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... EFFECTIVENESS OF CCRT APPROACH: TWO CASE STUDIES EFFECTIVENESS OF CCRT APPROACH WITH CLIENTS WITH ANXIETY AND DEPRESSION: TWO CASE STUDIES. A Doctoral Dissertation presented to the Graduate Department of Clinical Psychology University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Mrnalini Rao, M.A. March, 2023 i EFFECTIVENESS OF CCRT: TWO CASE STUDIES EFFECTIVENESS OF CCRT APPROACH WITH CLIENTS WITH ANXIETY AND DEPRESSION: TWO CASE STUDIES The signatures below certify that the Doctoral Dissertation Defense of Mrnalini Rao has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: ______________________________ Aaron Kivisto, PhD Dissertation Advisor John Kuykendall, PhD Dean, College of Applied Behavioral Sciences 3/9/2023 ____________________________ Samantha Gray, PhD Committee Member Michael Poulakis, PsyD Committee Member 3/3/3023 _________________________ Date ________________________ Date ii EFFECTIVENESS OF CCRT: TWO CASE STUDIES iii Abstract Evidenced-based practices are extremely valuable in the field of psychology. Randomized clinical trials have been considered the gold standard of evaluating the effectiveness of treatments. However, the importance of single-subject design and its focus on individual differences to understanding what therapeutic interventions works for whom offers complementary evidence. This study examined the efficacy of brief psychodynamic therapy using Luborskys (1999) core conflictual relationship theme (CCRT) approach with two clinical case studies in the treatment of major depressive disorder and generalized anxiety disorder. The participants were selected based on convenience sampling. A single-subject method with time series data was utilized. Statistical methods of Percentage of NonOverlapping Data (PND) and Reliable Change Index (RCI) were used for analysis. Outcome measures used to assess change across treatment included the Brief Symptom Inventory (BSI) and Participant Health Questionnaire-depression and anxiety disorders (PHQ-SADS). The results of the present study indicate that CCRT approach provided clinically significant improvement for depression and anxiety concerns for both clients. All areas of functioning assessed using BSI and PHQ-SADS demonstrated significant and positive changes. Keywords: Core Conflictual Relationship Theme (CCRT), Short-term psychodynamic treatment, depression, anxiety, brief therapy, single-subject design, PND, RCI, clinical case study EFFECTIVENESS OF CCRT: TWO CASE STUDIES iv Acknowledgments I would like to thank my parents for always supporting, encouraging and for believing in me. I would like to express my sincere gratitude to my dissertation chair Dr. Aaron Kivisto for the continuous support of my dissertation, for his patience, motivation, enthusiasm, and immense knowledge. He has been incredibly supportive from the beginning. He has guided me through the initial stages where I was formulating my thesis and helped me brainstorm and carry the idea through. He has encouraged me to organically organize and coherently approach the topic and its various facets. I would also like to thank my friends for being supportive and helping me remain motivated through the process. EFFECTIVENESS OF CCRT: TWO CASE STUDIES v Table of Contents SIGNATURE PAGE .................................................................................................................. ii ABSTRACT ........................................................................................................................................... iii ACKNOWLEDGEMENTS ................................................................................................................... iv LIST OF TABLES ................................................................................................................................. vi LITERATURE REVIEW ........................................................................................................................ 6 Review of Single-subject Case Design ............................................................................................... 6 Analytic Approaches to Case Study Research ...................................................................... 9 Evidence for Psychodynamic Therapy ................................................................................. 11 CCRT description ................................................................................................................ 15 Evidence for CCRT with anxiety disorders and depressive disorders ................................. 20 CLIENT DESCRIPTION ......................................................................................................... 21 Presenting Problem Client 1 .............................................................................................. 22 History and Background .............................................................................................. 22 Diagnosis ...................................................................................................................... 25 Treatment Plan ............................................................................................................. 26 CCRT Conceptualization ............................................................................................. 26 Course of Treatment ..................................................................................................... 28 Presenting Problem Client 2 ............................................................................................... 32 History and Background .............................................................................................. 32 Diagnosis ...................................................................................................................... 35 Treatment Plan ............................................................................................................. 36 CCRT Conceptualization ............................................................................................. 36 Course of Treatment ..................................................................................................... 38 CLINICAL RESEARCH QUESTIONS .................................................................................. 42 EFFECTIVENESS OF CCRT: TWO CASE STUDIES vi METHOD ................................................................................................................................. 43 Research Design .......................................................................................................... 43 Participants ................................................................................................................... 43 Measures....................................................................................................................... 43 Statistical Approach .................................................................................................... 45 RESULTS Testing results Client 1 ................................................................................................. 48 Testing results Client 2 ................................................................................................. 54 DISCUSSION .......................................................................................................................... 60 REFERENCES ......................................................................................................................... 63 EFFECTIVENESS OF CCRT: TWO CASE STUDIES vii LIST OF TABLES AND FIGURES Table 1. .....18 Tallberg et al. (2020) CCRT categories for Wish, Response to self and Response from Others Table 2. .....46 PND Scores and interpretation Table 3. .....48 PHQ-SADS Scores for Client 1 Table 4. .....49 BSI scores for client 1 Table 5. .52 RCI Data for BSI, Client 1 Table 6. .53 RCI Data for PHQ-SADS, Client 1 Table 7. .....54 PHQ-SADS Scores Client 2 Table 8. .55 BSI Scores for client 2 Table 9. .55 RCI data for BSI, Client 2 Table 10. .56 RCI Data for PHQ-SADS, Client 2 Figure 1. .....50 PND analysis for BSI scores client 1 Figure 2 .....50 PND analysis for PHQ-SADS scores client 1 Figure 3. .....56 PND analysis for BSI scores client 2 Figure 4. .....56 PND analysis for PHQ-SADS scores client 2 EFFECTIVENESS OF CCRT: TWO CASE STUDIES 6 Chapter 1 Literature Review Although group-level randomized controlled trials (RCTs) are frequently regarded as the gold standard for psychotherapy research, single-subject research designs provide complementary, idiographic data that is not obtainable with group-level designs. Proponents of single-subject designs have described clinical practice as a natural laboratory for psychotherapy research (Borckardt et al., 2008). Kazdin (2018) notes that the term singlesubject could be misleading, since this design is not necessarily limited to just one individual, but could be utilized with a large group of participants where the data analytic approach remains individualized. A key feature of single-subject designs is that it combines actual clinical treatment, as it occurs naturally, and empirical evaluation. Whether carried out with one or more clients, single-subject designs enable clinicians to use the client as their own control, which means treatment effects can be investigated in terms of clients symptoms and adaptive functioning over time. In other words, single-subject designs emphasize withinsubject change, whereas group-level designs emphasize between-subject change. Strengths and Limitations of Randomized Controlled Trials Hariton and Locascio (2018) described the strengths of RCTs that have led these designs to be regarded as the gold standard of evidence-based practice. One of the major factors that make RCT exceptional is its ability to evaluate causality and reduce bias by using randomization. Biases such as selection bias, performance bias, assessment bias and confounding errors are minimized when using RCT method. This also allows researchers to account for individual differences, which are presumably washed out between groups through the randomization process. Another advantage of RCTs is that they allow for comparisons between treatment modalities and are able to establish relative superiority and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 7 non-inferiority. This makes it the strongest source of evidence regarding the efficacy of psychological treatments. However, it is important to understand the limitations of this gold-standard group level design. Westen (2004) argues that RCTs are far from perfect and cites several limitations of this methodology. First, he contends that many RCTs make assumptions that are not validated or applicable to all disorders and treatments. For example, many RCTs assume that psychopathology can be controlled, that most clients can be treated for a single disorder, and that psychopathology can be treated independent of personality aspects. Second, he notes that many RCTs do not account for comorbidities due to ruling out participants with particular comorbid conditions that are common in clinical practice. Goldfried (2000) found that RCTs for brief therapy frequently lacked systematic data to guide the length of treatment. Instead, psychotherapy researchers commonly based the prescribed length of treatment on assumptions adopted from medication studies. There were also problems with basing treatment research on DSM categories, as the sheer number of distinct disorders listed in the DSM makes having manuals for all unrealistic. Westen and colleagues (2006) also identified significant limitations in the evidence obtained from psychotherapy RCTs. For instance, they found RCTs of treatment for major depressive disorder commonly excluded participants with symptoms of suicidality or substance abuse, resulting in questionable generalizability for patients with depression seen in practice. This creates challenges for clinicians, as they might be trying to apply results of an RCT to a client that may likely have been excluded from the RCTs (Zane, 2004). Strengths and Limitations of Single-Subject Designs Kazdin (2018) suggests that single-subject methodologies provide viable designs for clinicians as data provides information regarding whether therapeutic change has occurred. Borckardt et al. (2008) suggest that all practitioners might want to assess whether there is an EFFECTIVENESS OF CCRT: TWO CASE STUDIES 8 effective change from the baseline to treatment phase, and single-subject designs can provide relevant evidence regarding psychotherapy outcomes and processes (e.g., how change in treatment unfolds over time and under what circumstances). Single-subject time series methods are also advantageous in bridging the gap between evidence derived under highly controlled experimental settings and practice-based knowledge. Single-case designs are considered to provide systematic and detailed analysis for clinical interventions and allow for valid results (American Psychological Association, 2018) Elaborating on using single-subject methodologies as a way to evaluate treatment in clinical settings, Kazdin (1983) suggested that single-subject designs compliment research from experimental settings where conditions often differ from those in actual clinical practice. For clinicians wanting to conduct single-subject research, Kazdin (1983) recommends first identifying a specific treatment and a measurable goal that would be expected to be achieved through treatment. This entails selecting measures that can reflect client progress in treatment (e.g., measures that quantify mutable, clinically relevant constructs rather than trait-based measures that would be insensitive to change). Second, Kazdin emphasizes the importance of continuous assessment that examines clients clinical status over time. He concludes that single-subject methods help strengthen inferences beyond those derived from uncontrolled case studies. Psychotherapy process and outcome data provided by single-subject research designs help clarify group-level validity evidence of psychological treatments (Sexton-Radek, 2014). Benefits of single-subject designs include the fact that they are relatively cost-effective, easy to implement, and able to provide immediate feedback to clients. Rapoff and Stark (2008) and Lenz (2015) further note that single-subject designs are flexible and allow clinicians to make modifications as new information comes to light. Further, this method is amenable to small samples, which allows for studying rare disorders where group-level research designs would EFFECTIVENESS OF CCRT: TWO CASE STUDIES 9 be prohibitive. Single-subject methods also allow for flexibility as it might include marginalized populations that might be difficult to recruit for large scale RCTs. Whereas group-based designs ideally aim to ensure standard procedures for all through fidelity checks, single case designs are flexible to accommodating treatment depending on individualized client needs. The data that is provided by single-subject designs enables clinicians to obtain in-depth understanding of the client and understanding of not just whether treatment works, but whom it might not work with (Lobo et al., 2017). Through the use of repeated measures, single-subject designs are able to test for causal relationships regarding the impact of treatment that can be directly interpreted. Lastly, it promotes meaningful evidence-based practice. As noted by Romeiser and colleagues (2008), by capturing the ebb and flow of symptoms over the course of treatment, single-subject designs offer a particularly nuanced window into psychotherapy process that if often neglected in group-based designs. Although single-subject designs afford considerable benefits, these strengths come at the cost of external validity, creating challenges to the generalizability of results. Rather than generalizing results of single-subject psychotherapy research to large and heterogeneous groups of individuals, a more conservative approach is warranted to focus on individuals who have similar characteristics to the research subject(s), psychological concerns, and prognostic characteristics. However, generalizability might not be of paramount importance for clinicians seeking to specifically test the effectiveness of their treatment modality with their specific client. Further, because individual clinicians frequently see similar types of clients, it is possible that the evidence derived from their single-subject studies might generalize quite directly to groups of clients typically seen in their own practice. Analytic Approaches to Case Study Research EFFECTIVENESS OF CCRT: TWO CASE STUDIES 10 There are several empirical approaches to analyzing psychotherapy process and outcome in single-subject designs. Common across these approaches, single-subject designs require, at a minimum, one pre-treatment and one post-treatment data point. For several empirical approaches, multiple baseline and treatment data points are required, with daily measures typically representing the high end of the measurement frequency spectrum. Percentage of Non-Overlapping Data. Alresheed and colleagues (2013) described the percentage of non-overlapping data (PND) approach as one of the oldest methods of calculating effect sizes in single-subject research designs. To determine if the treatment is effective using the PND approach, the percentage of non-overlapping data between baseline and treatment is calculated. Alresheed et al. (2013) describe several circumstances under which the PND approach is limited. First, if the data has many outliers, it can misrepresent the effectiveness of the intervention. Second, the PND approach must be interpreted carefully in order to identify situations in which the treatment had negative effects (e.g., a decrease in desirable behavior or increase in undesirable behavior), as these situations might lead to low levels of overlapping data between baseline and treatment phases that carry distinct implications. Another disadvantage, the PND approach is sensitive to extreme baseline scores. For example, if a client obtains a score of zero at baseline on a symptom inventory, the PND approach would not be able to detect any symptom improvement (Olive & Franco, 2008). Lastly, PND is unable to analyze continuous trends in the data (Allison & Gorman, 1993). Alresheed and colleagues (2013) recommend scoring based on multiple matrices for estimating effectiveness of treatment and combining statistical analysis with visual analysis. There are several notable strengths of the PND approach, which is one of the most used methods for testing meaningfulness of change (Lenz, 2013; Olive & Franco, 2008). One major advantage of the PND score is that researchers are able to easily interpret data. A PND EFFECTIVENESS OF CCRT: TWO CASE STUDIES 11 score is also easy to calculate and intuitive. It also lends itself to visual analysis, which enables researchers to understand what it means when 90% of data are not overlapping with baseline. Further, because the method relies on individual data points rather than the distribution, it does not require parametric assumptions about the distribution of data (Parker et al., 2011). Reliable Change Index Another approach created by Jacobsen and Truax (1991) is the Reliable Change Index (RCI). The RCI is used to evaluate clinically significant changes between pretest and posttest. They defined clinical significance as when clients in therapy move from a dysfunctional range to a functional one. Statistically, the RCI measures whether symptom change is larger than would be expected due to simple measurement error, and as a result the RCI is calculated as a function of the pre- and post-treatment scores, along with the standard error of the measurement instrument. When the amount of change is small or within the range of expected measurement error it is deemed unreliable. For treatment effects to be considered reliable it should pass two stages. Firstly, it must prove to be statistically reliable using RCI, and secondly, clients must pass from a dysfunctional to functional range. This means that each client in the treatment study could be classified as recovered (if passed clinical significance criteria and RCI), improved (passed only RCI criteria), unchanged or indeterminate (passed neither) or deteriorated (if RCI is significant in the opposite direction as that expected, indicating an increase in symptoms larger than would be expected from simple measurement error). Evidence for Psychodynamic Therapy This research focuses on testing the effectiveness of Luborskys (1999) Core Conflictual Relationship Theme (CCRT) approach to brief psychodynamic therapy with two clients suffering from depression and generalized anxiety disorder (GAD). The following EFFECTIVENESS OF CCRT: TWO CASE STUDIES 12 section describes the efficacy of psychodynamic therapy generally before discussing CCRT specifically. Hilsenroth and colleagues (2003) and Barber et al. (2012) studied the effectiveness of brief psychodynamic therapy for patients with depression. In Hilsenroth et al.s (2003) study, 27 participants were recruited with a diagnosis of major depressive disorder from a community outpatient setting. Four participants prematurely terminated after about four sessions. A total of 21 participants (11 men, 10 women) completed the study. Treatment involved twice weekly sessions of short-term psychodynamic therapy (STPP) across 30 sessions. Treatment was aided by integrating four STPP treatment manuals based on management of depression. The therapists were ten advanced graduate students enrolled in an APA-accredited program. Participants were assessed before and after treatment using three self-report measures: the Symptom Checklist-90-Revised (SCL-90-R), Social Adjustment Scale (SAS), and DSM-IV rating scales. The participants also answered two questions assessing their confidence in treatment and credibility. Sessions were rated using the Comparative Psychotherapy Process Scale (CPPS-PI). Results were calculated using paired ttests assessing pre- and post-treatment changes. The mean CPPS-PI pre-test score was 1.21 (SD = 0.27) and the posttest was 3.56 (SD = 0.79). Therapeutic focus was found to be significantly associated with reduced depression symptoms (t = 11.54, p < .001) indicating that this therapy worked to reduce depression symptoms. Results indicated that the credibility, satisfaction, and perceived effectiveness were all high. Driessen and colleagues (2013) compared the relative efficacy of psychodynamic therapy and CBT for depression in a randomized controlled trial designed to test noninferiority. The sample of 341 patients were treated for depression in psychiatric outpatient clinics. Participants were selected based on meeting DSM-IV criteria for Major Depressive Disorder and a score above 14 on the Hamilton Depression Rating Scale (HAM-D). EFFECTIVENESS OF CCRT: TWO CASE STUDIES 13 Participants were randomly assigned to 16 sessions of short-term psychodynamic therapy or manualized CBT treatment. Results were calculated using HAM-D scores to examine treatment effectiveness immediately following treatment and at one-year follow-up. The primary outcome measure was posttreatment remission rate, defined as HAM-D scores below seven. Secondary outcomes were measured at one-year follow using HAM-D scores and score on the Inventory of Depressive Symptomology-Self Report (IDS-SR). Results showed that 22.7% of all patients met remission criteria at posttreatment and after one year follow up 26.8% showed remission rates. No differences were observed between the psychodynamic and CBT conditions, supporting the non-inferiority of psychodynamic therapy for depression relative to CBT. Leichsenring (2001) also compared the effectiveness of psychodynamic treatment and CBT for clients with depression. A sample of sixty participants were recruited from outpatient clinics with a DSM-IV diagnosis of depressive disorder. Participants were randomly assigned to CBT or psychodynamic intervention groups. Manualized CBT and short-term psychodynamic therapy were applied for 16 sessions. The Beck Depression Inventory (BDI) was utilized to assess depression symptoms pre- and post-treatment. Results showed significant symptom reduction in both conditions, with effect sizes ranging between 0.94 and 2.44. Consistent with Driessen et al.s (2013) non-inferiority trial, psychodynamic therapy was found to be as effective as CBT with regard to symptom reduction. Ajilchi et al. (2016) examined whether intensive short-term dynamic therapy (ISTDP) would result in reduced symptoms of depression and improved executive functioning. Participants with a DSM-IV diagnosis of Major Depressive Disorder (MDD) and a score of over 20 on the Beck Depression Inventory-II (BDI-II) were recruited from a mental health outpatient clinic in Iran. This study recruited sixteen participants who were randomized to ISTDP or a to a waitlist control group. Pre- and post-test measures were used to calculate EFFECTIVENESS OF CCRT: TWO CASE STUDIES 14 differences between groups. Outcome measures included the BDI-II, which was used to measure depression symptoms, and the Wisconsin Card Sorting Task (WCST) and Stroop test, both of which measure executive functioning. Results showed significant improvements in depressive symptoms and executive functioning from pre- to post-treatment for the ISTDP group, and participants in the active treatment condition showed significantly greater improvements than those in the waitlist control condition. Monti et al. (2014) analyzed the effectiveness of psychodynamic therapy (PDT) (n = 29) and CBT (n = 40) for anxiety disorders in university students at the University of Bologna. Dropout rates were higher in the CBT (n = 10) condition than in the PDT condition (n = 5). Participants were administered the Symptom Questionnaire (SQ) at the beginning, middle, and end of treatment to measure symptom change. There were no specific manuals used for CBT or PDT, only core principles of each therapy were applied. The duration of treatment was one year of weekly 50-minute sessions. Results showed significant effect within-group effects of treatment on the SQ anxiety scale, such that post-treatment scores were significantly lower than pretest scores (ps < .001). There were no significant differences in between-group scores or the interaction between within and between group scores. Both treatments led to significant decrease in anxiety symptoms after one year, and consistent with the findings above, no differences were detected between CBT and psychodynamic psychotherapy. Leichsenring et al. (2013) conducted a multicenter randomized trial to study the effectiveness of psychodynamic therapy and CBT for social anxiety disorder. Patients (N = 495) from an outpatient clinical setting were randomly assigned to a manualized CBT condition, manualized psychodynamic condition, or a waitlist condition. All participants had a diagnosis of social anxiety disorder and were administered the Structural Clinical Interview for DSM-IV (SCID-IV) and Liebowitz Social Anxiety Scale. Assessments were conducted at EFFECTIVENESS OF CCRT: TWO CASE STUDIES 15 the start, week eight, week 15, and at the end of treatment. CBT and psychodynamic treatment went on for 25 sessions (once a week and 50 minutes). Results indicated that CBT and psychodynamic therapy were superior to the waitlist condition. In this study, remission rate is understood as treatment leading to no longer meeting criteria for diagnosis and response rate is a patients reduction in symptoms over the course of treatment. There were significant differences when comparing CBT and psychodynamic therapy in terms of remission rate in favor of CBT, such that remission rates for CBT, psychodynamic, and waitlist conditions were 36%, 26%, and 9%, respectively. However, results showed no difference in response rates between CBT (60%) and psychodynamic (52%) conditions, with improvements in depressive and anxiety symptoms found with each of these therapies. Bgels et al. (2014) researched the efficacy of CBT versus psychodynamic therapy for social anxiety disorder (SAD). Forty-seven participants were recruited based on a SAD diagnosis according DSM-IV based on evaluation with the SCID. Outcome measures used at pre- and post-test included the Social Phobia and Anxiety Inventory- Social Phobia subscale (SPAI), the Social Sensitivity subscale from the Symptom Checklist-90 (SCL-90), Social Phobia Disorders Severity and Change Scales (SPDSC), Social Phobic Beliefs Inventory (SPB), and the Defense Mechanism Inventory (DMI). Participants were randomly assigned to psychodynamic (n = 22) or CBT (n = 27) conditions. Psychodynamic treatment was time limited and focused and guided by Malans principles. CBT treatment was manualized. Results showed that there was no difference between PDT and CBT treatments and indicated that both treatments were highly efficacious, with remission rates over 50%. These results also were similar to Driessen et al.s (2013) study in finding no difference in SAD remission rates between CBT and PDT. CCRT description EFFECTIVENESS OF CCRT: TWO CASE STUDIES 16 Luborsky et al. (1994) developed the Core Conflictual Relationship Theme (CCRT) as a brief psychodynamic treatment model. Luborsky described that the CCRT model as focused on self-other narratives as a way of identifying relationship episodes for the purpose of understanding the ways in which these episodes illuminate the etiology and maintenance of psychological distress. Depending on a clients psychological resources and level of impairment, Luborsky suggested that clients require different types of interventions that fall on a continuum, from supportive to expressive. Supportive interventions are described as those that strengthen ego functioning and existing defenses. By contrast, expressive interventions are described as aiming to develop increased self-understanding, such as bringing previously unconscious material to conscious awareness. In essence, supportive and expressive approaches can be considered interventions aimed at either bolstering existing psychological resources versus loosening overly restrictive defenses, respectively. Interventions along both ends of the supportive-expressive continuum focus on relationship patterns as they impact clients current difficulties. Luborskys development of a CCRT manual was unique among psychodynamic theorists and, as a result, his approach has become widely adopted by psychodynamic psychotherapy researchers. Luborskys (1994) CCRT manual includes selection criteria for clients working with expressive and insight-oriented therapy. These include client having good ego strength, in terms of having intact reality testing, adequate capacity to be reflective and not impulsive, adequate frustration tolerance, and adaptive defenses. Other factors include a clients capacity to be psychologically minded, that is, able to see connections between past and present, an ability to view oneself as agent as much as victim, and the motivation and capacity to engage and disengage readily. Book (1998) developed a guided manual to practice the CCRT approach. This manual is an extensive guide that helps practitioners apply a 16-session version of CCRT. According EFFECTIVENESS OF CCRT: TWO CASE STUDIES 17 to Book (1998), CCRT has three phases of treatment. Phase one is between the first and fourth sessions. This period involves helping clients to identify their wish (W) in narratives and to develop insight. The Wish, is an impulse, what a individual wants to do, and needs to do to effectively deal with a situation. However, the wish can also be something thats very often blocked by defenses and maladaptive efforts avoid the anxieties that are aroused by the wish. The aim is to enable the client to see how the CCRT affects a persons day-to-day life. The therapists role is to be active, direct, and to focus on relationship episodes (RE). The therapist also encourages clients to discuss interactions and relationships. Phase two of treatment occurs between sessions five and 12. This phase involves identifying and working through the response from others (RO) and response to self (RS), which entails helping the client understand how the response of others, whether real or imagined, influences their reactions to their wish. The RO is often anxiety-arousing, and so the psychological operations that follow are aimed at minimizing this anxiety. That is, it is the product of defenses doing what they are originated to do, which is, reduce anxiety. The RS consists of a behavioral component and an affective component. It pertains to what the client did and what he, she or they felt. The therapist at this stage supports the client in understanding how others might shape their own response and to begin working with transference that might arise in the therapeutic alliance. In CCRT, the transference is referred to as enactments, which are seen as a way of helping the client process the responses of others in the here-and-now of the therapy office. The clients ability to understand repetitive patterns is strengthened in this phase as they become better able to understand the patterned and selfdefeating nature of their relationship episodes. Finally, phase three of treatment is between sessions 13 and 16. This phase involves the termination process. The therapist must pay particular attention to termination-related unconscious comments by the eighth session. In this phase therapist shares the progress made EFFECTIVENESS OF CCRT: TWO CASE STUDIES 18 in the CCRT developed with the client. The therapist also engages the patient in discussions surrounding the patients thoughts, concerns, and fears regarding ending therapy. CCRT Conceptualization Wilczek and Weinryb (2010) examined the validity of CCRT conceptualizations in distinguishing between different psychological disorders. The aim of the study was to assess if