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Group interventions for anger in people with intellectual disabilities
Research in Developmental Disabilities 21 (2000) 171–181
Group interventions for anger in people with intellectual disabilities John Rosea,*, Chris Westb, David Cliffordb a The University of Birmingham, Edgbaston, Birmingham,England, B15 2TT Gwent Community Health (NHS) Trust, Llanfrechfa Grange Hospital, Cwmbran, Wales
b
Abstract This paper describes an evaluation of a group intervention for reducing inappropriately expressed anger (as aggression) in people with intellectual disabilities. Group intervention was compared to a treatment as usual group consisting of people referred to the group but who had to wait to participate. The intervention used was based on the work of Novaco (1976; 1978) and Benson (1994). However, further modifications to the group that emphasized the contextual perspective of anger, such as the participants being accompanied by a support worker and more collaborative recording procedures, were devised. A reduction in expressed anger and measured levels of depression occurred after group treatment. Reductions in expressed anger were maintained at 6 and 12 months follow up. However, scores on the depression scale tended to increase on follow up. While caution must be expressed when considering these results, this type of intervention shows promise for reducing inappropriately expressed anger in people with intellectual disabilities Suggestions are made for future research and clinical practice. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Anger management approaches have been shown to be effective with a number of different client groups (e.g., Chemtob et al., 1997; Novaco, 1980, 1985, 1997). Most of this work has been based on a model developed by Novaco (1976, 1978). In this model, anger is seen as an emotional state with three principle components: physiological, cognitive, and behavioral. These three components are all inter-related with both anger and the environment. Novaco (1977, 1980) also describes anger treatment interventions with core components * Corresponding author. Tel.: ⫹1-0121-414-4932; fax: ⫹1-0121-414-4897 E-mail address: [email protected] (J. Rose). 0891-4222/00/$ – see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 8 9 1 - 4 2 2 2 ( 0 0 ) 0 0 0 3 2 - 9
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of cognitive restructuring, arousal reduction, and behavioral skills training. A differentiation between anger management and treatment has recently been clearly articulated (e.g., Novaco et al., 2000). Anger management is seen as a psycho-educational approach that is less treatment intensive than anger treatment. Anger treatment explicitly integrates assessment with treatment and centrally involves substantial cognitive restructuring and the acquisition of arousal reduction and behavioral coping skills. An important development in anger treatment over recent years has been a greater emphasis on a contextual perspective of anger, which may involve distal or ambient determinants (Black et al., 1997; Novaco, 1993). As a result, Novaco (1993) suggests that clinicians should pay more attention to the “contextual perspective that addresses its emergence within a fabric of physical, temporal and sociocultural milieu.” The group described in this paper is based on the procedures described by Benson (1994), with some modifications and developments which attempted to recognize the importance of enduring features of the environment within the lives of the participants. Studies have shown that some of the theoretical approaches and techniques used in anger management and treatment are potentially useful for people with intellectual disabilities (Benson et al., 1986; Black et al., 1997; Rose, 1996). However, reports have tended to concentrate on case studies or small groups with a relatively short follow up period (if any) and no control group. A number of successful case studies have been reported in the literature (e.g., Black and Novaco, 1993; Murphy and Clare, 1991). For example, Black and Novaco (1993) successfully treated a man with intellectual disabilities who had been both verbally and physically aggressive and was living in a secure setting. Treatment gains were transferred when the man moved to the community. One of the first group studies was conducted by Benson et al. (1986) who compared four conditions: relaxation training, self instructional training, problem solving, and a multicomponent condition. Significant reductions in measures of anger were noted, but with no significant differences between groups. It was also difficult to judge efficacy, as there was no true control group. Benson (1992, 1994) has subsequently developed her work to describe a treatment manual that also includes procedures for developing emotional recognition in participants. Rose (1996) describes a group based on the work of Benson, but adapted for people with more severe disabilities. Rose (1996) reports that the clinical use of cognitive techniques appeared to be relatively ineffective when compared to the behavioral elements of the treatment used. However, a systemic element was also introduced by inviting care staff to participate in groups with individuals with whom they worked. A reduction in aggressive behavior was found for all five participants who completed the treatment both over the course of the group and at 3 months follow up. However, this was a relatively small group with no control group and a relatively short follow-up period. Another similar group is described by Moore et al. (1997) which was evaluated positively both by participants and the staff who accompanied them. However, no control group or follow up was reported.
