Culturally Sensitive Treatment of Anger in African American Women: A Single Case Study 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 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 cognitivebehavioral 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 minorities 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 experience 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: aa3232@wayne.edu 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 expectations 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 DiGiuseppe 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. GonzálezPrendes (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 practice 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 populations. 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 processing 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, emotional, 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 destructive 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; WarrenFindlow, 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 important 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 balanced 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 problems including, as indicated earlier, the treatment of anger. From a cognitive-theory perspective, the experienced of anger has been associated with cognitive 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); attributions 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 behavioral 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 expression 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 dissatisfaction 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 powerlessness 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 disempowering 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 disparities 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 importance 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 experiencing 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 Americans than for Whites. 2 Case Introduction Karen is a 51-year-old, single, African American woman with one adult daughter and two grandchildren. 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 striving 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 examining 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 violence 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 members 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 increasingly 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 underprivileged 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 stressors. 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 overburdened 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 completion 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 episode) 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 expression 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 difficulties 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 situation. 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 therapy 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 available 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 outlined 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 selfcondemnation 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 selfdenial 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 pivotal 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 therapeutic 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 390 Clinical Case Studies 8(5) 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 sessions 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 cognitions (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-environment 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 outlined 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 internalized messages impacted on her emotions and behaviors. Equally important was to help Karen understand her anger within the context of her gender and race. The focus here was to help her become aware of and connect with the various underlying gender and sociocultural schemas that shaped her anger expression. The second stage focused on skills development. To help her manage her anger effectively, the therapist introduced Karen to specific cognitive and behavioral skills. We presented and discussed these skills in therapy session; we then used role-play and behavioral experiments to promote practice of the learned skills. The third stage focused on applying the new insight and skills to specific life situations. Karen would bring these specific situations to therapy during which they were reviewed to reinforce successes and troubleshoot setbacks. The process of treatment ebbed and flowed among these three components. The specific treatment approach for treating anger in women has been presented elsewhere (González-Prendes, 2008). Treatment includes specific processes such as: helping clients increase awareness of the impact of their thinking on their moods and behaviors; identifying idiosyncratic thoughts that fuel anger and learning to assess the validity and functionality of those thoughts; restructuring cognitions to reflect a more balanced and rational view of self, the world and others; recognizing physical, emotional, and mental cues that signal the onset of unhealthy anger; implementing strategies to self-monitor so as to increase the client’s sense of responsibility for and control over her emotions; learning relaxation strategies; and building skills for assertive communication and conflict resolution. We introduced and reinforced these techniques