Development of Anger Management Strategies to Address Domestic Violence

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
(No Transcript)
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
(No Transcript)
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
(No Transcript)
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
(No Transcript)
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)