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Anger Management And Domestic Violence In Learning Disabilit
 

Anger Management And Domestic Violence In Learning Disabilit

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    Anger Management And Domestic Violence In Learning Disabilit Anger Management And Domestic Violence In Learning Disabilit Presentation Transcript

    • Development of Anger Management Strategies to Address Domestic Violence By Anna M Shepherd Trainee Clinical Psychologist Queen’s University Belfast
    • Overview of Presentation
      • Introduction
      • Literature Review
      • Case example : David and Susan
      • Conclusions and Implications
      • Questions
    • 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)
    • 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)
    • 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)
      • 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)
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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”
    • 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.
    • 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.
      • 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 .
    • 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.
    • 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.
    • 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
    •  
    • 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.
    • 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.
    •  
    • 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”
    • 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
    • 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
    • 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.
    • 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
    • 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.
    • 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
    • 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
    • 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
    • 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”
    • 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
    •  
    • 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
    • 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
    • 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
    • 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
    • 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
    •  
    • 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
    • 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”
    • 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
    • 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
    • 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.
    • 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?
      • 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)