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Running Head: Anger Therapy for Youth Who Have Offended.

Advanced Clinical Social Work Practice with Groups

SK 653, Section 1

Professor Margaret Notar

Literature Review for Final Groups Paper

April 2, 2013

Sonam Bhojwani

Student number: 115803240

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A) Literature Review

When the words ‘anger management’ are typed in the search engine, one can be

overwhelmed by the plethora of literature and interventions available for this topic. Cognitive

Behavior Interventions often combined with relaxation interventions seem to be the most

commonly used and established interventions for anger management (Feindler, 2006) The focus

of this literature review will be on anger management therapy models and interventions for youth

who have offended and/or interventions for similar populations.

Group cognitive behavior treatments for anger are often psycho-educational in nature and

begin with psycho-education about anger as an emotion, the difference between anger and

aggression and the aggression cycle, in order to build a common ground for understanding anger

(Reilly, Shopshire, Durazzo, & Campbell, 2002). Other pscyho-educational interventions for

adolescents include the healthy relationships curriculum developed by a group called men for

change, which included professionals in the field of education. The healthy relationships

curriculum defines anger as a secondary emotion and that there are underlying emotions that

contribute to anger such as fear, shame and guilt. This curriculum has metaphorical illustrations

and personal reflection exercises that enable youth to think about what underlies their anger

(Safer, Davies & Davison, 1994).

One of the third wave cognitive behavior therapies; Dialectical Behavior Therapy is

being used and modified as an evidence based practice with the young offenders (Quinn &

Shera, 2009). Majority of youth have offended, have grown up in abusive and

psychologically/physically impoverished environments and present with personality disorders.

Poor impulse control, lack of emotional regulation, interpersonal problems , intense experience

of anger may are characteristics often associated with this population(Quinn & Shera, 2009).
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Dialectical behavior therapy is a model designed to address these needs. The DBT skills

training involve lecture, discussion and practice of interpersonal effectiveness skills such as

‘DEARMAN’, ‘GIVE’ and ‘FAST, mindfulness skills, emotion regulation and distress tolerance

skills such as ‘IMPROVE’ (Linehan, 1993).

In a research study, DBT interventions for oppositional defiant adolescents included

encouraging them to self-monitor (diary card keeping of) their CALM skills (connecting;

attending; listening; manners), and providing short written and oral examples of the use of

prosocial skills. (Nelson Gray et al, 2006). DBT interventions for adolescent were made age

appropriate through the change of language and age appropriate illustrations. In another study of

group DBT treatment, home work was given on a weekly basis which consisted of filling out

the diary card which recorded the frequency with which each skills was attempted (Trupin,

2002).

A summary of annotated bibliographies of anger management programs and outcomes in

correctional institutions have revealed that common elements among anger management

therapies including anger diaries, arousal indicators, and coping techniques led to immediate

success rate: however, the long-term effects are unclear. Importantly it is mentioned that these

approaches negated the client subjective experiences. (Ward & Baldin, 1997)

Clients including youth, youth offenders etc. have their own rich experiences including

narratives of their lives that brought anger into their lives and experiences that fuelled this anger.

An important and empowering aspect of the narrative approach is that it empowers clients by

making them aware of the dominant cultural narrative and enabling them to share and reflect on

their subjective experiences and separate the problem from themselves (Sach, 2006). Narrative
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group therapy approaches have been used with female youth who have been in trouble with the

law and women who are facing child protection issues. The approaches used in these studies

included externalizing the problem, mapping the problem domain, exploring unique outcomes

and spreading the news that is creating an audience and reinforcing the new story. These

approaches were found to be qualitatively effective in changing peoples’ relationship with anger

(Sach, 2006 & Kelley, Blankenburg, McRoberts, 2002) .

Furthermore, solution-focused therapy approaches enable clients and practitioners to

focus on strengths and solutions which is needed in a criminalizing setting. Certain approaches

have been adapted for adolescents experiencing trouble in foster placements. These included

using the miracle question when they lacked direction of goal, exception to the rule when

describing fighting/anger incidents, scaling question, and the use of relationship question when

they complained about interactions with other people. (Koob & Love, 2010)

Moreover, creative arts therapy combined with other psycho-educational modalities have

been used in prison settings (Breiner, Tuomisto, Bouyea, Gussak, & Aufderheide, 2011). They

support and deepen clients’ learning, giving them a sense of accomplishment and enable them to

enhance their interpersonal skills. Examples of interventions include making an arts project in

small groups of metaphors that represent the aggression cycle and ways to overcome it.