through the use of therapeutic discussions, the application of a “Thought Record” (Greenberg & Padesky, 1995), role-plays, behavioral experiments, imaginal exposure and homework assignments. The theoretical foundation of this treatment approach to anger in African American women rests on the following hypothetical assumptions: treatment must help the woman become aware of how gender and culture messages shape her expression of anger; it must also empower the woman to rewrite the script of those messages in a more balanced, rational, and realistic manner; and treatment should introduce prosocial corrective measures to increase the client’s ability to express anger in an appropriately assertive way, set healthy boundaries and, overall, to cope effectively with setbacks and adversity. González-Prendes and Thomas 391 Helping Karen Make Sense of her Anger The first stage of treatment assisted Karen in developing a conceptual understanding of her anger. This involved helping Karen increase awareness of specific cognitive processes that influence the experience of anger, (i.e., externalization of blame, rigid demands, attributions of intentionality/personalization, etc.) as well as gender-role and cultural messages that impacted on how she expressed her angry feelings. Karen engaged in a process of exploration and discovery about the ways she had been socialized to express feelings of anger. She eagerly agreed to capture in a journal her early memories and thoughts about such messages. The prevailing theme that emerged was that, from an early, age Karen was encouraged to be in control of her emotions and that the expression of anger was seen as “losing control.” Since Karen’s mother was alive, she was able to ask her mother about how she had learned to express anger and how she had passed those messages to her children, including Karen. Interestingly, Karen learned from her mother that “getting angry and fussing” were not acceptable options for the women in her family. Karen could not recall one single event in which she saw her mother “lose control” and get angry. However, the men were not held to the same standards and their expression of anger, although not violent, was seen as a form of determination, strength, and forcefulness. Karen recalled that, even though she was never told directly that expressing anger openly was “unfeminine” or “unladylike,” the message was clear that “you just don’t do it.” The women in her family were expected to endure adversity with stoicism; giving in to emotions such as anger and depression was not acceptable. If anything, the women were expected to rely on their personal and religious strength to endure and cope with adversities. Besides becoming more aware of the variations of anger expression for men and women within her family, and the relative level of acceptance or lack thereof, Karen also began to explore the attitudes of society at large toward anger expression in women. Karen identified specific examples of how female public figures in politics and popular culture had at times, openly expressed anger, only to be faced with public scorn and criticism and saddled with derogatory labels, even by other women. Slowly, Karen began to tease out messages, often covert and subtle, but at times direct and open, that influenced the way she processed and expressed angry feelings. Using a model of anger diversion in women, (Cox & St. Clair, 2005; Cox et al., 1999; Cox et al., 2004) the therapist helped Karen to recognize ways in which she often diverted her angry feelings and to also discover the emotional and physical consequences that resulted. These consequences included physiological symptoms such as increased shallow respiration, accelerated heart rate, increased blood pressure and muscle tension, among others. These were all symptoms that had originally brought Karen to her primary-care physician. In addition Karen engaged in an exploration of the paradoxical juxtaposition of strength and powerlessness, a condition that creates unique aspect of anger in African American women (Thomas & González-Prendes, 2009). The challenge was for Karen to identify such issues in her. As Karen became aware of the specific and idiosyncratic messages that had shaped her style of anger expression, she began to systematically evaluate their validity and functionality. At this point Karen began using a thought-record form (Greenberger & Padesky, 1995) that methodically allowed her to challenge and reconstruct those messages. The thought record allowed her to focus on specific situations connected with anger episodes; identify the specific thoughts connected to those events and recognize how they contributed to her behavioral and emotional distress (i.e., anger); identify and assess evidence for or against the identified thoughts; and to formulate more balanced and healthy perspectives in order to engender healthier emotional and behavioral responses to upsetting situations. Karen, perhaps due to her background as an 392 Clinical Case Studies 8(5) educator, responded well to the systematic and organized approach the thought record provided. It became an important tool throughout the treatment process. Confronting Unrealistic Expectations of Strength Harris (1995) and Martin (2002) have suggested that cultural expectations in African-American women may create unrealistic demands of strength that increase stress. Therefore, it was important for Karen to recognize how the experience of her mother and other women in her family and community had contributed to her internalizing these unrealistic expectations. Karen enthusiastically began to revisit