Thursday, July 28, 2011

Fundamentals of Anger Management


For more information about my services, both individual and training programs for schools, please visit my web page at http://www.relatedminds.com/the-angry-child  General information can be found at http://www.relatedminds.com  My offices are located in both Burnaby and Vancouver, BC

Many families come to me because of issues relating to anger and aggression.  They hope to receive anger management training of some sort, and are often surprised by the exact nature of anger management programs which often include a component on assertiveness training.  For the next few blogs I'd like to walk you through some information about anger management and what is out there that is helpful. There are a lot of anger management books available, some make much more sense than others. Some are evidence based, that is, developed through a process of program assessment, and others are not.  I'm going to start with a review of a program we often use in the schools- Aggression Replacement Training. This program comes with staff training videos, workbooks, social skills programming as well as specific training in anger replacement and cognitive therapy. That will be today's post. In the next post I'll be reviewing a workbook I often use: The Anger Control Workbook by Matthew McKay and Peter Rogers.  This workbook is a cognitive therapy based program about anger management and when used with some materials on assertiveness training can form the basis of a good program on anger management.
Aggression Replacement Training: ART
Aggression Replacement Training (ART) is manual-based program focused on teens. It is designed to  help them to with aggressive emotions. It is a complex, multichannel, program that uses three coordinated components to reach the youth; Social skillsAnger management and moral reasoning.  These three components cover most of the materials necessary to make significant changes in children with problems with aggression. (For younger children there are specific social skills books, and an alternative suggestion is The Explosive Child by Green.)
Anger Replacement Training is used in schools and correctional settings in North America as well as Europe. It was designed by Arnold P. Goldstein, Barry Glick and John C. Gibbs in the 1980s. They took concepts from a number of other theories for working with youth and incorporated them into one comprehensive system. The main methods for the youth to learn from the various components is though repetition. Practice, role play, and practice again. The model also focuses on Jean Piaget’s concept of peer learning. 
Social Skills
Social Skills training is the behavioral component of ART. Many youths who are involved with criminal behavior and/or have difficulties with controlling their anger lack social skills. Many of the concepts of the social skills component are taken from Albert Bandura’s. There are many different social skills that these youth are thought to lack, such as;
Making a complaint
Apologizing
Understanding the feelings of others
Dealing with someone else's anger
Keeping out of fights
Dealing with an accusation
The program begins with an assessment of the youth’s social skill levels. Then these social skills are broken down into various steps (both thinking and action steps). The facilitator discusses the day's skill, bringing out relevant examples. Then the facilitator demonstrates a practice situation to give the youth a picture of using the skill. The youth are asked to point out each of the steps using behavioural techniques such as sub-vocalizing while engaging in the behaviour. This component also provides a great deal of psycho-education for each student. Each of the youth is asked to use a practice situation that they have recently had using the skill. Again the other youth go though and discuss each of the steps each time. Modelling and practice are key components, with homework for generalizing these skills.
Anger Control Training
Anger control training is the emotional component of ART. This moves from the teaching of social skills, to losing anti-social skills and replacing them with pro-social skills. The anger control training uses what is called the “anger control chain.” This is a process taught to the youth to deal with situations that cause them to get angry. Once again, one segment of the anger control chain is taught each week and the both the facilitators and the youth practice the new skills with relevant life activities.

The anger control chain is as follows:
Triggers (internal & external) -- The situation that starts the slide into anger and the self talk that perpetuates it
Cues -- physical signs of becoming angry
Anger reducers -- activities that are done to reduce or take our mind off of the situation
Reminders -- short positive statements
Thinking ahead -- If then thinking
Social Skill -- Implementing a pro-social skill into the situation
Evaluation -- Looking back over the use of the anger control chain and evaluating how was implemented
Again, youth practice these skills, use subvocalization, model the skills, role play and use homework assignments to generalize the behavioural skills.

Moral Reasoning Training
Moral reasoning training is the “values component” of the program. This component takes various scenarios and asks whether various activities would be right or wrong to do in those situations. Thinking errors are also taught during this day of training. The thinking errors that are taught are:
Self-centered thinking -- "it's all about me"
Assuming the worst -- "it would happen anyway" or "they would do it to me"
Blaming others -- "it's their fault"
Mislabeling / minimizing -- "it's not stealing, I'm only borrowing it..." or "everybody else does it"
This, and all other componets, of the program are all well planned out. Lessons are specific with a good deal of teacher specific suggestions incorporated into the written materials. The program comes with an excellent training video to help facilitators learns these specific skills, although having some supervision for new trainers would be best. 
The books: Berj Harrootunian, Arnold P. Goldstein, Jane Close Conoley (1994), Student Aggression: Prevention, Management and Replacement Training, Guilford Press, 
All of the necessary materials are available from Research Press. 
If your a teacher or behaviour specialist, take a look at these materials. They are all you really need to start an excellent program addressing aggression and anger within the school. A great way to start!
Next blog post will be addressing Anger Control for adults. This will specifically look at readings and skills programs for individuals with anger management problems from a cognitive behaviour   therapy perspective. After that, which may take two or three posts, we will discuss assertiveness training and how it is a critical component of any successful program.


