Anger Management - Community of Practice

Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

Discussion Paper

What we can do to help people experiencing problem anger in Liverpool and Sefton Visit us online

www.inclusion-matters-liverpool.org.uk

Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

Executive Summary This paper explores problem anger and how it affects individuals and families, and what we can do to support well being and minimize harm in Liverpool and Sefton through establishing a Community of Practice to advance the provision of anger management.

Despite the fact that problem anger causes difficulties for a large number of people, resources available to help are currently limited in Liverpool and Sefton. If people do not fit the diagnostic criteria for depression or anxiety disorders, or for treatment with severe mental illness or substance misuse, they will not easily find their way to the help they need. For some people, the resources are too little and too late before their behaviour requires intensive intervention in the criminal justice system A Community of Practice could address some of these issues through a twofold approach: 1) Creating greater awareness of problem anger and how to deal with it effectively.

2) Mapping out local resources for problem anger and providing care pathways and broadening of criteria for people who seek help for problem anger, however they engage with services.

In turn, this will contribute to increased health and well-being, improved relationships at home and in work, and to minimising costs to the individual and others around him or her when anger gets the better of them.

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

Introduction This paper explores problem anger and how it affects individuals and families, and what we can do to support well being and minimize harm in Liverpool and Sefton through establishing a Community of Practice to advance the provision of anger management.

When is anger a problem?

By itself, anger is not a problem. It is a common human response, frequently experienced by people of all ages and backgrounds. Most people will deal with anger in positive ways that helps them to look after their mental and physical health, achieve goals, solve problems and support their relationships.

However, for some people, anger can become entrenched in everyday life with destructive consequences.

Some people experience anger frequently and intensely, in ways that interfere with their thinking, feelings, actions and relationships, often creating misery for themselves and others.

From this perspective, we can define ‘problem anger’ as ‘any dysfunctional way of relating to and managing anger that persistently causes significant difficulties in a person’s life including their thinking, feeling, behaviour’1 Kassinove and Tafrate2 link chronic and intense anger with coronary heart disease, stroke, cancer and common physical illnesses including colds and flu, and generally poorer health; as well as increased risk taking, poor decision-making and substance misuse. Problem anger also creates difficulties in family relationships and friendships and in the workplace.3 Higher levels of anger are related to lower levels of social support4 and with mental health problems including depression5 and self-harm.6 The most visible consequences of anger are aggression and violence. Dealing with violence in human services, such as the NHS and prison, has attracted much attention recent years.7 Similarly, we have seen a growing awareness of domestic abuse. This is the term used to describe the physical, sexual or emotional (mental) abuse of one person by another who is or has been close to them, usually a partner, ex-partner or family member.

Statistics show that the police receive one telephone call every minute from a member of the public requesting help for an incident involving domestic violence. Most domestic abuse happens to women. Younger women, women who are pregnant and women who have young children are more at risk.8 There is also clear evidence regarding the links and overlaps between alcohol, domestic abuse, child protection and mental health for victims, survivors and children9.

Mental Health Foundation (2008) Boiling Point: Problem Anger and what we can do about it. London Kasinove,H and Tafrate,R (2002) Anger management: the complete treatment guidebook for practitioners. Atascader,CA: Impact Publishers,Inc 3 DiGiuseppe, R and Tafrate, R (2007) Understanding Anger Disorders, Oxford 4 Ibid above 5 For example, Maiuro,R.; Cahn,T.; Vitaliano,P; Wagner,B; Zegree,J. (1988) Anger, hostility, and depression in domestically violent versus generally assaultive men and nonviolent control subjects. Journal of Consulting and Clinical Psychology, 56, 17-23 6 Mental Health Foundation (2006) Truth Hurts, 2006 7 For example: NHS Security management Service (2007/2008 ) The cost of violence against NHS staff: A report summarising the economic cost to the NHS of violence against staff. www.nhsbsa.nhs.uk; Law K. (1997) Further evaluation of anger-management courses at HMP Wakefield: An examination of behavioural change. Inside Psychology: 1 2

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

What is the scale of problem anger?

