Development of Anger Management Strategies to Address Domestic Violence By Anna M Shepherd Trainee Clinical Psychologist Q...
Overview of Presentation <ul><li>Introduction </li></ul><ul><li>Literature Review </li></ul><ul><li>Case example : David a...
Introduction <ul><li>“ Anger and aggression are a heavy burden for the whole system concerned with the care and rehabilita...
Introduction cont. <ul><li>“ An excess of anger, and its expression through aggression, has been a significant problem for...
Statistics <ul><li>More than 60% of clients with a learning disability referred to a community based service for challengi...
<ul><li>Problems with anger management in this population can lead to: </li></ul><ul><ul><li>Poor community adjustment </l...
Literature Review <ul><li>Traditional methods of treating challenging behaviour include medication and behaviour programs ...
Anger Management Packages <ul><li>Novaco (1977)  : Original article on cognitive approach to anger. Describes Stress Innoc...
Lindsay et al (2003):  Long term treatment and management of violent tendencies of men with intellectual disabilities conv...
Taylor et al (2002):  Cognitive behaviour treatment of anger intensity among offenders with intellectual disabilities. <ul...
Allen et al (2001): Treatment of women with intellectual disabilities who have been involved with the criminal justice sys...
Collins & Kelly (2000):  Cognitive behavioural approach to anger management in forensic patients with learning disability ...
Modification of CBT methods for Anger Management in Learning Disability <ul><li>Howells et al (2000)  : addition of teachi...
Case Example : David and Susan <ul><li>Referral </li></ul><ul><ul><li>David (26, FSIQ=57)was referred by his Social Worker...
<ul><li>Police involved due to these and other public inappropriate behaviour including theft from local shops </li></ul><...
Previous Contact with Psychology Services <ul><li>David met fiancé Susan (27yrs) in residential facility and were engaged ...
Current lifestyle <ul><li>David and Susan live together in community </li></ul><ul><li>David was working but gave up his j...
Assessment <ul><li>Methods used:   </li></ul><ul><ul><li>Existing information from case file and information from social w...
 
Assessment Revealed <ul><li>David’s ability to label his thoughts, feelings and behaviours very clearly </li></ul><ul><li>...
Formulation   <ul><li>Breakdown of contributing factors agreed with David and Susan. </li></ul><ul><li>Provided clear stru...
 
David’s Self Report 1 <ul><li>“  At the moment I feel sad lonely hurt” </li></ul><ul><li>“  I want to put things right but...
Sequence of Topics <ul><li>Marital relationship </li></ul><ul><li>Practical issues – money and housekeeping </li></ul><ul>...
Evidence Based Components <ul><li>Relaxation techniques </li></ul><ul><li>Diaries/Self report methods </li></ul><ul><li>Pl...
Overview of Sessions <ul><li>Clear structure used in every session </li></ul><ul><ul><li>Open, Topic, Close </li></ul></ul...
Sessions 1 & 2 <ul><li>Session 1 </li></ul><ul><ul><li>Interview about difficulties, background information taken </li></u...
The Ten Principles of Anger Control (Williams & Barlow 1998) <ul><li>1. Aggression is a learnt behaviour which can be chan...
Session 3 : Marital Relationship <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work: </li></ul><ul><ul><...
Session 4 : Practical issues <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>...
Session 5 : Violence <ul><li>Open : mood check, diary review </li></ul><ul><ul><li>Anger and aggression need not always go...
David’s Self Report 2 <ul><li>“ Things between me and Susan have been a lot better for I’m talking more to Susan if there ...
Session 6 : Introduction of CBT model <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work: </li></ul><ul>...
 
Session 7 : Sleeping and relaxation <ul><li>Open : mood check and diary review </li></ul><ul><li>Topic work : </li></ul><u...
Session 8 : Coping Skills <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Dis...
Session 9 : Past Issues <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Intro...
Session 10 : Assertiveness <ul><li>Open : mood check, review diary </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Ro...
Session 11 : Changes in lifestyle <ul><li>Open : mood check, review diary </li></ul><ul><li>Topic work : </li></ul><ul><ul...