the history of her family. An instance that illustrates how Karen first began to confront long-standing messages that underscored her own expectations of the strong African American woman came early in therapy. Karen related how her mother had raised her three children on her own, while living in the housing projects in St. Louis. Her mother, a highly accomplished and respected woman, completed her college education, became a teacher, worked a full-time job and attended law school in the evenings. Eventually, she moved her family out of the housing project, became an attorney and ultimately a judge. Karen later recalled that, despite the immense sacrifices she made and the hardships her mother faced, she could not remember any time when her mother complained; felt depressed or dwelt on self-pity. Rather, Karen’s memories of her mother were of a woman of stoic resolve to succeed and provide for her family, supported by her faith and religious convictions. Karen recalled how her mother was one of a long line of “strong” women who had strived to better their families, first in Mississippi and then in St. Louis, against a background of a hostile society, rampant with oppression and discrimination. The overt and covert messages that Karen received from an early age were that she had to be strong, be available to help others, and endure hardship with uncomplaining determination. For Karen these views had been functional at various points in her life. They helped her to achieve her own levels of success academically and professionally. However, such belief also drove her to blur boundaries of control; to take on more responsibilities than she could possibly handle; and to deny her own well-being and desires. Nonetheless, Karen saw herself as a “strong” African American woman, a member of a lineage of strong women in her family, and, as such, she had bought into the notion that she should be able to handle any challenge without complaint. The result, however, was that Karen often felt an undercurrent of resentment and anger at what she saw as a lack of consideration from others. She expected others to recognize her predicaments and not impose on her. However, she failed to realize how often it was she, who reflexively volunteered to tackle those challenges and failed to set healthy limits. Using the Thought Record to Address Unrealistic Expectations of Strength The Thought Record (Greenberger & Padesky, 1995) helps clients to deliberately and systematically assess and evaluate evidence for or against maladaptive thoughts or beliefs and eventually formulate more adaptive and functional views. An example of its use came early in the treatment process when Karen came in one day complaining of having experienced heightened anger and depression for the 2 weeks prior to the visit. Karen indicated that she had been struggling with pressures from work as well as with demands place upon her by her mother who daily was requesting Karen’s help to care for her ailing step-father. This despite the long hours she put in at her regular job in the high school. She also needed to attend to her own personal responsibilities outside work. As she struggled balancing these escalating demands on her time and energy, Karen began to grow increasingly angry and resentful at such requests. Yet she was constantly confronted by her desire to attend to her own needs, and on the other hand her internal beliefs that “I must be strong,” “I should be available to help those in need,” and “I should endure González-Prendes and Thomas 393 without complaining.” Even the fact that she struggled with such demands was “evidence” for Karen to see herself as “weak” and “not strong.” These self-condemnatory and negative evaluations of the self would feed a depressed mood. Simultaneously, she felt anger toward others who imposed upon her, and whom she often deemed as inconsiderate, because she believed they should have been more attuned to her predicaments. Yet, Karen could not bring herself to express her anger directly and openly; set healthy limits to protect her time and energy; or ask for help. For Karen those options were akin to complaining, and, as such, were viewed by her as a sign of weakness. The challenge for the therapist was to help Karen confront and challenge her unrealistic beliefs of strength so as to engender healthier emotional and behavioral responses, while at the same time preserving the historical and cultural significance of such belief. The therapist suggested that Karen begin using the Thought Record (Greenberg & Padesky, 1995) as a means of working through the anger and depression. When the client and therapist are able to identify and focus on a specific, well-defined issue, the use of a thought record is more effective. Karen’s working long hours and her caring for her ailing father, although fed by the same rigid beliefs of strength, were seen as two separate issues. Therefore, Karen agreed that first she wanted to work on addressing her mother’s daily demands for help. The first step in the use of the thought record is to specifically define the problematic situation. As Greenberg and Padesky (1995) indicated, this involves defining who? what? when? and where? In this instance the problematic situation was defined as: after working long hours at her job in the school and often feeling physically tired and emotionally exhausted, Karen would receive a phone call from her mother asking her to come over for the evening to help with the care of her ailing step-father. The next step in the process was for the Karen to identify the moods and behaviors connected with the