A respondent conditioning approach to reducing anger responses of a dually diagnosed man with mild mental retardation

BEHAVIORTHERAPY20, 459-464, 1989

A Respondent Conditioning Approach to Reducing Anger Responses of a Dually Diagnosed Man with Mild Mental Retardation PATRICK J.

SCHLOSS

The University of Missouri MELINDA SMITH

CHRIS SA~TORA RomN BRYANT Penn State Umversity This case study demonstrates the use of progressive muscle relaxation and systematic desensitization in reducing anger responses of an individual with mental retardation. Desensitization was conducted for three provoking stimuli- joke telling, criticism, and heterosexual talk. A multiple baseline analysts demonstrated that the onset of treatment was associated with a reduction of target responses to below a target level established through observations of nonhandicapped individuals. Observations outside of the treatment condition demonstrated that the positive effects generalized to natural settings. A follow-up evaluation demonstrated the durability of treatment. Results of this demonstration are discussed with reference to alternatives to aversive treatments for reducing aggressive responses in dually diagnosed persons with mental retardation.

Existing literature emphasizes the need for alternatives to punishment for reducing excessive social and emotional responses (Matson and DiLorenzo, 1984). One method demonstrated to be effective with individuals of normal intelligence is systematic desensitization. Deffenbacher, Deem, Brandon (1986), Deffenbacher, Story, Stark, & Hogg (1987), and Hmaleus & Deffenbacher (1986) have demonstrated the effectiveness of an anxiety management program including relaxation training and desensitization for reducing anger in young adults. Particularly noteworthy were Deffenbacher, Deem, & Brandon's (1986) data suggesting that anxiety reduction was associated with a reduction in verbal and physical aggression. Tentative support for the application of these procedures to individuals with mental retardation has been provided by Benson, Rice & Miranti (1986). The Requests for reprints should be addressed to Patrick J. Schloss who is Professor and Chair of Speoal Educauon at the Umversity of Missouri/Columbia, Columbia, Missouri 65211

459 0005-7894/89/0459-046451.00/0 Copyright 1989 by Assooatlon for Advancementof Behavior Therapy All rights of reproduction in any form reserved

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researchers conducted a component analysis of relaxation training, self instruction, problem solving, and combined anger management treatments. Dependent variables included self reports, ratings of role plays and ratings of sheltered workshop supervisors. No significance between group differences were reported. Within-group analyses, however, indicated a reduction in anger during treatment. Unfortunately, the experimental design did not allow the researchers to rule out the influence of motivation, history or other threats to internal validity (Campbell & Stanley, 1966). Also, direct observations in natural settings and follow-up data were not reported. The present study was conducted to extend these findings by evaluating the effectiveness of systematic desensitization with a man who was borderline mentally retarded and demonstrated limited anger control. The treatment appeared particularly well suited as several discrete events appeared to provoke anger responses. Further, these anger responses frequently escalated to verbally and physically aggressive behavior.

METHOD Client Characteristics The client was a 26-year-old man previously served in special classes for individuals with mild mental retardation. The client functioned in the borderline mild range of mental retardation with a Wechsler Adult Intelligence Scale - Revised Intelligence Quotient of 70. Adaptive behavior deficits were noted in communication, social functioning, and academic performance. The client had been involved in a social skill training program conducted by the authors. Social functioning improved substantially. Unfortunately, the young man was unable to self-manage anger and utilize the socially skillful responses. The current treatment was initiated shortly after the client's release from a dishwashing position for frequent physical and verbal aggression toward co-workers and supervisors. The office of Mental Health and Mental Retardation declined additional services indicating the ineffectiveness of traditional forms of treatment. Prebaseline Assessment The client, his mother, and staff members of the Association for Retarded Citizens identified situations likely to provoke anger. These included "jokes" (i.e., humorous anecdotes told to the client), "criticism" (i.e., statements made to the client that identified deficienceis in his conduct or appearance), and "heterosexual talk" (i.e., discussions of dating, physical attributes, marriage, childbirth, etc). A hierarchy of provoking events within each category was also established. Finally, specific responses characterizing the client's anger reactions and consistent with Benson's (1986) conceptualization of anger responding were used to construct a dependent variable. Response Definitions and Recording Procedures The same recording procedure was used throughout the study. Seven "barb" cards were prepared for each of the three categories. Each card included a

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general script that outlined the barb statements used during observation sessions. One of six graduate students used the first question or statement from the card and waited 10 seconds for a response. If the client responded, the student was instructed to use an ad lib follow-up that continued the barb within the response category. When more than 10 seconds elapsed without a response from the client, or when his response did not permit a continuation in the category, the graduate student used the next statement or question from the card. Prior to the recording sessions one of the graduate students randomly selected one card from each category. The graduate student sat next to the client in a lounge and began with one of the three cards. He or she followed the script of questions and statements for 90 seconds and then proceeded to the second and third cards. Videotapes of the sessions were scored using a 10 second momentary time sample. Every 10 seconds after the start of the first barb, recorders judged whether the following responses were occurring: breathing~voice, defined as inhaling and exhaling faster than one cycle per second, unnatural vocal utterances and voice volume audible at 20 or more feet; posture~facial tension, forceful grasping of chair, facial expression associated with anger, and unnatural movement of the jaw or tongue; gaze aversion, avoiding eye contact with the speaker, and fidgeting, movement of the extremities that occurs at a rate of more than 1 movement per second. The rate o f each behavior was determined by dividing the number of intervals in which each of the four responses occurred by 9 (number of available intervals). The rate for each of the four behaviors was then averaged to produce an overall rate of agitation/aggression in the response categories.