In order to find out more about our attitudes towards and understanding of anger, The Mental Health Foundation commissioned YouGov to carry out a survey of adults aged 18+10. This took place in January 2008 among a sample size of 1,974 people. The poll asked respondents about their experience of anger and how well they are able to manage it, about problem anger in people close to them, about their perception of anger in our society as a whole and about their knowledge of support available for people who have difficulties with problem anger.

The results are presented in Figure 1 below.

Figure 1.

Key findings from Mental Health Foundation 2008 survey on problem anger • Almost a third of people polled (32%) said they have a close friend or family member who had trouble controlling their anger • More than one in ten (12%) said that they have trouble controlling their own anger • More than one in four people (28%) said that they worried about how angry they sometimes feel • One in five of people (20%) said that they had ended a relationship or friendship with someone because of how they behaved when they were angry • 58% of people did not know where to seek help if they needed help with an anger problem.

• Fewer than one in seven (13%) of those people who said they had trouble controlling their anger sought help for their anger problems.

• Those who sought help were most likely to do so from a health professional (such as a counsellor, therapist, GP or nurse), rather than from friends and family, social workers, employers or voluntary organizations.

• 84% strongly agreed or agreed that people should be encouraged to seek help with their problems with anger.

The survey revealed that is a cause of concern for many more of us and that we are broadly in favour of encouraging people with problem anger to seek help.

In the next section, we will examine what options are available to people with problem anger in Liverpool and Sefton.

Department of Health (2005) Responding to domestic abuse: a handbook for health Professionals. London Alcohol Concern (2011) Embracing alcohol, domestic abuse and families – a new approach 10 Mental Health Foundation (2008) Boiling Point: Problem Anger and what we can do about it. London 8 9

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

What are we doing now to tackle problem anger?

There are effective interventions for problem anger.11 Much of this work has arisen from a criminal justice perspective to understand the nature of anger and its outward expression as aggressive or violent behaviour. 12 This is reflected in anger management programmes available to people in prison or under probation, or in secure mental health settings across Liverpool and Sefton.

Conceptualisation of problem anger and its consequences is less well developed in the mental health field. There are relatively few assessment instruments for anger, and little treatment-outcome research.13 So, according to DiGiuseppe and Tafrate: ‘Although research... affirms the negative influences of anger on one’s health, work, effectiveness, interpersonal relationships and propensity to aggression, anger is rarely regarded as a debilitating emotion to the same extent as anxiety and depression.’14 This has a knock-on effect in clinical practice. Problem anger on its own is generally not seen as ‘a way in’ for health and social care services. Many people do not recognize they have a problem, or feel ashamed to come forward. For those that do, GPs report that they feel at a loss and have few options for helping patients who come to them with problem anger. Some GPs signpost patients to the NHS Direct website,15 or to the NHS Choices self-help guide to anger management.16 This includes information on a range of self-help methods for anger management (exercise, breathing techniques, relaxation), plus details of help that might be available via the health service (counselling, CBT, anger management or domestic violence programmes).

GPs can refer or signpost people to the voluntary sector or private sector. However, many GPs do not feel confident to do this, either because they do not know what is available or they are not sure the service is suitable or quality checked.

DiGiuseppe, R and Tafrate, R. (2003 ) Anger treatment for adults: a meta-analytic review. Clinical Psychology: Science and Practice,10, 70-84 Ireland, J, L. (2004) Anger management therapy with young male offenders: an evaluation of treatment outcome.

Aggressive Behaviour, 30, 174-185.

13 DiGiuseppe,R and Tafrate,R Understanding Anger Disorders, Oxford, 2007 14 DiGiuseppe,R and Tafrate, R Understanding Anger Disorders, Oxford, 2007 [page 9] 15 NHS Direct www.nhs.direct.nhs.uk/ 16 NHS Choices Anger management: self help www.nhs.uk/Conditions/Anger-management 11

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

GPs can also refer patients in Liverpool and Sefton to primary care psychological therapy services or IAPT NHS services.17 These provide interventions for problem anger as part of any treatment plan forTrust people with common mental health problems. As the case studies in Figure 2 below illustrate, problem anger may feature in depression, or anxiety related conditions such as post-traumatic stress disorder, or generalized anxiety disorder and treated accordingly by primary care services, but not when it is associated with a severe mental illness or personality disorder and requires a multidisciplinary approach.