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Until recently, the assessment of anger in people with intellectual disabilities has represented a considerable challenge for researchers. There has been some consideration as to whether people with intellectual disabilities can report their emotional states accurately. This situation is further complicated when attention is focused on the emotion of anger. Anger can be viewed as an adaptive response to some situations however, difficulties arise when it leads to aggression (Novaco, 1979; Benson, 1992). Evidence is growing that people with intellectual disabilities can report their own emotional states accurately (Stenfert–Kroese et al., 1997). For example, when completing a range of related self-report measures, individuals with intellectual disabilities have tended to reply in a consistent manner (Benson & Ivins, 1992; Lindsay et al., 1994) thus indicating the presence of a stable and reliable set of constructs related to emotion. Other studies have explored the link between the self report of people with intellectual disabilities and their carers. Voelker et al. (1990) found highly consistent results when comparing the reports of individuals with learning disabilities and others who knew them well for domains measuring adaptive behavior on the Vineland Adaptive Behavior Scales. However, the same authors report less consistency when considering the maladaptive behavior section of the same scale. In common with other authors (Benson & Ivins, 1992; Lally, 1993) they found that staff are more likely to rate individuals with intellectual disability as more problematic or angrier than the individuals themselves. There are a number of possible explanations. Voelker et al. (1990) suggested that the difference was due to a socially desirable response bias on the part of the individuals with intellectual disability. Benson & Ivins (1992) suggested that fatigue or denial by the people with intellectual disabilities may have been the cause. However, Lally (1993) considered that the staff were equally likely to have overestimated the difficulties they encounter because these behaviors may induce stress, which could bias their judgment. One recent study (Rose & West, 1999) established a relationship between the frequency of incidents of challenging behavior and self reported anger as measured by an anger inventory developed by Benson & Ivins (1992). This finding suggests that this measure could effectively be used as an appropriate indication of both anger and resultant aggression in people who have intellectual disabilities. The purpose of this study was to evaluate a group treatment procedure that was designed to reduce levels of physical and verbal aggression in individuals with mild to moderate intellectual disabilities, while comparing these individuals to a similar group of individuals waiting to participate.
2. Method 2.1. Research design Referrals were invited by a community clinical psychology department, for a group with a focus on the reduction of aggressive behavior in people with
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intellectual disabilities. Five groups were held over 2 years for between 6 and 9 participants. Individuals were assessed on referral, before the group, on completion of the group, and at 6 and 12 months after the group had finished. There was generally a short waiting list for the group; when this was the case, individuals were assessed 4 months before group intervention and then again immediately before intervention, thus providing a waiting list control. However, individuals on the waiting list were provided with other interventions, as appropriate, during this period (treatment as usual). 2.2. Participants Participants were all registered clients of the local intellectual disability service, provided through statutory health and social services in the United Kingdom. They were eligible for inclusion in the group if they met the following criteria: 1) they were experiencing problems with anger that had led to physical assault on other people and/or repeated damage to property and/or severe and repeated verbal aggression; 2) they had a degree of receptive language such that they could understand simple directions; 3) they were able to sit with one of the group leaders on an individual basis for 20 min or more during an initial interview; and 4) they could attend the group with a member of staff who could also accompany them to and from the group. 2.3. Assessment On referral, a number of assessments were carried out, which meant one or more therapist(s) from the group went to see each person referred on at least one occasion before intervention. The support workers involved would also receive one or more visits to explain the nature of, and requirements of the group. Information was also collected from carers about incidents of challenging behavior with associated antecedents and consequences. Individual assessments were generally designed to facilitate a closer understanding of the ability, circumstances, and particular difficulties that were being experienced. Assessments included: 1) a structured interview with the potential participant, adapted from Benson (1994); 2) an interview with a carer who knew the participant well; 3) the British Picture Vocabulary Scale (BPVS), a test of Receptive Hearing Vocabulary (Dunn et al., 1982); 4) an Anger Inventory (Benson & Ivins, 1992); 5) the revised McDaniel–Piers Self Concept Scale (Benson & Ivins, 1992); and, 6) a Depression Inventory (Benson & Ivins, 1992). Participants were also asked if they wanted to reduce their aggressive behavior. All of the participants who agreed to attend the groups recognized that their challenging behavior could be problematic and indicated that they would like to try and decrease their expressed aggression. They also expressed a willingness to attend.
