This week, your theoretical orientation is cognitive behavior theory. You will use the same case study that you chose in Week 2 and have been analyzing in this course. Use the “Dissecting a Theory and Its Application to a Case Study” worksheet to help you dissect the theory. You do not need to submit this handout. It is a tool for you to use to dissect the theory and then you can employ the information in the table to complete your assignment.
To prepare:
Use the same case study that you chose in Week 2. (JAKE LEVY)
Read this article listed in the Learning Resources: González-Prendes, A. A., & Thomas, S. A. (2009). Culturally sensitive treatment of anger in African American women: A single case study. Clinical Case Studies, 8(5), 383–402. ( I SENT THE ARTICLE VIA ATTACHMENT) This article provides a nice framework for how the authors’ cognitive-behavioral theoretical orientation shaped the conceptualization of the case and assessment and intervention.
1.In 1 to 2 sentences, identify and describe the presenting problem.
2.In 1 to 2 sentences, briefly define and conceptualize the problem from a cognitive-behavioral theoretical orientation.
3.Formulate 2 assessment questions that you will ask the client to better understand the client’s problem. Remember, the assessment questions should be guided by cognitive-behavioral theory.
4.In 1 to 2 sentences, identify two goals for treatment. Again, remember, the goals should be consistent with cognitive-behavioral theory.
5.In 1 to 2 sentences, describe the treatment plan from a cognitive-behavioral theoretical orientation. Remember, the treatment plan should align with the goal(s) for work.
6.Discuss one outcome you would measure, if you were to evaluate whether the intervention worked, and explain how this is consistent with cognitive behavior theory. Evaluate one merit and one limitation of cognitive behavior theory as it relates to the case study.
7.Evaluate the application of cognitive-behavioral theory in relation to a diversity issue pertinent to the case.
Case Study
Jake Levy
Identifying Data: Jake Levy is a 31-year-old, married, Jewish Caucasian male. Jake’s wife, Sheri, is 28 years old. They have two sons, Myles (10) and Levi (8). The family resides in a two-bedroom condominium in a middle-class neighborhood in Rockville, MD. They have been married for 10 years.
Presenting Problem: Jake, an Iraq War veteran, came to the Veterans Affairs Health Care Center (VA) for services because his wife has threatened to leave him if he does not get help. She is particularly concerned about his drinking and lack of involvement in their sons’ lives. She told him his drinking has gotten out of control and is making him mean and distant. Jake reports that he and his wife have been fighting a lot and that he drinks to take the edge off and to help him sleep. Jake expresses fear of losing his job and his family if he does not get help. Jake identifies as the primary provider for his family and believes that this is his responsibility as a husband and father. Jake realizes he may be putting that in jeopardy because of his drinking. He says he has never seen Sheri so angry before, and he saw she was at her limit with him and his behaviors. Family Dynamics: Jake was born in Alabama to a Caucasian, Eurocentric family system. He reports his time growing up to have been within a “normal” family system. However, he states that he was never emotionally close to either parent and viewed himself as fairly independent from a young age. His dad had previously been in the military and was raised with the understanding that his duty is to support his country. His family displayed traditional roles, with his dad supporting the family after he was discharged from military service. Jake was raised to believe that real men do not show weakness and must be the head of the household. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and although her mother lives in the area, she offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. Jake reports that he has not been engaged with his sons at all since his return from Iraq, and he keeps to himself when he is at home.
Employment History: Jake is employed as a human resources assistant for the military. Jake works in an office with civilians and military personnel and mostly gets along with people in the office. Jake is having difficulty getting up in the morning to go to work, which increases the stress between Sheri and himself. Shari is a special education teacher in a local elementary school. Jake thinks it is his responsibility to provide for his family and is having stress over what is happening to him at home and work. He thinks he is failing as a provider. Social History: Jake and Sheri identify as Jewish and attend a local synagogue on major holidays. Jake tends to keep to himself and says he sometimes feels pressured to be more communicative and social. Jake believes he is socially inept 11 and not able to develop friendships. The couple has some friends, since Shari gets involved with the parents in their sons’ school. However, because of Jake’s recent behaviors, they have become socially isolated. He is very worried that Sheri will leave him due to the isolation.
