Clinical Case Studies

Clinical Case Studies 8(5) 383 –402

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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

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(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

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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

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(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.

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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

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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

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manner” meant to her, and how she envisioned herself behaving, feeling and, most important, thinking differently, once that she had successfully completed therapy. Karen agreed that, as a homework assignment, she would work on defining what she wanted to get out of treatment. Three main objectives emerged. Behaviorally, Karen wanted to be able to verbally express her feelings of anger assertively and appropriately and she wanted to do so without the guilt and depression that she often experienced following her maladaptive forms of anger expression. Second, she wanted to be able to set healthy, reasonable limits as to how much she would take on or how much she would help others and she wanted to learn “how to relax.” Third, from a cognitive perspective, Karen wanted to be able think that it was okay to not always be avail- able to others, and to think that it was okay to take care of herself without feeling guilty for doing so.

6 Case Conceptualization Karen’s anger was conceptualized, using a cognitive-behavioral conceptualization model out- lined by Beck (1995) which identifies various levels of cognitions and their impact on the individual. Equally important, to increase the cultural relevancy of the conceptualization process, the schemas that supported her anger were framed within significant gender-role and culturally relevant factors that affected her mode of anger expression. Karen’s references to depression were conceptualized as the result of engaging in strong and persistent self- condemnation and self-blame, usually following her anger outbursts and her perceived “loss of control.” Beyond those incidents, Karen did not present with any symptoms of depression, nor did she have any significant history of depression; therefore, we agreed that anger was the primary problem.

Karen’s core beliefs related to how she viewed herself and the world/others. Her views of the self were underscored by these beliefs such as: “I am competent,” “I am strong,” and “I am a helper.” She saw the world as “hostile,” “cold,” and “uncaring.” Out of these central beliefs, Karen had developed important rules which she used to guide and measure her behavior, as well as the actions of others. Some of these rules were: “I should be able to help those in need,” “I should stand against the uncaring world that oppresses disempowered people,” “I should endure without complaint,” and “If I fail to help others, then I am a failure.” These beliefs and rules had translated into strategies that Karen used throughout her life. These strategies emphasized self- denial and attention to others’ needs. In addition, Karen often felt that others should recognize that she was overworked and therefore should stop being so demanding of her time. Yet, she was unable to verbalize such wishes to others. When others continued to demand her time, Karen concluded that they were insensitive and just did not care. This type of blame was seen as a piv- otal factor that fueled both her anger and depression. Whenever she felt frustrated in her attempts to achieve certain outcomes, she blamed others and her emotional response was anger directed, although unstated, at the perceived transgressor. Conversely, on those occasions when she blamed and belittled herself for not being “strong” and “losing control” by acting angrily, she experienced depression and guilt.

A critical aspect of working with clients with anger problems is the establishment of a thera- peutic alliance. This is particularly true when working with angry clients, whose view of the world is punctuated by suspiciousness and mistrust (DiGiuseppe, 1995; González-Prendes & Jozefowicz-Simbeni, 2009). In these situations, it is imperative that the client be engaged and actively included in every aspect and step of the treatment process. In Karen’s case, from the first interaction of the assessment process, it was imperative that she felt a sense of ownership of the treatment process. In cognitive behavior therapy, one strives to establish a collaborative empirical alliance (Beck, 1995) that empowers the client by getting her involved in the

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decision-making process, from the identification of the problems, to the establishment of the goals, the formulation of homework assignments, the design of behavioral experiments and other strategies. Cognitive-behavioral therapy has been described as an empowering approach because it acknowledges the client’s expertise about herself and her ability to control and change her thinking; engendering changes in her emotional and behavioral responses (Hays, 1995).

7 Course of Treatment and Assessment of Progress Karen’s treatment took place more than 20 individual therapy sessions of 50 minutes in length. The first 12 sessions were weekly, followed by 6 every-other-week sessions. The last two ses- sions were follow-ups at a 3-month and 6-month point after the initial 18 sessions were completed. Treatment followed a cognitive-behavioral model that acknowledges the primary role of cogni- tions (i.e., judgments, meaning, attributions, etc.) in determining how one responds, emotionally and behaviorally, to life situations (Beck, 1976; Ellis, 1962). We employed a person-in-environ- ment perspective to frame Karen’s beliefs within important sociocultural perspectives that gave special meaning to her actions.

The overall cognitive-behavioral treatment occurred within a three-stage framework as out- lined by Meichenbaum (1985, 1996). The goal of the first stage was to help Karen understand her anger. This entailed helping her to understand how her idiosyncratic thoughts and 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.

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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

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