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The Haumietiketike Anger Management Programme A New Zealand

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Title: The Haumietiketike Anger Management Programme A New Zealand

1
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.

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

5
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.

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.

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.

15
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.

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.

17
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.

18
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.

19
Additional Programme Features

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

20
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.

21
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.

22
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
23
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.

24
Haumietiketike Stepping Stones Programme Chain
Analysis Name Staff Members Name Date

25
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

26
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...

27
Future Directions