 
Session 12 : Final Session <ul><li>Open : mood check, review diary </li></ul><ul><li>Reviewed course and progress made </l...
David’s Self Report 3 <ul><li>“  she knows what I gone through as a young boy and the pain I endured” </li></ul><ul><li>“ ...
Outcome <ul><li>Significant reduction in reports of : </li></ul><ul><ul><li>Marital arguments (none) </li></ul></ul><ul><u...
Limitations <ul><li>Methodological rigour : pre and post quantitative measures </li></ul><ul><li>Longer treatment duration...
Conclusions <ul><li>Despite limitations on interpretation, case demonstrates that client was able to use cognitive behavio...
Implications <ul><li>Inappropriately expressed anger and aggression in clients with a learning disability can lead to prob...
<ul><li>I get angry when I want to, </li></ul><ul><li>I get angry when I don’t, </li></ul><ul><li>I’ll get angry when I’ll...
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Anger Management And Domestic Violence In Learning Disabilit

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Anger Management And Domestic Violence In Learning Disabilit

  1. 1. Development of Anger Management Strategies to Address Domestic Violence By Anna M Shepherd Trainee Clinical Psychologist Queen’s University Belfast
  2. 2. Overview of Presentation <ul><li>Introduction </li></ul><ul><li>Literature Review </li></ul><ul><li>Case example : David and Susan </li></ul><ul><li>Conclusions and Implications </li></ul><ul><li>Questions </li></ul>
  3. 3. Introduction <ul><li>“ Anger and aggression are a heavy burden for the whole system concerned with the care and rehabilitation of incarcerated offenders with intellectual disabilities” </li></ul><ul><ul><ul><ul><ul><li>( Taylor et al 2002) </li></ul></ul></ul></ul></ul><ul><li>“ Anger management treatment seems effective for men with intellectual disabilities in the community who have committed socially and legally unacceptable acts” </li></ul><ul><ul><ul><ul><li>(Lindsay et al 2003) </li></ul></ul></ul></ul>
  4. 4. Introduction cont. <ul><li>“ An excess of anger, and its expression through aggression, has been a significant problem for some people with a learning disability” </li></ul><ul><li>(Lindsay et al 1998) </li></ul><ul><li>“ Challenging behaviours have been a significant obstacle to resettlement in the community, and a frequent cause of requests for admission or readmission to hospital” </li></ul><ul><li>(Mansell 1994) </li></ul>
  5. 5. Statistics <ul><li>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 </li></ul><ul><li>(Lindsay & Laws 1999) </li></ul><ul><li>Between 10-24% of offenders with intellectual disability have committed offences involving violence </li></ul><ul><li>(Day 1993) </li></ul>
  6. 6. <ul><li>Problems with anger management in this population can lead to: </li></ul><ul><ul><li>Poor community adjustment </li></ul></ul><ul><ul><li>Poor interpersonal relations </li></ul></ul><ul><ul><li>General health problems </li></ul></ul><ul><li>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. </li></ul><ul><li>(Black et al 1988) </li></ul>
  7. 7. Literature Review <ul><li>Traditional methods of treating challenging behaviour include medication and behaviour programs using reinforcement principles. </li></ul><ul><li>Growing body of evidence in literature supporting the use of Cognitive/Cognitive Behavioural techniques with this client group. </li></ul><ul><li>Advantages : empowering client and giving them enhanced life skills for their future in the community. </li></ul><ul><li>Disadvantages : some clients may not be suitable for this type of approach for various reasons. </li></ul>
  8. 8. Anger Management Packages <ul><li>Novaco (1977) : Original article on cognitive approach to anger. Describes Stress Innoculation technique(cognitive appraisal, arousal reduction, and self monitoring) </li></ul><ul><li>Benson et al (1986) : Adapted Novaco’s package for clients with a learning disability using various CBT components. </li></ul><ul><li>O’Neill (1999) : Manual specifically designed for clients with a learning disability. Provides session formats, photocopiable resources and activities. </li></ul><ul><li>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. </li></ul>