Figure 2.

Referrals to IAPT services in Liverpool and Sefton featuring problem anger • Case example 1: Joe was referred with a range of problems including low mood, anger and binge drinking. His treatment plan focused on behavioural activation using an hourly activity diary in relation to his low mood. The dairy allowed Joe to review the situations and factors that impacted on his mood. His therapy incorporated structured goal orientated work in relation both his anger and his drinking.

• Case example 2: Pauline and Dave were referred for couples counselling for depression. Both reported that their marriage was ‘on the rocks’ and that there frequent arguments and verbal abuse towards each other and consequent misery and despair about their future together. Through counselling, they learnt to identify the triggers for their arguments and to develop their ability express their feelings of anger in healthy, respectful ways that helped to set their relationship in a more positive direction.

• Case example 3: Mike was a veteran. When he was discharged from the Army, his family felt he had changed -‘it was like walking on egg shells around him’. It was several years before he could acknowledge that his mood swings, heavy drinking, violent outbursts, flashbacks and sleepless nights were linked to his experiences from the Balkan conflict and he received treatment for post-traumatic stress disorder.

• Case example 4: Steve was referred for Anger Management with a history of domestic violence and assaultative behaviour. He had previously been assessed by secondary care services and was diagnosed as having an Antisocial Personality Disorder. Liverpool IAPT services declined the referral on the basis that they were not contracted to work with someone with an Antisocial Personality Disorder and their practitioners did not have the appropriate therapeutic skills.

These case studies also indicate that GP referrals to IAPT services are unlikely to be specifically for dedicated anger management programmes, and that primary care services are not geared towards managing acute or high risk situations. Furthermore, interventions for problem anger are not supported by NICE (National Institute for Health and Clinical Excellence) guidelines, or approved IAPT measures.

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Also known as Liverpool and Sefton Increasing Access to Psychological Therapy (IAPT) services

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

There are other limited resources available to people experiencing problem anger in Liverpool and Sefton.

Addaction,18 for example, provides accredited anger management programmes for people who are receiving interventions for substance misuse.

The Feelgood Factory in Netherton has spearheaded an innovative approach to intervention and prevention of problem anger, as part of a package of measures designed to promote health and wellbeing for local people.

Figure 3.

The Feelgood Factory The Feelgood Factory is a community inspired organization that has a long track record of developing a wide range of innovative projects to promote health and wellbeing for people living in Netherton and South Sefton.

Its Skills for Living project works directly with people who are affected by mental health issues. It also helps the local community maintain positive mental wellbeing by offering activities that promote social inclusion, encourage creative and positive thinking as well as helping to develop new skills. So far the project has provided courses on stress management; body image; positive thoughts; anger management; relaxation; confidence building; relationships; and thinking skills.

Summary of resources available The websites for Inclusion Matters Liverpool19 and Sefton20 provide a list of resources available to people living in Liverpool and Sefton and experiencing problems with their anger. Whilst this is unlikely to be complete, it is hard to escape the observation that the resources for people with problem anger are currently limited. If people do not fit the diagnostic criteria for depression or anxiety disorders, or for help with severe mental illness or substance misuse, they will not easily find their way to the help they need. For some people, the resources are too little and too late before their behaviour requires intensive intervention in the criminal justice system.21

Addaction http://www.addaction.org.uk/ Inclusion Matters Liverpool www.inclusion-matters-liverpool.org.uk 20 Inclusion Matters Sefton www.inclusion-matters-sefton.org.uk 21 Mental Health Foundation (2008) Boiling Point: Problem Anger and what we can do about it. London 18 19

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

NHS Trust

What more can we do?