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2.4. Procedure Group sessions were scheduled for a regular time each week and lasted 2 hr, including a short break. There were 16 sessions in each group. Each participant was accompanied by a care worker from either their residential home, place of work, or a community support team. It was hoped that participation would provide a defined role for staff, who could supply more extensive information about participants’ circumstances and patterns of behavior to the group. There was often some variation in the staff member who accompanied individuals; however, some continuity was encouraged for staff to develop a relationship with the individual and to enable them to contribute effectively to the group. There were also three group leaders: one was a qualified and experienced clinical psychologist and two were qualified and experienced nurses with a specialist qualification in working with people who have an intellectual disability. This resulted in a large group with a high staff ratio, ensuring that most difficulties that arose could be dealt with. However, it was always made clear to both staff and participants that if they wanted to, they could leave the room with a staff member and go outside. It was possible for two or more members of staff to accompany people to a place of safety outside of the group, if required. 2.5. Group content The basic structure and group content were similar for all five groups. The general plan of the group sessions followed the descriptions found in Benson (1994) and Rose (1996). However, there were some developments to the techniques applied. The innovations used in these groups were aimed at both examining the particular circumstances of aggressive incidents and increasing knowledge of their context. For example, defining individual difficulties was accomplished via initial, individual assessment and a self-monitoring diary. The diary was specially developed for the group and used pictures of facial expressions so that a simple tick or mark was sufficient for participants to record how they had felt during the day. Individuals were also encouraged to sit down with someone else either at their place of work or home each day, reviewing what had gone on and making further notes as necessary. A spirit of collaboration between the individuals with an intellectual disability and their care providers was emphasized. From initial assessment, monitoring via the diary, and contributions from the staff who accompanied participants, it was possible for group therapists to construct a psychological formulation (Sturmey, 1996) for the challenging behavior exhibited by each participant, both in terms of what situational factors were likely to trigger and maintain aggressive patterns of responding and also with respect to some of the more enduring features of the participants lives. As the group sessions progressed, a number of interactive techniques were introduced. For example, situations that may result in both aggressive and other
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responses (e.g., assertive but also non-aggressive and non assertive) were role played. A variety of responses were role played and discussed, within the group. Only members of staff generally role played aggressive reactions. Opportunities were taken to emphasize the (in)appropriateness of the range of possible responses and suggest alternatives. A video was used for immediate feedback and group discussion. This procedure enabled the therapist to develop a problemsolving framework with the participants and staff who attended. This method was subsequently developed within the groups with the inclusion of a structured problem-solving exercise that was often presented as complimentary to role playing exercises. Role-plays gradually became more realistic, incorporating situations that were difficult for participants, and also using members of staff who worked with them where appropriate. Again, a range of responses was provided and the advantages of an assertive but non-aggressive response were emphasized. Other techniques were also used, including thought-stopping and positive self statements. Because a staff member accompanied each group member, it was possible for them to explain to other workers how to modify setting events that may trigger aggression both in respect to their responses and features of the home or work environment. They could also remind individuals about self control elements of the anger management group at appropriate times. Finally, they could develop responses to aggression, which would tend to reduce the probability of reoccurrence.
3. Results Thirty people were selected for the groups, 27 men and 3 women. Sessions were well attended by both staff and participants. However, five people dropped out of the groups, for various reasons. Further data were not collected on these individuals and, consequently, they are not included in the final analysis, leaving a total of 25 individuals in the intervention group (23 men and 2 women). Nineteen people were included in the waiting list control, 16 men and 3 women, some of these were included in the groups reported here but a significant number have gone on to participate in subsequent groups. The British Picture Vocabulary Scale (BPVS) was administered to all participants prior to inclusion in the study. The intervention group had a mean raw score of 75 (range 52–113) and the control group a mean of 79 (range 50 –107). When compared on initial assessment using a MANOVA, there were no significant differences between the intervention group and control group on the BPVS, Anger inventory, Self Concept Scale, and Depression Scale. However, there was a significant difference in age with the intervention group being significantly older (mean 40 years, range 25– 62) compared to the control group (mean 32 years, range 20 – 45) F ⫽ 10.58, p ⬍ .01.
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Fig. 1. Anger Inventory scores over time.
3.1. Comparisons between pre- and postintervention scores
3.2. Anger Inventory Before the group mean Anger Inventory, scores for the intervention group were 103.7; this was reduced (i.e., lower expressed anger) to 91.8 after intervention, improvements were maintained at 6 months (mean 89.6) and 12 months (mean also 89.6) follow up. For the control group, there was a slight increase in scores from a mean of 100.79 at Time 1 to 103.32 at Time 2. When these results were compared using a repeated measures analysis of variance, with age as a covariate, a significant treatment effect was observed (F(1,41) ⫽ 21.5, p ⬍ .001). Intervention appeared to reduce levels of reported expressed anger (Fig. 1).
3.3. The revised McDaniel–Piers Self Concept Scale Before the group mean Self Concept scores for the intervention group were 19.9, this was increased (i.e., increased self concept) to 22.52 after intervention, improvements were maintained at 6 months (mean 23.28) and 12 months (mean 24.56) follow up. For the control group, there was a small increase in mean score from 19.8 at Time 1 to 19.9 at Time 2. When these results were compared by using a repeated-measures analysis of variance with age as a covariate, no significant treatment effect was observed.
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Fig. 2. Depression Inventory scores over time.
3.4. Depression Inventory Before the group mean Depression Inventory scores for the intervention group were 9.83, this was reduced (i.e., lower reported depression) to 6.87 after intervention, with an increase in reported level of depression at 6 months (mean 7.28) and 12 months (mean 7.56) follow up. For the control group, there was a slight increase in scores from a mean of 9.2 at Time 1 to 10.4 at Time 2. When these results were compared by using a repeated-measures analysis of variance with age as a covariate, a significant treatment effect was observed (F(1,41) ⫽ 7.5 p ⬍ .01. These results suggest that intervention reduces levels of reported depression (Fig. 2).