CCRT patterns differed for patients with different DSM-III diagnoses. Another objective was to compare CCRT conceptualizations of clients with and without a DSM diagnosis. They recruited 55 participants from clients who had registered to participate in therapy. Trained clinicians collected relationship episodes (REs) and identified and scored each component to identify the primary W, RO, and RS for each client. Results indicated that participants mostly had a diagnosis of depression (65%) and their CCRT reflected a negative perception of response of other (RO) and an immature dependency in object relation terms in their interpersonal patterns. Other common diagnoses included anxiety disorders (59%); these participants tended to have more paranoid responses to ROs and had problems establishing meaningful relationships. Clients without a DSM diagnosis tended to have both positive and negative ROs. Based on these patterned differences across diagnostic (and undiagnosed) groups, these authors concluded that CCRT conceptualizations provide discriminant validity. Tallberg et al. (2020) analyzed the inter-rater reliability of CCRT conceptualizations using a limited set of categories to classify clients wishes, response from others, and response to self. In this study, patients were randomly assigned to seven therapists who were trained in CCRT. Relationship episode coding options were limited to create a user-friendly CCRT conceptualization tool. They provided clinicians with eight categories of W, eight categories of RO, and eight categories of RS. The categories are shown in the table below: Table 1 Tallberg et al. (2020) categories EFFECTIVENESS OF CCRT: TWO CASE STUDIES Wishes (W) Response from Others 19 Response to Self (RS) (RO) Wishes (W) Response from Others (RO) Response to Self (RS) Achieve and help others Strong and independent Helpful Asserting self and being independent Opposing hurt and controlling others Be controlled, hurt and not responsible Be distant and avoid conflict Controlling Unreceptive Upset Respected and accepted Bad Oppose and hurt others Rejecting and opposing Be close and accepting Helpful Self-controlled and selfconfident Helpless Be loved and understood Likes me Disappointed and depressed To feel good and Understanding Anxious and shameful comfortable Note. Items are derived from Tallberg et al. (2020). Results indicated inter-rater reliabilities ranging from .33 to .75, which ranged from unacceptable to good. Despite these limitations, the authors suggest that the reliability demonstrated in this study is generally on par with previous, more complex CCRT conceptualization coding systems. Additionally, given that case conceptualization is a complex process known to result in lower reliability than is typically seen with psychological tests, the authors conclude that these results are promising. It should be noted that this study was only concerned with the inter-rater reliability of generating a CCRT conceptualization regarding the W, RO, and RS and did not examine whether the resultant conceptualizations were associated with treatment outcomes. The method involved using the semi-structured dynamic interviews for 2 hours and the raters rated based on those interviews. The inter-rater reliability for assessing results was measured by Cohens kappa coefficient. There were eight standardized clusters for wish, relationship with others and relationship with self-themes. The EFFECTIVENESS OF CCRT: TWO CASE STUDIES 20 research scored one or more categories in each theme. The mean Kappa for Wishes (W) was .33, Response from others (RO) was .71 and Response from Self (RS) was .75. The results indicated that rater agreements of wish theme showed the lowest level of agreement and the agreements for relationship with self and others theme showed the highest level of agreement. The researchers discuss that moderate level of inter-rater reliability was found and this was mainly due to the difficulty to score what categorizes as wishes for participants. Evidence for CCRT with Anxiety Disorders and Depressive Disorders Crits-Christoph and colleagues (1996) evaluated brief supportive therapy for individuals suffering from generalized anxiety disorder (GAD). In a sample of 26 individuals with GAD from different clinical settings, participants were provided 16 weeks of supportive expressive CCRT therapy provided by trained clinicians. The interpersonal conflicts that emerged in therapy were analyzed by clinicians using the CCRT approach emphasizing wishes, responses of others, and responses to self. The SCID and Hamilton scales was used to measure anxiety and depression. Results showed a statistically significant reduction in symptoms and overall quality of life after 16 weeks of CCRT therapy. Specifically, the authors reported that 79% of the participants did not meet criteria for GAD any longer, a remission rate much higher than that observed by Leichsenring et al. (2013). Additionally, the average symptom severity rating for non-remitted participants was 4.2 at post-treatment, compared to 7.8 at baseline. Connolly and colleagues (1998) recruited 33 patients with a diagnosis of depression and provided 16 weekly sessions of Supportive-Expressive therapy following CCRT principles. Participants were administered the Schedule for Affective Disorders and Schizophrenia Change version (SADS-C) and Penn Adherence/Competence scale for SE therapy (PACS-SE) to evaluate clinicians fidelity to the treatment. Results showed that SADS-C scores decreased significantly, from 17.9 to 7.8, across treatment. Results indicated EFFECTIVENESS OF CCRT: TWO CASE STUDIES 21 that 16 weekly sessions using SE therapy helped participants reduce symptoms, improve relationships, and improve overall quality of life. Dos Santos and colleagues (2020) compared the effectiveness of cognitive behavioral therapy (CBT) and brief psychodynamic therapy using the CCRT approach for Major Depressive Disorder using a randomized clinical trial. They recruited 50 patients between 18 to 60 years old. All participants diagnosis was based on DSM-IV and they were administered the Beck Depression Inventory-II (BDI-II) and Functioning Assessment Short Test (FAST). CBT was conducted using Becks manual and short-term dynamic therapy for 16 weeks using Luborskys manual. Across all participants, 82% showed significant symptom reduction. BDI-II total scores from baseline were 29 and post-treatment scores dropped to 6 for participants in CCRT group. Further, results showed that social functioning improved for participants who participated in brief psychodynamic therapy to a greater extent than those who participated in CBT. However, both psychotherapies were found to be equally effective and efficient forms of treatment for depressive symptoms. In a small study, Jarry (2010) assessed the effectiveness of brief psychodynamic therapy using CCRT to reduce anxiety and depression and improve overall self-growth. The Rosenberg Self Esteem Scale (RSES) was used to measure self-esteem, the Symptom Checklist-90 Revised (SCL-90-R) was used to test for clinical symptoms, the BDI-II was used to measure depression, and the State Trait Anxiety Inventory (STAI) was used to assess for anxiety. These measures were administered once during the pre-treatment phase and again after 16 sessions. Results showed that patients who received CCRT showed significantly increased self-esteem and significantly decreased anxiety. Additionally, CCRT appeared to improve relationship styles and defenses in interpersonal situations. Jarry (2010) recommended conducting future studies on clients diagnosed with depression to study the effectiveness of CCRT since participants in their study did not have a formal diagnosis. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 22 Client Descriptions These case studies focus on two clients, a male and female. Presenting problem (Client 1) The client is a 25-year-old Caucasian female, residing with her partner and 8-monthold infant. She recently stopped working outside the home following the birth of her child and is currently a homemaker. The client has three siblings and her mother and father are separated. She had several stepfathers and two stepmothers in her childhood. Her siblings are all younger than her; she adores them and finds herself frequently placed in the role of being their caregiver. She shared that her maternal grandparents also lived with her as a child and she feels extremely close to her grandmother. She sought therapy services due to feeling anxious, experiencing physical symptoms, and stress. Additionally, she was facing family and relationship issues which she described as further heightening her symptoms. Recently, she reported feeling extremely worried about her infants health and well-being. The client described experiencing tightness in her chest quite often. She mentioned going to the doctor for this and he suggested that she might be feeling anxious. She shared being affected by her family problems and feeling anxious when her siblings have any problems in their life. She described having difficulty sleeping, worrying constantly about something bad happening, and feeling upset often about her relationship with partner. For instance, client reported waking up two to three times each night and finding it difficult to sleep as she is worried about her sister. Client shared that sometimes she also worries about health concerns and Googles them, which increases her anxiety. History and Background The client was born to a low SES family. She described being Caucasian and also identifies with Black and Latinx experiences and culture more than White mainstream culture. This she shared for her means living in a neighborhood with people of color and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 23 struggling with issues similar to them such as lacking resources and living in difficult situations. As a child she used to live with her mother and grandparents as her father was suffering from substance use problems. Her parents separated in her early years, and she does not recall much from this time. She has three siblings and they had lived separately for a few years. Her three siblings came in to her life beginning when she was 10 years old. She shared being extremely close to them and practically raising them. She believes that her mother was not as supportive and involved as she should have been. Client described herself as a parental figure for her siblings. Her father returned to their lives when she was about 12 years old and visited her frequently. She described always wanting to live with her father but, because his schedule was busy, she was never able. She shared that her stepbrothers father raised her until she caught her mother being unfaithful to him. Clients relationship with her mother has always been complicated. She felt like her mother did not validate her feelings or support her throughout her childhood. She described that her mother was a child of an abusive father and developed poor communication skills. Her mother tends to avoid taking responsibility, which has caused distress for client. After client graduated from high school she moved out of her house and has not reached out to her mother since. Client has always been independent and believes her mother does not feel that she needs to worry about her. She also believes that her mothers anxious nature has rubbed off on her. However, client described being close to her stepmother, whom she viewed as a trusting caregiver and relied on her for support. She also felt supported by her grandmother who lived next door at the time. Clients relationship with her biological father has been good, despite his lengthy absence during her childhood she perceives him as a source of support and views him in a positive lens. She did not get to spend time with him when she was a child as he was traveling EFFECTIVENESS OF CCRT: TWO CASE STUDIES 24 for work and her mother had custody of her. Presently, her father messages her a lot. He is often saying something positive and visits her too. Client is attached to her siblings and loves them like a mother. She feels the need to advocate for them because of their age differences. Her sister has had suicide attempts, which make her feel protective of her. Her brother identifies, as transgender but is not comfortable around their mother as his mother is unaccepting. Client is extremely concerned for her brother and resents the way her mother treats them. She feels responsible for her siblings as she took care of them as children. Moreover, regarding her social relationships, she discussed that she has had close and meaningful relationships. Prior to giving birth she was in a relationship where she became very attached to this person; however, the relationship ended because he moved to another city. She tried to reach out and connect with him but he became dismissive of her. Her current relationship has lasted for five years; she is with the father of her child. She shared that her partner is extremely supportive and they are happy. However, she has recently been having problems in the relationship because of partner's frequent decision to watch pornography. She believes it is an addiction and feels insecure about his choice to watch it. She also seems to suspect that her partner has been unfaithful in the past as she found another womans clothing in his bag. Although, at the time they had a roommate who was female and clarified that it became entangled with his belongings. Client fails to believe this entirely. Client is a social person but is not able to maintain friendships as she recently became a mother and is busy with that. She described that she is close to family and is mostly the support system for everyone else. She feels that she can rely on her partner for somethings but recently he is busy at work and she feels emotionally distanced. Client has previously worked and kept herself extremely busy. She has had diverse jobs some related to health services and few that required to her to travel. She enjoyed EFFECTIVENESS OF CCRT: TWO CASE STUDIES 25 working. However, after giving birth she has not worked and finds it challenging to just be at home. She has been informed that because she was liked, she would be permitted to join back again in the future. Client has an interest in further pursuing her Masters degree as she enjoys studying. Additionally, relevant to her medical and mental history she reported that her mother and sister both are diagnosed with an anxiety disorder and her sister is diagnosed with depression as well. Her father suffers from a history of substance use problems. She shared that she has had therapy in the past and worked on coping skills. She believes that therapy was helpful and seeks services again as she has been anxious and had some panic attacks. She described her physical health as being good and she does not take any medication. Regarding trauma history, she described that as a child her maternal uncle had molested her and when she told her mother about it, her mother did not believe her. This has been a constant struggle in her relationship with her mother. However, her father believed her and wanted to get her tested and file a report but her mother convinced her not to report this. At the time she never realized that this was abuse and as an adult she feels it does significantly affect her life. Client denied any substance use. She used to smoke cigarettes but quit after she became pregnant. She denied any suicidal ideation or attempts. The strengths of this client include that she is able to recognize that she is struggling and sought therapy and she is hopeful about life. She is goal oriented. Diagnosis F41.9 Generalized Anxiety Disorder Z63.0 Relationship Distress with Intimate Partner Client reported feeling anxious about self, others, relationships which she is not able to control, and anxiety interfering with day-to-day tasks at home and at work. She also EFFECTIVENESS OF CCRT: TWO CASE STUDIES 26 mentioned feeling irritable, fatigued, restlessness, and experiencing difficulty sleeping as she over thinks. Therefore, she meets criteria for generalized anxiety disorder. Client also reported having relationship issues and feeling stressed because of interactions with her partner, therefore meeting criteria for relationship distress with intimate partner. Treatment Plan Based on the CCRT approach her treatment plan included objectives related to her Wish, Response to self, and Response from others. 1. Client will note down what triggers her anxious thoughts and the wishes/reactions that come to mind. 2. Client will identify relationship patterns in therapy in her daily reactions 3. Client will develop healthy communication pattern in treatment based on expressing her wishes. 4. Clients anxious thoughts and feelings will decrease based on ratings on screeners administered in the beginning, middle and end of treatment. CCRT Case Formulation Client presented as insightful, confident, and guarded. She described feeling like the caregiver in all situations and not receiving support from anybody. She described wanting to be needed in relationships and having this underlying Wish of having her emotional needs met and understood. Client desired to protect self from the world and felt like she could not trust anybody completely. She shared being hesitant to trust her partner or mother as they both seemed to have betrayed her when she wanted to be cared for. Her mother, though physically present, emotionally abandoned her as a child. This gave way to her feeling like needing to step in and take responsibility of others. Her partner seemed to have triggered feelings of anxiousness for her, as she had constant thoughts of him being unfaithful to her. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 27 She believed that her partner did not understand her, but she did love him and he was a great caregiver to her infant daughter. Throughout her childhood she expressed feeling burdened by this need to be perfect that caused anxious feelings of failure. She described feeling anxious regarding every small detail in life. While growing up she was anxious about not living up to her parents expectations, her siblings falling apart, not being loved and falling ill. She shared being worried about her health and her familys well-being. Client is consciously trying to be someone who her partner can rely on and can be supported. She wishes to have this love and support that she gives others for herself. She is able to understand everyones needs and work towards making everyone happy. However, she wishes that she were the one receiving this love and attention. As a child, Client had witnessed her parents divorce and arguing, and does not want the same thing for her relationship. She tends to avoid conflict and be open with her feelings as, she fears her partner will reject her. She unconsciously compares her relationship with her parents and is consciously afraid of losing partner and the relationship ending which prevents her from discussing her difficulty around trust. As a child, she tended to blame herself for the divorce and this is the same pattern playing out in her relationship. Client blames herself for her partner dismissing her or rejecting her needs. Moreover, Client believes her infant is a way to strengthen their relationship. Her partners constant rejection of her needs of support has triggered her to seek therapy and she wants to learn to express her needs. Her fear of asserting herself again arises from the idea that if she does that their relationship will somehow weaken and they would separate. Client feels insecure of relationship as partner is watching porn and is anxious about him rejecting her and not valuing her body. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 28 Client struggles with establishing boundaries with family members, and later becomes upset when they cross those boundaries and take advantage of her. She identifies as a mother for her siblings which cause immense anxiety related to their wellbeing and feeling responsible for their shortcomings in life. Overall, client wants people in her life to understand her, maintain healthy boundaries and support her needs like she does with them. Her anxious feelings seem to be related to this main theme of trust and communication patterns in her relationships with others. Course of Treatment Pretreatment phase involved a two-hour intake which included socialization process, where in, clinician gathered information and appropriateness of client for CCRT was established. Client was shared information about how CCRT would work and based on mutually agreed upon consent CCRT was adopted as the treatment model. During phase one of treatment client was made aware of the CCRT approach and what we would work on in our 16 sessions. Sessions one to four she described feelings of hurt, distrust and difficulty expressing her needs with family members and her partner. Client explored and identified her wishes in intersections with others with the help of clinician. She seemed to have motivation to address agreed upon goals for treatment. Client felt misunderstood in her interactions and described always trying to help others but people did not understand her or care for her needs. For instance, she shared a conversation with her partner where she wanted to discuss with him that she did not appreciate him working overnight. However, before starting this discussion her partner talked about needing to spend more time at work and she agreed since she wanted to be understanding of him. Client also shared that when talking to anyone she tends to be extremely understanding and supportive except for her mother. She described underlying feelings of anger and resentment towards her. For instance, in one conversation her mother talked about EFFECTIVENESS OF CCRT: TWO CASE STUDIES 29 sharing pictures of clients baby on social media and client became annoyed with her. Client shared in session that she wished that her mother called and asked how she and her baby were doing instead of posting pictures and acting like she cared. Applying Tallberg et al.s (2020) typology of CCRT themes, client showed clear themes of a desire for others to be close and accepting, to achieve and help others, be loved and understood, and to feel good and comfortable. By session 4 we solidified her exploration and identification of wishes. While sharing the CCRT with client it was made sure that it was a collaborative process. Client seemed to be reflecting on her conversations outside of therapy and bringing them to sessions to be able to identify her patterns of interactions. The CCRT formulation involved clarification questions, in-depth discussion of patterns and collaborative reflections. Client described wanting to be cared for, loved and supported in any relation, however, in her patterns of interaction she felt others controlling her, taking advantage of her and her response was to be helpful and secretly feel angry with self and others. Her response to self included, being silent based on expectations that others will disappoint. This CCRT was shared on the second session and when shared with her was shared by using her words and being reflective which resonated with the client. She agreed with her CCRT and showed interest in changing her patterns and actualizing her wish. During phase two of treatment (sessions five to twelve), client worked with therapist on identifying relationship with others and understanding the impact of this on her life. We worked on focusing on the uniqueness of her CCRT. Initially clinician and client analyzed relationship episodes for the client. Client described episodes where she felt others misunderstood her, with a tendency to describe interactions where she believed that she was trying to be helpful and she wished for the other person to be helpful in response. However, often experienced the responses from others as angry and contributing to misunderstandings and arguments. For instance, she invited him to spend time with her in order to improve and EFFECTIVENESS OF CCRT: TWO CASE STUDIES 30 nurture their relationship, instead of immediately going to his room and being on his mobile phone. She described that in the conversation she felt hurt as he refused to and wanted his space. Her response to self was becoming upset, withdrawing and started to cry. The response from others she experienced was retaliation and an argument and response to self was to feel helpless and cry. Another example she described was a wish to be loved and understood by her mother. She described calling her mother to talk with her and tell her how she was doing. Her mother responded instead by talking about her problems and things that were going wrong in her life. Client then became an understanding ear for her mother. She described feeling angry with her mother but not being able to express it. Client could not express her wish to be understood and instead her response to self was to feel disappointed and decided to not call her mother again. She also shared a conversation with her mother where she wished that her mother showed her love. She described expressing to her mother that she did not appreciate her putting clients babys photo on social media since she did not call client or behave like she cared for her. Her mother responded (response from others) by becoming angry with client which led to an argument. Clients response to self was to blame self, shut down and not want to talk to her mother again. Client also described interaction with sister where she wished to seek love and support. She described calling her sister to tell her about her day and her sister started talking about how she was feeling suicidal and client had to be supportive of sister instead. In this RE, the RO is to reject clients feeling or what had happened for her to call, and RS is client feeling dissatisfied with the conversation. During the second phase of treatment clinician paid attention to statements like it could have been better, I hoped for this and other statements clients made to indicate her wishes in interactions with others. We also focused on processing clients response to others EFFECTIVENESS OF CCRT: TWO CASE STUDIES 31 and understanding her past interactions that how she felt when others response did not fit her wish. Client expressed feeling upset, having self-doubt and feeling anxious about not feeling loved and supported. This phase also involved enactments with clinician. Client tended to repeat pattern of interaction with clinician. The clinician processed then in the here-and-now therapy space through immediacy clients feelings in session. Client expressed in the sixth session her feeling of mistrust to the world and how she was unable to trust since people would eventually betray her trust. When clinician asked if this is how she felt about therapy she nodded. Client and clinician worked toward working through this enactment to allow for further exploration of CCRT process. Clinician and client discussed several REs like above and slowly moved towards forming clients CCRT and started on the third phase of treatment. Phase two also involved the thrust of therapeutic work where client and clinician processed clients interactions in past that have led to her interactions in the present. We worked through childhood patterns, understanding response to others and response to self. She disclosed on the sixth session pervasive feelings of always being taken for granted, as her mother was never present, she felt the need to be independent and take control of everyone at home, which included siblings and her father. She shared wanting to be supported and not having anyone to go to as she became everybodys support person. She cared and loved for everyone; it became important to be understanding but she believed nobody cared for her. In therapy we worked on understanding patterns in interactions and reframing ways she would express her wish and response to others. Client identified interactions where she was cared for by her partner and father. We worked on actualizing her wish of being understood, loved and supported. During session 13 to 16 the focus was on termination. Client shared her anxieties around termination. She shared being worried that the problem would arise again or she might not be able to express her needs without therapy. We processed her feelings and helped her EFFECTIVENESS OF CCRT: TWO CASE STUDIES 32 understand that she was already using her tool box outside of therapy and would be able to function just has she has been through the therapy process. Client and therapist also discussed alternatives such as coming back for therapy if another problem arises or checking in with another clinician if need be. In the last session client shared her sadness about therapy coming to an end but also discussed the skills she had gained and the ability to express her needs had helped her in all areas of life. She reported better relationship with partner, family and self. She shared her future goals of going to graduate school and accomplishing some other goals that she could not express with others earlier. Presenting problem (Client 2) The client is a 25-year-old Caucasian male. He resides with his wife. Client sought services as he has been struggling with depression and anxiety. He described that recent career changes have led to stress and he wants to prevent it from impacting his relationships and work. As a child, client had requested his parents to take him for therapy as he felt like he was depressed, however his parents refused. Client described that he tends to over think and worries in relationships about people being angry with him. He reported overcompensating and trying to keep people happy or he believes they will leave him. Client reported few obsessions, which involve thinking about doors being locked; compulsions of going back and checking to make sure the door was locked. Also, obsesses on whether or not he left the iron on. He mentioned compulsively picking on his fingernails. He more recently has been constantly thinking about his worth. He said he wants to learn to communicate better in relationship as he feels he has some issues in communicating. Client also reported feeling depressed at times for no reason and at those times he does not want to talk to anybody and portrays a flat affect. History and Background EFFECTIVENESS OF CCRT: TWO CASE STUDIES 33 Client described his childhood, as having challenges but overall, it was good. He lived with his parents and younger brother as a child. His brother and him have a 13-year age gap; client felt like a parent figure for sibling and was almost always left to supervise him. Client scared being close with his mother. His mother is similar to him and mostly they get along well but sometimes they need a break from each other. His mother would encourage him to perform his best academically. His father was always out for work, rarely physically present but they were close. Presently, his father and him have a conflictual relationship as his father has negative feeling about client earning more money than him and choosing his own career path. His parents were going through a divorce during his teen years and this caused him a lot of emotional turmoil. He experienced his parents as being emotionally abusive, as they would manipulate him. For instance, he explained that his father would tell him things like his mother never wanted him to be born and he would blame his mother for clients problems. His father has negative opinions about women that client identified as being unhealthy. Client feels a lot of his perceptions about being a man are also influenced by his father and he understands that he needs to work on these. His mother would be upset and depend on client to take care of her. He wished his mother would stand up to his father. Clients relationship with his younger brother has been good. He always wanted to protect his brother from his mother and father, and would distract brother when parents were arguing. He now feels guilty since his brother is still living with parents and client has moved out. They live in different states so they meet each other once or twice a year. They stay in contact with each other and play video games regularly. Client wants his brother to live with him but parents would not agree. Moreover, client met his current wife in college and they have been together for seven years. They have been married for three years. He described his wife as his best friend. They EFFECTIVENESS OF CCRT: TWO CASE STUDIES 34 are very close and he is able to trust her. He believes she is the single most positive part of his life. Recently, they have been having issues, client expressed that he has been having difficulty being open about his emotions. He believes his mood has been changing and sometimes he becomes quiet for no reason, which starts fights. Client worries about becoming like his parents. Part of seeking therapy was that he does not want his issues to become a part of their relationship. His wife is patient with him, supportive and understands that he is going through some things. Client expressed having few close friends and he was able to get support from them. However, he mentioned that he tends to push people away and create boundaries, which has reduced his friend circle. In school, client had been bullied and this has really bothered him. He described being bullied because of his hair color and physical appearance. Later as a teen he became popular and he resorted to being the bully to protect himself. He stated this was the time his parents were going through a conflictual period and he acted out in school. He said he did not really like school as a child but as a teen he enjoyed it. He pursued his Masters degree and has been working in a company in a head position for a while. He mostly is satisfied with his career but wants to be successful and move out of where he is working currently. Additionally, regarding trauma history, client shared his father was physically abusive towards him when he was 14 years old. He said his brother had a metabolic disorder, his parents were always low on sleep and client was responsible for waking them up to keep check on his brother. He said one day when he woke his father up, his father got furious and just pressed clients arm violently and lay on him in a physically powerful way. Client felt like his father was relieving his aggression on him for no reason. Client has experienced bullying which he found traumatic. