Development of Anger Management Strategies to Address Domestic Viol.ppt

1、Development of Anger Management Strategies to Address Domestic Violence,By Anna M Shepherd Trainee Clinical Psychologist Queens University Belfast,Overview of Presentation,Introduction Literature Review Case example : David and Susan Conclusions and Implications Questions,Introduction,“Anger and agg

2、ression 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

3、 legally unacceptable acts”(Lindsay et al 2003),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 t

4、he community, and a frequent cause of requests for admission or readmission to hospital”(Mansell 1994),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

5、 1999)Between 10-24% of offenders with intellectual disability have committed offences involving violence (Day 1993),Problems with anger management in this population can lead to: Poor community adjustment Poor interpersonal relations General health problemsAlso is an important distinction between t

6、he individual being given the means to manage their own behaviour and those interventions that rely on medication and restraint.(Black et al 1988),Literature Review,Traditional methods of treating challenging behaviour include medication and behaviour programs using reinforcement principles. Growing

7、 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 f

8、or various reasons.,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 usi

9、ng 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 gui

10、dance.Can also be modified to suit different client groups.,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 c

11、ognitive restructuring and arousal reductionAt follow up, 5 had not re-offended, 1 re-offended within 6mths but had not for 4 yrs since then.,Taylor et al (2002): Cognitive behaviour treatment of anger intensity among offenders with intellectual disabilities.,Detained men with intellectual disabilit

12、y 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 s

13、kills and role play)Results: reported anger significantly reduced following treatment compared to WLC.,Allen et al (2001):Treatment of women with intellectual disabilities who have been involved with the criminal justice system for reasons of aggression,N=5 women who had history of offending Referre

14、d 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.,Col

15、lins & 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 Beha

16、vioural eg role play, relaxationOutcome : “the inclusion of this treatment approachhas a promising contribution to make towards a return to the wider community”,Modification of CBT methods for Anger Management in Learning Disability,Howells et al (2000) : addition of teaching of basic skills eg reco

17、gnising 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 durat

18、ion. Issues : Kroese (1998) :examines how deficits in self report, understanding of abstract concepts and deficits in self regulation can be overcome.,Case Example : David and Susan,Referral David (26, FSIQ=57)was referred by his Social Worker for anger management treatment following outbursts of te

19、mper 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 activ

20、ity took place between David and his foster brother, and two younger girls. Foster placement broke down.,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 mov

21、ed 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.,Previous Contact with Psychology Services,David met fianc Susan (27yrs) in re

22、sidential 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 injur

23、ies such as a black eye and injured limbs. Was a sensitive issue for the couple at this time.,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 se

24、e father regularly Sees his sister socially and appears to have a good relationship with her and her boyfriend Has strained relationship with Susans family.,Assessment,Methods used: Existing information from case file and information from social work reports Semi Structured interview (ONeill 1999) C

25、lients perspective of their own anger Identification of triggers Bodily sensations Thought processes Behavioural responses Costs and benefits Self report (diaries) ABC charts,Assessment Revealed,Davids ability to label his thoughts, feelings and behaviours very clearly His motivation was genuine and

26、 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.,Formulation,Breakdown of contributing factors

27、 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 l

28、ifestyle Issues/topics to be covered placed in order of priority with David and Susan.,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 s

29、ee 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”,Sequence of Topics,Marital relationship Practical issues money and housekeeping Aggression and Violence Thought processes (CBT model)

30、Sleeping and relaxation Coping skills Past issues Assertion Daily activities and lifestyle,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 P

31、ractical living advice Exploration of traumatic events Psycho-education,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 sessio

32、ns of 1-1.5 hours duration each.,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

33、 Anger? Psycho-education sheet given about anger,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 thin

34、k 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 hel

35、ps 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 p

36、ositive and empowering emotion if used constructively.,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 chan

37、ged 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,Session 4 : Practical issues,Open : mood

38、 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

39、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,Session 5 : Violence,Open : mood check, diary review Anger and aggression need not always go together Discuss

40、ion 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

41、Close : review and homework task,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

42、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”,Session 6 : Introduction of CBT model,Open : mood check, diary review Topic work: Differentiating between a thought, an emotio

43、n 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,Session 7 : Sleeping a

44、nd 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

45、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,Session 8 : Coping Skills,Open : mood check, diary review Topic work : Discussion of what coping skill

46、s 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 Develop

47、ing a solution worksheets Close : review, homework task,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

48、 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,Session 10 : Assertiveness,Open :

49、 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 asserti

50、vely not aggressively Role plays and imaginary situations Close : review and homework task,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,