4. Discussion This therapeutic approach was successful in reducing reported levels of expressed anger and depression in people who have intellectual disabilities. Treatment effects were maintained over time, at least up to 12 months after intervention. Although the effect of reducing expressed anger was predicted, achieving improvements in reported levels of depression was also welcome. This link is supported by the findings of previous research where Benson & Ivins (1992) found a significant correlation between scores on the anger and depression inventories employed here. Involving people with intellectual disabilities in their own treatment seemed to provide them with ownership of the problem and motivation to change their
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own behavior. Group work can also help in the diagnosis of problems, both in terms of analyzing particular incidents and considering the context of the anger. Including members of staff who knew the clients well in the group also assists in assessing other more enduring features of the environment that may be influencing the level of expressed anger. Indeed staff or staff cultures may unwittingly present particular triggers to aggressive behavior or be responsible for perpetuating difficulties in some instances. In other cases, particular features of the environment can be identified with the assistance of staff. Some cautions must be expressed when considering these results. For example, there is only a relatively limited amount of psychometric data available on the questionnaires used in this study (Benson & Ivins, 1992; Rose & West, 1999). Further investigations into the link between expressed anger with aggression would also seem useful. However, many participants and carers reported a reduced incidence of physical and verbal aggression that coincided with group treatment which was maintained at follow up. Unfortunately, it was not possible to keep accurate and reliable records of aggressive incidents over the duration of the group treatment and follow up for all participants. The ability of some participants to complete the questionnaires appropriately could also be questioned; however, few difficulties were experienced in practice. It would also have been helpful to keep records of additional interventions, such as medication, counseling, behavioral work and the provision of additional staff support, to see if the group reduced the need for these types of services, or indeed, if the results were an artifact of additional interventions. Unfortunately, the resources were not available to collect this data. Another important question that arises from this work is what was the mechanism underlying change for the individuals in the group? Is it a cognitive (therapeutic) process? Even though Novaco’s model was used to guide the development of the intervention described here, the full range of practical therapeutic approaches used by Novaco was difficult to employ with people who have intellectual disabilities (they may be applicable with further adaptation). In practice, the techniques that seemed to be most successful were behavioral or educational in nature (e.g., teaching emotional recognition, role play and relaxation). Using these techniques in a problem-solving framework ensured a greater emphasis on self-regulation and ownership by group participants than many other forms of therapy. Introducing carers into the groups also introduced a systemic element into the treatment process. Carers were encouraged to develop formulations about the behavior of participants and develop intervention strategies that were practiced in the group and applied in the home or work setting. These formulations were generally behavioral, often relying on antecedent control strategies. Further work on integrating clinical and theoretical approaches in this area would be interesting and potentially valuable. Research is also required to determine which elements of the treatment are responsible for producing and maintaining change. For example, it would be interesting to compare groups in which participants were accompanied by staff who worked closely with groups
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where supporters had no close association. Detailed monitoring of the application of therapeutic techniques in the home environment would also be useful. However, the final conclusion of this paper must be that this type of intervention shows great promise in reducing levels of expressed anger in people with intellectual disabilities, whatever the mechanism(s) for change.
References Benson, B. (1992). Teaching Anger Management to Persons with Mental Retardation. International diagnostic system, Inc., University of Illinois. Benson, B. (1994). Anger management training: A self control program for people with mild mental retardation. In N. Bouras (Ed.), Mental Health in Mental Retardation (pp. 224 –232) Cambridge: Cambridge University Press. Benson, B. & Ivins, J. (1992). Anger, depression and self-concept in adults with mental retardation. J Intell Disabil Res, 36, 169 –175. Benson, B., Johnson–Rice, C., & Miranti, S. V. (1986). Effects of anger management training with mentally retarded adults in group treatment. J Consult Clin Psychol, 54, 728 –729. Black, L., Cullen, C. & Novaco, R. (1997). Anger assessment for people with mild intellectual disabilities in secure settings. In B. Kroese, D. Dagnan & Loumidis, K. (Eds.) Cognitive Behaviour Therapy for People with Intellectual Disabilities. (pp. 33–52) London: Routledge. Black, L. & Novaco, R. (1993). Treatment of anger with a developmentally handicapped man. In Wells, R. & Giannetti, V. (Eds.) Casebook of the Brief Psychotherapies. (pp. 143–158) New York: Plenum Press. Chemtob, C., Novaco, R., Hamada, R. & Gross, D. (1997). Cognitive-Behavioural treatment for severe anger in post-traumatic stress disorder J Consult Clin Psychol, 65, 184 –189. Dunn, L., Dunn, L., Whetton, C. & Pintilie, D. (1982). British Picture Vocabulary Scale. Windsor, UK: NFER. Lally, J. (1993). Staff issues: training, support and management. In I. Fleming & B. Stenfert Kroese (Eds.) People With Learning Disabilities and Severe Challenging Behaviour. (pp. 141–163) Manchester: Manchester University Press. Lindsay, W., Michie, A., Baty, F., Smith, A, & Miller, S. (1994). The consistency of reports about feelings and emotions from people with intellectual disability. J Intell Disabil Res, 38, 61– 66. Moore, E., Adams, R., Elsworth, J. and Lewis, J. (1997). An anger management group for people with a learning disability. Br J Learn Disabil, 25, 53–57. Murphy, G. and Clare, I. (1991). MIETS: A service option for people with mild mental handicaps and challenging behaviour or psychiatric problems. 2. Assessment, treatment, and outcome for service users and service effectiveness. Ment Handicap Res, 4, 2, 180 –206. Novaco, R. W. (1976). The functions and regulations of the arousal of anger. Am J Psychi, 133, 1124 –1128. Novaco, R. W. (1977). A stress inoculation approach to anger management in the training of law enforcement officers. Am J Comm Psychol, 5, 327–346. Novaco, R. W. (1978). Anger and coping with stress. In J. Foryet & D. Rathgen, Cognitive Behaviour Therapy: Research and Application. (pp. 203–206) Plenum: New York. Novaco, R. W. (1979). The cognitive regulation of anger and stress. In P. Kendall & C. Hollon (Eds.), Cognitive–Behavioural Interventions: Theory Research and Procedures (pp. 241–285). New York: Academic Press. Novaco, R. W. (1980). The training of probation counsellors for anger problems. J Counseling Psychol, 27, 385–390. Novaco, R. W. (1985). Anger and its therapeutic regulation. In M.A. Chesman & R.M. Roseman (Eds.), Anger and Hostility in Cardiovascular and Behavioural Disorders. (pp. 203–226) New York: Hemisphere.
