INCORPORATING CLIENTS' UNDERLYING RELIGIOUS AND SPIRITUAL BELIEFS IN THERAPY MAY IMPROVE SUBSTANCE ABUSE TREATMENT PRACTICES, ESPECIALLY FOR PERSONS OF COLOR

Author: Marguerite E. Hendrickson

Dissertation Chair: Ram Cnaan, Ph.D.

Although pharmacological breakthroughs have improved treatment outcomes for

alcohol and opioid dependence through decreased cravings and blocked reward

effects, there are no FDA approved medications for the treatment of cocaine

dependence. In addition, many routinely practiced psychotherapy models for

addiction remain limited in their effects. As composite case studies will reveal,

cravings and urges to use cocaine prevent clients from obtaining and sustaining

abstinence. Multiple case studies will examine how clients use their underlying

religious and spiritual beliefs to cope with cravings and urges. The first paper in

this dissertation investigates how clients’ religious problem-solving styles can both

positively and negatively affect the recovery process when viewed through the lens

of a scientifically validated instrument, Religious Problem-Solving Scale. The

second paper examines how addressing religious/spiritual issues in therapy may

strengthen the therapeutic alliance with African Americans in outpatient treatment

for cocaine dependence. Given the research evidence that African Americans and

Hispanics actively engage their religious/spiritual beliefs during recovery, this multi-

paper dissertation suggests that clinicians adapt evidence-based therapies by

incorporating religious/spiritual content to meet the needs of the growing

population of color in the United States.

Bridging the Gap Between Adult Children and Their Aging Parents: Developing and Assessing a Life Review Education Program

Abstract

Background: The parent-child relationship is one of the most influential and integral relationships in the life of both members of the dyad. Studies show that the parent-child relationship continues to maintain a place of great importance throughout the life course. In the steadily aging population of the United States, the value of the parent-child relationship is often minimized or overlooked by shifting the focus from a role of parent/child to patient/caregiver. Purpose: The purpose of this mixed-methods exploratory study was to design and implement a Life Review Education (LRE) intervention to: (a) increase understanding; and, (b) facilitate communication within the aging adult/adult child dyad, thereby generating knowledge on the emotional and psychological aspect of the relationship. Methods: The study used a pre-post test design. Ten adult children of aging parents participated in “Bridging the Gap,” a pilot psychoeducational group that implemented Life Review Education through a structured, 75-minute, manualized intervention. The intervention group took place in a physical therapy center in Cherry Hill, New Jersey. Measures: The study assessed subjects’ understanding of life review using the Life Review Understanding Questionnaire (L-RUQ) and the impact of life review education on their communication via the Family Problem Solving Communication Scale (FPSC). The study employed qualitative interviews to gain a more in-depth understanding of the program’s effect on participants. Results: Findings supported the positive impact of the intervention on the adult child’s understanding of life review as well as the positive benefits of a psychoeducational group format. Scores on the FSPC scale did not indicate a statistically significant change in communication within the dyad. The impact of this program on family communication is in need of further examination. Conclusion: This exploratory study serves to integrate the concepts of life review, aging adult/adult child dyads, and psychoeducation and lays the groundwork for future exploration and implementation of life review education.

Methods: This study used a secondary analysis of data from the Survey of Asian American Families which was a cross-sectional study with a total sample size of 273. In the current study, a sample of 259 Asian American immigrant parents who identified to be first-generation was included for analysis. Descriptive, One-way ANOVA, and multiple regression analyses were conducted to examine study questions: relationships between parenting stress, social support, and risk of child maltreatment as well as potential moderating effect of social support.

Results: The results showed that there was a significant positive relationship between parenting stress and risk of child maltreatment even after controlling other predictors. While a significant relationship between social support and risk of child maltreatment was found, the relationship became weakened and insignificant as other predictors were controlled. Contrary to the hypothesized expectation, the moderating effect of social support possibly buffering the negative impacts of parenting stress on risk of child maltreatment was not warranted. Interestingly, there were significant differences in parenting stress, social support, and risk of child maltreatment among Asian ethnic subgroups.