  9. 9. Lindsay et al (2003): Long term treatment and management of violent tendencies of men with intellectual disabilities convicted of assault. <ul><li>N = 6 </li></ul><ul><li>Single case repeated measures design </li></ul><ul><li>Techniques : modified anger management package including cognitive restructuring and arousal reduction </li></ul><ul><li>At follow up, 5 had not re-offended, 1 re-offended within 6mths but had not for 4 yrs since then. </li></ul>
  10. 10. Taylor et al (2002): Cognitive behaviour treatment of anger intensity among offenders with intellectual disabilities. <ul><li>Detained men with intellectual disability and history of offending </li></ul><ul><li>Used Taylor & Novaco (1999) manual for anger management for the disabled offender </li></ul><ul><ul><li>Advanced self monitoring </li></ul></ul><ul><ul><li>Focus on individuality of problems </li></ul></ul><ul><ul><li>Construction of personal anger provocation hierarchy </li></ul></ul><ul><ul><li>Arousal reduction and problem solving techniques </li></ul></ul><ul><ul><li>Stress innoculation (coping skills and role play) </li></ul></ul><ul><li>Results: reported anger significantly reduced following treatment compared to WLC. </li></ul>
  11. 11. Allen et al (2001): Treatment of women with intellectual disabilities who have been involved with the criminal justice system for reasons of aggression <ul><li>N=5 women who had history of offending </li></ul><ul><li>Referred for problems with aggression </li></ul><ul><li>Duration = 9 mths (40 sessions) </li></ul><ul><li>Techniques : </li></ul><ul><ul><li>Cognitive appraisal of anger provoking situations </li></ul></ul><ul><ul><li>Cognitive appraisals of personal arousal </li></ul></ul><ul><ul><li>Arousal reduction techniques </li></ul></ul><ul><li>All made treatment gains, effects only seen however once cognitive aspects of treatment implemented. </li></ul>
  12. 12. Collins & Kelly (2000): Cognitive behavioural approach to anger management in forensic patients with learning disability : A Pilot Study <ul><li>Group treatment on levels of aggression </li></ul><ul><li>2 stages : </li></ul><ul><ul><li>8 wk self control of anger and aggression </li></ul></ul><ul><ul><li>8wk social skills training </li></ul></ul><ul><li>Using : </li></ul><ul><ul><li>Cognitive strategies eg self talk </li></ul></ul><ul><ul><li>Behavioural eg role play, relaxation </li></ul></ul><ul><li>Outcome : “the inclusion of this treatment approach…has a promising contribution to make towards a return to the wider community” </li></ul>
  13. 13. Modification of CBT methods for Anger Management in Learning Disability <ul><li>Howells et al (2000) : addition of teaching of basic skills eg recognising emotions in others and anger arousal cues at an early stage. </li></ul><ul><li>Lindsay et al (1998) : personal characteristics and needs of clients should guide components of interventions. </li></ul><ul><li>Whitaker (2001) : describes a number of strategies including using more visual aids, simpler language and a longer duration. </li></ul><ul><ul><li>Issues : </li></ul></ul><ul><li>Kroese (1998) :examines how deficits in self report, understanding of abstract concepts and deficits in self regulation can be overcome. </li></ul>
  14. 14. Case Example : David and Susan <ul><li>Referral </li></ul><ul><ul><li>David (26, FSIQ=57)was referred by his Social Worker for anger management treatment following outbursts of temper and suspected domestic violence. </li></ul></ul><ul><li>History </li></ul><ul><ul><li>Early experiences of sexual abuse by both parents. </li></ul></ul><ul><ul><li>Parents described as having poor marital relationship, living in inadequate housing conditions, and displaying poor parenting skills. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  15. 15. <ul><li>Police involved due to these and other public inappropriate behaviour including theft from local shops </li></ul><ul><li>Undertook therapeutic work with social worker and police for behaviour. </li></ul><ul><li>David and sister moved to residential care where further inappropriate sexual activity took place between the siblings and other residents. </li></ul><ul><li>Supervised meetings with parents continued, but relationships strained between David and both parents . </li></ul>
