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Women Offender Programs and Issues

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Literature Review on Women's Anger and Other Emotions

Treatment Modalities/Programmes

1. Cognitive-Behavioural
2. Psychotherapy Using Ego Based Developmental Theory
3. Summary of Treatment Guidelines

One of the identifying marks of a healthy individual is the ability to tolerate occasional hostility (Malmquist, cited in Meyer, 1988). Interventions designed to assist individuals in recognizing and managing their anger however, have "lagged significantly behind" (Deffenbacher & Stark, 1992, p. 158) treatments for emotional problems such as depression or anxiety. This reality, confirmed by Lopez and Thurman (1986), exists despite the popularity of the subject of anger in popular psychology and self-help books and the "importance of anger in the psychological, social, educational, vocational, and physical functioning of clients" (Deffenbacher & Stark, 1992, p. 158), and reflects the scarcity of research in this area.

The first controlled study of anger reduction was conducted in 1975 research (Novaco, cited in Deffenbacher & Stark, 1992) that assessed a programme of stress inoculation that combines relaxation and cognitive approaches. In a 1985 review of the literature, the same author noted that "until the era of behavioral and cognitive-behavioral therapy, there was virtually no empirical evaluations of anger interventions" (Novaco, cited in Thomas, 1990, p. 208) and, further, "until more controlled experimental studies are conducted, our confidence in available treatments should be tempered". (Novaco, quoted in Thomas, 1990, p. 212).

As noted above, the widespread belief that the purpose of the treatment of anger lies in assisting persons to acknowledge and ventilate hostile feelings is strongly challenged and noted as the basis of much of the mistreatment of anger among clinicians (Meyer, 1988). As Greenspan (1993) notes, anger expression in itself is not enough to empower individuals, suggesting it is "at best a half truth and a dangerous falsification" (p. 315) Gaylin (cited in Wilt, 1993) cautions therapists to attend to the interconnectedness of emotions, the complexity of which is often underestimated. Wilt cites an example of feeling simultaneous rage and love for children when they place themselves in positions of danger. Treatment of anger includes "identification of adaptive, maladaptive, and ego-defending responses to anger, and implementation of specific treatment approaches" (Wilt, 1993, p. 234). There are times when women may need an initial treatment approach that assists in suppression of anger, followed by the introduction of calming techniques that allow for verbalization as an effective means of expression.

A search of the literature and a survey among therapists working in the field, revealed few programmes for treatment of anger and related emotions among women. Several identify anger as a small and usually brief component of the overall programme (eg. Carlson, n.d.; Saxe, 1993), or part of an ongoing therapy group (Campbell, 1989), but the paucity of specific treatment programmes reflects the scarcity of research conducted to date. No published studies report anger management programmes with female offenders prior to 1986 (Wilfley, Rodon, & Anderson, 1986). The following is a summary of programmes and treatment modalities identified in the search.

 

1. Cognitive-Behavioural

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A series of studies were conducted to examine relaxation and cognitive treatments of anger, in response to Novaco's earlier research (Moon & Eisler, 1983; Hazaleus & Deffenbacher, 1986; Lopez & Thurman, 1986; Deffenbacher, Story, Stark, Hogg, & Brandon, 1987; Deffenbacher, Story, Brandon, Hogg, & Hazaleus, 1988; Deffenbacher & Stark, 1992). Each of the studies, with the exception of Moon and Eisler, was conducted on a combined female and male university sample. Moon and Eisler conducted their study using all male subjects. In addition to these studies, Perry (1991) reports the success of an individualised thirty nine week anger control programme running concurrently with a twelve week anger management training group in the treatment of a woman institutionalised after being convicted of arson.

Though conducted on nonclinical samples, research supports the effectiveness of cognitive and relaxation methods in anger reduction. Novaco's 1975 study compared a combined relaxation and cognitive treatment (stress inoculation) with relaxation and cognitive treatments alone. The study revealed that the combined treatment was preferable followed by a cognitive approach. The effects of relaxation were limited, owing, as proven later (Hazaleus & Deffenbacher, 1986) to poor intervention design. In their study, Hazaleus and Deffenbacher (1986) determined that both cognitive and relaxation interventions were equally effective. In two studies (Deffenbacher et al., 1988; Deffenbacher & Stark, 1992) no differences were found in the effectiveness of cognitive and combined cognitive-relaxation treatments. The 1987 study by Deffenbacher et al. compared cognitive-relaxation and social skills interventions and determined that while both significantly reduced anger, cognitive-relaxation subjects responded more favourably to their treatment than did social skills subjects. Moon and Eisler (1983), in comparing stress inoculation training with social skills training and problem-solving training noted each "had significant effects in reducing the cognitive components of anger" (p. 503), but the effect was accomplished in different ways. Those receiving cognitive treatment reduced their anger provoking thoughts but did not increase in their level of assertion. Those receiving problem-solving treatment increased in both areas, indicating they were better able to both reduce their angry thoughts and assert themselves. They, and subjects who received social skills training "displayed increases in socially skilled assertive behavior in the presence of anger-provoking stimuli" (p.505). It will be useful to summarize the methods of treatment examined.

Social Skills Training:

In an eight session group interaction, social skills were described, modeled, and role played by the group in dyads (Deffenbacher et al., 1987). Homework was assigned between sessions. Sessions focused on communication and listening skills, constructive and negative feedback, clarifying options in difficult situations, and assertiveness in initiating reasonable requests and declining unreasonable requests.