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 35 Client reported that his maternal grandmother has been diagnosed with bipolar disorder; paternal grandmother with major depressive disorder and paternal grandfather suffers from anxiety and likely has a drinking problem. He believes that at least two of his aunts on his fathers side have been diagnosed with depression and anxiety. Regarding his medical history, client is suffering from Crohns disease and in the past he has had his rectum removed. He described his overall health as fair. He takes medication for Crohns disease. He shared feeling like his Crohns disease as something he has been dealing with and feels okay about it currently. Furthermore, client was first introduced to alcohol by his father when he was 13 years old. He said he occasionally drinks with his partner on weekends. He does not smoke or use drugs. The strengths for him include that he is able to express his difficulties and he wants to work towards becoming a better version of himself. He also enjoys exercising and taking walks to cope with his mood. Diagnosis F41.9 Generalized Anxiety Disorder F33.0 Major Depressive Disorder, recurrent, Mild Z63.0 Relationship Distress with Intimate Partner Client described feeling anxious about several situations such as meeting new people, leaving the door unlocked and having ruminative negative self-thoughts. He reported worrying about work, family and his marriage. He described frequently feeling irritated, trouble falling asleep due to worry thoughts and difficulty making decisions. Therefore, client meets criteria for generalized anxiety disorder. Client also described feelings of low selfesteem, self-worth, feeling sad and lack of motivation. He described feeling inferior to others and having distressing thoughts about the future. He meets criteria for major depressive EFFECTIVENESS OF CCRT: TWO CASE STUDIES 36 disorder. It is also important to note that his diagnosis of Crohns disease could also be a adding or causing some of his depressive and anxiety concerns. Addolorato et al. (1997) and Panara et al. (2014) discussed the impact of bowel diseases as factors that increase and lead to depression and anxiety concerns when compared to the normal population. Client shared that he was having several arguments with partner, feeling disconnected with his wife and struggling to describe his feelings to her. Therefore, meeting criteria for relationship distress with intimate partner. Treatment Plan Based on the CCRT approach her treatment plan included objectives related to his Wish, Response to self and Response from others. 1. To better understand self, client will identify and report what triggers his depression and anxiety 2. To decrease negative thoughts about self, client will identify interactions in daily life and what he wishes outcomes were. He will develop healthy coping and communication skills. 3. To have more satisfying and meaningful relationship with wife, client will express his needs in therapy and work towards communicating emotions and feelings. 4. Clients depressive and anxious thoughts and feelings will decrease based on ratings on screeners given in the beginning, middle and end of treatment. CCRT Case Formulation Client sought services to improve relationship with self and others. He described being reserved and not sharing how he feels so that he does not hurt the other person. He seemed to foster low self-worth and thoughts of being a failure. His interaction with family seemed to include his father playing a dominant role and telling him what to do and client following this. He presented in therapy with wanting to change this pattern on doing what others expect of EFFECTIVENESS OF CCRT: TWO CASE STUDIES 37 him. He struggled with being assertive and communicating his needs to friends, family, wife and colleagues at work. His interaction with his boss seemed to be based on self-doubt as his boss referred to him as loser and talked down to him a couple of times a day. He described this relationship as dominating and hating feeling like a child but not knowing how to change this. His self-esteem seemed to be dependent on how others in his life thought or expected out of him. He was always wished to please people and be appreciated, however, response from others was always looking at him as inferior to them and not being a man. He described wishing to be able to be kind and assertive at the same time. He felt stuck in this idea of wanting to impress his father and also be respected by him. Clients relationship with mother seemed to be based on one sided care and support. He described that his mother leaned on him for emotional support which was exhausting for him. He shared wishing that he could share how he feels with her and have a balance of needs met. Clients relationship with wife has been healthy, however, recently he feels that feeling depressed as interfered with their interaction. He described avoiding talking about his feelings with her and struggling to feel connected to her. They argue about clients recent emotional withdrawal from her as he is unable to understand his needs. He is struggling to cope with the pressures of a marriage and seems to wish that his wife understands his needs without him expression them. Client wishes to be supportive of wife and take on traditional masculine roles but at the same time struggles with understanding her needs which leads to arguments. For instance, he shared that he was not picking up her phone calls to help her understand that he was busy at work like other men are, however, she perceived this as a sign of ignoring her immediate needs. He also tends to avoid arguments and escape them by emotionally withdrawing form wife. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 38 In conclusion, clients relationship cycles involve him trying to be supportive of others needs, caring for them, however, response from others includes belittling him or shaming him for this support, or taking advantage of his support and response to self is low self-worth and seeing self as inferior to others, especially not seeing self as a typical man. Client wishes to be understood and supported just as he thinks he is doing with others. He perceives self as open, understanding and wanting to care for others but also strong like a man. When he cries or feels emotions other than anger he responds negatively to self and feels ashamed. Course of Treatment Pretreatment phase involved a two-hour intake which included socialization process, where in, clinician gathered information and appropriateness of client for CCRT was established. Client was shared information about how CCRT would work and based on mutually agreed upon consent CCRT was adopted as the treatment model. Phase one of treatment between sessions one to four involved sharing his unique CCRT and identifying his wish, response to others and response to self. Client was open to brief method of treatment and described wanting to try other ways of interacting in relationships. First session therapist and client explored what CCRT means and formulating the base of treatment. From sessions two to four, we focused on uniqueness of his CCRT when making statements like I really want to be more assertive, he was able to identify his wish as accomplishing his needs in relationship and wanting to be assertive. He identified his actual way of conveying this was trying to be supportive and taking care of others needs or becoming angered with another. His response to other as giving up and listening to what somebody else is telling him to do. He tends to be understanding when he wishes to be able to stand up for his needs. He also identified wanting to be a man without having to be this person who is seen as stereotypically strong and not expressing emotions. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 39 He described some relationship episodes, for instance, when his father talked about politics, and client did not agree with his beliefs he tend to shut down since his father spoke in a louder voice which made him seem powerful and client left conversation feeling ashamed about self. Another example, when he went to share with his mother his feelings of depression, his mother was quick to dismiss him and talk about what she needed him to do as a man. He left conversation feeling resentful for bringing this up in the first place. With his wife, he described feeling guilty for putting his needs or telling her that he needs some space in the relationship as she would always take care of him and is considerate of his feelings. He tended to instead only share his feelings when frustrated and drinking which made her feel upset and in turn, he felt upset about sharing this with her. At work, whenever he tried to talk to his boss about wanting to transition to a different department his boss would shame him and yell at him in front of other office members, his response to self then would be to go home and cry and feel ashamed. He described when he felt upset or when he was unable to communicate what he needed his anxious behaviors would increase like checking if the door was locked or worrying that he left the iron on and wanting everybody to check for him. Phase one ended with helping client gain insight about the uniqueness in his patterns of interactions. Whenever he wants to share his needs, he worries about feeling ashamed or feels frustrated with self. By session four we solidified his exploration and identification of wishes. During phase two of treatment (between sessions five and 12) therapist and client worked on response from others and response to self. Clients response from others seems to mostly be dismissal or getting angry with him. Client recalled that as a child whenever he tried to talk to his father about feeling sad or being bullied his father would ignore his feelings and be angry at him for not being tough or acting like a man. He also recalled his mother telling him about her needs and his younger brothers needs come before him and he would have to take care of them once he is older. Therapist and client during middle phase worked EFFECTIVENESS OF CCRT: TWO CASE STUDIES 40 on understanding how these childhood patterns of interactions and experiences are repeating in his current relationships. He explored and identified his wish as a child was to be understood and supported by his parents but when he met with dismissal or disapproval his response to self was feeling dissatisfied and doubting self. This feeling of not understanding self is something he has felt and is repeated in his response to self. While exploring his response to self he identified behavioral aspects such as crying, becoming angry isolating self and often feeling confused about expectations. During session 10 therapist worked on bringing some unconscious aspects such as expecting reactions from others based on his past experiences. He recalled how he withdrew from a conversation with his wife as he expected her to dismiss that his needs. He described wanting to tell her feeling upset about his friend yelling at him and then she shared about her mother being sick and he immediately decided not to tell her about his day since he respected her needs more than his. He tended to put others first instead of taking care of self which is something his mother had said to him in childhood. During phase two he was able to bring his wish of needing to express his needs and take care of self into awareness. We then worked through ways he could actualize his wish. He shared trying out in a conversation with his wife talking about how he felt misunderstood by his father and allowing her to support him and then asking her about her day. He discovered that she did not dismiss his needs and did not react the way he expected or based on previous patterns in his responses from others. During phase two therapist also worked through responses from others that client feared. He described a conversation with a friend wherein he agreed to do something he did not want to. He shared his friend needing him to take care of his pet, however client had allergies to that breed. Client felt compelled to say yes because he was afraid his friend would get angry or they would no longer remain friends. He then explored how his father would never feel like whatever client did was good enough and this feeling kept returning in EFFECTIVENESS OF CCRT: TWO CASE STUDIES 41 conversations which he would expect others to respond similarly to his relationship episodes with his father. When this transference of interaction was made aware to client, he was able to explore the guilt he felt and the anger that he had repressed towards his father. This second phase helped client uncover early experiences and transference reactions that hindered him expressing his actual wish or needs. After client and therapist worked through hindrances and relationship episodes to help actualize his wish, we moved towards phase three. During phase three of treatment (between sessions 13 to 16) the focus was on termination and exploration of gains. We explored clients progress in therapy and experiences where he was able to actualize his wish. There were also instances of client regressing to his core conflictual relationship theme which were processed and focus was kept on ability to identify response to self and actualization of wish. We also explored clients anxiety around separation from therapy and focused on using these insights gained in therapy to practice expressing his wishes and being able to identify response to self and response to others. The client was able to share instances of interactions wherein he identified CCRT and was able to actualize his wish without fear of rejection or dismissal which helped establish termination and dealing with reactivation after termination. He was able to achieve his goals and termination was successful after 16 sessions. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 42 Clinical Research Questions Psychotherapy outcome questions Q1. Does the client get better in terms of reduced symptoms after the 16 sessions of CCRT? Q2. Did treatment improve their interaction in relationships? Q3. If the clients improved on symptom scales, was the improvement on the symptom scales reflected on pre-treatment/post-treatment research measures, and was the magnitude of the symptom change greater than would be expected due to measurement error? EFFECTIVENESS OF CCRT: TWO CASE STUDIES 43 Chapter 2 Method Research design A single-subject time series design was utilized to examine symptom change across phases of treatment (Borckardt & Nash, 2002). Time series analysis is a method used to track changes in target behavior. Pre-treatment data provides a baseline by which to evaluate symptom change across treatment (Hudson et al., 2019), which in this case involved 16 sessions of CCRT therapy. This time series study involved collecting data at three phases of intervention to evaluate symptom change. Participants This case study involved two Caucasian participants, one male and female, both 25 years of age. Initially five participants were selected, however, two dropped out after session three and one after session one. Participants were selected based on convenience sampling from an outpatient private clinic and the two who completed 16 sessions were selected. Client 1 met criteria for diagnosis: Generalized Anxiety Disorder and Relationship Distress with Intimate Partner. Client 2 met criteria for diagnosis: Generalized Anxiety Disorder, Major Depressive Disorder, recurrent, Mild and Relationship Distress with Intimate Partner. They were both assessed during the baseline phase, treatment and post treatment phase to track changes. CCRT therapy was implemented followed using Books (1998) manual. This manual provides a detailed guide for the clinician to practice CCRT, described above. Participants were informed earlier that they were entering CCRT because of dissertation consent and measurement process which required researcher to label the treatment as CCRT earlier than may have happened according to Books treatment manual. Measures EFFECTIVENESS OF CCRT: TWO CASE STUDIES 44 Participants were administered the Patient Health Questionnaire-Depression and Anxiety Disorders (PHQ-SADS) and Brief Symptom Inventory (BSI). Participants completed PHQ-SADS at baseline, after session 8 (mid-treatment), and after 16 sessions (posttreatment). The BSI was administered at baseline and at the last session. The clients were also asked three survey questions designed by this clinician at the end of treatment. These questions included: 1) How do you feel about your relationships? (Good, Could be improved/worked on, Do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes or No); 3) If yes, in what way? (Positive or Negative). The PHQ-SADS is a self-report measure of somatic symptoms, depression, and anxiety. It is comprised of the PHQ-9, PHQ-15, and GAD-7. The normative data for PHQSADS is based on 5,031 subjects and a mean age of 18 years. The PHQ-9 is a measure screening and assessing depression symptoms and identifying depressive disorders. It consists of 9 questions and questions are scored on a scale of 0 to 3. The scores range from 0 to 27. The score of 5, 10 and 15 act as cut off for mild, medium and severe depressive symptoms respectively. The questions are based on the Diagnostic and Statistical Manual of Mental disorders, 4th edition (DSM-4) criteria for depressive disorders. This scale was initially developed for primary care clients and has since has been validated for the general population. It has a sensitivity and specificity of 88%, internal consistency reliability of .86, and criterion validity with other measures of depression of .89 (Gilbody et al., 2007). The PHQ-15 is a 15-item somatic symptoms questionnaire. It measures 15 somatic symptoms and accounts for more than 90% of physical complaints. Each item is rated on a scale from 0 to 2 with total scores ranging from 0 to 30. Research has shown an internal consistency reliability of 0.85 and relevant criterion validity of 0.80 (Han et al., 2009). The EFFECTIVENESS OF CCRT: TWO CASE STUDIES 45 scores of 5, 10, and 15 have been recommended as cut-offs for classifying mild, moderate, and severe somatic symptoms, respectively. The GAD-7 is a 7-item scale that measure anxiety symptoms. It was developed to identify cases of generalized anxiety disorder and questions are based on diagnostic criteria from DSM-4. Total scores range from 0 to 21 and scores of 5, 10 and 15 have been recommended as cut-offs for classifying mild, moderate, and severe anxiety symptoms, respectively. It has a sensitivity of 89% and specificity of 82% in primary care patients. It has also been shown to correlate with the Beck Anxiety Inventory (BAI) at r = 0.72 (Spitzer et al., 2006). It has been validated in the general population and meta-analytic results support its psychometric properties (Plummer et al., 2006). The BSI is a 53-item self-report measure appropriate for individuals ages 13 years and older. Items are rated on a five-point Likert scale ranging from 0 to 4. It includes nine symptom scales: Somatization (SOM), Obsessive Compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP), Anxiety (ANX), Hostility (HOS), Phobia Anxiety (PHOB), Paranoid Ideation (PAR), and Psychoticism (PSY). It has been shown to correlate with the MMPI-2 scales at .89, supporting its convergent validity (Adawi et al., 2019). Statistical Approach This study uses the percentage of non-overlapping data (PND) approach and Reliable Change Index (RCI) to measure change across treatment. With the PND approach, treatment effectiveness is estimated based upon the percentage of non-overlapping data between baseline and treatment. When values are expected to decrease, such as in the case of measuring depressive symptoms across psychotherapy, PND is calculated as the percentage of treatment and/or post-treatment phase depressive symptom measures that are lower than the lowest depressive symptom value obtained during baseline. When values are expected to increase, such as in the case of a measure of wellness across psychotherapy, PND is the EFFECTIVENESS OF CCRT: TWO CASE STUDIES 46 percentage of treatment phase data that are higher than the highest value obtained during baseline. Possible PND scores range from 0 to 100, and higher scores (closer to 100) indicate higher levels of effectiveness (i.e., there is more discrepancy between baseline and treatment symptoms). Interpretively, Scruggs and Mastropieri (1998) suggest that scores less than 50% indicate that the treatment is ineffective, between 50 and 70% questionable, between 70% and 90% effective, and higher than 90% means the treatment is very effective. Because the current study includes two post-baseline measures from the PHQ-SADS and one post-baseline measure with the BSI, the possible PND values are limited. For the PHQ-SAD, possible PND values include 0, 50, or 100 percent; for the BSI, possible PND values include 0 or 100 percent. Given this limitation, the RCI was also used as a complementary empirical approach. Table 2 PND Scores and interpretation PND Scores Interpretation 0%-50% Not effective 50%-70% Questionable 70%-90% Effective 90%+ Very effective Note. Table is derived from data from Scruggs et al. (1998) Jacobsen and Truax (1991) introduced the reliable change index (RCI) to estimate whether the observed symptom change across treatment is greater than what would be expected solely due to measurement inconsistency. The formula for calculating RCI is: RCI = (x2 x1)/Sdiff. In this equation, x1 is the participants pre-treatment test score and x2 is the participants post-treatment test score, and Sdiff is the standard error of difference between the two test scores. The Sdiff is computed as the standard error of measurement, which will be derived from each tests technical manual or other sources of psychometric information. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 47 The RCI provides an estimate of whether statistically significant change has occurred, accounting for the reliability of the measure(s) used. With the RCI, scores of positive or negative 1.96 correspond to the 95% confidence interval, and therefore RCI scores of at least 1.96 are considered to be statistically significant (i.e., treatment was associated with a reliable change). Scores for RCI scores between -1.96 and 1.96 are considered absence of change. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 48 Chapter 3 Results Client 1 Client was administered Patient Health Questionnaire-depression and anxiety disorders (PHQ-SADS) test three times, including at baseline, mid-treatment, and posttreatment. The PHQ-SADS is a 16-item self-report measure devised for screening functional impairment in the areas of depression, anxiety and somatic concerns. Anxiety, depression and somatic concerns commonly co-occur and hence this measure was developed to reflect this (Miller, 2019). The PHQ-SADS was developed from a combination of three existing measures, including the PHQ-9 (measures depression), PHQ-15 (measures somatic concerns), and GAD-7 (measures anxiety). Client was also administered the Brief Symptom Inventory (BSI) at baseline and posttreatment. The results are displayed in the table below. Table 3 PHQ-SADS Scores for Client 1 PHQ-SADS Baseline Mid-Treatment Post-treatment PHQ-15 10 7 3 GAD-7 10 8 5 PHQ-9 11 7 0 On the PHQ-SADS, clients scores at baseline suggest moderate somatic symptoms, moderate symptoms of anxiety, and moderate symptoms of depression. Client reported panic attack symptoms the night before the session. She described she felt like the baby or she was shaking and she started to feel breathless and her heart was racing. On this questionnaire, when asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Very difficult." EFFECTIVENESS OF CCRT: TWO CASE STUDIES 49 The results on her mid-treatment PHQ-SADS suggest mild to moderate somatic symptoms, mild to moderate anxiety symptoms and mild to moderate depression symptoms. Her symptoms in each of these domains were decreased relative to baseline. When asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Somewhat difficult." The post-treatment PHQ-SADS results displayed continued improvement in each domain and showed little to no somatic symptoms, mild anxiety symptoms, and no depression symptoms. Client denied having a panic attack in the past 4 weeks. When asking her how difficult these problems made it to do her work, take care of things around the home or get along with people, she said, "Not difficult." Moreover, her BSI profile scores were as displayed: Table 4 BSI scores for Client 1 BSI Baseline Posttreatment Somatization 4 3 Obsession-Compulsion 1 0 Interpersonal Sensitivity 4 0 Depression 8 2 Anxiety 9 2 Hostility 2 0 Phobic anxiety 1 0 Paranoid ideation 6 2 Psychoticism 4 2 Her scores on the baseline BSI measure suggest mild somatic symptoms, minimal obsessive-compulsive symptoms, mild interpersonal sensitivity, mild depression symptoms, EFFECTIVENESS OF CCRT: TWO CASE STUDIES 50 mild to moderate anxiety symptoms, minimal hostility symptoms, minimal phobic anxiety symptoms, mild paranoid ideation, and mild psychoticism. Her total score was 39 indicating moderate psychological distress. On the post-treatment BSI scores suggest minimal somatic symptoms, no obsession compulsion symptoms, no interpersonal sensitivity, minimal depression symptoms, minimal anxiety symptoms, no hostility symptoms, minimal phobic anxiety symptoms, minimal paranoid ideation and minimal psychoticism. Her total score was 11 suggesting minimal psychological distress. In this study, two treatment measures are used to assess effectiveness Brief symptom inventory (BSI) which was administered baseline phase and posttreatment and Patient Health Questionnaire-Depression and Anxiety Disorders (PHQ-SADS) which was administered baseline phase, mid-phase and posttreatment. Figure 1 PND analysis of BSI scores client 1 PND FOR BSI 10 9 8 7 6 5 4 3 2 1 0 SOM OC IS DEP ANX Baseline Figure 2 HOS Post PHOB PAR PSY EFFECTIVENESS OF CCRT: TWO CASE STUDIES 51 PND analysis of PHQ-SADS scores client 1 P ND FOR P HQ -S ADS GAD-7 PHQ-9 PHQ-15 60 50 40 30 20 10 0 BASELIN MID POST-TREATMENT Using the PND to calculate results for BSI for client 1, from baseline phase to posttreatment her scores for the Somatization scale, Obsession-compulsion scale, Interpersonal Sensitivity scale, Depression scale, Anxiety scale, Hostility scale, Phobic anxiety scale, Paranoid ideation scale and Psychoticism all decreased as shown on table 4 and figure 1. That is, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase for all scales. This means that the treatment PND score is 100% which suggests that treatment was very effective for client 1. For PHQ-SADS, the scores for client 1 for scales PHQ-15, GAD-7 and PHQ-9 consistently decreased from baseline, to mid-treatment to posttreatment as shown on table 3 and figure. This indicates, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase and mid-treatment phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 1. Table 5 below, lists the RCI for 9 Clinical scales of the BSI, for the BSI lower scores from pre to post treatment suggest better functioning. Table 5 showcases the RCI results for EFFECTIVENESS OF CCRT: TWO CASE STUDIES 52 client 1, all the BSI scores have RCI scores>1.96 which means that this client has achieved reliable change (i.e., RCI > 1.96, p < .05). Table 5 RCI Data for BSI, Client 1 BSI Scales Mean SOM 0.945 SD 0.8715 Test-retest reliability 0.68 SEm 0.493 RCI Interpretation 2.87 Reliable change OC 0.884 0.7698 0.85 0.298 2.37 Reliable change IS 0.856 0.7986 0.85 0.309 2.28 Reliable change DEP 1.225 0.8264 0.84 0.331 12.84 Reliable change ANX 1.244 0.7936 0.79 0.364 13.60 Reliable change HOS PHOB 0.978 0.931 0.8103 0.8073 0.81 0.91 0.353 0.242 4.00 Reliable change 2.92 Reliable change PAR 1.101 0.8516 0.79 0.390 7.24 Reliable change PSY 1.239 0.8854 0.78 0.415 3.40 Reliable change For client 1, the Somatic scale score changed from four to two over the course of treatment and the RCI score is 2.87 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her score for Obsession-Compulsion scale changed from one to zero the RCI score is 2.37 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For interpersonal sensitivity scale her scores changed from four to zero and RCI score is 2.28 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For Depression scale her scores changed from eight to two and RCI score is 12.84 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Anxiety scale scores changed from nine to two and RCI score is 13.6 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Hostility scale scores changed from two to zero and RCI score is 4.00 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Her Phobic Anxiety scale score changed from one to zero and RCI score is 2.92 which suggests client has achieved reliable EFFECTIVENESS OF CCRT: TWO CASE STUDIES 53 change and made improvement (i.e., RCI > 1.96, p < .05). Her Paranoia scale score changed from six to two and RCI score is 7.24 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, her Psychoticism scale score changed from four to two and RCI score is 3.40 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for BSI for client 1 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. Table 6 RCI Data for PHQ-SADS, Client 1 PHQ-SADS Mean SD Test-Retest Reliability SEm RCI Interpretation PHQ-15 3.2 3.8 0.82 1.62 3.07 Reliable change GAD-7 4.6 4.7 0.88 1.59 1.81 Reliable change PHQ-9 3.3 3.8 0.86 1.42 5.47 Reliable change For client 1, Table 6 above shows PHQ-SADS, RCI scores from baseline to posttreatment. Her PHQ-15 changed from 10 to three and RCI score is 3.07 which suggests client has achieved reliable change and made improvements (i.e., RCI > 1.96, p < .05). Her GAD-7 scale score changed from 10 to five and RCI score is 1.81 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, her PHQ-9 scale score changed from 11 to zero and RCI score is 5.47 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for PHQSADS for client 1 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. In addition, clients were also asked two survey questions post treatment 1) How do you feel about your relationships? (Good, could be improved/worked on, do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes EFFECTIVENESS OF CCRT: TWO CASE STUDIES 54 or No); 3) If yes, in what way? (Positive or Negative). Client one responded to survey question one as good and question two as yes and in a positive way. Client 2 Client was administered the PHQ-SADS at baseline, mid-treatment, and posttreatment. Client was also administered the BSI at baseline and post-treatment. The results are displayed in the table below. Table 7 PHQ-SADS Scores Client 2 PHQ-SADS Baseline Mid-Treatment Posttreatment PHQ-15 15 10 4 GAD-7 15 10 5 PHQ-9 22 11 6 On his baseline PHQ-SADS scores suggest severe somatic symptoms, severe symptoms of anxiety, and severe symptoms of depression. Client denied having a panic attack in the past 4 weeks. On this questionnaire, when asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Extremely difficult." The results on his mid-treatment PHQ-SADS suggest moderate somatic symptoms, moderate anxiety symptoms and moderate depression symptoms. When asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Somewhat difficult." Client mentioned having a panic attack within the past 4 weeks. He described being overwhelmed at work. The results also indicate a decrease in overall symptoms from baseline to mid-phase of treatment. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 55 The results for post-treatment PHQ-SADS show minimal somatic symptoms, mild anxiety symptoms, and mild depression symptoms. Client denied having a panic attack in the past 4 weeks. When asking him how difficult these problems made it to do his work, take care of things around the home or get along with people, he said, "Somewhat difficult." The results in table 7 also indicate a decrease in overall symptoms from mid-phase of treatment to posttreatment. Moreover, his baseline BSI profile scores were as follows: Table 8 BSI Scores for client 2 BSI Baseline Posttreatment Somatization 4 2 Obsession-Compulsion 10 5 Interpersonal Sensitivity 9 1 Depression 13 6 Anxiety 9 4 Hostility 6 0 Phobic anxiety 10 6 Paranoid ideation 5 1 Psychoticism 5 1 His baseline BSI scores suggest minimal somatic symptoms, moderate obsession compulsion symptoms, mild to moderate interpersonal sensitivity, moderate depression symptoms, moderate anxiety symptoms, mild hostility symptoms, moderate phobic anxiety symptoms, mild paranoid ideation and mild psychoticism. His total score was 71 indicating high psychological distress. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 56 On his post-treatment BSI, the scores suggest minimal somatic symptoms, minimal obsession compulsion symptoms, minimal interpersonal sensitivity, mild depression symptoms, minimal anxiety symptoms, no hostility symptoms, mild phobic anxiety symptoms, minimal paranoid ideation and minimal psychoticism. His total score was 26 indicating mild psychological distress. Figure 3 PND analysis for BSI scores client 2 PND FOR BSI 14 12 10 8 6 4 2 0 SOM OC IS DEP ANX HOS Baseline PHOB PAR PSY Post Figure 4 PND analysis for PHQ-SADS scores client 2 P ND FOR P HQ -S ADS GAD-7 PHQ-9 PHQ-15 60 50 40 30 20 10 0 BASELIN MID POST-TREATMENT EFFECTIVENESS OF CCRT: TWO CASE STUDIES 57 Using PND method for client 2, to calculate results for BSI, his scores from baseline phase to posttreatment for the Somatization scale, Obsession-compulsion scale, Interpersonal Sensitivity scale, Depression scale, Anxiety scale, Hostility scale, Phobic anxiety scale, Paranoid ideation scale and Psychoticism all decreased as shown on table 8 and figure 3. That is, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 2. For PHQ-SADS, the scores for client 2 on scales PHQ-15, GAD-7 and PHQ-9 consistently decreased from baseline, to mid-treatment to posttreatment as shown on table 7 and figure 4. This indicates, the percentage of symptom measures during posttreatment phase are lower than the lowest symptom value obtained during baseline phase and mid-treatment phase for all scales. This means that the treatment PND score is 100% which suggests that the CCRT approach to therapy was very effective for client 2. In addition, the RCI varies due to the factor that the smaller the test-retest reliability coefficient the larger the RCI and since the RCI uses SD in calculation the larger the SD the larger the RCI score. All scores larger than 1.96 signify positive reliable change indicating improvement of client due to treatment. Table 9 below, lists the RCI for 9 Clinical scales of the BSI, for the BSI lower scores from pre to post treatment suggest better functioning. Table 9 showcases the RCI results for client 2, all the BSI scores have RCI scores>1.96 which means that this client has achieved reliable change (i.e., RCI > 1.96, p < .05). Table 9 RCI data for BSI, Client 2 BSI Scales SOM OC IS DEP Mean 0.945 0.884 0.856 SD 0.8715 0.7698 0.7986 1.225 0.8264 Test-retest reliability 0.68 0.85 0.85 SEm 0.493 0.298 0.309 0.84 0.331 RCI Interpretation 3.13 Reliable change 9.13 Reliable change 3.91 Reliable change 11.45 Reliable change EFFECTIVENESS OF CCRT: TWO CASE STUDIES ANX HOS PHOB PAR PSY 1.244 0.978 0.931 1.101 1.239 0.7936 0.8103 0.8073 0.8516 0.8854 0.79 0.81 0.91 0.79 0.78 58 0.364 0.353 0.242 0.390 0.415 7.72 10.47 10.71 6.5 6.93 Reliable change Reliable change Reliable change Reliable change Reliable change For client 2, the Somatic scale score changed from four to two over the course of treatment and the RCI score is 3.13 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His score for Obsession-Compulsion scale changed from ten to five and RCI score is 9.13 which means client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For interpersonal sensitivity scale his scores changed from nine to one and RCI score is 3.91 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). For Depression scale his scores changed from 13 to six and RCI score is 11.45 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Anxiety scale scores changed from nine to four and RCI score is 7.72 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Hostility scale scores changed from six to zero and RCI score is 10.47 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Phobic Anxiety scale score changed from ten to six and RCI score is 10.71 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). His Paranoia scale score changed from five to one and RCI score is 6.50 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, his Psychoticism scale score changed from five to one and RCI score is 6.93 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for BSI for client 2 suggests that CCRT was an effective treatment as indicated by her positive and clinically significant RCI scores for all scales. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 59 Table 10 RCI Data for PHQ-SADS, Client 2 PHQ-SADS Mean SD Test-Retest Reliability SEm RCI Interpretation PHQ-15 3.2 3.8 0.82 1.62 4.83 Reliable change GAD-7 4.6 4.7 0.88 1.59 4.34 Reliable change PHQ-9 3.3 3.8 0.86 1.42 7.95 Reliable change For client 2, Table 10 above shows PHQ-SADS, RCI scores from baseline to posttreatment. His scores for PHQ-15 changed from 15 to four and RCI score is 4.83 which suggests client has achieved reliable change and made improvements (i.e., RCI > 1.96, p < .05). His GAD-7 scale score changed from 15 to five and RCI score is 1.81 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Lastly, his PHQ-9 scale score changed from 22 to six and RCI score is 7.95 which suggests client has achieved reliable change and made improvement (i.e., RCI > 1.96, p < .05). Overall, results for PHQ-SADS for client 2 suggests that CCRT was an effective treatment as indicated by his positive and clinically significant RCI scores for all scales. In addition, clients were also asked two survey questions post treatment 1) How do you feel about your relationships? (Good, could be improved/worked on, do not have many close friends or relationships); 2) Do you feel a change in your interaction with others? (Yes or No); 3) If yes, in what way? (Positive or Negative). Client two responded to question one as good and question two as yes and in a positive way. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 60 Chapter 4 Discussion This study aimed to evaluate the effectiveness of Core Conflictual Relationship Theme (CCRT), a brief psychodynamic therapy, in treatment of two clients suffering from depression and anxiety disorders. The CCRT is a 16-session brief therapy it is a manualized treatment (Book, 1998). I conducted CCRT therapy with two clients identified as male and female. This research focused on a single case study method used a time series component. Researcher used Brief Symptom Inventory (BSI), Patient Health Questionnaire Depression and Anxiety Disorders (PHQ-SADS) and two survey developed questions over the course of treatment to evaluate effectiveness. The PHQ-SADS was administered baseline, mid-phase and posttreatment, the BSI was administered pre and posttreatment and the survey questions were asked posttreatment. Statistical measures of Percentage of Non-Overlapping Data (PND) and Reliable Change Index (RCI) were used to assess clinically significant change and effectiveness of treatment. The PND and RCI values indicated that treatment was associated with meaningful reductions in each of these clients primary symptoms. In comparison to previous research conducted by Luborsky (1994), Leichsenring et.al. (2013), Hilsenroth et al. (2003), Ajilchi et.al. (2016) and Jarry (2010) this study also found short-term psychodynamic therapy using CCRT to be an effective treatment to decrease symptoms of depression and anxiety. This study does not compare CCRT with another treatment modality, however, similar to Bgels et al. (2014), Monti et al (2014), Driessen et al. (2013) and Dos Santos (2020) this study found that short-term psychodynamic therapy is comparable to any other treatment modality in allowing for progress in a brief period of time. One unique finding, is that this study was able to also assess effectiveness of CCRT in treatment of interpersonal and relationship concerns that have not been integrated in previous research finding, this study using BSI and research questions designed to understand EFFECTIVENESS OF CCRT: TWO CASE STUDIES 61 effectiveness of treatment specifically with relationships found that CCRT is effective in helping with relationships, as both clients perceived meaningful improvement in their interpersonal interactions. This study also is specifically focused on single-subject design with two clients one male and one female, this specificity allowed for in-depth understanding of gendered navigation of relationships and effectiveness of CCRT particularly with both genders in their different views of the world. It is interesting to note that both clients BSI scale scores for psychoticism and obsessive-compulsive symptoms also reduced, however, there is research yet to be conducted on brief psychodynamic models specifically targeting obsessive compulsive and psychoticism treatment. This study provides some evidence of CCRT being effective with these symptoms, however, the original intent of the study was to only measure effectiveness with depression and anxiety. One of the major limitations of this case study is its inability to generalize findings to a larger clinical body. More generalizability could have been obtained if the sample was larger. There is a need for researchers to further evaluate the effectiveness of CCRT approach with a larger population. Since PND method was used for statistical analysis, in this study, PND was constrained as only two or three follows were possible for BSI and PHQ-SADS over the course of treatment which results in limited data. Another limitation includes diversity variables, this case study is focused on clients who identified as Caucasian and heterosexual. It is recommended that further research must be developed to assess the effectiveness of CCRT with clients from diverse ethnicities, gender and sexual orientations. Moreover, in the case of single subject designs, the lack of a control group has implications. For instance, clients present for therapy typically when they are in acute distress and research shows that with some therapy or, even waitlist controls show some improvement, even if its generally of a smaller magnitude than the treatment groups. It is worth noting that some EFFECTIVENESS OF CCRT: TWO CASE STUDIES 62 decreases are probably expected, regardless of treatment, owing to this fact (Cook et al., 2017). However, the magnitude of the symptom reductions found in this study based on RCI results for both clients being RCI > 1.96, p < .05 were clinically significant and also account for some improvements that could be possible due to general treatment as change here is statistically larger than would be expected from measurement error. Given this, although the lack of a control group is a limitation, even in its absence this data appears to offer fairly reliable evidence that these clients benefited from CCRT. Another limitation included clients dropping out for therapy initially five participants were selected. However, only two moved forward and completed from sessions one to 16. Leichsenring at al. (2019) shared 50 to 60% of participants prematurely terminate from therapy in randomized control trials. In this study, about 40% prematurely dropped out of the three, two of them dropped out after session three and one of them dropped out after session one. However, the dropout rates for this study are not greater than other studies that use CBT, CPT and other forms of brief therapy as stated in Leichsenring at al.s (2019) and Fernandez et al.s (2015) papers. This suggests that CCRT can still be considered as effective as other brief therapy models. EFFECTIVENESS OF CCRT: TWO CASE STUDIES 63 References Adawi, M., Zerbetto, R., Re, T. S., Bisharat, B., Mahamid, M., Amital, H., Del Puente, G., & Bragazzi, N. L. (2019). Psychometric properties of the Brief Symptom Inventory in nomophobic subjects: insights from preliminary confirmatory factor, exploratory factor, and clustering analyses in a sample of healthy Italian volunteers. Psychology research and behavior management, 12, 145154. Addolorato, G., Capristo, E., Stefanini, G. F., & Gasbarrini, G. (1997). Inflammatory bowel disease: a study of the association between anxiety and depression, physical morbidity, and nutritional status. 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... BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY A Doctoral Dissertation presented to the Graduate Department of Clinical Psychology University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Megan Pethtel March 2023 ii BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY The signatures below certify that the Doctoral Dissertation of Megan Pethtel has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: ________________________ Debbie M. Warman, PhD Dissertation Advisor John Kuykendall, PhD Dean, College of Applied Behavioral Sciences 3/28/2023 _____________________ Lisa S. Elwood, PhD Committee Member Trevor A. Yuhas, PsyD Committee Member 3/28/2023 ________________________ Date ________________________ Date iii ABSTRACT There is minimal research that examines effective treatment for individuals diagnosed with Adjustment Disorder (AD) (OConner & Cartwright, 2012; Carta et al., 2009; Zelveine & Kazlauskas, 2018). The current case study aimed to examine the effectiveness of brief psychodynamic therapy as a treatment with a traditional aged college student diagnosed with AD. Specifically, the current case study examined an individual diagnosed with AD receiving weekly therapy in a college counseling center for a total of 6 sessions. The client was administered the CCAPS-62 on three separate occasions (e.g., before his intake session, after his third therapy session, and before his sixth and final therapy session). The RCI was calculated using pre, mid, and post mean ratings for each CCAPS-62 subscale. Cutoff scores were also calculated using means and standard deviations from normal and clinical populations, which were provided by the Center for Collegiate Mental Health (CCMH) annual report (2010). The clients scores on some subscales (e.g., Social Anxiety, Eating Concerns, Hostility, and Substance Use) post treatment fell below cutoff points, suggesting the client ended treatment closer to the normal population than to the clinical population for those subscales. Results from the RCI suggest the client demonstrated reliable change on the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre to mid treatment and on the Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Family Distress, and Substance Use subscales from pre to post treatment. iv Table of Contents TITLE PAGEi SIGNATURE PAGE...ii ABSTRACT...iii TABLE OF CONTENTSiv INTRODUCTION...5 Case Study........5 Client Information..16 Adjustment Disorder......23 Brief Psychodynamic Therapy...27 Case Formulation...48 Treatment Plan...50 Clinical Research Question....51 METHOD..52 Counseling Center Assessment of Psychological Symptoms-62.......52 Reliable Change Index.......53 Course of Treatment...54 EMPIRICAL FINDINGS WITH ANALYSIS..60 DISCUSSION64 REFERENCES..71 5 BRIEF PSYCHODYNAMIC THERAPY WITH A TRADITIONAL COLLEGE STUDENT DIAGNOSED WITH ADJUSTMENT DISORDER: A CASE STUDY Introduction Case Study Overview. Psychotherapy research has appeared to gain new interest in being able to study an individual case more in depth (Rice & Greenberg, 1984; Scruggs & Mastropieri, 1998; Yin, 2009). When conducting research, case studies, also referred to as single-case designs, can evaluate interventions effects and can examine questions often developed from between-group studies. Single-case designs are considered to be true experiments and have the capability of demonstrating causal relationships and ruling out threats to validity. Single-case designs are able to make inferences about interventions effects by comparing different conditions that are usually presented to a singular participant over time (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009). An example of a case study includes research conducted by Watson and colleagues (2002) where they used an effective program on a single nine-year-old boy in order to eliminate thumb sucking behaviors. In single-case designs, a participants performance is usually observed repeatedly over time. This allows the investigator to study the pattern of the participants performance initially, before the intervention is introduced, which is referred to as the baseline phase. After the intervention has begun, the investigator can then study changes and if those changes occur in relation with the introduction of the intervention (Brockardt et al., 2008; Kazdin, 2022; Scruggs & Mastropieri, 1998; Yin, 2009). In single-case designs, the examiner holds the ability to further examine the processes that help to promote therapeutic change by analyzing the interaction between the therapist and client (Greenberg, 1986). This ability to further examine the 6 interaction between the therapist and patient allows the examiner to have a better understanding of the processes that encourage therapeutic change and allows for effective clinical treatments to be examined (Jones, 1993). According to sources (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009), data gathered during the baseline phase can inform the investigator about the participants current level of functioning and the severity of the behavior needing to be changed. Multiple data points during the baseline can also predict the participants behavior if the intervention were not introduced. However, it is possible that participants behaviors could change over time without any interventions. In order to be sure of future performance, baseline data would need to be continuously collected before introducing the intervention, which cannot always be done given the purpose of therapy - to provide therapeutic interventions (Brockardt et al., 2008; Kazdin, 2022; Yin, 2009). When reviewing the data once plotted on a graph, the line on a graph shows the direction of the data points collected, which is referred to as a trend line. During the baseline observation period, data might show a horizontal trend line that shows the behavior is remaining steady over time, neither increasing nor decreasing. After the intervention has begun, a decelerating trend line would demonstrate the problematic behavior has decreased. Alternatively, an increasing trend line would demonstrate the problematic behavior has increased (Brockardt et al., 2008; Kazdin, 2022). Strengths and limitations. Single-case designs have provided researchers with solid methodology that has been utilized in countless studies over the span of several decades (Kazdin, 2022; Yin, 2009). Single-case designs have examined psychological processes in research with both animals and diverse human populations. Single-case designs have been used with 7 participants ranging from infancy through late adulthood; participants who had clinical presentations ranging from conduct disorder, autism spectrum disorder, substance use disorders, and anxiety disorders; and participants in settings ranging from educational settings, home settings, military settings, college dorms and athletics, and more. It is from these single-case designs that evidence-based interventions have emerged (Kazdin, 2022). In fact, many early breakthrough discoveries in psychological science were the result of single-organism methods (Ebbinghaus, 1913; Pavlov, 1927; Skinner, 1938; Watson, 1925). Over the last few decades, psychotherapy research has experienced a revived interest in these intensive individual case studies. This revival of case studies has been influenced by multiple factors both in clinical research and clinical practice (Jones, 1993). To begin, there has been more consideration of controlled clinical trials limitations for being able to provide information about how clients change through psychologically mediated interventions and more acknowledgment that being able to understand the processes that develop therapeutic change requires closely analyzing the therapist-patient relationship and interaction (Greenberg, 1986). Notably, multiple researchers over time have shown interest in how laboratory-validated interventions end up translating to clinical practice (Jacobson & Christensen, 1996; Westen & Bradley, 2005; Westen, Novotny, & Thompson-Brenner, 2004). Additionally, there is the demand to test clinical theoretical models. Last but certainly not least, is the notion that psychotherapy research has previously had little influence on theory building and clinical practice (Jones, 1993). However, the case study method establishes itself in naturalistic observations and still upholds the primary means of clinical inquiry, teaching, and learning in psychotherapy (Jones, 1993). 8 In line with this renewed interest in case studies, the American Psychological Associations (APAs) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures has specifically named time-series designs as important methodological approaches that can properly test treatment efficacy and/or effectiveness (Chambless & Ollendick, 2001). Additionally, the APA Task Force on Evidence-Based Practice (2005) even endorsed single-case studies as contributing to effective psychological clinical practice. Despite this endorsement, and even with sincere interest in learning what works for their clients, clinicians are still sometimes intimidated by research and are often unfamiliar with the single-case time-series option (Borckardt et al., 2008). When considering the single-case design, it is important to note both its advantages and disadvantages. According to Kazdin (2022) and Yin (2009), one of the biggest concerns discussed about single-case studies is its external validity. Specifically, the concern is about whether or not the findings from single-case studies are generalizable to others. Searle (1999) also notes concern about the generalizability of the results, given the individual being studied could be atypical. However, single-case design research has long been connected with interventions created from both human and nonhuman animal research, which have shown to be widely generalizable. Single-case design research findings have demonstrated interventions that are widely applicable (Kazdin, 2022). When discussing concerns of generalizability, it is also important to remember that both between-group and single-case designs face challenges with this issue of generalizability. In both instances, a key solution is being able to replicate findings with new participants, though between-group studies typically handle concerns regarding the generalizability of findings better than single-case studies. Because between-group designs often study moderators, which are variables that might influence the direction or magnitude of change, 9 this helps investigators to better understand the generalizability of the intervention utilized in the study based on participants characteristics (Kazdin, 2022). Additional disadvantages of single-case designs include the difficulty for the investigator, who is often the therapist, to remain objective if the nature of the work requires a large amount of contact with the participant being studied. It is also possible that the investigator is selective about what appears in the final report (Searle, 1999). If a case study includes retrospective material, it is possible that this information is not accurate. For example, it can be difficult to determine if an adults recollection of early childhood events is indeed accurate or not (Searle, 1999). There are also concerns about if clients improvements during treatment were in fact actually because of the treatment implemented or because of some external factors in the clients environment and independent of the client and treatment altogether. Even when alternative explanations can be ruled out and the intervention appears to be the cause of improvement, it can be difficult to determine what features of the intervention can actually account for the improvement (Borckardt & Nash, 2008). Despite these limitations of single-case designs, they still have multiple strengths and contributions unique to single-case designs that are worth noting. First, single-case designs expand the scope of opportunities for the study of intervention programs in normal everyday life as administered relative to diverse goals, settings, and domains (Kazdin, 2022). Single-case designs offer rich, in-depth insight into an individual or group that is usually far more detailed and recognizes the uniqueness of individuals. Single-case designs also acknowledge the importance of the subjective feelings of the participants being studied as well as can sometimes highlight extraordinary behaviors and even open new areas of study (Searle, 1999). This was demonstrated by Skeels (1966) when research on deprived babies revealed that intelligence 10 scores are not set at birth but can indeed be impacted by life experiences. Single-case designs can also be pooled together to create a large amount of detailed information that can then be sorted and analyzed, which can then highlight variables to be further studied. Single-case designs are valuable exploratory tools that can lead to the generation of hypotheses for future research (Kazdin, 2022; Searle, 1999; Yin, 2009). Additional advantages of single-case designs include how they can provide a way to evaluate change and the impact of interventions for a single participant without needing to accumulate a large number of participants and then assign these participants to different control or comparison groups. In this sense, single-case designs can provide a method of evaluating change and impact of interventions for a particular participant or a particular setting. Single-case studies are able to address the danger of believing someone is making a difference without ever actually evaluating to see if one has indeed made a difference (Kazdin, 2022; Yin, 2009). According to Kazdin (2022) and Yin (2009), single case designs also allow for an intervention to be gradually implemented on a small-scale before applying it to a larger scale. This allows for an intervention to be tried and then modified as needed before applying the intervention to a larger group or to other individuals. During between-group research, the intervention is pre-planned and administered in full to keep with the plan. The impact of the intervention is then evaluated at the end of treatment during the posttest assessment. During single-case designs, ongoing feedback is provided and can allow for informed decision making to help clients while the intervention is still in effect. This ongoing assessment during the intervention phase of treatment helps to make single-case designs user-friendly to both the investigator and to the participant (Kazdin, 2022; Yin, 2009). 11 Kazdin (2022) highlights single-case designs also allow investigators the chance to examine rare presentations within individuals who would not likely be studied in between-group research. Often times, an individual could be presenting with a primary concern that is not rare but is entangled with other conditions or circumstances that would make it difficult to do a group study to develop or test an intervention on that individual. Single-case studies, however, allow for exactly that. In single-case studies, examiners are able to research and study an individual with a rare primary concern, or an individual with a common primary concern that is entangled with other challenging conditions and circumstances, to develop or test the effectiveness of an intervention (Borckardt et al., 2008; Kazdin, 2022; Yin, 2009). Single case design methods. When conducting a single-case study, multiple methods may be utilized, such as time series analysis, reliable change index (RCI), or percentage of nonoverlapping data (PND). A time-series analysis allows investigators to regularly track symptoms of one, or a few, clients across baseline and intervention phases in hopes to produce data that address whether and when an intervention is effective (Borckardt et al., 2008; Kazdin, 2022). There are multiple types of time-series analyses that all share the fundamental feature of tracking change in at least one target symptom across phases and examining if there is a relationship between implementing the intervention and the status of the target symptom. The simplest time-series analysis includes just two phases: the pretreatment baseline phase, referred to as phase A, and the treatment phase, referred to as phase B (Borckardt & Nash, 2008; Kazdin, 2022). Another variation of this time-series analysis includes four phases: phase A, phase B, followed by another phase A and phase B. This design is similar to the simple A-B designs and tracks the impact of an intervention on the target symptom but is then followed by a 3rd phase 12 where the intervention is no longer implemented before then being resumed in the 4th and final phase. By examining a clients data from the baseline and treatment phases, researchers then may have the ability to determine if a client has made statistically significant change when comparing the baseline and treatment phases (Borckardt & Nash, 2008; Kazdin, 2022). This design is able to nicely address questions of cause and effect. Improvements made during the first intervention phase, however, do not always decline when the intervention is taken away. The goal of therapy, after all, is for clients to continue making improvements even after they have terminated from therapy. Additional notable limitations of this design include the ethical question of removing an intervention that is helping a distressed client as well as the logistical reality of clients being understandably hesitant to agree to discontinue an intervention that is working for them (Borckardt & Nash, 2008; Kazdin, 2022). In addition to time-series analysis, percentage of nonoverlapping data is another method utilized when conducing single-case studies. To calculate the PND, the investigator draws a line through the most extreme data point from the baseline phase that follows the expected direction of treatment effect and extends through the treatment phase (Scruggs & Mastropieri, 1998). Once data is collected and visually analyzed, the portion of plotted data points in the treatment phase that do not overlap with plotted data points from the baseline phase are considered to be statistically reliable (Kazdin, 1978). One notable advantage of the PND approach includes its ability to provide meaningful information about the interventions effectiveness through a visual presentation of data points Additionally, PND combining efforts are seen as generally accurate reflections of the research studies they review (Scruggs & Mastropieri, 1998). Despite these notable strengths, some investigators have still argued that PND is not able to accurately represent the experiment, 13 stating that reducing data to one-number summaries of overlap seen across data abandons some of the most interesting information (Salzburg et al., 1987). Additional concerns have been raised about the PND method not adequately assessing meaningful trends in the data (White, 1982), the PND method not being sensitive to powerful treatment effects (White et al., 1989), and that PND statistics effect size estimates may approach 0.0 with more and more observational data, regardless of treatment efficacy (Allison & Gorman, 1994). Another popular method used in single-case studies, and the method that will be utilized in the current study, is the reliable change index. According to De Souza Costa and Jardim de Paula (2015), the RCI is a statistical procedure that allows investigators to compare two psychometrically derived scores from items such as scales, tests, or questionnaires. The RCI evaluates whether a clients scores difference at two points in time is more likely to be explained by measurement error or if it is because of real significant change. Mathematically, the RCI can be defined as a clients change in score on a psychometrically supported measure divided by the standard error of the difference, which is dependent on the psychometric measures standard error. The psychometric measures standard error includes the standard deviation from the normative sample and the test-retest reliability. The results of this mathematical equation represent a standard score (De Souza Costa & Jardim de Paula, 2015). To understand the RCI, we must first understand that there are multiple ways to identify variability in treatment response and to determine if changes are clinically significant, which is typically demonstrated when the client returns to normal functioning (Jacobson et al., 1999). For any individual, the magnitude of change should be statistically reliable and should be further than the range of what might reasonably be associated to chance or measurement error. This results in a two-part criterion for clinically significant change. First, the magnitude of change has 14 to be statistically reliable. Second, by the end of therapy, clients must end up in a range that shows them as indistinguishable from the population classified as normal functioning. Clients who show statistically reliable change and who end within normal limits on the variable of interest are classified as recovered; clients who show statistically reliable change but are still somewhat dysfunctional and not within normal limits are classified as improved but not recovered; and clients who end in the functional range but do not show statistically reliable change are unable to be classified. Being able to apply this to treated clients allows one to identify the percentage of clients who recovered, the percentage of clients who improved but did not recover, and the percentage of clients who remained unchanged or regressed (Jacobson et al., 1999). In order to demonstrate that a client has moved from the dysfunctional to the functional range of functioning over the course of therapy, three mathematical criteria were proposed in the form of cutoff points (Jacobson et al., 1999). Cutoff point A is achieved when the clients level of functioning falls outside the range of the dysfunctional population, with range being defined as 2 standard deviations more than the populations mean in the direction of functional behavior. Cutoff point B is achieved when the clients level of functioning falls within the range of the normal population, with range being defined as 2 standard deviations less than the normal populations mean. Cutoff point C is when the clients level of functioning suggests that they are statistically more likely to be among the functional population than they are to be with the dysfunctional population. Preferably, cutoff points are based on norms collected for both dysfunctional and normal populations. If the cutoff point is crossed when therapy is terminated, then the client can be labeled as recovered. If the cutoff point is not crossed at the termination of therapy, then