  16. 16. Previous Contact with Psychology Services <ul><li>David met fiancé Susan (27yrs) in residential facility and were engaged shortly afterwards </li></ul><ul><li>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. </li></ul><ul><li>During this time Susan suffered visible injuries such as a black eye and injured limbs. </li></ul><ul><li>Was a sensitive issue for the couple at this time. </li></ul>
  17. 17. Current lifestyle <ul><li>David and Susan live together in community </li></ul><ul><li>David was working but gave up his job due to feeling victimised by co workers </li></ul><ul><li>Continues to have strained relationship with his mother </li></ul><ul><li>Does not see father regularly </li></ul><ul><li>Sees his sister socially and appears to have a good relationship with her and her boyfriend </li></ul><ul><li>Has strained relationship with Susan’s family. </li></ul>
  18. 18. Assessment <ul><li>Methods used: </li></ul><ul><ul><li>Existing information from case file and information from social work reports </li></ul></ul><ul><ul><li>Semi Structured interview (O’Neill 1999) </li></ul></ul><ul><ul><ul><li>Clients perspective of their own anger </li></ul></ul></ul><ul><ul><ul><li>Identification of triggers </li></ul></ul></ul><ul><ul><ul><li>Bodily sensations </li></ul></ul></ul><ul><ul><ul><li>Thought processes </li></ul></ul></ul><ul><ul><ul><li>Behavioural responses </li></ul></ul></ul><ul><ul><ul><li>Costs and benefits </li></ul></ul></ul><ul><ul><li>Self report (diaries) </li></ul></ul><ul><ul><li>ABC charts </li></ul></ul>
  19. 20. Assessment Revealed <ul><li>David’s ability to label his thoughts, feelings and behaviours very clearly </li></ul><ul><li>His motivation was genuine and focused, his goals were clear and realistic </li></ul><ul><li>Admission of one incident of domestic violence and suggestions of others </li></ul><ul><li>Co operative manner and honest about his difficulties </li></ul><ul><li>David accepted offer of having Susan coming to sessions with him to work together. </li></ul>
  20. 21. Formulation <ul><li>Breakdown of contributing factors agreed with David and Susan. </li></ul><ul><li>Provided clear structured visual sequence of topics to be covered in sessions. </li></ul><ul><li>Main issues : </li></ul><ul><ul><ul><li>Marital relationship and practical living situation </li></ul></ul></ul><ul><ul><ul><li>Misinterpretation of social cues/paranoia </li></ul></ul></ul><ul><ul><ul><li>Critical life events and relationships eg abuse, relationship with mother </li></ul></ul></ul><ul><ul><ul><li>Current lifestyle </li></ul></ul></ul><ul><li>Issues/topics to be covered placed in order of priority with David and Susan. </li></ul>
  21. 23. David’s Self Report 1 <ul><li>“ At the moment I feel sad lonely hurt” </li></ul><ul><li>“ I want to put things right but feel I’m not being allowed to do so” </li></ul><ul><li>“ I don’t want the label as a wife beater for I’m not proud of what I’ve done” </li></ul><ul><li>“ I do see it as a problem and I’m getting help” </li></ul><ul><li>“ 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” </li></ul>
  22. 24. Sequence of Topics <ul><li>Marital relationship </li></ul><ul><li>Practical issues – money and housekeeping </li></ul><ul><li>Aggression and Violence </li></ul><ul><li>Thought processes (CBT model) </li></ul><ul><li>Sleeping and relaxation </li></ul><ul><li>Coping skills </li></ul><ul><li>Past issues </li></ul><ul><li>Assertion </li></ul><ul><li>Daily activities and lifestyle </li></ul>
  23. 25. Evidence Based Components <ul><li>Relaxation techniques </li></ul><ul><li>Diaries/Self report methods </li></ul><ul><li>Pleasant activities </li></ul><ul><li>Enhanced communication </li></ul><ul><li>Role play work </li></ul><ul><li>Problem solving skills </li></ul><ul><li>Assertiveness/Self esteem work </li></ul><ul><li>Cognitive appraisal </li></ul><ul><li>Practical living advice </li></ul><ul><li>Exploration of traumatic events </li></ul><ul><li>Psycho-education </li></ul>