situation. Her immediate emotion response following her mother’s call was anger, followed by feelings of resentment, guilt and, later on, depression. Yet, Karen would not say “no” and instead she would go and help her mother. Often, after Karen went home late at night she would feel tense, experience headaches, and have difficulties sleeping. The third step was for Karen was to identify the automatic thoughts that had crossed her mind at the time of or following the identified event. Karen was asked to focus on what had she told herself, relative to the situation, that sparked her emotional and behavioral responses. In some cases, due to the passage of time, the client might have some difficulty identifying the specific thoughts that she had at the time of the event. When that happens, the use of imaginal exposure may help the client to remember those thoughts. In this process the client is asked, while in session, to relive the identified situation, closing her eyes and, as specifically as possible, using the present tense and the “I” pronoun, recount in detail what transpired during the identified event. As the client relates the story, the therapist, in the least intrusive manner possible, asks the client to relate specific thoughts going through her mind at that moment, as well as the ensuing emotional reactions. During the exercise Karen was able to relive both the anger and guilt that she had experienced. The automatic thoughts that she described included “she (mother) should not be asking me to come over”; “she should know that I work long hours and that I am tired and exhausted”; “she should be more considerate”; “I must be strong and provide help as needed”; “If I say no to my mother then I am a weak and bad person.” Following identification of the automatic thoughts, the client, with the help of the therapist, engages in a systematic process of discovering evidence for or against the identified beliefs. At that point it is not unusual for clients readily to come up with extensive evidence that supports their irrational negative beliefs (i.e., “If I say no to my mother then I am weak and a bad person,” “I must be strong and provide help as needed”). On the other hand it is equally common for the client to have difficulty identifying evidence that refutes the validity of those irrational beliefs. 394 Clinical Case Studies 8(5) In the case of Karen, her thoughts relative to what it meant to be a strong Black woman (e.g., self-sacrifice, self-denial, always ready to help others, etc.) seemed to have more influence on her emotional and behavioral responses than other thoughts. These beliefs were deeply rooted in the history and culture of her family. She referred to the implicit and explicit messages related by her mother who had sacrificed to better herself and provide opportunities for her family. In challenging and restructuring such beliefs, it was imperative to tease out and nurture their healthy, cultural and historical aspects, separating those from the irrational and rigid demands that Karen put on herself and that tyrannized her and fueled her anger and depression. The work went on for several sessions and Karen painstakingly wrote in her thought record identifying “evidence” against the idea that she was “weak” and “not strong.” She would bring this information to therapy, during which she would further process and synthesize important aspects of it. Gradually, the use of the thought record forced Karen to look at her life in a more deliberate manner; stopping to recognize the importance and significance of many actions that, in the past, she had simply overlooked or taken for granted. She began to systematically detail her many accomplishments: her ability to endure multiple personal losses; her caring for her family; the long hours she spent helping her students succeed against seemingly insurmountable odds; her creativity and ability to write prose and poetry and the positive feedback she had received from friends or even strangers during her participation in local “poetry nights” and her social and political activism on behalf of a number of causes. Every time Karen returned to therapy with new evidence, she was asked to reflect on what she would make of such information, vis-à-vis her belief that, if she did not help others at all times and endure without complaining, that meant that she was a weak person. For the first time she began to seriously question the validity of that belief. Armed with that new evidence, the challenge for Karen was to create a more balanced perspective of herself that recognized and acknowledged her strength and the legacy of strong women in her family who survived, persevered and thrived often against a backdrop of racism and sexism. At the same time Karen began to separate those positive aspects of strength from the unrealistic expectations and demands that she had created for herself and the burden associated with them. Subsequently, Karen began to raise this issue with some of her African American female friends. This led her to realize how some of these other women had similar experiences, accompanied by similar beliefs and emotions. The fact that she never saw these women as “weak” further forced Karen to reassess her own negative self-evaluations. Furthermore, she began to see how her internalized sense of strength often prevented her from giving a voice to her burden and sense of powerlessness; expressing her frustration in a healthy manner; and setting clear boundaries for what she could and could not do for others. She became more cognizant of how, in her view, voicing her anger had not been