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)

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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)

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• 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)

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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• 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.

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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.

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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.

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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

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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.

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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.

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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

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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

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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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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?

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• 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)