  24. 26. Overview of Sessions <ul><li>Clear structure used in every session </li></ul><ul><ul><li>Open, Topic, Close </li></ul></ul><ul><ul><li>Opportunity to change agenda given </li></ul></ul><ul><li>Offered individual session </li></ul><ul><li>Topics, themes and tasks overlapped </li></ul><ul><li>Visual aids used in every session </li></ul><ul><li>Fortnightly sessions of 1-1.5 hours duration each. </li></ul>
  25. 27. Sessions 1 & 2 <ul><li>Session 1 </li></ul><ul><ul><li>Interview about difficulties, background information taken </li></ul></ul><ul><ul><li>Introduction of anger diary and relaxation tape </li></ul></ul><ul><li>Session 2 </li></ul><ul><ul><li>Discussed last week </li></ul></ul><ul><ul><li>Discussed use of anger diary and tape </li></ul></ul><ul><ul><li>Explored Susan’s perspective on David’s difficulties </li></ul></ul><ul><ul><li>Explored ‘What is Anger?’ </li></ul></ul><ul><ul><li>Psycho-education sheet given about anger </li></ul></ul>
  26. 28. The Ten Principles of Anger Control (Williams & Barlow 1998) <ul><li>1. Aggression is a learnt behaviour which can be changed. </li></ul><ul><li>2. The beliefs that we develop influence the way we understand people and situations. </li></ul><ul><li>3. Awareness and understanding of what we think affects the way we behave. </li></ul><ul><li>4. What you feel affects the way you think and behave. </li></ul><ul><li>5. Anger has a physiological component. </li></ul><ul><li>6. Aggression almost always results in negative consequences for ourselves and others. </li></ul><ul><li>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. </li></ul><ul><li>8. Loss of control is usually a result of a build up of small irritants that have not been dealt with. </li></ul><ul><li>9. An imbalance of chores and pleasures in your general lifestyle increases the likelihood of your behaving aggressively. </li></ul><ul><li>10. Anger can be a positive and empowering emotion if used constructively. </li></ul>
  27. 29. Session 3 : Marital Relationship <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work: </li></ul><ul><ul><li>Description of good and bad sides of their marriage </li></ul></ul><ul><ul><li>Description of good and bad points about each other </li></ul></ul><ul><ul><li>If marriage meets their expectations </li></ul></ul><ul><ul><li>Reflection of what has changed in their relationship over time </li></ul></ul><ul><ul><li>How they treat each other on day to day basis </li></ul></ul><ul><ul><li>Important aspects of relationships : love, trust, honesty, respect </li></ul></ul><ul><ul><li>Communication and teamwork in the relationship </li></ul></ul><ul><ul><li>External pressures on relationship </li></ul></ul><ul><li>Close : Review, homework set </li></ul>
  28. 30. Session 4 : Practical issues <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Finances : current problems and how these could be solved </li></ul></ul><ul><ul><li>Housework : current problems and how these could be solved </li></ul></ul><ul><ul><li>The ‘contract’ of marriage and living together </li></ul></ul><ul><ul><li>How and why practical issues can affect relationship </li></ul></ul><ul><ul><li>How they feel about the current situation and each other </li></ul></ul><ul><ul><li>In the future what will affect this eg children </li></ul></ul><ul><ul><li>Made a contract / plan for teamwork and shared responsibility </li></ul></ul><ul><ul><li>Budget for finance and rota for housework </li></ul></ul><ul><li>Close : review and homework task </li></ul>
  29. 31. Session 5 : Violence <ul><li>Open : mood check, diary review </li></ul><ul><ul><li>Anger and aggression need not always go together </li></ul></ul><ul><ul><li>Discussion of the ‘control factor’ </li></ul></ul><ul><ul><li>Goal : reduce anger and remove aggression </li></ul></ul><ul><ul><li>Start: focus on safe target eg punchbag </li></ul></ul><ul><ul><li>Developing coping strategies as alternatives </li></ul></ul><ul><ul><li>Discussed experience of aggression in past </li></ul></ul><ul><ul><li>Use of ‘thermometer’ or ‘hulk’ imagery </li></ul></ul><ul><ul><li>Understanding of physiology behind anger and recognition of triggers </li></ul></ul><ul><li>Close : review and homework task </li></ul>