Mental Health History: Jake reports that since his return to civilian life 10 months ago, he has difficulty sleeping, frequent heart palpitations, and moodiness. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. Jake says that he does not really understand what PTSD is but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expresses concern that he will never feel “normal” again and says that when he drinks alcohol, his symptoms and the intensity of his emotions ease. Jake describes that he sometimes thinks he is back in Iraq, which makes him feel uneasy and watchful. He hates the experience and tries to numb it. He has difficulty sleeping and is irritable, so he isolates himself and soothes this with drinking. He talks about always feeling “ready to go.” He says he is exhausted from being always alert and looking for potential problems around him. Every sound seems to startle him. He shares that he often thinks about what happened “over there” but tries to push it out of his mind. Nighttime is the worst, as he has terrible recurring nightmares of one particular event. He says he wakes up shaking and sweating most nights. He adds that drinking is the one thing that seems to give him a little relief. Educational History: Sheri has a bachelor’s degree in special education from a local college. Jake has a high school diploma but wanted to attend college upon his return from the military. Military History: Jake is an Iraqi War veteran. He enlisted in the Marines at 21 years old when he and Shari got married due to Sheri being pregnant. The family was stationed in several states prior to Jake being deployed to Iraq. Jake left the service 10 months ago. Sheri and Jake had used military housing since his marriage, making it easier to support the family. On military bases, there was a lot of social support and both Jake and Sheri took full advantage of the social systems available to them during that time. Medical History: Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Jake reports sometimes feeling inadequate because of the reduction in the use of his hand and tries to push through because he worries how the injury will impact his responsibilities as a provider, husband, and father. Jake considers himself resilient enough to overcome this disadvantage and “be able to do the things I need to do.” Sheri is in good physical condition and has recently found out that she is pregnant with their third child. Legal History: Jake and Sheri deny having criminal histories. Alcohol and Drug Use History: As teenagers, Jake and Sheri used marijuana and drank. Both deny current use of marijuana but report they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports that he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Jake spends his evenings on the couch drinking beer and watching TV or playing video games. Shari reports that Jake drinks more than he realizes, doubling what Jake has reported. Strengths: Jake is cognizant of his limitations and has worked on overcoming his physical challenges. Jake is resilient. Jake did not have any disciplinary actions taken against him in the military. He is dedicated to his wife and family. Jake Levy: father, 31 years old Sheri Levy: mother, 28 years old Myles Levy: son, 10 years old Levi Levy: son, 8 years old
Clinical Case Studies
8(5) 383 –402
© The Author(s) 2009
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650109345004
http://ccs.sagepub.com
Culturally Sensitive Treatment
of Anger in African American
Women: A Single Case Study
A. Antonio González-Prendes and Shirley A. Thomas
Abstract
Culturally sensitive clinical practice challenges practitioners to recognize the cultural significance
and importance of clients’ behaviors and belief systems. This article reports a case study of the
treatment of anger in an African American woman. Presented within a framework of cognitive-
behavioral theory, the case illuminates three important issues that influence experience and
expression of anger in African American women: the influence of gender role socialization
on the mode of anger expression; the experience of powerlessness, rooted in historical and
contemporary discriminatory and oppressive realities; and culture-related messages that
create unrealistic expectations of strength. The article addresses conceptualization, assessment,
treatment processes, and clinical strategies, as well as limitations of a single case study, implications
for practice and recommendations for future research.
Keywords
African American women, anger treatment, cultural sensitivity, cognitive-behavioral
1 Theoretical and Research Basis
Culturally sensitive treatment approaches must be able to conceptualize, recognize, and evaluate
the client’s belief system and behaviors within the context of the client’s gender, race and culture,
among other factors. This is particularly important when working with individuals from minori-
ties and other traditionally disempowered groups, whose beliefs and behaviors run the risk of
being pathologized when taken out of the context of their cultures and measured against the
standards of the dominant group. This article presents and discusses, within the framework of a
case study, central elements of a culturally sensitive approach to the treatment of anger problems
in an African American woman. The conceptual model for the treatment approach suggests that,
if anger in African American women is to be understood accurately, it must be viewed through
the twin prisms of gender and race (Thomas & González-Prendes, 2009). Previous studies have
underscored the idea that, in order to develop an accurate understanding of the emotional experi-
ence of women of color, one must be able to integrate issues related to gender, culture, and race
Wayne State University
Corresponding Author:
A. Antonio González-Prendes, Wayne State University, School of Social Work, 4756 Cass Avenue, Room #301, Detroit,
MI 48202
Email: [email protected]
384 Clinical Case Studies 8(5)
(King, 1988, 2005). More specifically, related to women’s anger, deMarraias and Tisdale (2002)
emphasized that emotions are sensitive to the contexts in which such emotions are experienced.