the 15 client can be labeled as still dysfunctional, regardless of if the change was statistically reliable or not. The RCI then, as the second criterion for determining clinically significant change, is utilized to ensure that the magnitude of change exceeds the margin of measurement error by diving the magnitude of change during therapy by the standard error of the difference score (Jacobson et al., 1999). When using the RCI method, there are some noteworthy strengths and weaknesses that should be taken into consideration. Jacobson and Revenstorf (1988) identified conditions where the RCI was either irrelevant or misleading as a criterion for defining clinically significant change. Jacobson and Revenstorf (1988) explained the RCI method is irrelevant for any clinical data that surpasses the cutoff point because that alone defines a magnitude of change that is only possible with statistically significant change. Thus, the RCI is no longer necessary to determine clinically significant change. They also argued that the RCI method is misleading when used on its own for clinically significant change, without using cutoff points. It is important to note that when the RCI is used on its own, cannot determine if the change was clinically significant (Jacobson & Revenstorf, 1988). Additional weaknesses include the RCI method working best only when adequate norms are available for both normal and dysfunctional populations as well as the concern over having discrete cutoff points, although Jacobson and Revenstorf (1988) suggested that by forming confidence intervals around cutoff points, one could define boundaries of these intervals using the RCI, allowing participants who fell outside the boundaries to be reliably classified and participants who fell inside the boundaries to not be reliably classified. Additionally, the RCI method is not able to establish a causal relationship between the intervention being used and the outcomes this treatment may be associated with. The RCI method is not able to determine 16 clinically significant deterioration. Although the RCI is necessary when crossing a cutoff point, it does not prove that change is real by itself and cannot be used to validate a measure (Jacobson et al., 1999). Despite these limitations, the RCI method is one of the favored methods to evaluate significant changes associated with both psychotherapy and psychopharmacological treatment, as it supplies a combination of both statistical and clinical components. It has been referred to as a useful method to define the favorable outcome of an intervention on an individual clinical basis and has been highly recommended as being able to objectively describe improved symptoms beyond measurement error. Overall, the RCI is known as a solid method to measure changes in symptoms in both psychiatric and psychological interventions (De Souza Costa & Jardim de Paula, 2015). Client Information Presenting concerns. Client is an undergraduate student at a small university in Indiana in his early twenties. He identifies as a white gay cisgender male. Client attended his intake session in February 2020. He presented with concerns about past issues that had recently resurfaced, as well as with adjustment related concerns. He reported that he found himself dwelling on his past experiences and identified having a turbulent previous month because of the big changes that had reportedly taken place in his life, which he noted as unwelcome changes. Client reported that the following changes had recently taken place in his life: his family, who was previously ten minutes away from him, moved twelve hours away from him and left him feeling lonelier than before; he recently quit his job, which he had held for four years; his lifelong high school friends all moved away; he was placing more focus on his personal life; and he recently learned his mother was very ill, which was reportedly extra stressful for the client 17 because of his moms reported fear of doctors that acted as a barrier to her receiving the proper medical help. During the intake, client reported feeling bogged down and identified having many interpersonal stressors. He stated it was hard to stop thinking about some of his past interpersonal experiences (e.g., his relationship with his ex-boyfriend) to the point where his sleep, focus, homework, and social life were being negatively impacted. He reported feeling melancholy and stated sleeping approximately two to five hours of sleep each night, with reported difficulty falling asleep at night. Client reported eating two meals per day, endorsed a normal appetite, and denied any disordered eating behaviors. At the time of the intake, client stated that he wanted to continue with therapy to explore the possibility of medication. During the first therapy session, client was unable to identify any goals for treatment and identified he was attending therapy because of a friend who had referred him for services. Client provided verbal and written consent for his information to be used for this case study. Developmental/Social History. Client is reportedly the oldest of three children, with his parents married and living together. Per client report, his brother is 6 years younger than him and his sister is 12 years younger than him. He reported that his relationship with his parents has fluctuated over the years and is currently not at its best. He identified that his familys recent move has been challenging for them and has negatively impacted his parents relationship with one another. Client identified having a closer relationship with his mother than his father. Because of clients mothers reported illness and her fear of doctors, client reported often worrying about her. Client reported never feeling close to his father and identified his father as a disciplinary figure rather than a father figure. Clients father, per client report, has been 18 diagnosed with Bipolar, which has made it difficult for client to be able to navigate any relationship with his father. Client reported having a good relationship with his siblings but did not elaborate on their relationship any further. He identified his support system as his fraternity brothers and reported enjoying living in his fraternity house because he felt supported there. Client is currently single, but he did report one previous serious relationship, which will be discussed in more detail in the trauma history section below. Trauma History. During the intake, client reported witnessing his father physically abuse his mother when he was 8 years old. He stated that he went to stay at his grandmothers house, which was reportedly close by, after the incident and reported that the incident was reported to the police. He reported remembering that his father had to go to court but denied being able to remember any further details. Toward the end of treatment, client also identified being in a previous relationship that was traumatic for him. He reported meeting this individual, who client identified as a male, soon after graduating high school. He noted dating this male for approximately one year over the course of his freshman year in college. During this relationship, client reported doing things he would not normally do to make his boyfriend happy. For example, he reported his boyfriend did not want their relationship to be monogamous, so client agreed to a non-monogamous relationship in an effort to make his boyfriend happy. He even stated he switched college majors because of the pressure his boyfriend put on him. Client reported that this relationship was overall very bad for him and identified that during his relationship he had isolated himself from all his other friends. Client identified only having his boyfriend and his family at that time. 19 During clients relationship with this boyfriend, he reported experiencing a traumatic interaction with another male. Because his boyfriend did not want their relationship to be monogamous, client reportedly often felt pressure to also have relations with other men. This led client to be intimate with someone he did not know but had been talking to online. Client said that when he first met this person face to face, he immediately knew they were not who they claimed to be. Client identified feeling fearful but reported not knowing how to actually stop the interaction from taking place. He described that this interaction as mildly violent and painful, but again reiterated that he was unsure how to ask the other individual how to stop. Client reported that the interaction resulted in multiple wounds on his back, which resulted in the client bleeding afterward. He described himself as feeling more scared than ever that night. Client noted he has not had any contact with that individual since the interaction. He reported that he tried to move past this situation by throwing himself into his relationship with his boyfriend, but he identified still feeling guilty and mortified about the event that occurred. After this event, client reported he continued to be intimate with his boyfriend out of fear of losing his attention to the other men his boyfriend was being intimate with, although he reported he did not enjoy the intimacy. Medical/Mental Health History. Client denied any significant medical history but did endorse family history of multiple sclerosis on his mothers side of the family and history of heart disease on his fathers side of the family. Client reported this to be his first time in therapy, though he endorsed a history of anxiety, trauma, and depression. He also reported being prescribed anti-anxiety medication by his primary care physician in spring 2017 for six months. He reported one previous suicide attempt in 2019 but denied any hospitalizations because of mental health concerns. Client reported a history of depression on his fathers side of the family, 20 with his father reportedly being diagnosed with and medicated for Bipolar Disorder. He also identified that his paternal great grandparents, his paternal great aunts, and his paternal great uncles all died by suicide. Self-Harm/Suicidal Ideation History. During the intake, client endorsed a sporadic history of self-harm, specifically cutting. He identified that this behavior began first in high school and resurfaced in September 2019. He reportedly typically cuts his upper arm. His last time cutting was reported to be right after Christmas 2019. Client identified that after cutting himself, he often felt less frustrated and less agitated long enough for him to be able to fall asleep. Despite reporting occasional thoughts of wanting to cut himself, client denied any cutting behaviors while in therapy. Client also reported recurrent suicidal thoughts at least once per day, usually at night, which he reported often preoccupy him. Client described these suicidal thoughts as usually thinking about cutting deeper and in different spots and by imagining how everything would just be gone. Clients noted suicide attempt in 2019, which was mentioned above, reportedly happened when he was lying in his bedroom in the dark, was thinking about things, and was feeling particularly frustrated with his inability to get out of his thoughts. He claimed he tried to slice [himself] deeply on his left wrist. He denied going to the hospital because of his cut, but instead reported that he cleaned himself up, went to bed, woke up the next morning and went to class like he usually did. He denied any suicide attempts as well as any intent to complete suicide over the course of therapy. Client identified his fraternity brothers as protective factors and reported one of his close friends, who eventually became his roommate, removed all sharp objects from his room so he could not use them to cut himself. 21 Diagnosis. Based on the clients presenting concerns and history, the client was diagnosed with 309.28 (F43.23) Adjustment Disorder with mixed anxiety and depressed mood. This is supported by the clients report of all the recent changes he was experiencing in his life within the past 3 months, such as his family moving, his friends moving, learning his mother was sick, and him quitting his job, that were causing the client significant emotional distress that seemed more severe than expected. Although client reported a history of anxiety, trauma, and depression and reported a history of self-harm and suicidal thoughts, the clients primary presenting concerns for current treatment were related to his adjustment related difficulties. Per the clients report, he was experiencing challenges related to coping with recent changes in his life, thus leading to a diagnosis of AD. At the time of diagnosis, the therapist differentiated between several other mental health diagnoses, such as Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and PTSD. GAD is often characterized by feelings of excessive worry most days over the course of six months. During these six months, individuals with GAD typically experience symptoms such as restlessness, fatigue, trouble concentrating, irritability, muscle tension, and trouble sleeping. Individuals with GAD may experience symptoms for as little as six months or as long as years at a time (American Psychiatric Association, 2022). Although this client reported experiencing periods where he was unable to control his worry, he reported this to only occur occasionally rather than more days than not. The client also reported trouble falling asleep at night, but he did not endorse other symptoms characteristic of GAD over the course of the previous six months, such as feeling restless or fatigued, trouble concentrating, irritability, or muscle tension occurring more days than not. Further, the client endorsed often feeling worried about specific stressors rather than in general about a number of different activities. 22 MDD is characterized by the presence of five or more symptoms over a two-week period, with at least one of the symptoms including depressed mood or loss of interest. Additional common symptoms of MDD include changes in weight and/or appetite, trouble sleeping, psychomotor agitation, fatigue, feelings of worthlessness, feelings of hopelessness, trouble concentrating, and thoughts of death. Similar to GAD, MDD can last anywhere from as little as two weeks to months or years at a time (American Psychiatric Association, 2022). Although this client reported having a "melancholy mood and feeling bogged down occasionally, he did not endorse these to be present more often than not. This client also failed to endorse any changes in weight or appetite nor any feelings of psychomotor agitation, fatigue, or feelings of worthlessness or hopelessness. The client had a history of suicidal ideation, but he only reported passive suicidal ideation during the first and sixth therapy sessions and denied any suicidal ideation, active or passive, throughout the rest of treatment. The final differential diagnosis considered, PTSD, occurs after an individual has either experienced or witnessed a traumatic event, such as actual or threatened death, serious injury, or sexual violence. Individuals with PTSD experience various symptoms from separate clusters, such as intrusive symptoms associated with the traumatic event, avoidance of triggers related to the traumatic event, negative changes in mood and thoughts related to the traumatic event, and increased reactivity and arousal. These symptoms typically last at least for 30 days one month following the traumatic event occurred and can last for several months or years at a time (American Psychiatric Association, 2022). During his fifth therapy session, this client disclosed a history of sexual abuse occurring approximately two years prior. However, the client did not endorse intrusive symptoms related to the abuse, nor did he report any feelings of increased reactivity or arousal. 23 Therefore, given clients presentation and report of symptoms and the nature of adjustment related concerns as they relate to college students, AD with mixed anxiety and depression appeared to be the best fit for this client. Because of the additional symptoms the client was reporting, such as low mood and feeling down and trouble with feeling nervous and worried, the addition of the specifier with mixed anxiety and depressed mood was included to account for the clients feelings of anxiety and depressed mood. This allowed the clients diagnosis to encapsulate those symptoms that otherwise did not meet full criteria for additional diagnoses. Adjustment Disorder Adjustment disorder background and symptoms. AD is a severe reaction to an identifiable stressor or stressors (American Psychiatric Association, 2022; OConner & Cartwright, 2012; Carta et al., 2009; ODonnell, et al., 2019). These different stressors that result in AD can appear as minor stressors to some but can be majorly distressing to the individual who experiences the stressor themselves. It is critical that clinicians, as well as other observers, recognize the importance of how stressors are perceived by the individual rather than how the stressors may appear to others. Among stressors, continuous stressors are considered more likely to cause AD, although OConner and Cartwright (2012) highlight that the effects of AD are often moderated by social support. AD was first introduced into the third edition of the DSM (American Psychiatric Association, 1980). It then appeared in the DSM-IV-TR (American Psychiatric Association, 2000) with minor changes made to the disorder and now appears in the current DSM-5 TR (American Psychiatric Association, 2022) with the following diagnostic criteria: 24 A) The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s); B) These symptoms of behaviors are clinically significant, as evidenced by one of both of the following: 1) Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation, 2) Significant impairment in social, occupational, or other important areas of functioning; C) The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder; D) The symptoms do not represent normal bereavement; and E) Once the stressor or its consequence have terminated, the symptoms do not persist for more than an additional 6 months (American Psychiatric Association, 2022, pg. 1133-1134). AD has the following six subtypes: AD with depressed mood, AD with anxiety, AD with mixed anxiety and depressed mood, AD with disturbance of conduct, AD with mixed disturbance of emotions and conduct, and AD unspecified (American Psychiatric Association, 2022). According to the American Psychiatric Association (2022), AD is a common diagnosis, with roughly 5% to 20% of individuals in outpatient mental health treatment settings having a principle diagnosis of AD. AD can occur at any point in an individuals life span, although young people are reportedly more vulnerable to the disorder because of their less well-developed coping skills and resources (OConner & Cartwright, 2012). The prevalence of AD in child and adolescent community samples fluctuate between 2% and 8% (American Psychiatric Association, 2000; Strain & Newcorn, 2003). AD appears to be more common among 25 disadvantaged persons (Vanin, 2008) and among individuals who have previously experienced trauma (OConner & Cartwright, 2012). Among individuals diagnosed with AD, their symptoms can widely vary. Some of the emotional and cognitive symptoms of AD could include hopelessness, sadness, lack of enjoyment, crying episodes, anxiety, irritability, suicidal ideation, worry, difficulty concentrating, and feeling overwhelmed. Some of the behavioral symptoms of AD could include sleep disturbances, fighting, reckless driving, mismanaging finances, truancy, and vandalism. Additionally, AD can have negative effects on close relationships, performance at school and work, and parenting (Carta et al., 2009; OConner & Cartwright, 2012). AD has come to be known as the cornerstone between major psychiatric disturbance and normal functioning. Strain and Diefenbacher (2008) further elaborate that AD straddles the border between normal and significant distress experienced when faced with acute and chronic stressors. Because of this, less research has focused specifically on AD than other Diagnostic Statistical Manual (DSM) disorders (Carta et al., 2009; OConner & Cartwright, 2012). Empirical support for treating adjustment disorders. When considering how to effectively treat individuals with AD, interventions are necessary to ease distress and to reduce the risk of suicide and future psychopathology, especially with younger individuals. Primary goals of interventions specific to AD include symptom relief, restoring typical functioning, and preventing the development of more serious disorders. Additional treatment goals might include helping clients understand their roles in stressful life events, reviewing and reinforcing positive steps clients take to deal with stress, learning to avoid and cope with stressors, and helping clients perceive their experiences as opportunities for growth and development (Carta et al., 2009; OConner & Cartwright, 2012). 26 Some of the recommended interventions for individuals with AD include support groups, individual therapy, and family therapy. Time-limited, or brief, interventions that support the clients attempts to identify and understand stressors, to establish and strengthen coping skills, and to build supportive relationships are desirable. Furthermore, it is important that interventions be specifically tailored to each individual depending on their current and previous difficulties (Carta et al., 2009; OConner & Cartwright, 2012). Despite the apparent need for effective interventions for individuals with AD, not many treatment outcome studies for AD exist in the literature, especially when compared to the extensive literature that exists for other disorders (Carta et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). Multiple factors can help to explain the lack of research pertaining to AD. First, by definition, AD is a brief disorder that is a reaction to stressors and often fades on its own (OConner & Cartwright, 2012). Because ADs are often short-lived and can resolve on their own over time, this may explain the lack of including AD in various research studies (Carta et al., 2009). AD can involve a wide range of stressors, which makes the population of individuals who meet criteria for AD largely heterogeneous. Furthermore, individuals with AD are occasionally a part of treatment outcome studies focused on related disorders when they have related symptoms, such as depression or anxiety. It is possible that these different factors led potential researchers to conclude that treatment outcome studies specific to AD are either difficult, unjustified, or unnecessary because interventions that are effective for other DSM disorders should also be effective when treating less severe versions of the same symptoms that develop in individuals with AD (OConner & Cartwright, 2012). 27 Contrary to this belief of ADs being short-lived and able to resolve over time is a study conducted by ODonnell and colleagues (2016) that found trauma survivors diagnosed with AD three months after the trauma exposure were 2.67 times more likely to eventually meet criteria for additional, more severe, mental health disorders after 12 months when compared to individuals who had no AD diagnosis at 3 months post-exposure. This study (ODonnell et al., 2016) provides support for effective intervention for individuals diagnosed with AD, rather than simply allowing time to resolve the matter on its own. Among current research, psychotherapy stands as the preferred treatment for AD (Kaplan & Sadock, 1998). However, a lack of controlled clinical trials of different psychotherapies makes it challenging to answer which form of psychotherapy may be most effective (Carta et al., 2009). Few between-group studies for AD have been conducted thus far. Some current studies, which provided support for treatment of AD and demonstrated a decrease in reported symptoms, have included a variety of therapeutic approaches, such as cognitive-behavioral therapy (Steinhardt & Dolbier, 2008) and brief group psychodynamic therapy (Ben-Itzhak et al., 2012). Maina and colleagues (2005) acknowledged the effectiveness of brief dynamic psychotherapy and of brief supportive psychotherapy when treating minor depressive episodes. Although this study did not examine the effectiveness of brief psychodynamic therapy in AD, it provides possible direction for future studies given the overlap between AD and depressive diagnoses (Maina et al., 2005). Another study found interpersonal psychotherapy to be effective when working with patients who were human immunodeficiency virus (HIV)-positive with depressive symptoms (Markowitz et al., 1998). Brief Psychodynamic Therapy 28 Qualities of brief psychodynamic therapy. When discussing brief psychodynamic therapy, it is important to acknowledge that it is a modification from traditional psychodynamic therapy (Levenson, 2017). As a modification from traditional psychodynamic therapy, brief psychodynamic therapy leans on different common components of psychodynamic theories, like the importance of childhood experiences and developmental history (Fonagy, 1999), unconscious influences on behavior (Freud, 1900), repetitive behavior, transference and countertransference (Freud, 1936), the role of conflict (Freud, 1931), and the therapeutic alliance. A therapist working within a brief psychodynamic therapy model, compared to a therapist working within a traditional psychodynamic therapy model, is more likely to highlight clients strengths and resources when facing life issues instead of focusing on regression and fantasy. Because of this difference, some popular psychodynamic techniques, such as lying on a couch or free association, are not utilized (Levenson, 2017; Strupp & Binder, 1984). According to Levenson (2017) and Strupp and Binder (1984), another modification made from traditional psychodynamic therapy in brief psychodynamic therapy is the greater emphasis placed on the clients present life rather than their previous childhood life. In addition to using modified psychodynamic interventions, brief psychodynamic therapy also utilizes techniques from other therapeutic models, such as experiential-process therapy and cognitive-behavioral therapy (Abbass, 2015; Fosha, 2000; Lilliengren et al., 2016; McCullough & Magill, 2009; Safran & Muran, 2000). Although the brief psychodynamic therapist might think and conceptualize psychodynamically, they are free to use a variety of intervention strategies (Levenson, 2017). Messer and Holland (1998) acknowledge that there are several different models of brief psychodynamic therapy. Some brief psychodynamic therapies have been developed primarily 29 from ego psychology and drive theory (Freud, 1923), and typically focus on conceptualizations that highlight aggressive, sexual, and dependent impulses and defenses, as well as oedipal conflicts (Messer & Holland, 1998). Other brief psychodynamic therapies, however, are largely focused on object relations and interpersonal relations, which help to identify problems from a perspective of maladaptive interpersonal patterns (Levenson & Strupp, 1997), focus on clients wishes, responses of others and responses of the self (Luborsky, 1997), focus on schemas and role relationships (Horowitz & Eells, 1997), and focus on problematic beliefs and how they play out between the client and therapist (Curtis & Silberschatz, 1997). Additionally, Mann (1991) detailed a brief 12 session therapy that consists of ideas stemming from self-psychology, specifically the use of empathy to help heal clients longstanding feelings of pain. Because there are so many brief psychodynamic therapy models to choose from, the current study will focus on a contemporary brief, time-limited psychodynamic therapy, as proposed by Levenson (2017) and originally Strupp and Binder (1984). There are multiple qualities that help to characterize brief psychodynamic therapy (Levenson, 2017; Levenson et al., 2002; Strupp & Binder, 1984) . The main factor that differentiates brief psychodynamic therapy from long-term psychodynamic therapy is its defined focus. In brief psychodynamic therapy, therapists must focus on a central theme, topic, or problem to help guide their work with their clients because of its brief nature. Additionally, it should be noted that in brief psychodynamic therapy, therapists and clients usually have limited goals. Brief psychodynamic therapy is not meant to be a once and for all cure but should provide clients with opportunities to foster changes in behavior, thinking, and feelings as it pertains to the main problem explored in session. Brief psychodynamic therapy should help clients learn more adaptive coping skills, help clients develop better interpersonal relationships, 30 and/or help clients gain a better sense of ones self. Therefore, brief psychodynamic therapy is seen as a chance for clients to begin a process of change that hopefully persists even after therapy is over (Levenson, 2017; Strupp & Binder, 1984). Another quality of brief psychodynamic therapy is its time limited nature (Levenson, 2017; Strupp & Binder, 1984). Messer and Holland (1998) described that brief psychodynamic therapy can range anywhere from 1 to 40 sessions, although it appears that most brief psychodynamic clinicians working today set a standard of 12 to 20 sessions as their model (Barber et al., 2013; Levenson, 1995; Strupp & Binder, 1984). Levenson (2017) and Strupp and Binder (1984) explain that brief psychodynamic therapists believe that by limiting the length of therapy sessions clients are allowed, clients are encouraged to have a sense of individuation and autonomy as well as positive expectations for treatment. In fact, there is evidence that providing these shorter time limits could encourage clients who might have otherwise prematurely terminated in a longer, open-ended therapy format to stay in therapy longer until they can successfully terminate (Hilsenroth, Ackerman, & Blagys, 2001). Another common belief among brief psychodynamic therapists is the belief that psychological change happens outside of the therapy room and that by setting time limits on therapy, this actually intensifies the therapeutic work done (Bolter, Levenson, & Alvarez, 1990). Additionally, in brief psychodynamic therapy, the therapist needs to be an active participant in the therapy process (Levenson, 2017; Strupp & Binder, 1984). It is important for the therapist to remember, however, that activity is only necessary in order to maintain the focus of therapy, to foster a positive therapeutic alliance, and to make progress within their allotted time. This requires the therapist to have an awareness of the therapy goals and a plan for how to achieve them, all while remaining sensitive to the clients presentation and to the context of the 31 clinical material. A therapists activity in sessions can range from supportive interventions such as validation, reassurance, and strengthening adaptive defenses to more exploratory interventions such as confrontation and interpretation. The therapists level of activity should be dependent on the different factors during the session, such as the strength of the therapeutic alliance, and on the characteristics of the client, such as their psychological health and their quality of interpersonal relationships (Levenson, 2017; Strupp & Binder, 1984). An additional quality of brief psychodynamic therapy is the therapeutic alliance, which has commonly been thought to include the emotional bond between therapist and client, the agreement on treatment goals, and the agreement on the plan on how to accomplish those treatment goals (Levenson, 2017; Strupp & Binder, 1984). The strength of the therapeutic alliance, especially from the clients view, has been consistently shown to be one of the strongest components in predicting treatment outcomes (Martin, Garske, & Davis, 2000; Zilcha-Mano, Dinger, McCarthy, & Barber, 2014). Furthermore, Heinonen and colleagues (2014) discovered that therapists with an engaging and encouraging relational style with their clients were able to foster working alliances with their clients, especially in the case of short-term therapies. Being able to develop a positive therapeutic alliance as quickly as possible is important in all therapy models but is especially important when working with a brief therapy model where the therapist might have fewer chances to repair any ruptures in the therapeutic relationship (Levenson, 2017; Strupp & Binder, 1984). According to Levenson (2017) and Strupp and Binder (1984), some additional qualities of brief psychodynamic therapy include the important ability of the therapist to quickly formulate the clients case and begin intervening and the therapists necessary willingness to terminate with clients in carefully considered style because of the short-term nature of the 32 therapy. The final major difference between long-term psychodynamic therapy and brief psychodynamic therapy includes the idea of establishing a therapeutic contract. Although the specifics of contracts vary and are not always written and should not necessarily be considered as legal contacts, there needs to at least be a mutual understanding between the therapist and client that their work together will be time limited and focused in scope (Levenson, 2017; Strupp & Binder, 1984). Theoretical background. It is important to know that this theoretical approach intertwines three different theories: attachment theory, interpersonal-relational theory, and experiential-affective theory. Let us first explore the components of attachment theory, which helps to provide the motivational explanation for brief psychodynamic therapy (Levenson, 2017; Strupp & Binder, 1984). Attachment theory suggests that infants exhibit a collection of natural behaviors in an effort to maintain physical closeness to caregivers (Bowlby, 1969). From an attachment theory perspective, people are designed to gravitate toward others considered to be older and wiser, especially during times where one feels stressed or threatened. As infants, humans are genetically programmed to seek attention from caregivers they depend on (Bowlby, 1969). One notable name in the attachment theory world, Mary Ainsworth, developed a now famous experiment to examine the attachment patterns of infants called the Strange Situation (Ainsworth, 1967). From this experiment, Ainsworth identified multiple distinct attachment patterns: secure attachment and insecure attachment (e.g., avoidant attachment and anxiousambivalent attachment). Another notable name in the attachment theory world, John Bowlby, developed a triad between attachment, separation, and loss that displayed the importance of the emotional quality 33 of early childhood in order to understand psychopathology (Bowlby, 1969, 1973, 1980). Although attachment initially referred to an infants proximity seeking, Bowlby later explained how attachment needs and behaviors continue later throughout the life cycle, with even adults turning to other adults, especially in stressful times (Bowlby, 1988). Bowlby (1988) explains that individuals have this internal psychological organization that consists of very specific features, such as representational models of the self and of attachment figures, that develops over time and is continuously built upon through early life experiences with caregivers. Therefore, a child has both an internalized expectation about how others will treat them and an internalized model of how they see themselves, feel about themselves, and treat themselves based on how they have been treated by others. Bowlby hypothesized that a child with a secure attachment learns to think that there are not any forms of the self that cannot be noticed, responded to, and dealt with (Levenson, 2017; Strupp & Binder, 1984). Children who do not have a secure attachment, on the other hand, learn that they cannot count on others to keep them safe when they are threatened. Children with an insecure attachment pattern have negative models of the self and/or others. These children have a difficult time being able to correct these negative internalized models because of their difficulties with cognitively and emotionally attending to incoming information that disconfirms their internal model. Because these working models are originated and then maintained out of awareness, this cycle only continues (Levenson, 2017; Strupp & Binder, 1984). Additionally, insecurely attached childrens internal working models persist partially because of the ongoing interactions these children have with the very individuals who contributed to this in the first place. For example, 34 someone who had harsh parents as an infant and child is likely to continue to have those harsh parents through toddler and adolescent ages (Wachtel, 2008). Bowlby viewed attachment as significant from birth through death, although adults typically do not need the proximity to another human in order to physically survive like infants do (Levenson, 2017; Strupp & Binder, 1984). According to Pietromonaco and Barrett (2000), adults feel secure when their attachment figures confirm they are loved, capable of love, and competent. In time, this sense of security internalizes within adults and is carried with them throughout life. Bowlby (1969) recognized that people, celebrities, and even institutions, as well as the mental representations of these figures, could be identified as attachment figures and sources of comfort to people. Recently, Shaver and Mikulincer (2008) were able to demonstrate that when people were asked to visualize the faces of their attachment figures, this promoted positive feelings, reduced painful feelings, and fostered empathy for those people. Although there is not a specific attachment therapy approach for adults, there is a lot of importance in the role of attachment theory for therapeutic formulation and intervention (Levenson, 2017; Strupp & Binder, 1984). Bowlby (1988) defined the five following tasks for the therapist to complete throughout therapy: be a trusted aid and provide a secure base so clients can examine the painful parts of their lives; help clients explore their expectations and biases in connecting with others; encourage clients to connect early parenting experiences to current functioning; help clients view the past as it is and help them identify healthier alternative ways of thinking and behaving; and help clients examine the therapeutic relationship as clients working models of self and others occur in therapy. Additionally, Bowlby (1988) believed that the therapist should explore a clients past only when it is useful in helping to understand the clients current feelings and ways of coping with their interpersonal world. 