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Novaco, R. W. (1993). Clinicians ought to view anger contextually. Behav Change, 10, 4, 208 –218. Novaco, R. W. (1997). Remediating anger and aggression with violent offenders. Legal Crimin Psychol, 2, 77– 88. Novaco, R. W., Ramm, M. and Black, L. (2000) Anger treatment with offenders. In C. Hollin (Ed.), Handbook of Offender Assessment and Treatment, In Press. Rose, J. (1996). Anger management: A group treatment program for people with mental retardation. J Develop Physic Disabil, 8, 2, 133–150. Rose, J. & West, C. (2000) Assessment of anger in people with intellectual disabilities. J Appl Res Intell Disabil, 12 (3), 211–224. Stenfert–Kroese, B., Dagnan, D, & Loumidis, K. (1997). Cognitive Behaviour Therapy for People with Learning Disabilities. London: Routledge. Sturmey, P. (1996). Functional Analysis in Clinical Psychology. Chichester: Wiley. Voelker, S., Shore, D., Brown–More, C., Hill, L., Miller, L., & Perry, J. (1990). Validity of self report of adaptive behaviour skills by adults with mental retardation. Ment Retard, 28, 305–309.
Group interventions for anger in people with intellectual disabilities John Rosea,*, Chris Westb, David Cliffordb a The University of Birmingham, Edgbaston, Birmingham,England, B15 2TT Gwent Community Health (NHS) Trust, Llanfrechfa Grange Hospital, Cwmbran, Wales
b
Abstract This paper describes an evaluation of a group intervention for reducing inappropriately expressed anger (as aggression) in people with intellectual disabilities. Group intervention was compared to a treatment as usual group consisting of people referred to the group but who had to wait to participate. The intervention used was based on the work of Novaco (1976; 1978) and Benson (1994). However, further modifications to the group that emphasized the contextual perspective of anger, such as the participants being accompanied by a support worker and more collaborative recording procedures, were devised. A reduction in expressed anger and measured levels of depression occurred after group treatment. Reductions in expressed anger were maintained at 6 and 12 months follow up. However, scores on the depression scale tended to increase on follow up. While caution must be expressed when considering these results, this type of intervention shows promise for reducing inappropriately expressed anger in people with intellectual disabilities Suggestions are made for future research and clinical practice. © 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Anger management approaches have been shown to be effective with a number of different client groups (e.g., Chemtob et al., 1997; Novaco, 1980, 1985, 1997). Most of this work has been based on a model developed by Novaco (1976, 1978). In this model, anger is seen as an emotional state with three principle components: physiological, cognitive, and behavioral. These three components are all inter-related with both anger and the environment. Novaco (1977, 1980) also describes anger treatment interventions with core components * Corresponding author. Tel.: ⫹1-0121-414-4932; fax: ⫹1-0121-414-4897 E-mail address: [email protected] (J. Rose). 0891-4222/00/$ – see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 8 9 1 - 4 2 2 2 ( 0 0 ) 0 0 0 3 2 - 9
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of cognitive restructuring, arousal reduction, and behavioral skills training. A differentiation between anger management and treatment has recently been clearly articulated (e.g., Novaco et al., 2000). Anger management is seen as a psycho-educational approach that is less treatment intensive than anger treatment. Anger treatment explicitly integrates assessment with treatment and centrally involves substantial cognitive restructuring and the acquisition of arousal reduction and behavioral coping skills. An important development in anger treatment over recent years has been a greater emphasis on a contextual perspective of anger, which may involve distal or ambient determinants (Black et al., 1997; Novaco, 1993). As a result, Novaco (1993) suggests that clinicians should pay more attention to the “contextual perspective that addresses its emergence within a fabric of physical, temporal and sociocultural milieu.” The group described in this paper is based on the procedures described by Benson (1994), with some modifications and developments which attempted to recognize the importance of enduring features of the environment within the lives of the participants. Studies have shown that some of the theoretical approaches and techniques used in anger management and treatment are potentially useful for people with intellectual disabilities (Benson et al., 1986; Black et al., 1997; Rose, 1996). However, reports have tended to concentrate on case studies or small groups with a relatively short follow up period (if any) and no control group. A number of successful case studies have been reported in the literature (e.g., Black and Novaco, 1993; Murphy and Clare, 1991). For example, Black and Novaco (1993) successfully treated a man with intellectual disabilities who had been both verbally and physically aggressive and was living in a secure setting. Treatment gains were transferred when the man moved to the community. One of the first group studies was conducted by Benson et al. (1986) who compared four conditions: relaxation training, self instructional training, problem solving, and a multicomponent condition. Significant reductions in measures of anger were noted, but with no significant differences between groups. It was also difficult to judge efficacy, as there was no true control group. Benson (1992, 1994) has subsequently developed her work to describe a treatment manual that also includes procedures for developing emotional recognition in participants. Rose (1996) describes a group based on the work of Benson, but adapted for people with more severe disabilities. Rose (1996) reports that the clinical use of cognitive techniques appeared to be relatively ineffective when compared to the behavioral elements of the treatment used. However, a systemic element was also introduced by inviting care staff to participate in groups with individuals with whom they worked. A reduction in aggressive behavior was found for all five participants who completed the treatment both over the course of the group and at 3 months follow up. However, this was a relatively small group with no control group and a relatively short follow-up period. Another similar group is described by Moore et al. (1997) which was evaluated positively both by participants and the staff who accompanied them. However, no control group or follow up was reported.