(Breiner, Tuomisto, Bouyea, Gussak, & Aufderheide, 2011)

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Section B: Group Flyer

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Section C: Group’s Goal and Objectives

(Additional Note: This group is offered to youth on open custody who have committed minor offenses or
have been transferred from secure to open custody. Case workers will encourage youth to attend this
group and there may be some incentives offered but ultimately it will be their choice)

The group goal:

 to moderate the experience of anger and change the expression of anger from a
destructive to constructive form.

Objectives:

 Phase 1: Understanding Anger as an individual and as a group:

1. To change the group’s identity by recognizing the members’ strengths and valued
goals through the miracle question (SFT)
2. To educate about the difference between between anger and abuse through
teaching and discussion of anger as an emotion and the aggression cycle. (CBT)
3. Increase awareness of the triggers of anger and context in which it occurs through
externalizing questions (narrative therapy)
4. To become aware of the intensity of one’s anger in different situation through
scaling anger (CBT, creative arts)
5. To explore the underlying sources of anger as a secondary emotion through
psycho-education, group discussion and arts exercise (understanding me
curriculum):
6. To build awareness of anger’s effects on the different parts of their life through
mapping the problem’s domain approach (narrative).

 Phase 2: Transforming Negative Expressions of Anger to constructive expression

1. To enable them to track their own progress in moderating anger through diary
cards (DBT) on an ongoing basis
2. To develop mindfulness skills through teaching and practice of guided meditation
(Dialectical Behavior Therapy)
3. To enhance distress tolerance skills, in facing situations that evoke anger, through
teaching, discussion and practice of Radical Acceptance exercise and IMPROVE
(DBT).
4. To enhance interpersonal effectiveness skills in dealing with anger through
teaching, discussion and role play of the DEARMAN, GIVE and FAST
techniques. (Dialectical Behavior Therapy).
5. To build their confidence in moderating and using anger effectively through
exploring unique outcomes and creating audience (narrative)
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6. To build confidence in them moving towards their valued goals through scaling
progress and exception to the problem questions (Solution focused therapy) on an
ongoing basis.

Section D: Brief Outline Group’s Themes:

Session 1: (Session format and Theme)

 Introductions: Review of the purpose of the group:

 Group Pact regarding confidentiality and safety: (use of CALM)
 Miracle Question: (day without anger)
 What does this say about the qualities or traits you have?
 Arts Activity: Re-naming the group:

Program Format for sessions 2 to 9:

 Check in (experience with anger this week- who took control: the anger or you?, review
of diary card)
 Teaching/sharing and Discussion
 Planned Exercise –(could be arts activity, role play, exploratory questions etc.)
 Homework: Diary Card
 Check Out

Phase 1: Understanding Anger

Session 2: Understanding anger as an emotion, the difference between abuse and anger and
exploring when and where anger shows up (externalizing)?

Session 3: Scaling the levels of anger in different situations and mapping the effects of negative
and positive anger in one’s life.

Session 4: Anger as a secondary emotion

 What is under this veil of anger?

 Arts Activity: Photo collage of what anger means to you: On one piece of tissue paper
clients will make a collage of what anger means to them. On another piece of thin paper
clients will make a photo collage of the underlying unresolved feelings beneath anger.
The second paper will go under the first tissue paper. Then on a piece of cardboard
clients will make a collage of what their strong or aspired qualities and traits are
(recalling the valued goals of each person from session 1). We’ll see how the tissue paper
and the thin paper can sometimes cloud or veil the inner beauty of the person.

Phase 2: Transforming the Experience and Expression of anger

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Session 5: Mindfulness skills. ‘How are they useful?’ and guided meditation

 (Note: Sessions 6 through 10 will begin with short mindfulness exercise)

Session 6: Distress Tolerance Skills

Session 7: Interpersonal Effectiveness Skills: Part 1

Session 8: Interpersonal Effectiveness Skills: Part 2

Session 9: Preparation for Termination:

 Reviewing Diary Cards over the weeks: Exploring the exception to problem and
thickening the unique outcomes
 Acknowledging barriers, unresolved issues
 Seeking to resolve the unresolved
 Homework: Spreading the news of their progress

Session 10: Celebrating each other’s and the group’s Strengths and Achievements. Discussing
the future and providing information for further supports.

E) Personal reflection on challenges

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In thinking about my role in this group I feel a little apprehensive. Since this is a group of

youth who have offended, I carry some preconceived notions of them being defiant and difficult

to deal with given their age and context. However, I know from my experience from being in the

Inside Out program in Grand Valley Institution that it is not the case at all. Even in my work in

doing groups with youth, I have been challenged but in very constructive ways that have led to

my growth.

In facing challenges with engagement or behaviors that make the environment unsafe, I

think the pre-screening session and the first session would be very important. In the first session

we will discuss and review the purpose of the group. As a facilitator, I would really focus on

facilitating the youth’s understanding of why they are there. Moreover, the group members will

come up with majority of the group pact, and I may add in a few important things that are

missing. We’ll sign this pact together and briefly talk about what it would mean for our behavior

in the group.