35 According to Levenson (2017) and Strupp and Binder (1984), the next theory underlying brief psychodynamic therapy is interpersonal-relational theory, which helps to form the frame for brief psychodynamic therapy. Harry Stack Sullivan is often noted for first acknowledging the importance of the interpersonal dimension for psychotherapy when he pushed for interpersonal relatedness over the previous Freudian position that biological drives determined the development of personality (Sullivan, 1953). Sullivan believed that through interactions with their parents, children develop self-other role relationship patterns, which later emerge in strategies that help one to avoid or manage anxiety and to maintain self-esteem. These strategies are also known as interpersonal coping styles. Sullivan originated the term participant observer to explain how in therapy sessions, the therapist is an expert observer that makes note of what is happening during the therapy session, as well as a full participant in the interaction taking place between the therapist and the client. The interpersonal perspective of therapy mirrors a larger shift taking place in psychoanalytic thinking and practice that was previously usually framed as a one-person, focus within model instead of the current two-person, focus between model (Levenson, 2017; Strupp & Binder, 1984). In fact, Messer and Warren (1995) noticed that most psychoanalytic schools are becoming more relationally oriented and less drive oriented. This increase in using interpersonal perspectives can be seen not only in psychoanalysis, but in other therapy models as well, such as cognitive therapy (Castonguay & Beutler, 2005) and behavioral therapy (Kohlenberg & Tsai, 1991). For a clinician in practice, this change to a more relational approach has wide implications, such as what qualifies as pathology, how one conceptualizes a client and their clinical situation, what interventions might be most helpful, and how outcomes are evaluated (Levenson, 2017; Strupp & Binder, 1984). Pincus and Ansell (2003) acknowledged that the 36 existence of others and how they help interpersonal learning can have effects on self-regulation, field regulation, and emotion regulation. This brings us to the final component of brief psychodynamics theoretical underpinnings: experiential-affective theory. According to Levenson (2017) and Strupp and Binder (1984), the experiential-affective theory is an important component of brief psychodynamic therapy because it focuses on the critical change agent part of the model. For psychodynamic therapies, a key feature has been focusing on affect and emotion expression (Hilsenroth, 2007). Early emotion theorists, such as Frijda (1986), Lazarus (1991), and Tomkins (1963) stressed the functions of emotions as motivating, adaptive, and organizing to oneself and to others. Psychodynamic therapists have long spent time acknowledging and exploring the emotions of their clients, but now practitioners and theorists from other therapeutic orientations are acknowledging the key role emotions have in creating change. Back in 2009, Schore declared that we were in an emotional revolution. He further explained that within the field of psychology, there had previously been a focus on behavioral and cognitive theories during the 20th century, but during the 21st century the emphasis will increasingly be on emotions (Schore, 2009). Despite this shifted focus toward emotions, clients are not always consciously aware of their feelings. Therefore, helping clients become aware of their emotions, experience their emotions, and process their emotions are critical components of experiential therapy models (Greenberg, 2012; Greenberg, Rice, & Elliot, 1993). For decades now, being able to be emotionally aware and emotionally intelligent, being able to reprocess emotions, and being able to regulate emotions have been indicated as signs of mental health (Goleman, 1995; Linehan, 1993; Schore, 1994). According to Fonagy, Gergely, Jurist, and Target (2002) and Siegel (2007), 37 someones ability to regulate their emotions is heavily motivated by their early experiences with caregivers. Siegel (2007) proposed that parents who can accommodate their childs emotional state and can stabilize their childs emotions help their child to develop circuits in the brain that promote emotion regulation. This ability to regulate emotions then helps their child to have a source of resilience as they grow, which then evolves into their ability to regulate themselves and engage in empathic relationships with others. This attunement to emotions is not only the pathway to a healthy psychological life, but it may also be the pathway to the development of healthy brain structures and functions and to improved interpersonal and intrapsychic functioning. Once these children who are able to regulate their emotions grow up and have their own children, they can then help build healthy brain structures and functioning in their own children, leading another generation to developing these resilient characteristics (Siegel, 2007). Additional research has supported the use of experiential-affective therapy. Diener, Hilsenroth, and Weinberger (2007) conducted a meta-analysis that consisted of 10 processoutcome studies and discovered that client improvement was significantly related to the extent that therapists accessed and processed emotional experiences. Lilliengren and colleagues (2016) have suggested that experiential dynamic therapy tend to outperform other active methods of treatment. Additional research has found that the depth of emotional experience during therapy is related to positive outcomes, regardless of the theoretical orientation used and with a variety of disorders (Lilliengren et al., 2016; Thoma & McKay, 2015; Whelton, 2004). Assumptions and goals. According to Levenson (2017) and Strupp and Binder (1984), one of the basic assumptions of the brief psychodynamic therapy model is the idea that people are naturally motivated to seek out and maintain human relatedness, which can be a major 38 motivating factor for all human beings. Another basic assumption of the brief psychodynamic therapy model is that maladaptive relationship patterns and their connecting emotions are developed early in life, become schematized, and then underlie many presenting concerns. Often times, how we relate during adulthood connects back to our early relationships with caregivers. These early experiences then form mental representations or working models of someones interpersonal world. These working models then become the foundation that informs an individual about the nature of human relatedness, their own sense of self, and the actions and behaviors necessary to receive and maintain attention from others. Additional basic assumptions, according to Levenson (2017) and Strupp and Binder (1984), of brief psychodynamic therapy are as follows: relationship patterns and their connecting emotions continue because they are managed in current relationships and are consistent with the individuals sense of self and others, also known as circular causality; clients are viewed as stuck, not sick; the focus in therapy is on changing maladaptive relationship patterns and their connected emotions; the therapist is concerned with what goes on within the session and between the therapist and client rather than with specific content; the therapist and client focus on one of the clients main problematic relationship pattern; the therapist acts as both an observer and a participant; and the process of change will continue even after the client terminates from therapy. When it comes to brief psychodynamic therapy, there are two major goals to keep in consideration. The first major goal of this brief psychodynamic therapy model is to provide clients with new experiences within themselves and relationally with others (Levenson, 2017; Strupp & Binder, 1984). By allowing clients to experience this type of experiential learning, they should hopefully encounter healthier and more functional relational interactions that can work to challenge their repetitive maladaptive patterns and promote more positive, less guarded, and 39 widened sense of self, in addition to more positive outlook toward others. This first goal highlights clients ability to feel differently and become aware of feeling differently as well as to act differently and then become aware of acting differently. Experiential learning is also emphasized in this therapy because of the power this type of learning can have on bring about change in clients (Levenson, 2017; Strupp & Binder, 1984). In an effort to spark this change, experiential learning should take place at both interpersonal and intrapersonal levels for our clients. In order for clients to have new interpersonal experiences, they need to take a risk with the therapist and with other individuals in their lives when faced with something that is typically avoided, such as feelings of anxiety, hopelessness, or shame. When clients are able to take this risk and observe how others react, this helps to create a new experience for the client themselves and for other people involved in the interaction. As clients engage in different behaviors than before, these behaviors can be rewarded and lead to new patterns beginning to replace old patterns. It is important to note that since clients previous, dysfunctional interpersonal styles developed through sequences of various antecedents and consequences, they can also learn to develop a more functional interpersonal style through new sequences of antecedents and consequences. Over time then, these new experiences can then help to shift the clients previous internal working model. In addition to new interpersonal experiences, clients also need new intrapersonal experiences to help replace maladaptive emotional states with more positive emotional states. This can be done by therapists providing corrective emotional experiences to clients as well as therapists being empathic toward clients (Levenson, 2017; Strupp & Binder, 1984). According to Siegel (2006), therapists who are empathic toward their clients do more than just helping clients 40 feel better in the moment, but they help clients to create new cases of neural activity that can help to improve clients self-regulation. According to Levenson (2017; Strupp & Binder, 1984), the second major goal of this brief psychodynamic therapy model is to provide clients with new understandings about emotional shifts within themselves and about relational shifts between themselves and other people. By doing this, there is hope that clients will be able to reflect on their emotions and relations with others as well as make meaning of their emotions and relations with others. Again, this goal must be done both interpersonally and intrapersonally for clients. In an effort to help clients grow intrapersonally, therapists need to carefully attend to emotions that clients are experiencing and expressing during therapy sessions and help clients better be able to understand these emotions and understand their meaning. To help clients grow interpersonally, therapists should help clients be able to identify and understand their interpersonal patterns and how these became developed and then maintained. Some common therapeutic techniques therapists might use at this point in therapy include reflection, clarification, interpretation, confrontation, and discussing patterns that emerge in the therapy room between the client and therapist. To help clients better understand their interpersonal patterns, therapists can bring to light repeated patterns that have occurred between client and therapist, between client and previous significant others, and between client and current significant others (Levenson, 2017; Strupp & Binder, 1984). This can help clients start to realize their patterns that occur with different people in their lives. Once clients gain this new perspective, they can then begin to consider their role in maintaining these dysfunctional interactions and can gain the ability of self-observation. As clients begin to be able to identify these dysfunctional patterns and relate them to their emotions, 41 they can then start having awareness in the moment when these dysfunctional interactions begin to occur. This awareness then allows clients to recognize opportunities to be able to break the cycle of dysfunctional interactions and behave differently. It is important here for therapists to realize their role in normalizing clients behavioral and emotional reactions by helping clients learn how their now dysfunctional behaviors were at one point in their life functional and had some sort of purpose for the client (Levenson, 2017; Strupp & Binder, 1984). Interventions. According to Levenson (2017) and Strupp and Binder (1984), interventions for this treatment model are known to be therapeutic strategies that are extremely entangled into the interpersonal relationship between the client and therapist. It is worth noting that any intervention that is related and able to aid the goals of new experiences and new understandings are able to be used. Because of the brief nature of brief psychodynamic therapy, it is important that therapists become comfortable with initiating interventions even before they have all the information they desire. To help with this, tentative statements that allow for client feedback begin to build feelings of collaboration between client and therapist. Interventions can simply draw clients to see and feel things differently and from a different perspective. During brief psychodynamic therapy, it is important that the therapist works with clients in a respectful and nonjudgmental manner, validating their perceptions and feelings, and inviting their collaboration over the course of therapy. It is also important that therapists demonstrate active listening to the client, acknowledge clients strengths, and address any obstacles and opportunities that might influence the therapy process (Levenson, 2017; Strupp & Binder, 1984). Marcolino and Iacoponi (2003) conducted a study to examine the influence of the therapeutic alliance among clients receiving brief psychodynamic therapy and discovered that clients who 42 had higher levels of therapeutic alliance during the first therapy session had more favorable outcomes at the end of treatment. In addition to developing and maintaining that therapeutic alliance, therapists should also: help clients access, label, and process their emotions; utilize empathic exploration to better understand the client; maintain focused questions that pertain to the established goal; facilitate exploration of clients relationships with significant others as well as with the therapist; facilitate exploration of cyclical maladaptive patterns as well encourage new adaptive behaviors to replace the previous maladaptive behaviors; promote change directly to the client by providing the client with chances to have new experiences and new understandings; and discuss the time-limited nature of brief therapy (Levenson, 2017; Strupp & Binder, 1984). Thinking specifically about the importance of emotions, there is large support that emotional processing during therapy sessions and across treatment can be considered a core agent of change for clients engaged in therapy (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Jaycox, Foa, & Morral, 1998; Magnavita, 2006; Pos, Greenberg, Goldman, & Korman, 2003; Whelton, 2004). McCullough and colleagues (1991) as well as other studies (Hill, Helms, Spiegel, & Tichenor, 1988; Hilsenroth, Ackerman, Blagys, Baity, & Mooney, 2003; Town, Hardy, McCullough, & Stride, 2012; Diener, Hilsenroth, & Weinberger, 2007) have been able to demonstrate that the number of emotion-oriented interventions was related to clients outcome at the end of brief psychodynamic therapy treatment. Empirical support for brief psychodynamic therapy. According to Lambert (2004), a large number of psychotherapy research conducted in the United States involves brief therapies that last no longer than 20 sessions. In a study done by Falkenstrom, Josefsson, Berggren, and Holmqvist (2016), they found that the rate of change is indeed quicker for clients who attend 43 fewer number of therapy sessions. In 2013, Lambert studied the effectiveness of psychotherapy and observed that approximately 50% of clients responded to therapy by the 8th session. Hansen and associates (2002) discovered that approximately 60-70% of clients showed improvement within 13 sessions, while additional studies (Hoglend, 2003; Kopta, Howard, Lowry, & Beutler, 1994; Shapiro et al., 1995) have found that clients with both acute and chronic symptoms demonstrated clinically meaningful change between 13 and 18 sessions. When looking at the efficacy of brief psychodynamic therapy, Barber and colleagues (2013) gathered the results from multiple studies and found that psychodynamic therapies, most of which were reportedly short-term, appeared to be superior to control groups at the time of termination and during later follow-ups in regard to depressive, anxiety, and personality disorders. Additional meta-analyses found that brief psychodynamic therapy was superior to waiting list control groups and was just as effective as other psychotherapy treatments, such as cognitive-behavioral therapy and solution focused therapy, and medications (Abbass et al., 2008; DeMaat et al., 2008; Leichsenring, Rabung, & Leibing, 2004). Knekt and associates (2008) conducted a randomized trial to examine the effectiveness of short-term and long-term psychodynamic therapy and found that the participants from the brief psychodynamic therapy group were able to demonstrate maintained positive improvements throughout the 3-year post follow up. Empirical support for brief psychodynamic therapy with AD. In clinical settings, AD is a common diagnosis (Carta et al., 2009). Because quick intervention could help to prevent further complications for individuals diagnosed with AD, such as relationship problems or decreased functioning at places like school or work, being able to provide effective treatment for these clients is important (Strain & Diefenbacher, 2008). According to Strain and Diefenbacher 44 (2008), the main goals for therapy when working with an individual diagnosed with AD should include restoring their mental balance, uncovering the concerns and conflicts the client reports experiences, identifying coping skills and supportive relationships to aid in reducing current and future stressors, and helping the client regain perspective on the challenge they have encountered. Despite this need for effective quick intervention for individuals diagnosed with AD, AD is often overlooked by researchers (Azocar & Greenwood, 2007; Carta et al., 2009; Casey, 2009) and few studies have examined the treatment of clients with AD as their primary diagnosis (Stirman et al., 2005). Recently, a study examined the effect of 12 sessions using client-centered therapy among clients diagnosed with AD. This study discovered that these clients did indeed experience symptom relief at the end of treatment and found that this effect was maintained during the 2year post-treatment evaluation period (Gorschenek et al., 2008). Similarly, another study found that client-centered therapy with clients diagnosed with AD was superior to clients in control groups that went untreated (Altenhofer et al., 2007). Psychodynamic therapy has been found to be superior to untreated control groups for clients diagnosed with Minor Depressive Disorder (Maina et al., 2005). Since minor depression and AD share some of their characteristics (Casey, 2009), one might be able to hypothesize that psychodynamic therapy may also be superior to untreated control groups for clients diagnosed with AD (Ben-Itzhak et al., 2012). The amount of literature comparing the overall effectiveness of brief psychodynamic therapy versus longer psychodynamic therapy in general is limited, which has led to not enough evidence to support choosing between a brief or long-term therapy when working with clients diagnosed with different psychiatric disorders (Knekt et al., 2008). In an attempt to fill this gap, Ben-Itzhak and colleagues (2012) conducted a study to compare the effectiveness of brief 45 psychodynamic therapy, which consisted of 12 therapy sessions, to intermediate length psychodynamic therapy, which consisted of one year of therapy, when working with clients diagnosed with AD to see if there was any benefit from intermediate length therapy versus brief therapy. Their study found that after 3 months of therapy, clients from both groups showed significant improvement. Furthermore, the improvement achieved by both therapy groups was equally continued at the 9-month follow up after terminating from therapy. These results help to provide evidence that brief psychodynamic therapy is not inferior to long-term psychodynamic therapy when trying to restore previous psychological functioning prior to developing an AD (Ben-Itzhak et al., 2012). Additionally, Bloom (1997) and Steenbarger (1992a) conducted lengthy reviews of research on brief therapy, and both discovered there to be strong evidence supporting the effectiveness of brief therapy, even stating that brief therapy is often as effective as long-term therapy. Empirical support for brief psychodynamic therapy in college counseling. When considering brief therapy in college counseling centers, it is important to critically examine both the advantages and limitations of brief, time-limited models. Some notable limitations of brief therapy in college counseling centers include the argument that it is important to allow students the freedom and autonomy to decide when to engage in services and when to terminate services, given their developmental stage (Widseth & Webb, 1992). Furthermore, May (1988) supported this limitation by noting the important difference between a goodbye that is chosen by the student and a goodbye that is forced. It is also possible that students respond to time-limits in a negative manner that might hinder their ability to build an alliance with the therapist. Allowing 46 the students to choose just how much therapy they want when facing a development crisis could be especially important (Ghetie, 2007). Some college counseling center clinicians oppose time-limited therapy because they argue that therapy with college students is already inherently brief, with the median number of sessions between 4 to 5 (Rockland-Miller & Eells, 2006), thus making it questionable what the purpose of further limiting treatment is (Whitaker, 1994). Finally, a study conducted by Gyorky, Royalty, and John (1994) discovered that college counseling centers with imposed time-limits had longer wait lists and were not able to serve a high percentage of the study body when compared to college counseling centers without any imposed time-limits. Despite these limitations of brief therapy in college counseling centers, there are also many notable advantages that should be considered, such as the apparent support that brief, timelimited treatment has been shown to be effective in college counseling centers and in other treatment settings (Ghetie, 2007). Supporting this notion, Anderson and Lambert (1995) completed a meta-analysis that consisted of more than 20 empirical studies of brief psychodynamic therapy and discovered a moderate mean effect size. Additional studies have found that even very brief treatments, defined as consisting of less than 5 sessions, have been shown to be effective (Michel, Drapeau, & Despland, 2003; Pinkerton & Rockwell, 1994; Vonk & Thyer, 1999). Medalie (1987) noted that in college counseling centers, brief therapy can be effective in preparing students for long-term therapy completed at settings outside of counseling centers. Additional arguments have been made that brief, time-limited treatment can reduce wait lists, is cost effective, and allows clinicians to have more time for other services, such as outreach (Ghetie, 2007). Further supporting brief therapy in college counseling centers, Wolgast, 47 Lambert, and Puschner (2003) completed a study on the dose-response rate in college students in an effort to conclude how many therapy sessions are needed for significant change to occur. From their study, they discovered that 24% of students obtained significant change after the 7th therapy session and 51% of students obtained significant change after their 14th therapy session (Wolgast, Lambert, & Puschner, 2003). Looking specifically at college counseling centers, multiple research studies have demonstrated that short-term therapy is indeed practiced in these settings, as evidenced by the consistently low average number of therapy sessions students attend (Gallagher, R., & Bruner, L., 1995, 1996, 1997). Archer and Cooper (1998) have outlined six different reasons as to why brief therapy models should be utilized within college counseling centers, such as: the expanding evidence supporting the effectiveness of brief therapy with a wide range of clients and presenting problems; the suitability of the types of developmental and situational problems students often present with for brief therapy; the reality of clinicians in college counseling centers needing to limit their scope in order to equally reach as many students as possible; the need for consultation and prevention type work to address different important issues campus wide; the need for outreach and program development; and the growing demand for services as more students find themselves more accepting of therapy. As previously alluded to, the types of developmental problems that students often present with at college counseling centers, in addition to the reality of time limitations posed by academic calendars, have led most college counseling centers to adopt brief therapy models (Cooper & Archer, 1999; Steenbarger, 1992b). It should be noted that although some clinicians and authors make the argument that college counseling centers should indeed provide brief therapy for most students, typically lasing around 5 to 10 sessions, students in need of long-term 48 therapy should be properly assessed and either referred elsewhere for services or be given an exception and allowed long-term therapy if they are not able to obtain services elsewhere (Stone & Archer, 1990). Empirical support for brief psychodynamic therapy with members of the LGBTQ+ community. When trying to determine an appropriate and effective approach for particular clients, clinicians are faced with a critical decision of the therapeutic process (Fassinger, 1999). While working with clients who are highly verbal and are relatively well-functioning individuals who want to obtain better understandings of their past and how it relates to their current behaviors, psychodynamic approaches appear to be useful (Corey, 1996). For clients who identify as part of the LGBTQ+ community, psychodynamic therapys focus on clients own history and family history may be appropriate, especially when considering analyzing the type of experience a client might have during their process of coming out. Developing a better understanding of the dynamics between the client and their parents could help LGBTQ+ clients who report problems in seeking or accepting social support and in achieving intimacy, as well as help LGBTQ+ clients better understand typical and dysfunctional relationship patterns. As LGBTQ+ clients form strong attachments to their therapists, it is possible that this is the first time the client has been able to be open and honest with someone, has felt known and understood by someone, or experienced an accepting relationship with someone. Since LGBTQ+ clients could have countless numbers of concerns that they bring into the therapy room, an integrative approach is essential to effectively working with these clients (Fassinger, 1999). It is also important to address the high suicide rate of LGBTQ+ youth, who have up to four times the risk of attempting suicide compared to their counterparts that identify as heterosexual. LGBTQ+ youth that come from families who are not accepting of them have up to 49 eight times the risk of attempting suicide (McDaniel, Purcell, & DAugelli, 2001). Often times, LGBTQ+ youth can feel isolated and unsure of who to trust. These youth might not seek out mental health services because of their own fears of treatment or because of previous negative experiences with mental health professionals (Fauman & Hopkinson, 2010). This further highlights the importance of building rapport with clients who identify as members of the LGBTQ+ community as well as the importance of quick and effective interventions. Case Formulation Based on the clients background information, it appeared that in regards to his current treatment, there were a few different major events that contributed to this clients development and functioning: his past and possibly current relationship with his parents; his previous relationship with his ex-boyfriend; the reported sexual trauma the client experienced at the age of 18; and the recent negative changes in clients life (e.g., his family moving away; his quitting his job he previously had for 4 years; his lifelong friends moving away; his