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173
Until recently, the assessment of anger in people with intellectual disabilities has represented a considerable challenge for researchers. There has been some consideration as to whether people with intellectual disabilities can report their emotional states accurately. This situation is further complicated when attention is focused on the emotion of anger. Anger can be viewed as an adaptive response to some situations however, difficulties arise when it leads to aggression (Novaco, 1979; Benson, 1992). Evidence is growing that people with intellectual disabilities can report their own emotional states accurately (Stenfert–Kroese et al., 1997). For example, when completing a range of related self-report measures, individuals with intellectual disabilities have tended to reply in a consistent manner (Benson & Ivins, 1992; Lindsay et al., 1994) thus indicating the presence of a stable and reliable set of constructs related to emotion. Other studies have explored the link between the self report of people with intellectual disabilities and their carers. Voelker et al. (1990) found highly consistent results when comparing the reports of individuals with learning disabilities and others who knew them well for domains measuring adaptive behavior on the Vineland Adaptive Behavior Scales. However, the same authors report less consistency when considering the maladaptive behavior section of the same scale. In common with other authors (Benson & Ivins, 1992; Lally, 1993) they found that staff are more likely to rate individuals with intellectual disability as more problematic or angrier than the individuals themselves. There are a number of possible explanations. Voelker et al. (1990) suggested that the difference was due to a socially desirable response bias on the part of the individuals with intellectual disability. Benson & Ivins (1992) suggested that fatigue or denial by the people with intellectual disabilities may have been the cause. However, Lally (1993) considered that the staff were equally likely to have overestimated the difficulties they encounter because these behaviors may induce stress, which could bias their judgment. One recent study (Rose & West, 1999) established a relationship between the frequency of incidents of challenging behavior and self reported anger as measured by an anger inventory developed by Benson & Ivins (1992). This finding suggests that this measure could effectively be used as an appropriate indication of both anger and resultant aggression in people who have intellectual disabilities. The purpose of this study was to evaluate a group treatment procedure that was designed to reduce levels of physical and verbal aggression in individuals with mild to moderate intellectual disabilities, while comparing these individuals to a similar group of individuals waiting to participate.
2. Method 2.1. Research design Referrals were invited by a community clinical psychology department, for a group with a focus on the reduction of aggressive behavior in people with
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intellectual disabilities. Five groups were held over 2 years for between 6 and 9 participants. Individuals were assessed on referral, before the group, on completion of the group, and at 6 and 12 months after the group had finished. There was generally a short waiting list for the group; when this was the case, individuals were assessed 4 months before group intervention and then again immediately before intervention, thus providing a waiting list control. However, individuals on the waiting list were provided with other interventions, as appropriate, during this period (treatment as usual). 2.2. Participants Participants were all registered clients of the local intellectual disability service, provided through statutory health and social services in the United Kingdom. They were eligible for inclusion in the group if they met the following criteria: 1) they were experiencing problems with anger that had led to physical assault on other people and/or repeated damage to property and/or severe and repeated verbal aggression; 2) they had a degree of receptive language such that they could understand simple directions; 3) they were able to sit with one of the group leaders on an individual basis for 20 min or more during an initial interview; and 4) they could attend the group with a member of staff who could also accompany them to and from the group. 2.3. Assessment On referral, a number of assessments were carried out, which meant one or more therapist(s) from the group went to see each person referred on at least one occasion before intervention. The support workers involved would also receive one or more visits to explain the nature of, and requirements of the group. Information was also collected from carers about incidents of challenging behavior with associated antecedents and consequences. Individual assessments were generally designed to facilitate a closer understanding of the ability, circumstances, and particular difficulties that were being experienced. Assessments included: 1) a structured interview with the potential participant, adapted from Benson (1994); 2) an interview with a carer who knew the participant well; 3) the British Picture Vocabulary Scale (BPVS), a test of Receptive Hearing Vocabulary (Dunn et al., 1982); 4) an Anger Inventory (Benson & Ivins, 1992); 5) the revised McDaniel–Piers Self Concept Scale (Benson & Ivins, 1992); and, 6) a Depression Inventory (Benson & Ivins, 1992). Participants were also asked if they wanted to reduce their aggressive behavior. All of the participants who agreed to attend the groups recognized that their challenging behavior could be problematic and indicated that they would like to try and decrease their expressed aggression. They also expressed a willingness to attend.