compatible with her self-image of being a “strong” Black woman; it did not fit with the messages that she had internalized as she grew up in her family. Gradually she began to rewrite the scripts of those messages in a healthier, more balanced and rational manner. The new scripts were rooted in her strength and passion for helping others and reinforced the notion that she could be a better helper if she learned to pick her battles more selectively, and that doing so did not mean that she was “weak.” On the contrary, she began to see that the ability to set healthy boundaries was strength, in the sense that it allowed her become a more effective helper and advocate, while reducing and eventually eliminating the adverse effects of her unhealthy anger. Powerlessness Although the need to attend to others, while denying her own wishes, often left Karen feeling a lack of control over her life and a sense of powerlessness, she did not voice such feelings. Doing so, in Karen’s mind, was also akin to being weak. The unrealistic expectations of strength led her González-Prendes and Thomas 395 to endure and “bite her tongue.” The women in her family had used their strength to fight and overcome severe disempowering conditions in society. Therefore, in Karen’s family the notion of powerlessness was not openly considered or acknowledged. Yet, a sense of powerlessness surely fueled her anger and frustration. Karen’s feeling of powerlessness also manifested itself in her many attempts to help others. It was difficult for Karen to accept her relative lack of control over other people or situations. She had a difficult time recognizing and accepting the boundaries of her control. The culturally sensitive therapist needs to be aware that, for the African American woman with high expectations of strength, the acknowledgment of powerlessness can be difficult. Yet, the practitioner must help these women to give a voice to and acknowledge such powerlessness. One way of doing so is to help normalize the experience of anger by framing it within the larger societal system that has often created oppressive, limiting and disempowering conditions that disproportionately effect upon gender, racial and ethnic minorities. For Karen this led her to identify specific events when this had happened in her personal and professional lives. She recognized how she often left work meetings feeling angry because others would not concur with her ideas or be ready to take immediate action to solve problems as she saw it fit. Karen began to acknowledge that in those situations there was a side of her anger that was justifiably fueled by her perception of the unfairness and limitations faced by her students. However, she also was able to see how another side of her anger, fueled by her demands that others and the world must follow her advice, was not healthy. She began to realize that, if she could use her anger prosocially to correct a wrong and attain successful outcomes, rather than internalizing it and “exploding” at some later point, she could be more effective in her endeavors. Through this process she began to realize that anger is a common emotion that in itself is neither good nor bad. This notion challenged her previously held fundamental beliefs about her anger. Karen began to see her anger as a normal human emotion that seemed justified when viewed against the backdrop of the oppression and sometimes discrimination that often thwarted her attempts to help others. Cognitively, she was able to challenge the notion that experiencing anger somehow made her inconsiderate, weak or a “bad” person. This revelation allowed her to view her feelings of anger more objectively, and to acknowledge more realistic boundaries of her power and control. She had started to understand that the only thing she could change for sure was herself and in doing so she was able to accept her powerlessness to change others. To Karen accepting her powerlessness did not mean becoming passive or giving up her passion for fighting injustice. Rather it meant she was learning to use her power and strength in a more effective manner and, consequently, becoming less subject to bouts of maladaptive anger and more successful in her endeavors. Paradoxically, by accepting the limits of her power and control, Karen began to feel more empowered. Karen’s View of her Anger Through the Prisms of Gender and Race Through therapy, Karen began to understand her anger within the context of her gender and race. As a woman, she had assimilated the notion that our society looks unfavorably on an “angry woman” and, as an African American woman, she also internalized unrealistic expectations of strength that, when confronted with the disempowering conditions within herself and in society, fanned the flames of her anger. Although Karen was a highly educated and accomplished woman, she had never really given much thought to the confluence of these factors and how they contributed to the way that she experienced and expressed anger. In therapy she began to see the link. Thomas and González-Prendes (2009) suggested that the challenge for the therapist working with African American women who are struggling with unhealthy or maladaptive anger entails helping these clients to: 396 Clinical Case Studies 8(5) rewrite the script of the old messages in a way that promotes a more balanced and realistic view of themselves as African American women; to nurture the cultural tradition of strength in a more self-empowering manner; and also to help these women build a healthier and more functional sense of personal responsibility for their anger. Once those