learning of his mothers illness; and his placing more focus on his personal life). First, it was important to consider this clients attachment and how it related to his current functioning. Based on the clients reported relationship with his parents, it is possible that his parents inability to appropriately respond to him while growing up could have led the client to developing an insecure attachment with his parents that persisted throughout his life thus far. Specifically, it is possible that the client developed an anxious-ambivalent attachment pattern. Furthermore, when considering this clients relationship with his ex-boyfriend, it seemed that this relationship that had the client constantly worrying about whether he was good enough for his ex-boyfriend and constantly worrying about his boyfriend leaving him could have further reinforced this insecure attachment pattern. This also demonstrated the possibility that the client 50 learned, from this attachment pattern, that he was not able to count on others to keep him safe as well as learned to view himself and others in a negative manner. Taking the interpersonal-relational theory into consideration, which explains that children develop self-other role relationship patterns through interactions with their parents, it is possible that the client witnessed a dysfunctional type of relationship between his mom and dad growing up that then became the clients idea of what a typical relationship looks like. This was demonstrated by the clients relationship with his ex-boyfriend and was then possibly further engrained in the client through the sexual abuse he experienced at the age of 18. Building on the clients foundation of an insecure attachment style from his relationship with his parents, it is possible that his relationship with his ex-boyfriend and the sexual abuse the client experienced both further enhanced this attachment style for this client, who seemed to have repeatedly been exposed to unhealthy relationships throughout his life. When considering the experiential-affective theory and how emotions are motivating, adapting, and organizing to the client and to others, it was important to consider the impact the clients dad possibly had on him. The client reported an inability to form a relationship with his father because the client never knew how his father was emotionally going to act. This suggested that the clients dad was poor at regulating his own emotions and therefore could have modeled this poor emotion regulation to the client, rather than modeling appropriate emotion regulation. That lack of emotion regulation for the client could help to explain the clients history of selfharm as a way to cope in the past. Treatment Plan An important component of this brief psychodynamic therapy was the time-limited aspect of treatment. Although the time-limited component of therapy was never outright discussed at 51 the start of therapy, the structure of the academic calendar and the clients knowledge that therapy services would be ending at the end of the semester made it clear that the therapist and client had roughly 12 weeks to meet for individual therapy sessions on a weekly basis. Because of the impact the COVID-19 pandemic had on the university, the clients therapy lasted a total of six individual therapy sessions. Although the client originally came into therapy without any clear treatment goals, the client later identified a goal of wanting to come to terms with what had previously happened between him and his ex-boyfriend. In accordance with the brief psychodynamic therapy model and the therapists conceptualization of the client, the therapist had the following goals for the clients treatment plan: to build a strong therapeutic alliance with the client; to provide the client with a healthy and functional relationship to challenge his maladaptive relationship pattern in place; and to provide the client with new understandings about his emotions as they occur within him and as they occur within relationships with others. In order to achieve these goals, the therapist utilized appropriate interventions outlined in the brief psychodynamic therapy model, such as: working collaboratively with the client; validating the clients perceptions and feelings; demonstrating active listening to the client; helping the client access, label, and process his emotions; using empathic exploration; facilitating exploration of the clients relationships with others as well as with the therapist; and facilitating exploration of cyclical maladaptive patterns. Clinical Research Question Current research on effective treatments for individuals diagnosed with AD is minimal (Carta et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). However, previous research has demonstrated some support for a variety of therapeutic approaches in the treatment of AD, such as cognitive-behavioral therapy (Steinhardt & Dolbier, 2008) and brief 52 group psychodynamic therapy (Ben-Itzhak et al., 2012). Despite the lack of research surrounding the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD, there have been studies that have found brief psychodynamic therapy to be effective when treating individuals with minor depressive episodes (Maina et al., 2005). Given the current limited research on the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD, there is a significant need for research that provides support for effective treatment for work with individuals diagnosed with AD. The current case study examined a client diagnosed with AD who received outpatient treatment in a college counseling center. The treatment modality used in the current case study was a form a brief psychodynamic therapy. Although the current case study aimed to have roughly 12 individual therapy sessions with the client, the impact of the COVID-19 pandemic caused the current case study to take place over the course of six individual therapy sessions. The current study aims to provide further evidence supporting brief psychodynamic therapy as an effective treatment with this traditional aged college student diagnosed with AD. Based on the existing literature previously reviewed, the clients presentation, and the treatment plan for the client, the current study will ask the following two questions: Is this client better off than before therapy began? Which of this clients symptoms improved and which did not improve? The current study hypothesizes that the client will show improvements in treatment. Method Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62; Lock et al., 2011) The CCAPS-62 is a 62-item measure that was designed to evaluate a variety of psychological symptoms common to disorders found in the college population. The CCAPS-62 has eight 53 subscales: Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Eating Concerns, Hostility, Family Distress, and Substance Use. Individuals completing the measure are asked to rate themselves on a 5-point Likert-scale ranging from 0 (not at all like me) to 4 (extremely like me) over the course of the last 2 weeks. Of the 62 items on this measure, nine of the items are reverse scored. Subscale scores are calculated by adding together individual item scores, with higher scores indicating more distress. Average item ratings on each subscale can also be calculated across subscales. After the CCAPS was developed, Titanium Software, a common electronic medical record system used in college counseling centers, partnered with the Center for Collegiate Mental Health to incorporate the CCAPS within the Titanium software. This allows therapists in university counseling centers to seamlessly administer, score, and generate reports using the CCAPS (Penn State Student Affairs: Center for Collegiate Mental Health, 2023). In the current study, Titanium software was utilized to administer, score, and generate reports with percentile scores for the clients CCAPS-62. According to Locke and colleagues (2011), subscale scores have demonstrated acceptable internal consistency and test-retest reliability, as well as convergent validity in a largely nonclinical college population. In their studys sample, the test-retest reliability coefficients were r = .93 for Depression, r = .89 for Eating Concerns, r = .87 for Substance Use, r = .78 for Generalized Anxiety, r = .91 for Hostility, r = .83 for Social Anxiety, r = .92 for Family Distress, and r = .92 for Academic Distress. Cronbachs alpha were a =.92 for Depression, a =.85 for Generalized Anxiety, a =.85 for Social Anxiety, a =.83 for Academic Distress, a =.87 for Eating Concerns, a =.85 for Hostility, a =.84 for Family Distress, and a =.85 for Substance Use. These 54 test-retest reliability coefficients can be seen in Table 1 in the Empirical Findings section to further clarify how the RCI was calculated. For the current study, the CCAPS-62 was administered via the Titanium software program on three separate occasions, with the first CCAPS-62 being completed by the client upon arriving for his intake session, again after three individual therapy sessions, and then again before his final, sixth, individual therapy session. Average item rating scores for each subscale were calculated and utilized using each individual item response on every subscale and can be seen in Table 2, in the Empirical Findings section. Reliable Change Index For the current study, the RCI was calculated utilizing pre, mid, and post means for each subscale within the CCAPS-62. Table 2 details the average item rating scores for each subscale at pre, mid, and post phases of treatment and can be seen in the Empirical Findings section. Cutoff scores for each CCAPS-62 subscale were also calculated utilizing means and standard deviations for males in normal and clinical populations, which were provided by the Center for Collegiate Mental Health (CCMH) annual report (2010) and can be seen in Table 3 in the Empirical Findings section. Course of Treatment In accordance with the brief psychodynamic therapy model and in accordance with the Universitys academic calendar, therapist and client were originally planning to meet for approximately 12 individual therapy sessions on a weekly basis for 50 minutes each. Because of the COVID-19 pandemic, however, the therapist and client were only able to meet for six weekly individual therapy sessions for 50 minutes each. The client consistently attended his scheduled therapy sessions and was actively engaged in his treatment during sessions. 55 Through the course of the clients treatment, the therapist engaged as an active participant in collaboratively discussing and reflecting on the clients experiences. To accomplish treatment goals, the therapist utilized techniques from brief psychodynamic therapy. Because of the integrative nature of this brief psychodynamic therapy, the therapist also utilized techniques from other various theoretical orientations to facilitate conversations and discussion surrounding the clients thoughts about his mental health problems, himself and others, and his life experiences. Session one. The client was unable to initially identify goals for his treatment during the first session, but simply explained pursuing therapy after a friend recommended it to him. Given the briefness of this brief psychodynamic therapy, the therapist quickly formulated ideas and began utilizing interventions. Thus, the therapist and client began by discussing the events that led the client to pursue therapy (e.g., close friends and family moving away, quitting his job, placing more focus on his personal life, and learning of his mothers illness). During the first session, the therapist and client also began discussing the clients reported poorly developed sense of self and feelings of not belonging, specifically as it pertained to his degree field at the university. This is also when the client first introduced his past relationship with his ex-boyfriend, whom he dated for approximately one year during his freshman year of college. The therapist also assessed the clients level of risk, during which the client endorsed passive suicidal ideation without any intent. The client denied any self-harm behaviors and denied any active suicidal ideation. Through validating the clients reported experiences and maintaining empathic responses, the therapist was able to begin her attempt at building a strong therapeutic alliance with the client. This validation and empathy also functioned as an introduction into providing the client with a corrective emotional experience and increasing the clients ability to self-regulate. During 56 this first therapy session, the therapist also utilized reflections to demonstrate active and engaged listening, as well as basic interpretations to also demonstrate active listening and to elicit further elaboration from the client at times. This first session also allowed the therapist to begin building an understanding of the clients previous and current relationship patterns. Session two. The therapist continued building a strong therapeutic alliance with the client during the second session. Again, this was done by validating the client and empathically listening. During this session, the therapist and client began discussing the clients relationship with both his mom and dad. The client shared details regarding a recent experience with his mom where they got into a disagreement and the clients mom told the client he had been acting just like his father. The therapist provided a reflective statement providing a basic interpretation about the apparent negative impact that statement had the client. The therapist and client then explored the impact of this statement and the clients beliefs of how he views himself compared to how he views his father. This allowed the therapist to confront the client about some of his feelings surrounding his father. During this second session, the therapist also gained more understanding of the clients relationship with his mom and dad, but more specifically with his dad. The therapist and client discussed the relationship dynamic and patterns the client frequently experienced with his dad, which he described as challenging. The client noted that because his father struggled with Bipolar Disorder, he had little to no relationship with his dad because the client never knew how his dad was going to act. The client described a relationship pattern filled with uncertainty and volatility. With this knowledge of the clients fragile relationship with his dad, the therapist was able to begin emphasizing consistency and predictability within the therapeutic relationship in hopes of promoting an example of a healthy relationship for the client. The therapist also 57 emphasized validating the clients emotional experiences in order to provide the client with corrective emotional experiences to override his previous experiences of being invalidated by his dad. Given the flexibility of this brief psychodynamic therapy model, the therapist pulled techniques from other therapy models to assist the client in making progress toward therapy goals. In this session, that included having the client externalize his thoughts in an attempt to help the client separate his own thoughts from thoughts that may be rooted in anxiety. The client again denied any self-harm behaviors and any active suicidal ideation. Because the client was able to discuss his adaptive coping skills used when any thoughts of self-harm occur (e.g., turning lights on, taking a shower, brushing his teeth, and listening to music), the therapist was able to encourage the client to continue utilizing his adaptive coping skills as necessary. Session three. By the third therapy session, it seemed the client and therapist had the foundation for a strong therapeutic alliance. This allowed the client to begin feeling safe enough within the therapy space to share various stressors from the therapist that may have been viewed as more severe by the client, such as his previous relationship with his ex-boyfriend. Through exploration, the client and therapist were able to explore the impact his past relationship had on his current relationships. The therapist was able to use clarification techniques to explore more in depth the impact this was having on the client (e.g., in his communication with others, in his interactions with others, and in his development of trusting relationships with others). Given the therapeutic alliance at this point, the therapist was also able to begin confronting some of the clients stated thoughts and/or feelings in the session in hopes of guiding the client to new understandings about his thoughts and/or feelings. For example, when the client began discussing the blame he put on himself for his actions in his past relationship with his ex- 58 boyfriend, the therapist was able to confront this feeling of blame and encourage the client to understand that feeling from a different perspective (e.g., Are you to blame? Or were you being manipulated?) all while maintaining a supportive and empathic stance as the therapist. Session four. After spending some time during the fourth session reviewing goals for treatment, the client was able to identify a goal for therapy, which included being able to come to terms with his previous relationship between him and his ex-boyfriend. It was during this session that the client appeared to become more actively focused on this specific goal, which in turn allowed the therapist to become more actively focused and engaged on this specific goal. The client introduced some feelings he had surrounding his previous relationship (e.g., anger and resentment), which allowed the therapist to facilitate conversations with the client about those feelings and the clients understanding of those feelings. As the client shared thoughts surrounding his current pattern in relationships with men, the therapist was able to provide interpretations regarding the therapists understanding of how the clients past relationship was impacting the clients current relationships. The client reported several impacts, such as a fear of being manipulated again and a decreased ability to trust others. The therapist again made a conscious effort to again emphasize a stable, healthy, and functional therapeutic relationship with the client in hopes of challenging the maladaptive relationship patterns he previously experienced among his father and exboyfriend. The therapist also validated the clients hesitations toward men given his previous experiences while encouraging the client to gain new understandings of how different men in his life may be different than his ex-boyfriend. Session five. During the fifth therapy session, the client decided to disclose details to the therapist about a previous sexual assault he experienced the summer before his freshman year of 59 college. The client detailed the experience to the therapist and discussed how it resulted it him trying to move past the experience by throwing himself into his relationship with his exboyfriend. Given the clients goal of wanting to come to terms with what had previously happened between him and his ex-boyfriend, this allowed the client to explore his feeling surrounding the sexual assault and his relationship with his ex-boyfriend in a safe space while being supported by the therapist. The therapist and client were able to explore the clients feelings of blame and anger toward himself. The therapist actively used reflections to communicate active listening, interpretation to help the client label difficult feelings, and empathy and validation to provide the client with reassurance that he is in a safe environment and healthy relationship. This marked an important step in the therapeutic relationship, as it likely signified that the client felt safe and secure enough to share such a vulnerable experience with the therapist. In turn, this allowed the client to process his emotions surrounding the sexual assault and his past relationship in a safe and nonjudgmental environment, which allowed the client an opportunity to continue developing self-regulation skills and continue building new understandings about his different emotions. It was at the end of his fifth therapy session that the client first identified feeling genuinely better since before treatment began. He identified having the ability now to think about and sit with those past memories, whereas prior to counseling he would not have been able to do so. Session six. Because of the COVID-19 pandemic, as previously stated, the clients therapy sessions were abruptly cut short. After receiving news that the campus would be closing and all students would have to return home, the therapist and client were able to meet for a sixth and final therapy session. Much of the time in this session was spent processing the implications 60 of COVID-19 and campus closing. The client reported being in great distress over having to leave campus and live at home with his parents once again. The therapist validated these feelings and assisted the client in clarifying possible options to help make the transition home smoother (e.g., transitioning to see a therapist at home if possible, spending time outside and at nature parks, adopting a cat as a companion). The therapist also took the time to emphasize the strength of the therapeutic alliance that had been built over the course of the last six therapy sessions. Although the client reported experiencing suicidal ideations shortly after receiving the news about the campus closing, he denied any intent to act on these thoughts and denied any active suicidal ideation at the time of the final therapy session. The client reported that although he was feeling sad, he was not feeling as sad as he might have in the past. The therapist was able to reassure the client that he had built tools and coping skills that allowed him to handle the situation better than he would have prior to the start of therapy treatment. The client also denied any self-harm since before starting treatment. The therapist tried to provide the client with one last corrective emotional experience by providing the client with closure about their therapeutic relationship ending. The therapist also attempted to implement a healthy relationship pattern by praising the clients effort during therapy sessions throughout treatment and by providing the client with hope about his future. Empirical Findings with Analysis Results were based on the six individual therapy session with the client using a brief psychodynamic approach. Results were examined utilizing the clients CCAPS-62 scores from before his first session (pre), before his fourth session (mid), and after his sixth session (post). Pre, mid, and post mean ratings were hand calculated by averaging the clients reported responses for each individual subscale item using the CCAPS report generated by Titanium. The 61 RCI was calculated for pre- to mid- treatment, for mid- to post-treatment, and for pre- to posttreatment using the following formula, where X2 represents the post-treatment mean rating, X1 represents the pre-treatment mean rating, and Sdiff represents the standard difference (Jacobsen et al., 1984). Cutoff scores for each of the CCAPS-62 subscales were calculated using means and standard deviations for males both normal and clinical populations provided by Center for Collegiate Mental Health annual report (2010) shown in Table 3 using the following formula, where s1 represents the standard deviation of the normal population, s2 represent the standard deviation of the clinical population, 1 represents the mean of the normal population, and 2 represents the mean of the clinical population (Jacobson & Truax, 1991). The results from the cutoff scores helped to determine if the client made clinically significant progress and the RCI helped to determine if the progress the client made was reliable. By calculating the RCI and using cutoff scores for each of the specific CCAPS-62 subscales, this helped to answer the clinical question of if the client is better off than before therapy began. In order for the client to demonstrate reliable change throughout treatment, the RCI must be greater than 1.96, as pre-determined by Jacobson and Truax (1991). RCI scores below 1.96 demonstrate no reliable change throughout treatment and RCI scores below -1.96 demonstrate deterioration throughout treatment. Examining the results from the specific subscales indicated which symptom areas improved for the client and which did not. Using these criteria, it is possible to 62 classify the client as one of the following: Recovered (passed cutoff point for clinically significant change and passed RCI criteria), Improved (only passed RCI criteria), Unchanged (passed neither criteria), and Deteriorated (passed RCI in the negative direction) (Jacobson & Truax, 1991). Table 2 shows average individual subtest ratings scores for the client on each subscale during the pre-, mid-, and post-phases of treatment, while Table 4 shows the RCI and cutoff points for pre- to post, pre- to mid, and pre- to post treatment. Table 1 CCAPS-62 Subtest Test-Retest Reliability Coefficients CCAPS-62 Subscale Test-Retest Reliability Coefficient Depression 0.93 Generalized Anxiety 0.78 Social Anxiety 0.83 Academic Distress 0.92 Eating Concerns 0.89 Hostility 0.91 Family Distress 0.92 Substance Use 0.87 Note. Test-Retest Reliability Coefficients provided by Locke and colleagues (2011). Table 2 CCAPS-62 Clients Average Individual Subtest Rating Scores for Pre, Mid, and Post Phases of Treatment CCAPS-62 Subscale Depression Generalized Anxiety Social Anxiety Academic Distress Eating Concerns Hostility Family Distress Substance Use Pre-Treatment 2.62 3.22 2.29 3 0.33 0.86 3 2.17 Mid Treatment 1.69 2.56 2.29 2 0.33 0 1.33 1 Post Treatment 2 1.78 0.57 2 0.33 0.43 1.83 0.33 63 Table 3 CCAPS-62 Means and Standard Deviations of Males in Clinical and Non-Clinical Populations CCAPS-62 Subscale Clinical Population Non-Clinical Population Depression 1.44 (0.94) 0.80 (0.74) Generalized Anxiety 1.35 (0.88) 0.87 (0.68) Social Anxiety 1.72 (0.96) 1.46 (0.84) Academic Distress 1.84 (1.03) 1.24 (0.84) Eating Concerns 0.69 (0.69) 0.76 (0.68) Hostility 1.00 (0.88) 0.70 (0.70) Family Distress 1.08 (0.89) 0.70 (0.71) Substance Use 0.86 (0.89) 0.82 (0.89) Note. Standard Deviations shown in parentheses. Means and Standard Deviations were provided by the Center for Collegiate Mental Health (CCMH) Annual Report (2010). 64 Table 4 RCI and Cutoff Points for Pre to Post, Pre to Mid, and Mid to Post Treatment CCAPS-62 Subscale Pre to Post Pre to Mid Mid to Post Depression RCI 2.21* 3.32* -1.11 Cutoff Point 1.08 1.08 1.08 Findings Improved Improved Unchanged Generalized Anxiety RCI 3.20* 1.47 1.73 Cutoff Point 1.08 1.08 1.08 Findings Improved Unchanged Unchanged Social Anxiety RCI 3.50* 0.00 3.50* Cutoff Point 1.58* 1.58 1.58* Findings Recovered Unchanged Recovered Academic Distress RCI 2.86* 2.86* 0.00 Cutoff Point 1.51 1.51 1.51 Findings Improved Improved Unchanged Eating Concerns RCI 0.00 0.00 0.00 Cutoff Point 0.73* 0.73* 0.73* Findings Unchanged Unchanged Unchanged Hostility RCI 1.54 3.07* -1.54 Cutoff Point 0.83 0.83* 0.83 Findings Unchanged Recovered Unchanged Family Distress RCI 4.18* 5.96* -1.79 Cutoff Point 0.87 0.87 0.87 Findings Improved Improved Unchanged Substance Use RCI 4.09* 2.60* 1.49 Cutoff Point 0.84* 0.84 0.84* Findings Recovered Improved Unchanged Note. * indicates statistically reliable change for the RCI and clinically significant change for cutoff points. 65 The clients mean reported scores on the Eating Concerns subscale were identical at pretreatment, mid-treatment, and post-treatment. His average reported score was low, lower than both clinical and non-clinical population means. As a result, the clients Eating Concerns will not be further discussed. Results of cutoff points, found within Table 4, demonstrate the clients average individual subtest ratings scores mid treatment, found within Table 2, fell below the cutoff point and closer to the normal population than clinical population on the Hostility subscale, though this improvement was not maintained through the end of treatment. Results of cutoff points demonstrate the clients average individual subtest ratings scores post treatment fell below the cutoff point and closer to the normal population than clinical population on the Social Anxiety and Substance Use subscales. Results from RCI scores, also found within Table 4, demonstrate the clients average individual subtest rating scores from pre to mid treatment reflect statistically reliable change on the Depression, Academic Distress, Hostility, Family Distress, and Substance Use subscales. Minimal findings emerged for mid- to post treatment; the only finding that emerged was for Social Anxiety, which demonstrated statistically reliable change. In terms of pre- to posttreatment findings, the clients average individual subtest rating scores from pre- to posttreatment reflect statistically reliable change on the Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Family Distress, and Substance Use subscales. Discussion of Findings Currently, although some studies have demonstrated the effectiveness of brief psychodynamic therapy when treating minor depressive episodes (Maina et al., 2005) and when working with patients who were HIV-positive with depressive symptoms (Markowitz et al., 1998), little research examining treatment outcomes for Adjustment Disorder (AD) exists (Carta 66 et al., 2009; OConner & Cartwright, 2012; Zelveine & Kazlauskas, 2018). The current case study aimed to examine the effectiveness of brief psychodynamic therapy as a treatment with a traditional aged college student diagnosed with AD. In this current study, the therapists use of brief psychodynamic therapy provided findings that suggest the client Recovered from pre to post treatment on the Social Anxiety and Substance Use subscales. The findings also suggest the client Improved from pre- to posttreatment on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales. From pre- to mid-treatment, results indicate the client Improved on the Depression, Academic Distress, and Family Distress subscales. However, findings suggest the client remained Unchanged on every subscale from mid- to post-treatment, with the exception of the Social Anxiety subscale, suggesting that the majority of changes the client experienced in treatment occurred earlier, as opposed to later, in treatment. The clients change throughout treatment on the Social Anxiety and Substance Use subscales generate various questions regarding why those subscales saw significant, and reliable, change, while others did not. When thinking about types of clients and problems seeking help within a brief amount of time, some data exists that indicates during brief treatment, a clients overall well-being is the first to make a positive change, followed then by improvements in symptoms and later on positive changes in characterological and interpersonal factors (Howard et al., 1993). One study (Hilsenroth et al., 2001) found that by the ninth session of a brief psychodynamic therapy, clients reported the biggest area of change to be their sense of wellbeing, followed by their overall feelings of distress. In this study, the final area to see improvements during treatment were social and interpersonal functioning. In one meta-analysis 67 (Barber et al., 2013) researchers discovered that psychodynamic therapies, most of which were considered brief, were superior to control conditions and produced as effective results compared to alternative therapies at termination and follow-up for clients diagnosed with depressive disorders, anxiety disorders, and personality disorders. In the current study, it is possible that the clients overall sense of well-being began to improve first throughout treatment in the early sessions. Given this clients diagnosis of AD, and OConner and Cartwrights (2012) emphasis that the effects of AD can be moderated by social support, it is possible that the support therapy provided this client allowed the client to begin experiencing relief with some of his symptoms, as reflected in the clients Improved scores on the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre- to mid-treatment. Although the client began to see improvements of the Depression, Academic Distress, Family Distress, and Substance Use subscales from pre- to mid-treatment, those four subscales went Unchanged from mid- to post-treatment, which may be a reflection that the clients early improvements were sustained through the rest of treatment. The onset of COVID-19 occurred during the mid- to post-treatment phase for this client. It is possible this caused an increase in the clients distress and symptoms, thus reflecting minimal improvement in the clients subscales from mid- to post-treatment. Individuals can experience symptoms of AD at any point in life, but younger individuals may be more vulnerable to developing this disorder because of fewer coping skills to utilize in moments of stress (OConner & Cartwright, 2012). Inchausti and colleagues (2020) discuss how one particular group at risk for psychological challenges includes individuals who experienced psychopathology prior to the pandemic, which may be exacerbated by the pandemic and the impact of the pandemic. It is possible that the stressors related to the onset of COVID-19 68 exacerbated this clients mental health challenges, which this client may have lacked appropriate coping skills to effectively manage, thus resulting in the clients reported symptoms to remain Unchanged from mid- to post-treatment. Despite this possible stress with the onset of COVID-19 toward the end of treatment, the client still Improved on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales from pre- to post-treatment and Recovered on the Social Anxiety and Substance Use subscales. Thus, despite the client not making significant, reliable changes from mid- to post-treatment, the client was still able to demonstrate significant, reliable change from pre- to post-treatment on the Social Anxiety and Substance Use subscales and demonstrate reliable changes from pre- to post-treatment on the Depression, Generalized Anxiety, Academic Distress, and Family Distress subscales. Although the current treatment only lasted six sessions, one review of effective psychotherapies by Lambert (2013) noted a large number of clients make reliable improvements after just seven therapy sessions. These results provide evidence that even in as little as six therapy sessions, this client was able to begin seeing significant, reliable change in some of his mental health symptoms. When examining the current study, a considerable limitation to be considered includes the onset of the COVID-19 pandemic, which resulted in the clients treatment being cut short from approximately 12 therapy sessions to only six therapy sessions. It is also possible the stress the client reported experiencing after hearing the news of campus closing early because of COVID-19 could have impacted his mid to post treatment scores. An additional limitation includes the choice of the CCAPS to monitor the clients functioning and the overall typical goals for brief psychodynamic therapy. As a reminder, according to Levenson (2017) and Strupp and Binder (1984), brief psychodynamic therapy aims 69 to provide a client with positive new experiences of themselves and others and new understandings of themselves and others. This form of therapy often aims at fostering new relational experiences and enhancing ones attachment in hopes that will then impact other areas of ones life. With this knowledge, it is important to consider how any possible progress may or may not be reflected on the CCAPS, given its subscales. If someone improves relationally and strengthens their attachment style, it is possible that change may not be reflected on a measure looking at mental health symptoms, like the CCAPS (Travis et al., 2001). Thus, a measure that further examined both intrapersonal and interpersonal changes may have provided different results. Another limitation of the current study includes the clients history of sexual abuse. Given the information reported at the start of treatment, the therapist and clinical supervisor concluded an AD diagnosis to be the most appropriate diagnosis for the clients current functioning. However, the clients eventual disclosure to the therapist of prior sexual abuse might suggest a trauma-related diagnosis may have been appropriate. It is possible this alternative diagnosis may have informed the therapist to approach treatment in an alternative way. However, this represents a real-world scenario where therapists must provide treatment with sometimes limited information the client is willing to share. Additional limitations include those commonly associated with single subject research studies, such as issues of generalizability (Kazdin, 2022; Searle, 1999), uncontrollable variables (Cronbach, 1975), and the objectivity of the therapist throughout the research study (Searle, 1999). Because the current study is a case study, it is important to consider that one individual was studied. The client examined in the current study is a unique individual with his own life experiences and mental health challenges who likely does not reflect the experiences and 70 challenges of other individuals with similar life experiences and mental health challenges. Kazdin (2022) and Searle (1999) highlight how although a case study might discover findings that suggest what might take place in similar circumstances, further research is necessary to determine the generalizability of the case study. Despite these limitations, this case study provides research for a real-world application of brief psychodynamic therapy with a traditional aged college student diagnosed with AD. While other studies have examined the effectiveness of brief psychodynamic therapy with individuals experiencing minor depressive episodes (Maina et al., 2005) and with depressive symptoms (Markowitz et al., 1998), the current study allowed brief psychodynamic therapy to be examined after being utilized with someone diagnosed with AD. A significant strength of a case study includes the ability to examine the effectiveness of a modality in real-world scenarios (Kazdin, 2022). Given the limited current research, further research on the effectiveness of brief psychodynamic therapy with individuals diagnosed with AD would be beneficial for the psychology field. Further case studies examining effective treatments for individuals diagnosed with AD would provide useful information and insight into possible effective approaches to treatment. Alternative measures may be utilized to further examine common symptoms reported by individuals with AD. 