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2.4. Procedure Group sessions were scheduled for a regular time each week and lasted 2 hr, including a short break. There were 16 sessions in each group. Each participant was accompanied by a care worker from either their residential home, place of work, or a community support team. It was hoped that participation would provide a defined role for staff, who could supply more extensive information about participants’ circumstances and patterns of behavior to the group. There was often some variation in the staff member who accompanied individuals; however, some continuity was encouraged for staff to develop a relationship with the individual and to enable them to contribute effectively to the group. There were also three group leaders: one was a qualified and experienced clinical psychologist and two were qualified and experienced nurses with a specialist qualification in working with people who have an intellectual disability. This resulted in a large group with a high staff ratio, ensuring that most difficulties that arose could be dealt with. However, it was always made clear to both staff and participants that if they wanted to, they could leave the room with a staff member and go outside. It was possible for two or more members of staff to accompany people to a place of safety outside of the group, if required. 2.5. Group content The basic structure and group content were similar for all five groups. The general plan of the group sessions followed the descriptions found in Benson (1994) and Rose (1996). However, there were some developments to the techniques applied. The innovations used in these groups were aimed at both examining the particular circumstances of aggressive incidents and increasing knowledge of their context. For example, defining individual difficulties was accomplished via initial, individual assessment and a self-monitoring diary. The diary was specially developed for the group and used pictures of facial expressions so that a simple tick or mark was sufficient for participants to record how they had felt during the day. Individuals were also encouraged to sit down with someone else either at their place of work or home each day, reviewing what had gone on and making further notes as necessary. A spirit of collaboration between the individuals with an intellectual disability and their care providers was emphasized. From initial assessment, monitoring via the diary, and contributions from the staff who accompanied participants, it was possible for group therapists to construct a psychological formulation (Sturmey, 1996) for the challenging behavior exhibited by each participant, both in terms of what situational factors were likely to trigger and maintain aggressive patterns of responding and also with respect to some of the more enduring features of the participants lives. As the group sessions progressed, a number of interactive techniques were introduced. For example, situations that may result in both aggressive and other
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responses (e.g., assertive but also non-aggressive and non assertive) were role played. A variety of responses were role played and discussed, within the group. Only members of staff generally role played aggressive reactions. Opportunities were taken to emphasize the (in)appropriateness of the range of possible responses and suggest alternatives. A video was used for immediate feedback and group discussion. This procedure enabled the therapist to develop a problemsolving framework with the participants and staff who attended. This method was subsequently developed within the groups with the inclusion of a structured problem-solving exercise that was often presented as complimentary to role playing exercises. Role-plays gradually became more realistic, incorporating situations that were difficult for participants, and also using members of staff who worked with them where appropriate. Again, a range of responses was provided and the advantages of an assertive but non-aggressive response were emphasized. Other techniques were also used, including thought-stopping and positive self statements. Because a staff member accompanied each group member, it was possible for them to explain to other workers how to modify setting events that may trigger aggression both in respect to their responses and features of the home or work environment. They could also remind individuals about self control elements of the anger management group at appropriate times. Finally, they could develop responses to aggression, which would tend to reduce the probability of reoccurrence.
3. Results Thirty people were selected for the groups, 27 men and 3 women. Sessions were well attended by both staff and participants. However, five people dropped out of the groups, for various reasons. Further data were not collected on these individuals and, consequently, they are not included in the final analysis, leaving a total of 25 individuals in the intervention group (23 men and 2 women). Nineteen people were included in the waiting list control, 16 men and 3 women, some of these were included in the groups reported here but a significant number have gone on to participate in subsequent groups. The British Picture Vocabulary Scale (BPVS) was administered to all participants prior to inclusion in the study. The intervention group had a mean raw score of 75 (range 52–113) and the control group a mean of 79 (range 50 –107). When compared on initial assessment using a MANOVA, there were no significant differences between the intervention group and control group on the BPVS, Anger inventory, Self Concept Scale, and Depression Scale. However, there was a significant difference in age with the intervention group being significantly older (mean 40 years, range 25– 62) compared to the control group (mean 32 years, range 20 – 45) F ⫽ 10.58, p ⬍ .01.