Conclusions: This study suggests providing more culturally competent interventions that aim to reduce parenting stress and intergenerational transmission of child maltreatment, increasing utilization of available services and awareness on child protective services, and enhancing Asian immigrant families to develop a social support system of family and friends. The findings further suggest a possible direction for future research such as including more representative samples, adopting culturally sensitive measures, and examining similarities and differences in parenting stress, social support, and risk of child maltreatment among Asian American immigrants.

Utilizing online survey research, this first convenience sample (N=105) study of Bahá’í mental health practitioners explored participants’ intrinsic religious motivation as a measure of their religious identity, their use of spiritually integrated interventions, and their beliefs about these interventions as appropriate or inappropriate for mental health practice. Results of this study indicate that Bahá’í mental health practitioners are intrinsically motivated, showing similar results in measures of motivation and direction in life (Pargament, 1997) and perceptions of practicing spiritual beliefs (Stewart, Koeske, & Koeske, 2006) or following a spiritual path in life (Derezotes, 1995). Conceptually, intrinsic motivation seems to project perceptions of spiritual strivings (Baumeister, 1991), concept of meaning and purpose in life (Frankl, 1984), belief in God (Sheridan, Wilmer, and Atcheson, 1994), and measures of religious commitment (Wimberley, 1984). Bahá’í mental health practitioners’ belief in the inherent intrinsic value of a human being (e.g., client) and the synonymous parallelism that all therapeutic work is spiritual in nature were noticeably integrated into their use of spiritually integrated practice.

The Bahá’í mental health practitioners’ responses to RSPBQ Index of 29 interventions showed “often” to “very often” utilization of spiritually integrated interventions in contrast with Frazier and Hansen’s (2009) original survey of professional psychologists indicating “infrequent” responses to the same index. They indicate a willingness to use some evidence-based spiritually integrated interventions to their mostly private practices. Responses to open-ended questions show how Bahá’í respondents respect the ethical guidelines for professional practice. An appreciation for the “universality of human beings’ capacities” informs their practice. Viewing the client as “inherently whole and capable” instead of “someone to be fixed, controlled or cured,” the Bahá’í mental health practitioners use spiritually integrated services to achieve a goal of spiritual integration in therapy while fostering “peace and confidence within” instead of adherence to a specific creed, dogma or rituals.

Future research should explore other diverse perspectives, such as those of Muslim, Hindu, Buddhist, Native American, and/or non-religious practitioners. The efficacious use of evidence-based spiritually integrated interventions as alternative ways of coping with mental health problems should also be considered for future examination.

Informed by the historical development of self-determination described in the professional social work literature, eleven, seasoned MSW level child welfare social workers were interviewed in a qualitative study. Participants were asked about how they conceptualized self-determination within their practice, and how they handle working with mandated clients whose rights and decision-making can be limited by the state or agency. In the interviews, workers described self-determination in terms consistent with the literature, and also revealed themes about conflicts that they experience within their job function. Participants also described similar factors that hinder their ability to promote self-determination in practice. The study revealed several newly emerging themes regarding factors that promote a worker’s ability to promote client self-determination in practice. These findings provide insight into how professional social workers engage and interpret the professional mandate of promoting self-determination in the field, and provide direction to help educate and prepare social workers to address key ethical dilemmas, and foster important relationships with clients facing agency mandates and societal oppression.

In-depth interviews with women in long-term recovery from anorexia and/or bulimia were conducted, transcribed and analyzed in order to develop a grounded theory of the progression within the recovery process. This dissertation considers the phenomenology of phases of recovery; individual experiences of levels of recovery; and, how change, specifically from early recovery going forward, occurs.

Findings suggest a developmental process of recovery with central themes defining each stage. Participants’ in the study described nuanced experiences of recovery that lay between chronicity and complete freedom from all vestiges of the disorder. The dissertation proposes a model comprised of three-stages: 1) early recovery, which is dominated by a focus on behavioral change and seeking guidance from external sources, 2) transitional recovery in which change processes that introduce an inward focus emerge; and, 3) “full-enough” recovery, a stage marked by the presence of a flexible sense of self-trust. The term, “full-enough” recovery was developed to convey the participants’ experiences of a recovery that allows them both to acknowledge the presence of occasional mental remnants of the disorder and engage fully in their lives.