Therefore, we propose that if anger treatment in African American women is to be successful,
it must address the contextual nature of that anger, as well as gender-role and cultural expecta-
tions that have engendered beliefs that affect the experience and expression of anger in those
women. The model suggests that there are three central themes that underscore their experience
and expression of anger: the influence of gender-role socialization messages that dictate to the
woman “socially appropriate” ways to express her anger; culture-related messages translated
into beliefs or self-imposed demands that set up unrealistic expectations of “strength” among
African American women; and the experience of powerlessness often rooted in historical as well
as present-day situations of discrimination and disempowerment.
Limitations of Current Anger Research
A review of current anger research literature reveals several critical limitations. As DiGi-
useppe and Tafrate (2003) have noted, anger research has relied too heavily on college student
populations. This focus makes it difficult, if not impossible, to generalize those findings to
community-based samples of individuals with anger problems. Another significant limitation
is the overwhelming use of samples that are either entirely or overwhelmingly male. González-
Prendes (2008) reviewed a series of meta-analytic studies addressing the effectiveness of
anger research (Beck & Fernandez, 1998; DelVecchio & O’Leary, 2004; DiGiuseppe &
Tafrate, 2003; Edmondson & Conger, 1996) and reported that, of a total of 148 studies in the
meta-analyses, only two, both unpublished dissertations, focused exclusively on women.
Furthermore, none of the available studies focused exclusively on women of color. The need
for more research among racial and ethnic minorities has also been addressed in the United
States Department of Health and Human Services Surgeon General’s report discussing the
impact of culture, race and ethnicity on mental health (USDHHS, 2001). Yet, as clinical prac-
tice has emphasized the need for evidence-based practices, it is imperative to produce more
clinical research that examines the effectiveness of clinical methods with minority popula-
tions. Although a single case study has intrinsic limitations discussed elsewhere in this article,
it illuminates specific theoretical concepts, client variables, and practice concerns that could
lead to larger empirical research studies.
Adaptive-Healthy Versus Maladaptive-Unhealthy Anger
When discussing anger, it is imperative to differentiate between healthy and unhealthy types.
Anger is a normal and common human emotion that, in itself, is neither good nor bad; and indeed
anger often may play a positive adaptive and functional role for the individual. Therefore, anger
treatment does not focus on the total elimination of anger, but rather it focuses on enhancing the
healthy expression of it. Healthy anger is experienced through the realistic and rational process-
ing of information and environmental cues and with mild to moderate levels of internal
physiological arousal. This type of anger allows the person to organize cognitive, physical, emo-
tional, and behavioral capabilities in order to take prosocial constructive action to resolve a
problem. This often includes the ability to express one’s angry feelings directly, openly, and
appropriately in a way that facilitates healthy outcomes, while at the same time, respecting the
rights and dignity of the other person or entity.
However, anger becomes toxic for some individuals, when it becomes harmful and destruc-
tive to self and others. These individuals may experience internal hyperarousal and find
themselves either “stuffing” their angry feelings, using aggression, or diverting their anger to
González-Prendes and Thomas 385
other psychopathologies such as substance abuse (Gilbert, Gilbert, & Schultz, 1998; Larimer,
Palmer, & Marlatt, 1999; DeMoja & Spielberger, 1997), self-cutting (Abu-Madini & Rahim,
2001; Harris, 2000; Matsumoto et al., 2004), and bulimia (Meyer et al., 2005). Toxic anger is a
significant internal stressor that increases the risk of health problems such as: hypertension
(Webb & Beckstead, 2005), coronary heart disease (Bongard, al’Absi & Lovallo, 1997; Warren-
Findlow, 2006), cancer (Andersen, Farrar, & Golden-Kreutz, 1998); and obesity (Robert &
Reither, 2004; Wamala, Wolk, & Orth-Gomer, 1997). As Thomas (1995) has suggested these are
conditions that disproportionately impact the health of African Americans.