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Fig. 1. Anger Inventory scores over time.
3.1. Comparisons between pre- and postintervention scores
3.2. Anger Inventory Before the group mean Anger Inventory, scores for the intervention group were 103.7; this was reduced (i.e., lower expressed anger) to 91.8 after intervention, improvements were maintained at 6 months (mean 89.6) and 12 months (mean also 89.6) follow up. For the control group, there was a slight increase in scores from a mean of 100.79 at Time 1 to 103.32 at Time 2. When these results were compared using a repeated measures analysis of variance, with age as a covariate, a significant treatment effect was observed (F(1,41) ⫽ 21.5, p ⬍ .001). Intervention appeared to reduce levels of reported expressed anger (Fig. 1).
3.3. The revised McDaniel–Piers Self Concept Scale Before the group mean Self Concept scores for the intervention group were 19.9, this was increased (i.e., increased self concept) to 22.52 after intervention, improvements were maintained at 6 months (mean 23.28) and 12 months (mean 24.56) follow up. For the control group, there was a small increase in mean score from 19.8 at Time 1 to 19.9 at Time 2. When these results were compared by using a repeated-measures analysis of variance with age as a covariate, no significant treatment effect was observed.
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Fig. 2. Depression Inventory scores over time.
3.4. Depression Inventory Before the group mean Depression Inventory scores for the intervention group were 9.83, this was reduced (i.e., lower reported depression) to 6.87 after intervention, with an increase in reported level of depression at 6 months (mean 7.28) and 12 months (mean 7.56) follow up. For the control group, there was a slight increase in scores from a mean of 9.2 at Time 1 to 10.4 at Time 2. When these results were compared by using a repeated-measures analysis of variance with age as a covariate, a significant treatment effect was observed (F(1,41) ⫽ 7.5 p ⬍ .01. These results suggest that intervention reduces levels of reported depression (Fig. 2).
4. Discussion This therapeutic approach was successful in reducing reported levels of expressed anger and depression in people who have intellectual disabilities. Treatment effects were maintained over time, at least up to 12 months after intervention. Although the effect of reducing expressed anger was predicted, achieving improvements in reported levels of depression was also welcome. This link is supported by the findings of previous research where Benson & Ivins (1992) found a significant correlation between scores on the anger and depression inventories employed here. Involving people with intellectual disabilities in their own treatment seemed to provide them with ownership of the problem and motivation to change their
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own behavior. Group work can also help in the diagnosis of problems, both in terms of analyzing particular incidents and considering the context of the anger. Including members of staff who knew the clients well in the group also assists in assessing other more enduring features of the environment that may be influencing the level of expressed anger. Indeed staff or staff cultures may unwittingly present particular triggers to aggressive behavior or be responsible for perpetuating difficulties in some instances. In other cases, particular features of the environment can be identified with the assistance of staff. Some cautions must be expressed when considering these results. For example, there is only a relatively limited amount of psychometric data available on the questionnaires used in this study (Benson & Ivins, 1992; Rose & West, 1999). Further investigations into the link between expressed anger with aggression would also seem useful. However, many participants and carers reported a reduced incidence of physical and verbal aggression that coincided with group treatment which was maintained at follow up. Unfortunately, it was not possible to keep accurate and reliable records of aggressive incidents over the duration of the group treatment and follow up for all participants. The ability of some participants to complete the questionnaires appropriately could also be questioned; however, few difficulties were experienced in practice. It would also have been helpful to keep records of additional interventions, such as medication, counseling, behavioral work and the provision of additional staff support, to see if the group reduced the need for these types of services, or indeed, if the results were an artifact of additional interventions. Unfortunately, the resources were not available to collect this data. Another important question that arises from this work is what was the mechanism underlying change for the individuals in the group? Is it a cognitive (therapeutic) process? Even though Novaco’s model was used to guide the development of the intervention described here, the full range of practical therapeutic approaches used by Novaco was difficult to employ with people who have intellectual disabilities (they may be applicable with further adaptation). In practice, the techniques that seemed to be most successful were behavioral or educational in nature (e.g., teaching emotional recognition, role play and relaxation). Using these techniques in a problem-solving framework ensured a greater emphasis on self-regulation and ownership by group participants than many other forms of therapy. Introducing carers into the groups also introduced a systemic element into the treatment process. Carers were encouraged to develop formulations about the behavior of participants and develop intervention strategies that were practiced in the group and applied in the home or work setting. These formulations were generally behavioral, often relying on antecedent control strategies. Further work on integrating clinical and theoretical approaches in this area would be interesting and potentially valuable. Research is also required to determine which elements of the treatment are responsible for producing and maintaining change. For example, it would be interesting to compare groups in which participants were accompanied by staff who worked closely with groups
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where supporters had no close association. Detailed monitoring of the application of therapeutic techniques in the home environment would also be useful. However, the final conclusion of this paper must be that this type of intervention shows great promise in reducing levels of expressed anger in people with intellectual disabilities, whatever the mechanism(s) for change.
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