Bianca M. Harper

Lina Hartocollis, Ph.D

Sibling incest is an under-reported, under-researched social problem that devastates affected families and challenges social workers and other professionals who work with them. There is little research on family experiences and changes in family dynamics after sibling incest and even less on the reunification experiences of families after sibling incest. The purpose of this study was to gain insight into families’ reunification experiences after sibling incest in order to promote continued healing and improve service delivery. A qualitative study, using semi-structured interviews was conducted with fourteen multidisciplinary professionals involved in family reunification after sibling incest. Grounded theory guided the analysis of interview data. Findings include themes of role of therapist, process of reunification, challenges of multidisciplinary team member collaboration, challenges of ensuring family safety, challenges of determining family readiness, clinical concerns, and lack of a road map. Findings suggest that the process of family reunification after sibling incest is complex and filled with many challenges for both the family and team members. Implications for theory, practice, and future research are also discussed.

CONVERSATIONS IN THE SAND:

ADVANCED SANDPLAY THERAPY TRAINING CURRICULUUM FOR MASTERS LEVEL CLINICIANS

Jacquelyn E. Warr-Williams, MSW, LCSW

Ram A. Cnaan, MSW, PhD

Through their advanced degree and certificate programs, graduate programs in social work produce trained clinicians who are being called upon to work with an increasingly diverse population of clients. To most effectively meet the needs of these populations, clinicians are seeking post graduate trainings that enhance their clinical skills and competency by attaining quality and rigorous training in effective therapeutic methodologies.

Sandplay therapy is a psychodynamic method rooted in Jungian theory that is used with clients with a wide range presenting issues. Initially, Sandplay was exclusively used with children, but currently it has been expanded to treat adults, families, couples, and groups. Although the tools for this method are simple, including sand, a tray, and miniature figures; Sandplay includes intricate techniques that must be learned both didactically and experientially in order to be implemented appropriately with clients. Through exhaustive review of the literature on Sandplay as well as an evaluation of existing Sandplay training programs, a 19-month training curriculum was developed to provide an understanding of Sandplay and the necessary skills for its effective implementation. Participants are offered an academically-focused program comprised of lectures, readings, written assignments, experiential learning, and supervision of clinical Sandplay practice. The goal of this curriculum is to provide master’s level clinicians with advanced training by exposing them to Sandplay as a viable therapeutic method. This dissertation provides the rationale for offering such trainings in graduate social work programs, a detailed description of Sandplay, how it’s applied, and a detailed curriculum for post Master’s level training.

All study respondents acknowledged the disparity between prevalence and reporting and implicated the guilt, shame, and fear experienced by victim-survivors as a key factor in underreporting. Respondents blamed gender inequity, abuse of alcohol, and the developmental immaturity of male college students for high rates of on-campus acquaintance rape and described two distinct types of offending: situational offending refers to non-consensual sexual assault fueled by alcohol abuse and emotional immaturity; and pre-meditative offending refers to a more predatory trajectory, in which deliberate planning is enacted to manipulate and exploit vulnerability.

Respondents identified trust between community partners as the most important aspect to successful collaboration. Trust refers to a collective agreement to protect the confidentiality of alleged victims of sexual assault and to guarantee victims' decision-making control throughout their post-assault recovery process. Respondents endorsed primary prevention models and harm reduction strategies to target on-campus acquaintance rape. Models for prevention focused on eliciting changes in campus culture and on targeting predation. A harm reduction approach focused on teaching students how to minimize their risk for victimization.

Abstract

Jack B. Lewis, Jr.

Joretha Bourjolly, MSW, PhD.

Background: The NASW Code of Ethics charges social workers to be ethically responsible by providing culturally competent practice. The CSWE EPAS addresses teaching culturally competent social work practice in graduate education by requiring the inclusion of diversity content in the social work curriculum. Methods: This research examined the methods utilized by graduate social work programs to teach culturally competent practice to students utilizing diversity content. Data was collected through the analysis of interview transcripts with 12 study participants and the content analysis of 75 course syllabi submitted by the study participants. Analysis: The following concepts derived from the Cultural Competence Practice (CCP) model (Lum, 2011; Fong, 2001): 1. Cultural Awareness, 2. Cultural Values, 3. Knowledge Acquisition, and 4. Skill Development and, 5. Inductive Learning were utilized to guide the content analysis of the interview transcripts and seventy-five course syllabi. Any additional codes that emerged during analysis were also noted and discussed. Results: The study findings reflected that the graduate social work programs in the study sample taught cultural competent social work practice to students through varying combinations of three methods: a. Courses; b. Field Education and c. Non-Course Related Strategies e.g., student organizations, events, and/or community service projects. This limited exploratory study indicates CSWE accredited graduate social work programs utilize various methods to teach culturally competent practice to students. Clinical implications, limitations and further research are discussed.