messages are changed, the woman can begin to develop an assertive style of expression, underscored by the open, direct, and socially appropriate communication of her anger (p. 108). For Karen, the break-through in therapy came as she began to integrate the legacy of strength within her family with her new-found rational sense of boundaries and control. She was able to appreciate and nurture the history of strength among the women in her family as well as other African American women. She revisited the lives of historical Black women, such as Sojourner Truth and Harriet Tubman. She integrated her new-found perspectives in a way that led her to conclude that being “strong” did not mean that she had to be responsible for others’ emotional or physical well-being; nor did it mean that she had to stoically swallow her discomfort; nor did it mean that she had to stand passively by or stay inactive when confronted by injustice, coupled with her desire to help others. She could take action to help others while, at the same time, accepting that her actions might not always yield the results she anticipated. Introducing Relaxation and Other Strategies As treatment went on, Karen began to identify cognitive and somatic anger cues and became more aware of how they signaled an escalation to an unhealthy level of anger. The cognitive cues were demanding thoughts or mental images of specific situations in which her wishes had been frustrated. These thoughts and images would often intrude into her conscious awareness, fanning the flames of anger and frustration. As these demanding cognitions persisted, she would begin to experience somatic sensations such as muscle tenseness, accelerated heart rate, faster and shallower breathing and headaches. Karen learned to use these cues as alarms, alerting her to the need to take action to reduce their intensity. To help Karen slow her mind and body on those occasions, therapy built upon Karen’s personal interest in spirituality and meditation to incorporate strategies that increased her ability to relax in stressful situations. The strategies, although not a “solution” to anger, often help the client reduce the escalation of angry feelings and momentarily eliminate the internal discomfort and physiological symptoms that accompany unhealthy expressions. The expectation was that, in doing so, Karen would be in a better position to take healthy steps to address the source of anger. By incorporating the use of imagery, mindfulness, and diaphragmatic breathing, Karen learned to calm herself down whenever she began to notice a raising level of anger. At a particular session, she came to therapy in an agitated internal state, which she attributed to her school’s unwillingness to provide needed assistance to some of her students. On that occasion she was carrying a portable sphygmomanometer that she used to monitor her borderline hypertension. As an experiment to test the effectiveness of the relaxation strategies, Karen measured her blood pressure at onset of the session which read 147/99. The 50-minute session focused on rehearsing breathing relaxation steps while engaging in imagery and mindfulness exercises. By the end of the session Karen indicated that she felt rather relaxed and rechecked her blood pressure, it read 122/78. From that moment on, she was convinced of the usefulness of such strategies and began using them regularly in her daily life, not just when feeling upset. Therapy also helped Karen reinforce her assertive communication skills (Alberti & Emmons, 1990). She used “I-messages” to express feelings and wishes in a direct, clear, and unambiguous manner, while respecting others’ feelings and avoiding personal verbal attacks. Through insession role-play and reverse role-play, Karen engaged in various challenging scenarios that González-Prendes and Thomas 397 simulated work and personal situations, allowing her to rehearse and practice how to communicate her feelings and wishes assertively. The therapist also introduced Karen to the use of the Upsetness Scale and she found it to be particularly helpful (González-Prendes, 2007). This is a subjective instrument consisting of 10 increasing levels of upsetness intensity, ranging from mild disappointment (1) to enraged (10). The client uses it to measure the relative intensity of her upsetness in any given situation. This strategy helps the client to recognize alternative responses, other than anger, to unpleasant or upsetting situations. As González-Prendes indicated, the use of the term “upsetness” instead of “anger” is a deliberate attempt to reinforce the notion that a wider range of emotional responses to upsetting circumstances are available, besides anger. The therapist used the Upsetness Scale in combination with imaginal exposure to upsetting events to allow Karen to use coping selfstatements to actively dampen anger-inducing thoughts and thus maintaining a visual representation of the Upsetness Scale deliberately work to reduce the intensity of her reactions. These exercises employed a systematic approach in which: (a) Karen imagined specific upsetting situation that she had recently experienced. (b) Karen would allow her level of upsetness to raise to the maximum level associated with that event. (c) She then used self-statements and breathing relaxation while actively holding a mental image of her upsetness dropping in the scale. By employing the Upsetness Scale Karen was able to reinforce her ability to use coping, rational self-statements to control and manage her anger more effectively. Combined with her continued daily charting of her anger episodes, Karen was