Sunday, July 10, 2011

Antidepressants and effectiveness

Recently there have been many articles explaining why antidepressants don't really work. On several occasions I've tried to explain how these articles were a misunderstanding of the research. This New York Times article (see below) a pretty good job at explaining this, so I'm presenting it here. I think this is an important article because the same rationale applies to all of the research that has been in the press about ADHD medications, anxiety medications and so on.  The big drug companies are not to be fully trusted, however, neither are the writers of all the anti-medication nonsense you read on the web. Almost all of that is supported not by "big pharma" but instead by "big natural health food blah blah."  Here's the link to this excellent article:

http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html

The article points out that in the depression studies often subjects are included who don't really have depression. Well sooner or later, when filling out a form about their symptoms they report that they don't have depression. That's good, they never did, so at least these individuals didn't develop depression from simply taking part in the study. There are also problems with people participating who are after free care, or in some cases payments offered for participation in the trials. You often see ads for these studies on college campuses and elsewhere. After the study is over these people return to their original level of depression, whatever that might have been. The effect isn't a result of the medication or placebo as much as an artefact of the recruitment process to find people to participate. And who, today, would even volunteer to take a new, untried medication when so many cheap and generic medications are available?

In the most recent study of the effects of antidepressants by Dr. DeRubeis (this is the one every newspaper and health food/herbal medicine web page tells us that antidepressants are only as effective or less effective than placebos, we see some odd statistics that just don't support that claim. The overall result, that for healthier patients the medications are less effective - fell shy of statistical significance. The study looked at weak treatment, and intentionally maximized placebo effect. Still this paper ended up the talk of the town.

Another excellent article on how publications don't give us a really good view of things comes from the web page Science-Based Medicine. You can find that article here: Do Antidepressants Work? The Effect of Publication Bias

This article (which you really need to print out and read with an underliner!) should make you cautious about what you read. Statistics can be used to prove almost anything....to those who don't understand statistics. It's very difficult for the lay person to know what is right and what is wrong or misleading. As usual, I suggest that you ask your medical doctor...not your neighbour, brother, sister or something you've read on the internet that trashes medications or some other treatment and ....just by chance....is on a page covered with ads for "alternative treatments."

The Science Based Medicine article on AntiDepressants ends with this:
"At this time it is premature to conclude that modern antidepressant medications do not work. There is sufficient evidence for efficacy to continue to use medication as part of the overall treatment approach to depression. The current consensus is that therapy is also a critical component of the long term treatment of depression, and therefore looking at the use of medications in isolation may not reflect their actual clinical use. Multiple studies have now shown that combination treatment (medications and therapy) are better than either alone. There is also evidence that medication treatment is more successful when multiple agents are tried in order to find the optimal treatment. These so-called “real world” treatments are not well reflected in the pre-approval trials considered in this analysis."


My advice, print out articles that bring up concerns, put them in your pocket, and take them with you to doctor.  This goes for any medicine, medication, treatment or intervention your considering. 



Tuesday, July 5, 2011

About Dr. John Gottman and Gottman Couples Therapy

ABOUT GOTTMAN METHOD COUPLES THERAPY
I am often asked: "What is Gottman Method Couples Therapy?" I guess the best way to explain it is to refer directly to Dr. Gottman's webpage:

Gottman Method Couples Therapy:  Through research-based interventions and exercises, it helps couples break through barriers to achieve greater understanding, connection and intimacy in their relationships. Gottman Method Couples Therapy is a structured, goal-oriented, scientifically-based therapy. Intervention strategies are based upon empirical data from Dr. Gottman’s three decades of research with more than 3,000 couples. This research shows us what actually works to help couples achieve a long-term healthy relationship. Gottman Method Couples Therapy was developed out of this research to help couples:
-Increase respect, affection, and closeness
-Break through and resolve conflict when they feel stuck
-Generate greater understanding between partners
-Keep conflict discussions calm

Research shows that to make a relationship last, couples must become better friends, learn to manage conflict, and create ways to support each other's hopes for the future. Drs. John and Julie Gottman have shown how couples can accomplish this by paying attention to what they call the "Sound Relationship House," or the seven components of healthy coupleships.

The Gottman Theory For Making Relationships Work:

What does Dr. Gottman say about getting your marriage or relationship back on track?

1. Build Love Maps: How well do you know your partner’s inner psychological world, his or her history, worries, stresses, joys, and hopes? Find out!

2. Share Fondness and Admiration: The antidote for contempt, this level focuses on the amount of affection and respect within a relationship. (To strengthen fondness and admiration, express appreciation and respect.)

3."Turn Towards:" State your needs, be aware of bids for connection and turn towards them. The small moments of everyday life are actually the building blocks of relationship.

4. The Positive Perspective: The presence of a positive approach to problem-solving and the success of repair attempts.

5. Manage Conflict: We say “manage” conflict rather than “resolve” conflict, because relationship conflict is natural and has functional, positive aspects. Understand that there is a critical difference in handling perpetual problems and solvable problems.

6. Make Life Dreams Come True: Create an atmosphere that encourages each person to talk honestly about his or her hopes, values, convictions and aspirations.

7. Create Shared Meaning: Understand important visions, narratives, myths, and metaphors about your relationship.

For more information about Dr. Gottman's approach to therapy you can visit his website at Http://www.gottman.com or visit my website at http://www.relatedminds.com or http://www.relatedmindsbc.com/couples-therapy

(For a direct link to the Gottman web page, click here.) You can also find information on The Gottman Institute at the Gottman YouTube webpage, found here: http://www.youtube.com/user/TheGottmanInstitute

Books, DVD programs and CDs are available from the Gottman website, many on Amazon.ca and you can obtain several in my office. Visit the Gottman site, watch Dr. Gottman on YouTube to get an idea about what he is saying and if your interested in seeing me individually, as a couple or just as a consultant while you work your way through a video based Gottman program, give me a call.