CAREGIVER VIEWS ON MEDICATION TREATMENT FOR PERSONS WITH SCHIZOPHRENIA IN A CULTURAL CONTEXT

Tracy Griffith

Roberta Sands Ph.D

Schizophrenia is a disabling, often persistent psychiatric disorder that poses numerous challenges in its management and consequences. The burden of care for persons with schizophrenia has shifted from hospitals to families, resulting in a significant cost for the caregiver as well as for the person with schizophrenia (Jungbauer, Wittmund, Dietrich & Angermeyer, 2004). Although there is no agreement on whether a specific cluster of psychotic symptoms has the most impact on a caregiver’s burden of care, there is agreement that the severity of symptoms affects the caregiver. The more severe the symptoms, the larger the burden felt by the caregiver (Muhlbauer, 2008).

The cause of schizophrenia remains elusive and there is no known cure. The best practice model for treating the symptoms of schizophrenia is treatment with anti-psychotic medications and psychosocial supports for the person with schizophrenia and his or her caregiver (McDonald, Short, Berry & Dyck, 2003). Strong social supports, including family and community supports and a good relationship with the care team, reportedly exert a positive influence on medication adherence (Bentley & Walsh, 2006). A study by Drapalski, Leith and Dixon (2009) also has noted that when a family member acts as a caregiver, this has a positive effect on patient outcomes.

This qualitative study explored the views of African American caregivers on medication treatment for schizophrenia. It was guided by the following research questions: What are the views of African American caregivers toward the taking of medication for schizophrenia? How do the caregivers describe their role in relation to medication adherence? What kinds of strategies do the caregivers use to promote medication adherence? How do the caregivers describe their caregiving role in relation to activities outside medication adherence? How do African American caregivers incorporate cultural values into their caregiving role? How do caregivers view support, or lack thereof, provided by community mental health services?

The research used a modified grounded theory methodology. Semi-structured interviews were conducted with ten African American caregivers and two key informants. The major study findings were: (1) Monitoring of medication was a significant activity for caregivers. (2) Strategies to promote medication adherence varied among caregivers. (3) Non-medication adherence caregiver activities were around maintaining their loved one in the community. (4) The importance of family and church was a strong cultural value for the caregivers. ( 5) Supports and coping methods for the caregivers centered around a strong faith system and close family, friends and the relationship with the psychiatrist.

Two theories of explanation were used to interpret the findings, symbolic interactionism and a family life course developmental framework. Recommendations for social work intervention with caregivers were made.

Marni Rosner

Ram A. Cnaan, Ph.D., Dissertation Supervisor

Infertility, from a mental health perspective, is known to have a profound effect on the lives and identities of women. Although many women resolve their infertility by incorporating non-biological children into their conception of family, some women are either unable or unwilling to do so, and live without children. This qualitative study focused on the long-term transition to living without children after pursuing treatment for infertility, and the impact living without children after infertility has had on marriages, relationships with family and friends, and identity. In-depth interviews were conducted with 12 women, aged 35-54, who pursued treatment for infertility, are now living without children (either biological, conceived through third-party reproduction, or adopted), and have not pursued treatment for at least three years. Findings include themes of experiencing trauma; actively deciding to end treatment; moving into living without children; a sense of profound loss and grief; processing the grief; acceptance and choice; reestablishing identity and turning toward the future; growth and opportunity; improved spousal relationships, and enduring issues. Like most stage models, progressing through these phases was not systematic. Findings suggest that it took, on average, 3-4 years for the women to fully emerge from feeling like being infertile was their primary identity. Implications for clinical practice and future research are also discussed.