Cognitive Theory and Anger
A detailed discussion of cognitive theory is beyond the scope of this article. However, it is impor-
tant to underscore that cognitive theory rests on key fundamental assumptions which suggest that
cognitive activity affects emotions and behaviors; that the content and process of such activity
can be monitored and changed; and that, by restructuring cognitions in a more rational and bal-
anced direction, one can achieve behavioral and emotional changes and reduce symptoms
(Dobson & Dobson, 2009; Dobson & Dozois, 2001). Cognitive therapy approaches (Beck, 1976;
Ellis, 1962) have been used extensively to address a number of emotional and behavioral prob-
lems including, as indicated earlier, the treatment of anger.
From a cognitive-theory perspective, the experienced of anger has been associated with cog-
nitive processes such as: the threat to or perception of loss of a valued object in one’s life (Beck,
1999); external attributions of blame that lay responsibility for one’s loss on an identified
“transgressor” (Averill, 1982; Beck; DiGiuseppe, 1995; Hareli & Weiner, 2002); rigid demands
(Eckhardt & Jamison, 2002; Deffenbacher, 1999; Ellis, 2003; Ellis & Tafrate, 1997); attribu-
tions of intentionality or personalization (Epps & Kendall, 1995; González-Prendes &
Jozefowicz-Simbeni, 2009; Girodo, 1998); and condemnation or denigration of the identified
transgressor (Beck; Eckhardt & Kassinove, 1998; Ellis & Tafrate). In defining the experience of
anger, Kassinove and Sukhodolsky (1995) suggest that anger is:
A negative phenomenological (or internal) feeling state associated with specific cognitive
and perceptual distortions and deficiencies (e.g. misappraisals, errors, attributions of
blame, injustice, preventability, intentionality), subjective labeling, physiological changes,
and action tendencies to engage in socially constructed and reinforced organized behav-
ioral scripts (p. 7).
Anger and African American Women
The experience of anger in African American women must take into account factors such as
gender-role and culture-bound messages, as well as the realities of powerlessness. Addressing
the issue of gender-role socialization, several authors (Cox, Stabb, & Bruckner, 1999; Cox, Van
Velsor, & Hulgus, 2004; Hatch & Forgays, 2001; Munhall, 1993; Sharkin, 1993) have suggested
that cultural expectations and gender-role socialization messages shape the manner in which
anger is experienced and expressed by women. Such messages, reinforced from an early age,
discourage women from expressing anger directly and promote the view that such direct expres-
sion threatens the stability of their relationships. The outcome of these dynamics, according to
Cox and colleagues, is that women often find themselves diverting or rerouting their anger
expression in four ways: containment (e.g., a conscious attempt to avoid expressing anger, often
accompanied by prolonged physical responses); internalization (e.g., suppression); segmentation
386 Clinical Case Studies 8(5)
(e.g., dissociation from angry feelings, with little or no awareness of them); and externalization
(e.g., use of aggression or projection of blame for one’s uncomfortable feelings).
Besides the socialization process that African American women are exposed to as a function
of their gender, they also may be influenced by culture-bound expectations of strength.
Beaubeouf-Lafontant (2007) argued that the concept of the strong African American woman is
grounded on problematic assumptions that create unrealistic characterization, demands and
expectations that tyrannize African American women and, paradoxically, increases their risk of
depression and other emotional distress. Similarly, Harris (1995) suggested that this notion of
“strength” may often cut both ways: in one way it can be seen as a virtue needed to overcome
adversity; on the other hand, it may create the false image of a “superwoman,” who sees it as her
duty to help others, while ignoring her own distress. Harris (1995) goes on to state “this thing
called strength, this thing we applaud so much in Black women, could also be a disease” (p. 1).
As Thompkins (2004) asserted, too often the ideal of the strong back woman compels the woman
to assume the role of caregiver, engaging in self-sacrifice and self-denial to attend to the needs
of others. The woman may then find herself caught in a double-bind: on the one hand she may
experience anger and resentment related to the lack of control over her own life and the lack of
attention to her own needs, and on the other hand she may feel that expressing anger and dis-
satisfaction is nothing more than complaining, and therefore a sign of weakness. It might then
follow that legitimate anger feelings are left in silence or diverted into other forms of anger
expression (Cox et al., 1999; Cox et al., 2004).