  30. 32. David’s Self Report 2 <ul><li>“ Things between me and Susan have been a lot better for I’m talking more to Susan if there is anything bothering me” </li></ul><ul><li>“ Today Susan and I done the housework as a team and now we are listening to music together” </li></ul><ul><li>“ I feel like a huge weight has been lifted off my chest” </li></ul><ul><li>“ 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” </li></ul>
  31. 33. Session 6 : Introduction of CBT model <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work: </li></ul><ul><ul><li>Differentiating between a thought, an emotion and a behaviour </li></ul></ul><ul><ul><li>Explanation of how these interact using diagram of specific situation </li></ul></ul><ul><ul><li>Relation of physiological feedback to thoughts and emotions </li></ul></ul><ul><ul><li>Introduction of negative automatic thought patterns </li></ul></ul><ul><ul><li>Seeking alternative explanations for situations </li></ul></ul><ul><li>Close : review, homework task </li></ul>
  32. 35. Session 7 : Sleeping and relaxation <ul><li>Open : mood check and diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Effects of sleep withdrawal on thoughts, emotions, behaviour and physical symptoms </li></ul></ul><ul><ul><li>Reasons for not sleeping attributed to circular and distressing thoughts </li></ul></ul><ul><ul><li>Importance of routine relaxation: music, hot drink, baths etc </li></ul></ul><ul><ul><li>Increasing physical activities to increase tiredness </li></ul></ul><ul><ul><li>Use of thought diary to express worries before going to bed </li></ul></ul><ul><ul><li>Introduction of OSTAR relaxation technique (On The Spot Arousal Reduction) </li></ul></ul><ul><li>Close : review, homework task </li></ul>
  33. 36. Session 8 : Coping Skills <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Discussion of what coping skills are and how they could be used </li></ul></ul><ul><ul><li>What his current ones are and what works best for him </li></ul></ul><ul><ul><li>In which situations would he need alternative ways of coping </li></ul></ul><ul><ul><li>Relaxation techniques </li></ul></ul><ul><ul><li>Cognitive skills eg positive self statements </li></ul></ul><ul><ul><li>Use of routines </li></ul></ul><ul><ul><li>Practise plan for imagined situations, and role play exercise </li></ul></ul><ul><ul><li>Developing a solution worksheets </li></ul></ul><ul><li>Close : review, homework task </li></ul>
  34. 37. Session 9 : Past Issues <ul><li>Open : mood check, diary review </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Introduction of concept of past experience and its influence on current behaviour </li></ul></ul><ul><ul><li>Past experience of anger and aggression discussed </li></ul></ul><ul><ul><li>Discussed how he ‘bottles things up’ and used diagram to explain how this may be expressed as pressure is released </li></ul></ul><ul><ul><li>Discussed that he has had ‘bad things’ happen to him </li></ul></ul><ul><ul><li>Discussion of whether a ‘leopard can change its spots’ </li></ul></ul><ul><ul><li>Optimism for future and trying to move on from ‘bad memories’ </li></ul></ul><ul><li>Close : review and homework task </li></ul>
  35. 38. Session 10 : Assertiveness <ul><li>Open : mood check, review diary </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Role of self esteem and assertiveness in anger </li></ul></ul><ul><ul><li>Perceived self image </li></ul></ul><ul><ul><li>Difference between aggression, assertion and passivity </li></ul></ul><ul><ul><li>How he would like to come across to others </li></ul></ul><ul><ul><li>How to express your emotions appropriately </li></ul></ul><ul><ul><li>How to express your hurt, anger or confusion assertively not aggressively </li></ul></ul><ul><ul><li>Role plays and imaginary situations </li></ul></ul><ul><li>Close : review and homework task </li></ul>