At a national level, the Mental Health Foundation argues that we need greater acknowledgement of problem anger as a valid reason for referral to health care and greater use of anger screening tools as part of the assessment process. We also need greater provision of specific programmes of treatment - individual and group, so that everyone who seeks help for problem anger can receive support for it. This might take the form of anger management groups, or individual/group therapy and might be provided by the NHS or by the voluntary or private sector. For those whose anger has led to an aggression-related criminal offence, anger management treatment could be made available as a matter of course. Similar programmes could be more widely available for children and young people whose aggressive behaviour has led them into trouble at school.22 The Mental Health Foundation also suggests that we need more information and education related to problem anger in schools, in the workplace, in NHS and other community settings. This could be aimed not just at those people experiencing problem anger but all those who come into contact with them.23

Community of Practice One way of responding to the challenges set by the Mental Health Foundation is to establish a ‘Community of Practice’ amongst agencies currently providing interventions and support for people experiencing problem anger in Liverpool and Sefton. A Community of Practice is a group of people who share a common concern, a set of problems, or interest in a topic and who come together to fulfil both individual and group goals.24 Examples can be found in education25 and within clinical communities.26 Here, the Community of Practice could include providers of anger management and support across primary and secondary health care, prison and probation services, and the voluntary and independent sector.

Mental Health Foundation (2008) Boiling Point: Problem Anger and what we can do about it. London Mental Health Foundation (2008) Boiling Point: Problem Anger and what we can do about it. London Wenger, E.; McDermott,R.; & Snyder, W. (2002) Cultivating Communities of Practice: A Guide to Managing Knowledge Boston, MA: Harvard Business School Press.

25 Cambridge, D; Kaplan, S; & Suter,V (2005) Step-by-Step Guide for Designing and Cultivating Communities of Practice 26 Aveling, E.L.; Martin,G.P.; Armstrong,N.; Banerjeet,J; & Dixon-Woods,M. (2012) Quality improvement through clinical communities:eight lesons for practice. To be published in Journal of Health Organization and Management, vol 2.

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Manchester

Primary Care Trust

The Pennine Acute Hospitals

Approach The group determines specific goals. However, they could fall into two broad camps:NHS Trust 1)

Increase awareness of problem anger and how to deal with this.

For example:

•

2)

Develop awareness of problem anger and control through agency websites and local media.

In addition, seek to establish joint training of health and social care professionals to identify, empathise with and treat problem anger among their existing clients to ensure that, when it manifests as part of a complex range of mental health issues as it sometimes does, problem anger can be identified and dealt with as part of any treatment plan.

Map out and broaden local anger management resources.

For example:

• Map out anger management courses and psychological therapies services that take anger referrals, and any other sources of information and advice. This information will be provided to GP practices and probation officers, and, for example, Liverpool Advocacy Rights Hub.27

• Provide care pathways and broadening of criteria for people who seek treatment for problem anger, however they engage with services.

• Where there are demonstrable gaps in provision, seek possible extension of dedicated programmes through joint working and pooling of resources and, or, additional funding to enable this.

Conclusion Although anger is a common emotion, it is clear that intense, frequent and enduring anger contributes to a great deal of human misery and harm.

This paper highlights arguments for increasing our awareness of problem anger and how to manage it. Whilst there are examples in Liverpool and Sefton of agencies and professionals either running anger management programmes or incorporating approaches to dealing with problem anger in their work, there seems to be little shared knowledge about pathways to treatment that focus specifically on working with problem anger. When confronted by people asking for help in this area, many GPs do not know where to direct them.

Establishing a Community of Practice will be one way of beginning to bridge the gap in awareness of problem anger and provision of relevant help and support. In turn, this will contribute to increased health and well being, improved relationships at home and in work, and to minimising costs to the individual and others around him or her when anger gets the better of them.

A new page has been added to the professional area within the IML website to list other services and resources which deal with problem anger. http://inclusion-matters-liverpool.org.uk/professional-area/

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Liverpool Advocacy Rights Hub http://www.advocacyrightshub.co.uk/

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