Another significant factor that influences anger in women is powerlessness (Fields et al.,
1998; Thomas, 1995; Thomas & González-Prendes, 2009). Although the experience of power-
lessness seems to be more common among African-American women, who are more likely to
suffer from disparities related to income, education, employment, and poverty, the disempower-
ing experience also affects middle-class African American women, even those who have achieved
relative professional success (Fields et al., 1998; Richie et al., 1997). It could be argued that a
feeling of powerlessness in African Americans is not only a function of socioeconomic dispari-
ties but also could be paradoxically influenced by the same culture-bound messages of strength
that create unrealistic expectations for African American women. By emphasizing the impor-
tance of caregiving, self-denial and enduring adversities against all costs, paradoxically the
woman may be left feeling less control over her own life. Perceived control and optimism have
been associated with less emotional distress (i.e., depression and anger) among women experi-
encing a high number of exposures to acute and chronic stressors (Grote, Bledsoe, Larkin,
Lemay, & Brown, 2007). Mabry and Kiecolt (2005) have proposed that a sense of control, the
idea that one controls one’s outcomes, mediates the experience of anger more for African Ameri-
cans than for Whites.
2 Case Introduction
Karen is a 51-year-old, single, African American woman with one adult daughter and two grand-
children. She has a master’s degree in education and has completed all the course work for a
doctoral degree in counseling. She has been a public school teacher for nearly 30 years. She is
well-liked and well-respected by her students and colleagues. Karen, the oldest of three siblings,
comes from a family in which women were viewed as strong, determined, self-reliable, and striv-
ing to improve their lives by working to achieve the top of their potential. That path had been
established for generations, and was most evident in the example set by Karen’s mother, a single
mother who, while living in a low-income housing project in St. Louis, Missouri, had worked
full-time to support her family. She also attended law school in the evenings, and eventually
graduated.
González-Prendes and Thomas 387
3 Presenting Complaints
Karen initially went to see her primary-care physician, complaining of physical symptoms,
including headaches, high blood pressure, poor sleep, and feelings of tenseness and fatigue. In
addition, Karen had related that over the past year she had struggled with on-and-off depressed
mood, crying spells, social isolation, irritability, and anger bouts. Her anger bouts, although often
felt in silence, were at times punctuated by verbal outbursts directed at an individual or entity.
Karen tended to feel the episodic bouts of depression following her anger episodes. Upon exam-
ining her, the physician recognized that Karen’s symptoms were likely related to multiple
personal and occupational stressors that Karen was facing and for which she had not allowed
herself the time to process and find a healthy resolution. The physician suggested that Karen seek
professional counseling to help her address some of those stressors.
4 History
During her initial visit, Karen related how, in the past year and half she had experienced a number
of significant losses in her life including the deaths of her brother, sister, and father. At about the
time that Karen sought treatment, her oldest daughter had been diagnosed with terminal cancer
and her step-father, the man she thought of as her father, had been diagnosed with a malignant
brain tumor. Since Karen’s mother was advancing in years and struggling with her own health
issues, Karen had assumed the role of major caregiver; this while still handling her full-time
employment responsibilities as a teacher, as well as other personal responsibilities.
Karen also related how over the past 2 years she had witnessed the steady deterioration of the
educational atmosphere at the public school where she taught and the administration’s apparent
unwillingness to address important issues. Teaching was Karen’s passion. She was extremely
dedicated to her students and strived to provide them with the best learning experience, in the
face of increasing difficulties in the urban school in an area of the city populated by low-income
people. During the past year, there had been an increased in gang activity and the level of vio-
lence had increased both inside the school and in the surrounding area. On a number of occasions,
the school had gone on “lockdown,” while the police swept the building to search for gang mem-
bers and weapons. Teachers often felt that they worked in an unsafe environment, with a lack of
supplies adequate to perform their duties. Karen, along with other teachers, also felt that the
school administration did not care about improving the educational environment. The increas-
ingly chaotic work environment prompted Karen to start questioning whether to continue
teaching. This created a great deal of consternation because she found deep meaning and sense
of personal satisfaction in her teaching, particularly to disadvantaged, disempowered, and under-
privileged students. Karen’s frustration grew as her effort for advocacy and action appeared to
fall on deaf ears. Although initially she did not recognize it or acknowledge it overtly, Karen
often felt a profound sense of powerlessness in the face of such personal and professional stress-
ors. In the face of that powerlessness Karen would find herself alternatively blaming others (i.e.,
the school administration, society, etc.) and experiencing intense anger, or blaming herself as
being “weak” and “not strong enough” and feeling depressed.