  36. 39. Session 11 : Changes in lifestyle <ul><li>Open : mood check, review diary </li></ul><ul><li>Topic work : </li></ul><ul><ul><li>Changes in daily activities </li></ul></ul><ul><ul><li>Developing new interests and widening social circle </li></ul></ul><ul><ul><li>Increased physical activity </li></ul></ul><ul><ul><li>Seeing friends separately and time alone </li></ul></ul><ul><li>Review of topics covered </li></ul><ul><ul><li>Map of influences on anger made together </li></ul></ul><ul><ul><li>Discussed changes made in each area </li></ul></ul><ul><li>Close : review, and plans made for last session </li></ul>
  37. 41. Session 12 : Final Session <ul><li>Open : mood check, review diary </li></ul><ul><li>Reviewed course and progress made </li></ul><ul><li>Made reference to using coping skills in future </li></ul><ul><li>Handouts and visual reminders given to David and Susan </li></ul><ul><li>Satisfaction questionnaire completed </li></ul><ul><li>Close : review and follow up arranged </li></ul>
  38. 42. David’s Self Report 3 <ul><li>“ she knows what I gone through as a young boy and the pain I endured” </li></ul><ul><li>“ I feel more calm within my self and I’m proud of that too” </li></ul><ul><li>“ 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” </li></ul><ul><li>“ its great that we get our feelings out in the open” </li></ul>
  39. 43. Outcome <ul><li>Significant reduction in reports of : </li></ul><ul><ul><li>Marital arguments (none) </li></ul></ul><ul><ul><li>Violent outbursts (none) </li></ul></ul><ul><ul><li>Worries concerning practical matters </li></ul></ul><ul><li>Increase in : </li></ul><ul><ul><li>Self reported mood and happiness </li></ul></ul><ul><ul><li>Effective team work and communication in relationship and with families </li></ul></ul><ul><ul><li>Pleasant activities and enjoyment in these </li></ul></ul>
  40. 44. Limitations <ul><li>Methodological rigour : pre and post quantitative measures </li></ul><ul><li>Longer treatment duration required </li></ul><ul><li>Follow up to be completed </li></ul><ul><li>Did not address domestic violence directly </li></ul><ul><li>Could have been used in conjunction with eg assertiveness group </li></ul>
  41. 45. Conclusions <ul><li>Despite limitations on interpretation, case demonstrates that client was able to use cognitive behavioural techniques to take control of his own anger. </li></ul><ul><li>Using these techniques in a collaborative fashion indirectly addressed issues of domestic violence, self esteem and marital communication. </li></ul><ul><li>David showed evidence of transferable skills by calming others and facing old triggers in new situations by relying on his knowledge of anger control. </li></ul><ul><li>Domestic violence was prominent issue, but also dealt with other issues such as past sexual abuse and current relationships eg with mother. </li></ul>
  42. 46. Implications <ul><li>Inappropriately expressed anger and aggression in clients with a learning disability can lead to problems such as domestic violence and breakdown of placement. </li></ul><ul><li>Principles of equality – offering highly effective treatments for all clients regardless of intellectual ability. </li></ul><ul><li>Treating each case as an individual and modifying treatment packages to suit their needs and ability. </li></ul><ul><li>Giving them life skills to enhance settlement in community settings. </li></ul><ul><li>Reduce demand on forensic services and provide source of risk assessment for future offending. </li></ul><ul><li>Cost implications – resources and duration, compared to admission? </li></ul>
  43. 47. <ul><li>I get angry when I want to, </li></ul><ul><li>I get angry when I don’t, </li></ul><ul><li>I’ll get angry when I’ll try to, </li></ul><ul><li>I’ll get angry when I wont. </li></ul><ul><li>I get angry when I’m threatened, </li></ul><ul><li>I get angry when I’m sad, </li></ul><ul><li>But I get angry when I’m happy, </li></ul><ul><li>And that just makes me mad! </li></ul><ul><li>Anger is a good thing, </li></ul><ul><li>And then again its bad, </li></ul><ul><li>So now we’ve got it sorted, </li></ul><ul><li>I’m feeling really glad . </li></ul><ul><li>From Faupel, Herrick & Sharp (1998) </li></ul>
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