Problem-Solving Training:

Participants in this study (Moon & Eisler, 1983) were asked, after defining an anger problem and generating numerous possible solutions, to implement and evaluate the one perceived to offer the best possibility of success. This task followed initial discussion of anger as a normal part of life and acknowledging the possibility of effective coping, resisting the urge to act impulsively or do nothing when provoked to anger, and in defining and formulating anger problems.

Cognitive-Relaxation Coping Skills:

This method involves training in progressive relaxation and relaxation coping skills such as "(a) deepbreathing cued relaxation (relaxation on each exhalation of 3-5 breaths), (b) relaxation without tension (relaxing by focusing on and releasing tension from muscles without tension-release exercises), (c) cue-controlled relaxation (relaxing on the slow repetition of the word "relax"), and (d) relaxation imagery (visualizing personal relaxation images)" (Deffenbacher & Stark, 1992, p. 160). Cognitive restructuring skills taught included the identification and changing of demanding and overgeneralized self-dialogue. Application of skills learned involved "(a) preparing for an angering event, (b) confronting a moderate-anger situation, (c) confronting an angering event that was unresolved or in which the person limited the expression of anger, (d) confronting a high level of anger, and (e) confronting the individual's worst difficulties with anger" (p. 160).

Relaxation Coping Skills:

The relaxation coping skills treatment paralleled the cognitive-relaxation treatment, emphasizing only the relaxation skills.

 

2. Psychotherapy Using Ego Based Developmental Theory

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This treatment approach, identified by Wilt (1993), acknowledges both "physiologic maturational factors and environmental influences" (p. 236) affecting human growth, with early childhood development establishing the foundation for later growth. The client is encouraged to examine and change the blocks that inhibit the full development of potential, and with the therapist's partnership, to "build healthier emotional and cognitive structures" (p. 236). Before dealing directly with anger or rage, individuals are assisted to gain strength and understanding of their developmental process and the defense mechanisms used to defend against the anxiety that has become attached to the anger.

A core issue identified is the primary attachment women have to relationship, complicated by the cultural encouragement toward caretaking roles that reward women for nurturing others before speaking for their own needs. Addressing the negative cultural view of the direct communication of feminine anger is of primary importance.

The techniques outlined below are used after a therapeutic relationship has been developed. It is also crucial to have first managed the original crisis that brought the client to treatment. Specific treatment is outlined for women who express anger readily and for those who hold anger in. Included in the treatment guidelines is an emphasis on the development of a sense of self separate from others, the use of such cognitive tools as genograms before the stimulation of memory to assist in identifying patterns of difficulty within the family of origin, and social analysis which places a woman within the context of her environment and addresses social and cultural constraints that have affected her. After the relationship with the therapist has been developed, anger and rage issues with the family of origin are explored. It is noted that often underlying situations of "deep anger" (p. 245) the real issues of loss and hurt is accompanied by a strong sense of grief over not receiving the nurture that was needed. Calming techniques are used to decrease some of the physiological responses to anger such as decreasing "blood pressure, brain wave activity, and muscle tension" (p. 246). Finally, assertiveness techniques are suggested for teaching adaptive responses to anger.

 

3. Summary of Treatment Guidelines

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Treatment approaches in the therapeutic management of women's anger (same for both groups):

1. Develop a sense of self, separate from others, strengthening ego boundaries.

2. Facilitate healthy appraisal; use genogram to identify patterns of anger management and separation difficulties in family of origin.

3. Implement a social analysis.

4. Work out anger and rage issues regarding family of origin.

5. As client individuates, assist through panic, anxiety, and grief, being sensitive to the client's desire and fear of becoming engulfed with the therapist.

6. Facilitate anger where the response is avoided. Teach calming techniques when the response is overacted.

7. Assist client to focus anger and do something about the threat experienced.

8. Teach and reinforce effective techniques in dealing with anger.

Specific group treatment approaches for women who readily express anger:

1. Assist client to focus anger on real source, often family of origin, and to use calming techniques.

2. Assist client to do something effective with her anger to develop a sense of control.

3. Move client to use intellect rather than emotion.

4. Decrease ventilation of anger, teaching calming techniques.

5. Assist client to use assertive responses rather than aggressive responses.

For women who hold anger in:

1. Assist the client to increase awareness of anger and all feelings.

2. Facilitate the experience and expression of anger.

3. Assist client to experience that her anger is limited, and she does not have to become a "bitch."

4. Assist client to work through own guilt responses to anger and inhibiting responses from others.

5. Assist the client to use well-established nurturing skills on self. (Wilt, 1993, p. 241)

Specific emphasis is placed on treatment differences when working with women who hold anger in and with those who readily express anger. When women hold anger in more time may be required to nurture a positive sense of self as well as conduct a more in-depth social analysis to determine cultural conditions that have caused fear of the expression of emotion. Exploration of anger can take place only after a strong sense of safety has been established, accompanied by cognitive restructuring to assist in the development of a healthy perception of the expression of emotion. With women who readily express anger, facilitating the development of focus on the current source of anger will be an emphasis of early treatment. The approach will be more cognitive based, developing a "step-by-step plan" (p. 251) for the effective management of anger. Distracting and calming techniques may be beneficial. Stimulation of repressed anger is possible only after "the client has developed a solid beginning sense of control, focus, and boundary formation" (p. 252).