Reacting to these multiple losses and issues in her life, Karen projected a cynical view of the
world. She saw the world as a “cold and calloused place” and people as “uncaring.” At times she
questioned if she were doing a disservice to her students by trying to inject them with hope, when
she “knew” they would be mistreated by the “unfair and uncertain” future that her students were
about to face in life.
Nonetheless, Karen presented with a number of significant strengths that would be considered
throughout the course of treatment. Internally, Karen was an intelligent, insightful, and creative
388 Clinical Case Studies 8(5)
woman with a particular aptitude for music and writing poetry. Although she was not a religious
person, she saw herself as highly spiritual. Throughout her life she had been an activist, fighting
for women’s issues as well as confronting racism, sexism, and other forms of discrimination and
oppression of disempowered populations. Externally, Karen seemed to have a healthy support
network made up of family and friends. She belonged to various civic groups. However, when in
need, she felt hesitant and reluctant to use that support as she did not want to “burden others with
my problems.” On the contrary, she was the one that others came to when they needed support or
advice. Her narrative seemed punctuated by a prevailing theme: the need to be “strong” in the
face of adversity. She recognized that that often meant that she could not allow herself to appear
vulnerable to others. Others viewed her as the one who “kept it together.” Often she found herself
attending to others’ needs and striving to make things better for them, even when she felt over-
burdened by doing so. That need to be “strong” was passed on to Karen in overt and covert
messages and actions by her mother. Her mother’s stoic determination made a significant impact
on Karen’s view of self, others and the world; the fact that her mother had raised her family as a
single parent while going to law school and becoming an attorney and a judge, without much
complaining, created a challenging role model for Karen.
5 Assessment
The initial assessment consisted of a structured biopsychosocial assessment interview and com-
pletion of the Brief Symptom Inventory, (Derogatis, 1993) on which she had elevated scores in
the depression (52), anxiety (45), and hostility (62) categories. In addition, Karen was asked to
subjectively rate the frequency (how many times per week) and intensity (how strong each epi-
sode) of her anger episodes for the 4 weeks prior to coming to treatment. She did so by using a 0
to 10 subjective units of distress measure (Wolpe, 1990) and maintaining a log of such data (0 =
no anger and 10 = enraged) for the duration of treatment. At pretreatment Karen indicated that
she experienced 2-3 anger episodes weekly with an average intensity of 8-9. Her mode of anger
expression seemed to divert such expression into a form of anger containment as defined by Cox
et al. (1999) and Cox et al. (2004). In this form anger diversion, the woman “holds her tongue”
and contains her anger, which remains active but covert, and leads to physical symptoms (Cox,
Bruckner, & Stabb, 2003).
Following the assessment process, Karen and the therapist reviewed the information and
developed a list of concerns. Three main concerns emerged: (a) unhealthy experience and expres-
sion of her anger, (b) episodic bouts of depression that seemed to follow her anger outbursts, and
(c) unresolved grief issues related to the multiple losses in her life. After reviewing this data,
Karen acknowledged that she often experienced feelings of anger and also described her difficul-
ties in processing and expressing such angry feelings. She described a cycle in which she would
experience a setback or adversity, followed by the experience of anger. She would hang on to her
anger silently, for fear of hurting other people’s feelings. Meanwhile she would suffer headaches,
tension, restlessness, poor sleep and rumination as to how she “should” have handled the situa-
tion. At times, days or weeks later, she would just “explode” verbally at either the original object
of her anger or some other unsuspecting target. Following this “outburst” Karen would feel
guilty and depressed, fueled by self-condemnation for having “lost control.” She indicated that
she had been experiencing these episodes for approximately 2 years and decided on her anger as
the main focus of therapy.
The goal of her treatment, as expressed by Karen herself, was to be able to manage her
angry feelings in a healthier manner. A key aspect of the success of cognitive-behavioral ther-
apy centers on the client’s and therapist’s ability to define the target problem in behavior-specific
terms. Therefore, Karen was asked to describe what “managing her anger in a healthier
González-Prendes and Thomas 389
manner” meant to her, and how she envisioned herself behaving, feeling and, most important,
thinking differently, once that she had successfully completed therapy. Karen agreed that, as a
homework assignment, she would work on defining what she wanted to get out of treatment.