also able to increase her capacity to self-monitor her anger, as well as to take appropriate action to address it effectively. In addition to the daily charting and her work with the thought record, Karen and the therapist designed other written and experiential homework assignments. The aim of these activities was to help reinforce gains made through therapy; identify, challenge and reframe anger inducing beliefs; try out newly acquired skills (e.g., assertiveness); and test out newly formed beliefs about herself, other persons or the world-at-large. Karen’s log of anger episodes and thought record were reviewed at the beginning of each session and provided an ongoing means of measuring progress. The outcomes revealed Karen’s increased ability to identify, evaluate and reframe cognitions that fueled her maladaptive anger; the effective use and implementation of relaxation and communication skills to manage her mood and express herself more effectively; and the increased ability to gradually reduce the frequency and intensity of her anger episodes. At the end of the first 18 sessions, Karen felt more confident in her skills to manage her anger. Her behavior supported that confidence. Although her depression and grief issues had not been directly targeted during treatment, Karen was able to use the cognitive and behavioral skills she gained in therapy to help her with those issues as well. 8 Complicating Factors Although Karen’s cognitive-behavior therapy allowed her to implement significant positive cognitive, behavioral, and emotional changes in her life, she recognized that her work on the targeted issues would continue beyond the end of treatment. Karen knew that she was dealing with longstanding core beliefs that had formed the philosophy through which she had interpreted life for many years. These beliefs would not just disappear at the end of 18 weeks. She recognized that the same old messages were bound to resurface, particularly in time of stress or adversity, and if she did not stay alert to these, she could find herself struggling with the same old issues. The difference now however, was that Karen had increased awareness and knowledge of the old maladaptive beliefs and behaviors, but also had actively engaged in creating a new set of healthy and balanced cognitions and behaviors to help her cope effectively. She had integrated specific 398 Clinical Case Studies 8(5) skills that she could use daily to help her keep a rational perspective of self and others and thus avoid the perils of relapse. 9 Managed-Care Considerations The essential managed-care consideration was that Karen used her health benefits as a means of paying for treatment. Her insurance company, a health maintenance organization (HMO), allowed Karen 25 visits per calendar year for mental health treatment. We discussed this at the onset of treatment and spaced the therapy sessions to make maximum use of the available time. Including follow-up sessions, the therapist saw Karen for a total of 20 sessions. Of those 20 visits, two were used for a psychiatric evaluation and follow-up to evaluate Karen’s complaint of depression. Although the psychiatrist suggested a regimen of a low dose of antidepressant, Karen chose not to take the medication. Instead she decided to allow therapy to work. Cognitive therapy, with its rather short-term treatment approach and use of homework assignments, is effective within the managed-care constraints. Homework assignments reinforced the therapeutic gains Karen made in session, and this approach allowed extending the overall length of treatment by eliminating the need to meet weekly. 10 Follow-up At the end of the first 18 sessions, Karen agreed to return for follow-up or “booster” sessions at the 3-month and 6-month post-therapy periods. After the first 18 sessions were completed, Karen again completed the BSI (Derogatis, 1993). At that point her scores for depression (36), anxiety (34), and hostility (42) revealed a significant decrease from the pretreatment scores. No further assessment was made at the 3- and 6-month follow-ups, although at those points Karen demonstrated continued progress and command of the cognitive and behavioral skills learned in therapy. Even though she experienced some anger episodes, she was able to manage these effectively by communicating her feelings openly and appropriately and setting healthy boundaries for herself. The frequency and intensity of those episodes had been greatly reduced to 1-2 anger episodes per month at a 2-3 level of intensity. Karen observed that, if she had felt like this prior to treatment, she would not have felt the need to seek help. She embraced her idea of being a “strong AfricanAmerican woman” from a healthier and more empowering perspective. She also internalized a clearer idea of the boundaries of her control and power. After the 6-month follow-up, it was mutually agreed that Karen would end therapy, but if she felt a need, she could contact the therapist for additional “booster” session. 11 Treatment Implications Although illustration of a single case study may serve to provide a detailed discussion of a particular issue, there are a number of limitations associated with its presentation that should be considered when reading this case. We caution readers against making generalizations based on this case and to interpret the information as a general framework of suggestions for becoming more culturally sensitive when working with African American women who present with anger problems. Also, it is important to consider the demographics of the client discussed in this case. As an upper middle-class and highly educated woman, Karen may be a quite different client from women of lesser means and lower socioeconomic status. She also proved to have the ability for introspection and meta-thinking that made her a good candidate for cognitive-behavior therapy. Nonetheless, the case illustrates a process of conceptualizing and treating anger in an African González-Prendes and Thomas 399 American woman, while illuminating significant challenges and themes that contribute to and shape the experience of anger in those women. 