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Anger Management And Domestic Violence In Learning Disabilit

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  • 1. Development of Anger Management Strategies to Address Domestic Violence By Anna M Shepherd Trainee Clinical Psychologist Queen’s 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 Novaco’s package for clients with a learning disability using various CBT components.
    • O’Neill (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
    • N=5 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 approach…has 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, FSIQ=57)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 Susan’s family.
  • 18. Assessment
    • Methods used:
      • Existing information from case file and information from social work reports
      • Semi Structured interview (O’Neill 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.  
  • 20. Assessment Revealed
    • David’s 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.  
  • 23. David’s Self Report 1
    • “ At the moment I feel sad lonely hurt”
    • “ I want to put things right but feel I’m not being allowed to do so”
    • “ I don’t want the label as a wife beater for I’m not proud of what I’ve done”
    • “ I do see it as a problem and I’m getting help”
    • “ I hope…I 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 Susan’s perspective on David’s 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. David’s Self Report 2
    • “ Things between me and Susan have been a lot better for I’m 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.  
  • 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.  
  • 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. David’s 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 I’m proud of that too”
    • “ I have got help and I’m glad for that stands in my favour and shows that I do have the capacity to change and I’m 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 don’t,
    • I’ll get angry when I’ll try to,
    • I’ll get angry when I wont.
    • I get angry when I’m threatened,
    • I get angry when I’m sad,
    • But I get angry when I’m happy,
    • And that just makes me mad!
    • Anger is a good thing,
    • And then again its bad,
    • So now we’ve got it sorted,
    • I’m feeling really glad .
    • From Faupel, Herrick & Sharp (1998)

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