Three main objectives emerged. Behaviorally, Karen wanted to be able to verbally express her
feelings of anger assertively and appropriately and she wanted to do so without the guilt and
depression that she often experienced following her maladaptive forms of anger expression.
Second, she wanted to be able to set healthy, reasonable limits as to how much she would take
on or how much she would help others and she wanted to learn “how to relax.” Third, from a
cognitive perspective, Karen wanted to be able think that it was okay to not always be avail-
able to others, and to think that it was okay to take care of herself without feeling guilty for
doing so.
6 Case Conceptualization
Karen’s anger was conceptualized, using a cognitive-behavioral conceptualization model out-
lined by Beck (1995) which identifies various levels of cognitions and their impact on the
individual. Equally important, to increase the cultural relevancy of the conceptualization
process, the schemas that supported her anger were framed within significant gender-role
and culturally relevant factors that affected her mode of anger expression. Karen’s references
to depression were conceptualized as the result of engaging in strong and persistent self-
condemnation and self-blame, usually following her anger outbursts and her perceived “loss
of control.” Beyond those incidents, Karen did not present with any symptoms of depression,
nor did she have any significant history of depression; therefore, we agreed that anger was the
primary problem.
Karen’s core beliefs related to how she viewed herself and the world/others. Her views of the
self were underscored by these beliefs such as: “I am competent,” “I am strong,” and “I am a
helper.” She saw the world as “hostile,” “cold,” and “uncaring.” Out of these central beliefs,
Karen had developed important rules which she used to guide and measure her behavior, as well
as the actions of others. Some of these rules were: “I should be able to help those in need,” “I
should stand against the uncaring world that oppresses disempowered people,” “I should endure
without complaint,” and “If I fail to help others, then I am a failure.” These beliefs and rules had
translated into strategies that Karen used throughout her life. These strategies emphasized self-
denial and attention to others’ needs. In addition, Karen often felt that others should recognize
that she was overworked and therefore should stop being so demanding of her time. Yet, she was
unable to verbalize such wishes to others. When others continued to demand her time, Karen
concluded that they were insensitive and just did not care. This type of blame was seen as a piv-
otal factor that fueled both her anger and depression. Whenever she felt frustrated in her attempts
to achieve certain outcomes, she blamed others and her emotional response was anger directed,
although unstated, at the perceived transgressor. Conversely, on those occasions when she
blamed and belittled herself for not being “strong” and “losing control” by acting angrily, she
experienced depression and guilt.
A critical aspect of working with clients with anger problems is the establishment of a thera-
peutic alliance. This is particularly true when working with angry clients, whose view of the
world is punctuated by suspiciousness and mistrust (DiGiuseppe, 1995; González-Prendes &
Jozefowicz-Simbeni, 2009). In these situations, it is imperative that the client be engaged and
actively included in every aspect and step of the treatment process. In Karen’s case, from the first
interaction of the assessment process, it was imperative that she felt a sense of ownership of
the treatment process. In cognitive behavior therapy, one strives to establish a collaborative
empirical alliance (Beck, 1995) that empowers the client by getting her involved in the
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decision-making process, from the identification of the problems, to the establishment of the
goals, the formulation of homework assignments, the design of behavioral experiments and other
strategies. Cognitive-behavioral therapy has been described as an empowering approach because
it acknowledges the client’s expertise about herself and her ability to control and change her
thinking; engendering changes in her emotional and behavioral responses (Hays, 1995).
7 Course of Treatment and Assessment of Progress
Karen’s treatment took place more than 20 individual therapy sessions of 50 minutes in length.
The first 12 sessions were weekly, followed by 6 every-other-week sessions. The last two ses-
sions were follow-ups at a 3-month and 6-month point after the initial 18 sessions were completed.
Treatment followed a cognitive-behavioral model that acknowledges the primary role of cogni-
tions (i.e., judgments, meaning, attributions, etc.) in determining how one responds, emotionally
and behaviorally, to life situations (Beck, 1976; Ellis, 1962). We employed a person-in-environ-
ment perspective to frame Karen’s beliefs within important sociocultural perspectives that gave
special meaning to her actions.
The overall cognitive-behavioral treatment occurred within a three-stage framework as out-
lined by Meichenbaum (1985, 1996). The goal of the first stage was to help Karen understand her
anger. This entailed helping her to understand how her idiosyncratic thoughts and …