41
Session 12 Final Session
  • Open mood check, review diary
  • Reviewed course and progress made
  • Made reference to using coping skills in future
  • Handouts and visual reminders given to David and
    Susan
  • Satisfaction questionnaire completed
  • Close review and follow up arranged

42
Davids Self Report 3
  • she knows what I gone through as a young boy
    and the pain I endured
  • I feel more calm within my self and Im proud of
    that too
  • I have got help and Im glad for that stands in
    my favour and shows that I do have the capacity
    to change and Im also willing to change for the
    best
  • its great that we get our feelings out in the
    open

43
Outcome
  • Significant reduction in reports of
  • Marital arguments (none)
  • Violent outbursts (none)
  • Worries concerning practical matters
  • Increase in
  • Self reported mood and happiness
  • Effective team work and communication in
    relationship and with families
  • Pleasant activities and enjoyment in these

44
Limitations
  • Methodological rigour pre and post quantitative
    measures
  • Longer treatment duration required
  • Follow up to be completed
  • Did not address domestic violence directly
  • Could have been used in conjunction with eg
    assertiveness group

45
Conclusions
  • Despite limitations on interpretation, case
    demonstrates that client was able to use
    cognitive behavioural techniques to take control
    of his own anger.
  • Using these techniques in a collaborative fashion
    indirectly addressed issues of domestic violence,
    self esteem and marital communication.
  • David showed evidence of transferable skills by
    calming others and facing old triggers in new
    situations by relying on his knowledge of anger
    control.
  • Domestic violence was prominent issue, but also
    dealt with other issues such as past sexual abuse
    and current relationships eg with mother.

46
Implications
  • Inappropriately expressed anger and aggression in
    clients with a learning disability can lead to
    problems such as domestic violence and breakdown
    of placement.
  • Principles of equality offering highly
    effective treatments for all clients regardless
    of intellectual ability.
  • Treating each case as an individual and modifying
    treatment packages to suit their needs and
    ability.
  • Giving them life skills to enhance settlement in
    community settings.
  • Reduce demand on forensic services and provide
    source of risk assessment for future offending.
  • Cost implications resources and duration,
    compared to admission?

47
  • I get angry when I want to,
  • I get angry when I dont,
  • Ill get angry when Ill try to,
  • Ill get angry when I wont.
  • I get angry when Im threatened,
  • I get angry when Im sad,
  • But I get angry when Im happy,
  • And that just makes me mad!
  • Anger is a good thing,
  • And then again its bad,
  • So now weve got it sorted,
  • Im feeling really glad.
  • From Faupel, Herrick Sharp (1998)
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