12 Recommendations to Clinicians and Students Culturally sensitive therapy with African American women must take into account the realities of both gender and race. More specifically, as we have pointed out throughout this discussion, it is important for the client to discern and tease out internalized messages or themes that impact upon her ability to experience and express emotions. The case of Karen focused on three such themes: gender-role socialization for women in general, culture-bound expectations of strength for African American women, and realities of powerlessness they may face because of their gender and race. Throughout the narrative, we have stressed the importance of recognizing how gender-and-racial-socialization messages influence the experience and expression of anger in African American women. Such messages often contribute to unrealistic expectations of strength that interfere with the healthy expression of anger. They are often deeply entrenched in the woman’s consciousness, become part of her self-view and worldview, and could be, in themselves, disempowering. Knowing that some African American women may not readily acknowledge or even be aware of their powerlessness, it is imperative for practitioners to address and actively explore these issues when working with this population, even though they initially may present in treatment with other emotional distress, health problems, or self-defeating behaviors, the result of anger diversion. We encourage practitioners to recognize that empowering the client to be actively involved in every step of the way is an essential aspect of anger treatment. At the same time, practitioners should actively engage the African American female clients to evaluate the validity and functionality of those traditional gender and racially based socialization messages that have interfered with the healthy expression of their anger. The aim is to help these clients rewrite the script of these messages in a way that promotes a more balanced and realistic view of themselves; to nurture the historical and cultural tradition of strength in a more self-empowering manner; and help these women build a healthier and more functional sense of personal responsibility for their anger. Cognitive changes can then lead the woman to implement to behavioral changes, such as developing an assertive style of expression, underscored by the open, direct, and socially appropriate communication of her anger. Lastly, and equally importantly, we hope that, by discussing central themes that have been associated with the experience of anger in African American women, we may engender research, our own as well as by other sources, that would allow researchers to test some of the theoretical assumptions and client variables that underscore this approach. Therefore, we believe that experimental or quasiexperimental research studies with larger and more socioeconomically diverse populations are needed to begin to generate that kind of practice evidence that would allow practitioners to provide effective and culture-sensitive interventions for minority groups. A survey of the current anger treatment literature simply reveals a dearth of studies that investigate anger exclusively among African American women (González-Prendes, 2008). Therefore, if we are going to develop effective and culturally sensitive treatment approaches to help these women and other minorities with anger problems, we must actively target these groups specifically and develop quantitative, empirical studies to find out which approaches work best. There is also a strong need for additional studies that continue to explore possible client variables and theoretical constructs that may contribute to the experience and expression of unhealthy anger. 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Antonio González-Prendes, Ph.D., A.C.S.W. is an Assistant Professor at the School of Social Work, Wayne State University, Detroit MI. where he is the lead professor in the cognitive-behavioral track of the interpersonal practice concentration for M.S.W. students. Dr. González-Prendes has also been in clinical practice for over 16 years working in the areas of anger as well as other mental health issues and addictions. Dr. González-Prendes’ research interests focus on the investigation and application of cognitive-behavioral treatment to anger problems particularly to racial/ethnic and gender minorities. Shirley Thomas, M.S.W., Ph.D., is an Assistant Professor at the School of Social Work, Wayne State University, Detroit MI. Dr. Thomas has over 20 years of social work experience. During this time she has worked with issues related to family violence, aging, stress, grief and loss; including eight years in child protective service. Dr. Thomas’ research interests include child welfare, stress and stressors, groups and organizations and the armed forces with specific focus on sociological factors that influence social work service delivery in the areas of teaching, scholarship and community service.
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