Also, one thing I need to be very mindful of would be my own expectations of how the

group should go and being present in the real group process. Observing the progress of the youth

from the beginning i.e. pre-screening session through till the last session would be essential to a

good ongoing evaluation of the group. The group might not meet my standards. But I need to be

mindful that it is not about my standards, it is about the progress of each youth even though it

maybe tiny in my eyes.

The other challenge I would face is that in the dominant cultural narrative very assertive,

firm, loud, charismatic and strong looking professionals tend to work with such population.

Perhaps, this may not be true, but this is certainly the image I hold of the ‘ideal’ practitioner
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working with offenders. I don’t think I fit this ideal practitioner profile so I have my fears in

doing this work. I fear that I could be bullied by the youth and taken advantage of. This relates

back to my past as an adolescent.

As an adolescent, I moved to another country and lived in a boarding school for a period

of time, where I found relationships with certain peers particularly distressful as there were many

bullies among those younger youth and I often got bullied. I often coped with the bullying by

enduring it, avoiding it whenever possible and being bitter. I am afraid that I’ll carry those

inadequate coping strategies with me into this new situation.

However, my admiration for youth and my quest for learning and developing skills has

gotten me so far and has been enabling me to seek out such knowledge and experiences.

Assertiveness and firmness are qualities I am striving to further develop so the group would

highly motivate me to practice these sooner.

Another important characteristic I realize in my casual interactions with youth is that I

can be and have been very frank with them. I don’t re-think or hesitate as much with this

population as much. This is because they are very open and frank in exploring their own reality

and challenging things. It’s easy to pick up on and can used wisely in my group work.

A consideration I need to make with regards to this group work is that I won’t be

completely alone in doing this. Ideally I would have a co-facilitator and/or a supervisor whom I

can consult with regarding challenges, progress etc.

Lastly, anger in its forms of being explosive and out of control is not familiar to me in my

own body. In a certain sense, I wasn’t even allowed to get angry growing up. People who had

angry reactions were viewed as disrespectful, discourteous and having unreasonable demands.
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When anger was present, it was often channeled in a very passive aggressive ways, which

destroyed relationships of family members around and peers around me. Therefore I realize that I

need to do my own work on anger. Anger looks to be distant from my life, but it isn’t and I

would need to discover my own relationship with it. In order to be effective in addressing the

topic in the group I should do my own work around it first.

References
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Baldwin, S., & Ann, W. (1997) Anger and Violence management programs in correctional

services : an annotated bibliography [online]. Prison Journal., 77, 4, 472

Breiner, M. J., Tuomisto, L., Bouyea, E., Gussak, D. E., & Aufderheide, D., (2011) Creating an

Art Therapy Anger Management Protocol for Male Inmates Through a Collaborative

Relationship [online]. International Journal of Offender Therapy and.Comparative

Criminology, 56, 7, 1124-1143

Feindler, E. L. (2006) Anger-related disorders : A practitioner's guide to comparative treatments

New York: New York : Springer.

Kelley, P., Blankenburg, L., & McRoberts, J. (2002) Girls Fighting Trouble: Re-Storying Young

Lives [online]. Families in Society. The Journal of Contemporary Human Services, 83-

5/6, 530-540

Koob, J. J., Love, S. M., (2010) The implementation of solution-focused therapy to increase

foster care placement stability [online]. Children and Youth Services Review, 32(10),

1346-1350

Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New

York: Guilford Press.

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Nelson-Gray, R. O., Keane, S. P., Hurst, R. M., Mitchell, J. T., Warburton, J. B., Chok, J. T., et

al. (2006). A modified DBT skills training program for oppositional defiant adolescents

[online]. Behavior Research and Therapy. 44(12):1811-20

Reilly P. M., Shopshire M. S., Durazzo T.C., & Campbell T.A.(2002) Anger Management for

Substance Abuse and Mental Health Clients: Participant Workbook [online]. . Rockville,

MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health

Services Administration

Sach, Julie. (2007) Conversations in Groups with Women About Their Experiences of Using

Anger, Abuse and Violence [online]. International Journal of Narrative Therapy &

Community Work, 2, 32-44.

Safer, Davies & Davison (1994) Healthy Relationships Violence Prevention Curriculum

[online]. Men for Change, (http://m4c.ns.ca/)

Trupin, E.W,. Stewart, D.G., Beach, B., & Boesky, L. (2002) Effectiveness of a dialectical

behavior therapy program for incarcerated female juvenile offenders [online]. Child and

Adolescent Mental Health, 7 (3) , 121–127