Generalization and Maintenance Evaluations After 29 days of baseline and intervention, clinic sessions were discontinued and the client agreed to attend lunch practice sessions at a graduate commons. Consistent with ethical informed consent practices, he was told that unfamiliar individuals would join him and that these individuals might say provoking things. Once the client was seated, a confederate sat at his table and initiated a conversation. Approximately three minutes into the conversation, the confederate provided a signal to a recorder who was sitting within view and hearing of the client. The signal marked the onset of the interval recording procedure described above. The volunteer simultaneously initiated a "barbing" sequence, similar to that used as the principle dependent variabe but employing unique questions/statements. Once the "barbing" sequence was completed, the two individuals continued a congenial conversation. These procedures were used for a 6-month follow-up conducted during Association for Retarded Citizen's Centre County, PA, social events.

Reliability Twelve observations interspersed throughout the study were scored by an independent observer. Reliability was determined by dividing the number of

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intervals in which the raters agreed by the total number observed for each of the anger responses within each of the three "barb" areas. The lowest rate of agreement, .89, was for posture during heterosexual talk. Average reliability for all observations was .96.

Social Validation An absence of the target behaviors may be as inappropriate as excessively high rates since a subset of the target behaviors may be considered to be normal (e.g., some hand movements during conversations, looking away infrequently during a conversation, laughing, etc.). Therefore, the "barb" and data collection procedure was used with a 21- and a 23-year-old male college students. The mean score was established as the treatment goal. The mean rate for jokes was 36070 with a high and low of 36070. The mean for criticism was 32070 with a range of 36 to 28070. Finally, the mean for heterosexual talk was 26.5070 with a range of 31 to 22070.

Training Procedures and Experimental Design A multiple baseline across situations likely to provoke anger was used to establish experimental control. The three situations were telling jokes, criticizing, and engaging in heterosexual talk. Immediately before each of the six baseline observation sessions, the client learned progressive muscle relaxation using Bernstein and Borkovec's (1973) protocol. In the first treatment leg, "responding to jokes," progressive muscle relaxation was conducted with emotive imagery. The client was then asked to remain relaxed on the mat. The investigator then asked the client to imagine a "joke related" provoking situation. Early in the treatment phase only mildly provoking statements were used. As treatment progressed, increasingly more provoking statements were used. The client's ability to remain relaxed while being provoked indicated the strength of the statement that could subsequently be used. "Remaining relaxed" was operationalized by a relative absence of dependent variable responses. Once observational data indicated a low and stable level of anger responses to situations typically faced by the general population, treatment was initiated with "responding to criticism." Finally, when the anger response level reached a low and stable level for criticism, treatment was shifted to "engaging in heterosexual talk." In addition to these clinic-based procedures, a tape of the progressive muscle relaxation procedure was prepared and given to the client for use at home.

RESULTS AND DISCUSSION As can be seen from Figure 1, the baseline rates of the target responses exceeded the target rate in all but one observation. The onset of treatment in each leg of the multiple baseline produced a reduction in the target behaviors. Anger related responses dropped from above the target rate in baseline to below the target rate in the treatment condition. These effects were generalized to natural settings in each case. Follow-up evaluation data demonstrated the sustained influence o f treatment.

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Aside from these empirical outcomes, several collateral effects may be attributed to the treatment. First, the participant's parents reported a decrease in anger and aggression at home. When reactions did occur, they were more effective in encouraging him to relax and use social skills. Second, similar to results reported by Deffenbacher, Demm, and Brandon (1986), there appeared to be a collateral reduction in verbally and physically aggressive behavior. Shortly after the conclusion of treatment, the client began a new job as a custodian at a large motel. The client has been successfully employed in this position for more than one year. There have been strong performance evaluations and no episodes of aggressive behavior. Finally, the client had previously been involved in a social skill training program. He demonstrated an increased ability to remain relaxed and utilize self control skills acquired prior to the present intervention. Due to the specific nature of the treatment and its relationship to the characteristics of the participant, confident statements about its effectiveness with others cannot be made. In the present case, the prebaseline analysis suggested that the aggressive responses were not currently sustained by positive or negative reinforcement. Further, they may have been triggered by conditioned stimuli. These conditions were central to the theoretical rationale for applying the current treatment. The investigation was limited in that anecdotal reports of the relationship between anger control and aggression were subject to observer bias. Also due to informed consent procedures, demand characteristics of the generalization test may have artificially inflated performance outcomes. Future controlled investigations are required to support conclusions relating to response and setting generalization.

REFERENCES Benson, B. A. (1986). Anger management training. Psychiatricaspects of mental retardation reviews,

5(10), 51-55. Benson, B. A., Rice, C. J., & Miranti, S. V. (1986). Effectsof anger management trainingwith mentally retardedadults in group treatment.Journal of Consulting and ClinicalPsychology, 54, 728-729. Campbell, D. T., & Stanley, J. C. 0966). Experimental and quasiexperimental designsfor research. Chicago: Rand McNally. Deffenbacber, J. L., Detain, P. M., & Brandon, A. D. (1986).High general anger: Correlatesand treatment. Behavior Research and Therapy, 24, 481--489. Deffenbacher, J. L., Story, D. A., Stark, R. S., & Hogg, J. A. 0987). Cognitive relaxationand socialskillsinterventionsin the treatment of generalanger. JournalofConsulting and ClinicalPsychology, 54, 171-176, HaTaleus, S. L.,& Deffenbacher,J. L. (1986).Relaxationand cognitivetreatmentsof anger,Journal of Consulting and ClinicalPsychology, 54, 222-226. Matson, J., & Dilorenzo, T. M. 0984). Punishment and itsalternatives:A new perspectivefor behavior mod~cation. N e w York: Springer. I~cErwD: July 5, 1988 FINAL ACCEFrA~CE: November 1, 1988