Social Work: Week 6 Assignment

 

• 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

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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: 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 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

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 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 internalized
messages impacted on her emotions and behaviors. Equally important was to help Karen under-
stand 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 home-
work 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 influ-
ence 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 social-
ized 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 deter-
mination, 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 adversi-
ties. 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 thera-
pist 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 methodi-
cally 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 impor-
tant 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 enthusiasti-
cally 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 chil-
dren 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 discrimina-
tion. 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 predica-
ments 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 systemati-
cally 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 responsibili-
ties 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 evalua-
tions 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 sug-
gested 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 situa-
tion. 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 ses-
sion, 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 emo-
tional 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 chal-
lenging 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. Gradu-
ally, 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 accomplish-
ments: 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 per-
spective 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 set-
ting 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 help-
ing 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 rec-
ognized 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. How-
ever, 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 contrib-
uted 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 shal-
lower 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 incorpo-
rate 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 momen-
tarily 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 in-
session 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 communi-
cate 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 self-
statements 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 per-
sons 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 Kar-
en’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 cog-
nitive, 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 long-
standing 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 ther-
apy, 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 demon-
strated 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 African-
American 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 thera-
pist for additional “booster” session.

11 Treatment Implications
Although illustration of a single case study may serve to provide a detailed discussion of a par-
ticular 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 them-
selves, 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 behav-
iors, 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 function-
ality 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 nur-
ture 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 appro-
priate 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 exper-
imental 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 prac-
titioners 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 theoreti-
cal constructs that may contribute to the experience and expression of unhealthy anger. This
research will contribute to the knowledge base and further the understanding of the experience,
expression, and treatment of anger among African American women.

400 Clinical Case Studies 8(5)

Declaration of Conflicting Interests

The authors declare that they do not have any conflict of interest.

Funding

The authors received no financial support for the research and/or authorship of this article.

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Bios

A. 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 Uni-
versity, 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.