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... Running head: THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION THE APPRAISAL OF THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION COMPARING OBSESSIVE-COMPULSIVE TENDENCIES A Doctoral Dissertation presented to the College of Applied Behavioral Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Dallen Myers, M.A. May 2023 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION ii Signature Page THE APPRAISAL OF THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION COMPARING OBSESSIVE-COMPULSIVE TENDENCIES The signatures below certify that the Doctoral Dissertation of Dallen Myers, M.A. has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: Debbie Warman, Ph.D. Dissertation Advisor John Kuykendall, Ph.D. Dean, College of Applied Behavioral Sciences 5/4/2023 William Essman, Ph.D. Committee Member Kathryn Boucher, Ph.D. Committee Member 5/4/2023 Date Date THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION iii Abstract Intrusive thoughts are a symptom of Obsessive-Compulsive Disorder (OCD) which are thoughts that become obsessions when they are catastrophized by the individual experiencing them and are distressing to the individual (Rachman, 1997). According to the cognitive model of OCD, intrusive thoughts occur on a continuum affecting both clinical and non-clinical populations (Rachman & De Silva, 1978). Within intrusive thoughts are commonly occurring content thoughts that can have sexual, blasphemous, or violent themes (Corcoran & Woody, 2008; Levine & Warman, 2016). At this time, no studies have been conducted analyzing the appraisal of an intrusive thought of another individual vs. acting out the behavior of the thought while comparing OC tendencies. This study recruited 271 participants through Amazon Mechanical Turk (MTurk). Participants OC levels were measured using the ObsessiveCompulsive Inventory-Revised (OCI-R). Participants were randomly assigned to either be shown vignettes describing three taboo thoughts (sexual, violent, blasphemous thoughts group) or assigned vignettes describing the three taboo thoughts as actions (action group). Participants were asked to complete the Social Distance Scale (SDS) about the targets they read about after they read each vignette (Link, Cullen, Frank, & Wozniak, 1987). Regression analyses were conducted with thought vs. action as the predictor, OC tendencies as the moderator, and social distance as the outcome for each content type. Simple slopes analyses were conducted where moderation was found to be significant. Across all three content types, participants desired more social distance from targets who acted on thoughts compared to targets who exclusively had thoughts, but the difference was more pronounced for low and average OC participants compared to high OC participants. OC level was found to be a moderator for thought vs. action THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION iv and social distance across all three content types. Unexpectedly, OC level was not a significant predictor of social distance for the blasphemous content type. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION v Acknowledgements I would like to extend thanks and gratitude to Dr. Debbie Warman for her shared knowledge, guidance, and patience during this process. I would also like to extend my appreciation to Dr. William Essman and Dr. Kathryn Boucher for their contributions and support. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION vi Table of Contents TITLE PAGE ....................................................................................................................... i SIGNATURE PAGE ........................................................................................................... ii ABSTRACT ....................................................................................................................... iii ACKNOWLEDGEMENTS ................................................................................................ v TABLE OF CONTENTS ................................................................................................... vi INTRODUCTION .............................................................................................................. 8 Intrusive Thoughts .......................................................................................................... 9 Defining Intrusive Thoughts ....................................................................................... 9 OC Beliefs......................................................................................................................11 Cognitive Model. .......................................................................................................11 Obsessive-Compulsive Tendencies ........................................................................... 15 Thought-Action Fusion (TAF) within OC beliefs..................................................... 17 Attitudes Towards Intrusive Thoughts .......................................................................... 19 The Present Study ......................................................................................................... 23 Aims .......................................................................................................................... 23 Hypotheses ................................................................................................................ 23 METHODS ....................................................................................................................... 25 Participants.................................................................................................................... 25 Materials ....................................................................................................................... 25 Obsessive-Compulsive Inventory-Revised (OCI-R). ............................................... 25 Vignettes. .................................................................................................................. 25 Social Distance Scale. ............................................................................................... 27 Manipulation Check. ................................................................................................. 27 Procedure. ..................................................................................................................... 27 RESULTS.......................................................................................................................... 29 Power Analysis. ............................................................................................................ 29 Testing of Assumptions. ................................................................................................ 29 Preliminary Analyses. ................................................................................................... 30 Primary Analyses. ......................................................................................................... 30 DISCUSSION ................................................................................................................... 38 Limitations .................................................................................................................... 44 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION vii Conclusion .................................................................................................................... 46 REFERENCES ................................................................................................................. 47 APPENDICES .................................................................................................................. 63 Appendix A: Obsessive-Compulsive Inventory Revised (OCI-R) ............................ 63 Appendix B: Social Distance Scale .............................................................................. 64 Appendix C: Vignettes .................................................................................................. 67 Thought ..................................................................................................................... 67 Action ........................................................................................................................ 67 8 THE APPRAISAL OF THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION COMPARING OBSESSIVE-COMPULSIVE TENDENCIES Chapter 1 Introduction Obsessive-Compulsive Disorder (OCD) affects 1.2% of the population in the United States and can reduce quality of life as well as cause high levels of social and occupational impairment (American Psychiatric Association, 2013). An aspect of OCD includes a symptom dimension of taboo thoughts which are either sexual, violent, or blasphemous in nature (Corcoran & Woody, 2008). Fifty-one percent of those diagnosed with OCD will experience at least one taboo thought (Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002). For those with OCD, these taboo thoughts are considered intrusive and distressing to the individual experiencing them (Rachman, 2007). Taboo thoughts can be understood through the cognitive model which postulates that intrusive thoughts become obsessions when they are catastrophized by the individual experiencing them (Rachman, 1997). It is of importance to note that there is stigma associated with taboo thoughts. Taboo intrusive thoughts often are more socially rejected compared to other types of intrusive thoughts (Steinberg & Wetterneck, 2016). It has even been shown that clinicians are more socially rejecting of sexual and violent taboo thoughts compared to other types of obsessions (Steinberg & Wetterneck, 2017). Within OCD research, social rejection is commonly measured through social distancing via the Social Distance Scale (SDS) (Link et al., 1987). There are a number of studies that examine OC tendencies in non-clinical samples and their attitudes towards taboo thoughts (e.g. Corcoran & Woody, 2008); these studies have demonstrated that a persons level of OC tendencies is related to negative attitudes towards the thoughts. One gap in the literature is examination of how those with higher OC tendencies THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 9 may appraise the taboo thought of another individual versus the actual behavior consistent with the thought (i.e. having a thought about violence versus actually engaging in a violent behavior) compared to those with lower OC tendencies. The aim of the present study is to bridge that gap to better understand the significance individuals with higher OC tendencies give to intrusive thoughts relative to those thoughts in the form of actual behaviors. Intrusive Thoughts Defining Intrusive Thoughts Obsessive-Compulsive Disorder (OCD), according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is characterized by obsessions (intrusive thoughts) and compulsions, or behaviors that are recurrent and persistent with an attempt to suppress the obsessions by the individual who experiences them (American Psychiatric Association, 2013). Intrusive thoughts are repetitive thoughts, images, or impulses that are unacceptable and/or unwanted, internal in origin, and are upsetting or distressing to the individual (Parkinson & Rachman, 1981). Intrusive thoughts within OCD, by definition in the DSM-5, are obsessions. Thus, these terms will be used interchangeably throughout this paper. Taboo obsessions have even been found to be an independent risk factor of suicidality in patients with OCD (Cervin et al., 2022). Intrusive thoughts are considered to be part of a normal experience and do not always result in distress or a psychological disorder (Freeston, Ladouceur, Thibodeau, & Gagnon, 1991; Rachman & De Silva, 1978; Salkovskis & Harrison, 1984). In fact, around 80-99 percent of the general population experience intrusive thoughts (Barrera & Norton, 2011). Rachman and de Silva (1978) found that non-clinical subjects experience intrusive thoughts that are quite similar in terms of form and content to those of clinical subjects. In previous research, three common types or themes of intrusive thoughts in OCD have been primarily studied: blasphemous (e.g. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 10 defying God in some manner), sexual (e.g. the thought of molesting a child that you are babysitting), and violent (e.g. intentionally driving into pedestrian with your car). Taboo obsessions appear to be fundamentally different than reactive obsessions such as contamination, symmetry, and doubts (Lee & Kwon, 2003). They also differ experientially (internally versus externally generated) and in terms of associated appraisal and control strategies (Lee & Kwon, 2003). Sexual, violent, and blasphemous obsessions appear to be a symptom dimension of OCD and are considered taboo intrusive thoughts (Brakoulias et al., 2013). Individuals with OCD who have higher scores on obsessions subscales were found to also have higher scores on taboo thoughts symptom dimension scales (Brakoulias et al., 2013). However, individuals with OCD who also have a taboo thoughts symptom dimension are more likely to seek professional help compared to those who are diagnosed with OCD who do not experience taboo thoughts. Sexual, violent, and religious obsessions co-occur frequently (Abramowitz et al., 2003; 2010; MataixCols, Do Rosario-Campos, & Leckman, 2005; McKay et al., 2004). By far the most common taboo thought, 51 percent of individuals with OCD experience violent obsessions (Mataix-Cols et al., 2002). Religious obsessions are a prevalent manifestation of OCD. Nearly 25% of those with OCD who were North American college students reported experiencing religious intrusive thoughts (Mataix-Cols et al., 2002). Regardless of the severity of OCD symptoms, Tolin, Abramowitz, Kozak, and Foa (2001) found that individuals with religious intrusive thoughts had more magical ideation, poorer insight, and more perceptual distortions compared to those with other types of obsessions. Given that religious obsessions involve the perception of fear of punishment from God, fear of violating or having violated religious standards, and sin, it is not THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 11 surprising that these obsessions are distressing to affected individuals and impair social and occupational functioning (Siev, Steketee, Fama, & Wilhelm, 2011). Studies have shown that individuals who have higher levels of intrusive thoughts related to religion tend to also be more religious for both clinical and non-clinical populations (Abramowitz, Deacon, Woods, & Tolin, 2004; Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002; Greenberg & Shefler, 2002; Lewis & Maltby, 1995; Nelson, Abramowitz, Whiteside, & Deacon, 2006; Okasha, Saad, Khalil, El Dawla, & Yehia, 1994; Sica, Novara, & Sanavio, 2002; Siev & Cohen, 2007; Steketee, Quay, & White, 1991). Unfortunately, those with scrupulous, or religious, intrusive thoughts may be more difficult to treat (Ferro et al., 2006; Mataix-Cols et al., 2002; Miller & Hedges, 2008; Rufer et al., 2005). Less common than religious intrusive thoughts, 12.4% of individuals with OCD experience sexual obsessions (Mataix-Cols et al., 2002). Sexual obsessions often have themes surrounding pedophilia, incest, sexual orientation, or unfaithfulness (Cathey & Wetterneck, 2013). For example, an individual is a babysitter and has thoughts of molesting the child while they are being cared for. The babysitter will worry about having the thoughts and whether they may act on them. The babysitter has no history of pedophilic behavior. Because sex has high emotional and moral significance, it can become a prime topic for obsessions (Gordon, 2002). People who experience sexual obsessions also experience secondary disturbances in low selfesteem, impaired concentration, mood, and various inhibitions in sexual behavior (Gordon, 2002). OC Beliefs. Cognitive Model. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 12 Cognitive theories promote that it is not the content of an intrusive thought that makes it distressing, but rather the processing characteristics and appraisals of the thought that lead to distress (David A Clark & Purdon, 1995; Rachman, 1997, 1998; Salkovskis, 1985) For instance, a thought that an individual feels responsible for or ideas that the individual needs to control the thought is more likely to be distressing and to activate thought control efforts compared to thoughts that the individual does not feel responsible for (Rowa & Purdon, 2003). Again, cognitive theorists promote that it is not the intrusive thought itself that causes distress, but the negative appraisal of the thoughts that creates so much distress (Shafran, 2005). Cognitive theories of intrusive thoughts suggest that negative appraisals about the significance of a thought is crucial in converting a neutral thought into an obsession (Rachman, 1997, 1998; Salkovskis, 1985; Salkovskis, Forrester, & Richards, 1998) Thus, it is theorized that obsessions are produced by catastrophizing the significance of ones thoughts (Rachman, 1997). Moreover, individuals with OCD differ from non-clinical samples in the way they appraise intrusive thoughts (Salkovskis, 1985). Those with OCD are more likely to appraise intrusive thoughts as more distressing than normative samples (Berry & Laskey, 2012). They also tend to experience intrusive thoughts more frequently and in more severe forms compared to non-clinical populations (Berry & Laskey, 2012). Non-clinical populations typically do not attribute their thoughts to be personally relevant or meaningful. Those with OCD, particularly those with intrusive thoughts (Lee & Kwon, 2003; Lee et al., 2005), typically experience more attempts at suppressing their obsessions compared to non-clinical populations and usually are less successful at doing so (Ladouceur et al., 2000). Individuals with OCD tend to use unsuccessful suppression/neutralizing behaviors like worrying compared to more successful behaviors utilized by non-clinical individuals, such as accepting the thought (Marcks & Woods, THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 13 2005). People who are more accepting of their intrusive thoughts have lower levels of depression and are less anxious (Marcks & Woods, 2005). OCD symptoms can be viewed as being on a spectrum, thus displayed as a range by clinical samples and non-clinical samples alike. However, there are differences between those on opposing ends of the spectrum. One example of this is related to the Seeking Proxies for Internal States (SPIS) model of OCD. SPIS postulates that obsessive-compulsive (OC) individuals have decreased ability to access their internal states and so they seek out and rely upon external proxies for these states (Dar, Eden, van Dongen, Hauschildt, & Liberman, 2019). Additionally, the hypothesis of the SPIS model explains that OC tendencies are related to a deficiency in subjective understanding regarding internal states, which can cause those with high OC tendencies to rely more on self-perception processes when identifying their own internal states (Lazarov, Dar, Liberman, & Oded, 2012a). Moreover, the self-perception theory states that individuals likely will depend on their own behaviors, like attitudes and personal characteristics, to access their internal states given that their internal cues are ambiguous and/or uninterpretable (Bem, 1972). Also, individuals with OCD typically doubt their own feelings of internal states as well as have low confidence regarding their cognitive performance (Kang, Namkoong, Yoo, Jhung, & Kim, 2012; Nielen, Veltman, Jong, Mulder, & Den Boer, 2002). Lazarov, Dar, Liberman, and Oded, (2012b) named two mechanisms likely behind this. One is that individuals with OCD have access to their internal states, but meta-cognitive processes such as excessive self-monitoring and self-questioning lead to doubts about the internal states. The second is that inputs from internal states are attenuated for those with OCD so these meta-cognitive processes like self-monitoring only increase doubts. SPIS can help explain why individuals with OCD experience obsessions. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 14 Studies by both Lopatka and Rachman (1995) and Shafran (1997) demonstrate that by decreasing feelings of responsibility and preventing the possibility for guilt for those with OCD, there was a decreased urge to carry out rituals. Another group of studies shows that in nonclinical samples, feelings of guilt lead to OC-like symptoms (Shapiro & Stewart, 2011). However, it appears that when individuals with OCD learn to accept the possibility of feeling guilty, their obsessive symptoms decrease (Cosentino, DOlimpio, Perdighe, Romano, Saliani, 2012). Individuals diagnosed with OCD display a higher propensity to both guilt and disgust when compared to non-clinical samples (Gangemi & Mancini, 2017). An OCD individuals concern over a harmful event is largely reduced if responsibility for the event is not considered their own, regardless of the actual probability of harm (Lopatka & Rachman, 1995). Grisham and Williams (2009) also found a positive correlation between OC symptoms and increased rumination. Rumination can be explained cognitively by a focus of negative information that can lead to an elaboration of the original material in a way that produces increased pathways of retrieval back to the original activating event (Williams, Watts, MacLeod, & Mathews, 1988). It seems as though rumination may make retrieval of unwanted thoughts hyper accessible (Grisham & Williams, 2009). It is now growing traction in the literature and is theorized that intrusive thoughts, including taboo thoughts, are on a continuum (Wang & Clark, 2002). Thus, both clinical and non-clinical populations can experience intrusive thoughts on a spectrum from normal to the clinical range. For example, in a sample of non-clinical college students, it was found that violent intrusive thoughts were the most common, as 66% experienced them, followed by sexual (19%), miscellaneous (7%), religious (4%), and contamination (3%) (Markowitz & Purdon, 2008). Thus, it appears OCD experiences can be viewed on a continuum (Stip & Letourneau, 2009; THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 15 Schomerus et al., 2016; Thibodeau, 2016; Tomczyk et al., 2023; Wiesjahn, Jung, Kremser, Rief, & Lincoln, 2016). On one end of the spectrum someone may experience a taboo thought but appraise it as a neutral thought. At the other end of the spectrum, someone may have the same taboo thought and appraise it as threatening, creating an intrusive thought. Inherently, the cognitive model of OCD lends itself to this theory that individuals experience OCD symptoms on a continuum. In line with the continuum model, Clark and Rhyno (2005) gave explanation to a severity continuum regarding obsessions and intrusive thoughts, with distress, frequency, and perceived thought control as distinguishing factors. More evidence for a continuum model of OCD also comes from correlations between frequency of intrusive thoughts and obsessionality (Clark, Purdon, & Wang, 2003). Moreover, correlational and experimental studies using nonclinical samples and comparisons with clinical samples point to the idea that uncontrollability, importance of intrusive thoughts, and appraisals of responsibility may be central factors to the continuum of intrusive thoughts (Berry & Laskey, 2012). Obsessive-Compulsive Tendencies A number of information processing differences have been found between individuals higher and lower in OC tendencies. Individuals who have higher OC tendencies consider taboo thoughts to be more significant than do individuals with lower OC tendencies (Corcoran & Woody, 2008; Levine & Warman, 2016). A negative correlation was found between OC symptoms and perceived ability to control thoughts (i.e. the more OC symptoms an individual experiences the lower the likelihood they believe they can control their own thoughts) (Grisham & Williams, 2009; lafsson et al., 2014). Grisham and Williams (2009) also found that in nonclinical populations more OC symptoms predicted increased levels of distress and more attempts to suppress the target thought. Even when attempting to suppress the target thought, those with THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 16 higher OC tendencies take longer to replace intrusive thoughts as measured by more reoccurrences while attempting to replace the thoughts than do those with lower OC tendencies (lafsson et al., 2014). Another study found that individuals with higher OC tendencies showed a propensity to use non-agentic speech more than individuals with lower OC tendencies demonstrating that people with higher OC tendencies may have a decreased sense of agency (SoA) (Oren, Friedmann, & Dar, 2016). It was found that the non-agentic speech included the omission of the agent altogether in an attempt to detach the event from the entity that caused it (Oren et al., 2016). Lastly, there is evidence to show that patients with OCD display higher impulsivity than control subjects (Sahmelikoglu Onur et al., 2016). People with higher OC tendencies have a stronger readiness for action, which may be a reason for higher impulsivity compared to people with lower OC tendencies, especially regarding threatening stimuli (Dayan, Berger, & Anholt, 2014). Also related to executive functioning, those with higher OC tendencies were characterized by deficits in neurocognitive flexibility (Bradbury, Cassin, & Rector, 2011). This may help explain the obsessionality and rumination of taboo intrusive thoughts experienced by those with higher OC tendencies. Rhaume, Ladouceur, and Freeston (2000) found that, in a non-clinical sample, perceived danger, perfectionism, and responsibility were all moderately related to OC tendencies. Those with higher OC tendencies generally tend to distrust their own cognitive functions (Aardema, OConnor, & Emmelkamp, 2006; Brown, Kosslyn, Breiter, Baer, & Jenike, 1994; Macdonald, Martin, Macleod, & Richter, 1997; Tuna, Tekcan, & Topuolu, 2005; Woods, Vevea, Chambless, & Bayen, 2002; Zitterl et al., 2001). Moreover, it has been shown that people with high OC tendencies have impaired access to their internal emotional states, theoretically caused by doubting those states (Dar, Lazarov, & Liberman, 2016). Individuals with higher OC tendencies tend to be less willing to report answers that are not held THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 17 high in confidence suggesting they also conservatively take risks (Shachar, Lazarov, Goldsmith, Moran, & Dar, 2013). In sum, research supports numerous differences in how individuals higher and individuals lower in OC tendencies process information and take meaning from events. Thought-Action Fusion (TAF) within OC beliefs. According to Beck (1976), one of the dysfunctional assumptions that can interact with intrusive thoughts is that having a thought about committing an action is appraised equivalently to performing the action. Becks ideas lay the foundation for the concept of thought-action fusion (TAF), which is the belief that having an intrusive thought is near or equivalent to the morality of actually performing the action and that having a thought can increase the probability of the situation occurring (Shafran & Rachman, 2004). TAF is associated with OCD tendencies and may exacerbate distress for individuals with clinical levels of symptoms (Berle & Starcevic, 2005). TAF is not specific to just OCD; it is also found in other disorders such as generalized anxiety disorder, depression, eating disorders, and psychotic disorders (Berle & Starcevic, 2005). In OCD, TAF is thought to apply to a variety of intrusive thoughts, rather than any one type in particular (e.g. someone who has both sexual and violent taboo thoughts can experience TAF of both types) (Berle & Starcevic, 2005). Within OCD research, TAF is considered an appraisal (Berle & Starcevic, 2005). Thus, an individual may have an intrusive thought such as I will kill my dog when I see him next and believe/appraise it equivalently to if they had actually committed the action. This association between OCD symptoms and TAF suggests that from a cognitive perspective, TAF plays a role in the psychopathology of OCD (Berle & Starcevic, 2005). Rachman (1997) hypothesized that a normal obsession/thought becomes an abnormal obsession/thought when it is interpreted as being personally relevant and/or threatening in nature. TAF plays a role in this interpretation of thoughts and is expected to be a mechanism in the development of obsessions (Berle & THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 18 Starcevic, 2005). According to Rachman (1993), if someone considers intrusive thoughts to be personally relevant and of high importance, particularly when the thoughts are violent in nature, it is associated with a moral responsibility experienced by the individual. In turn, this causes the individual to feel responsible for his or her thoughts. Guilt and responsibility are closely aligned experiences. An individual who feels responsible for their thoughts may feel guilt associated with these thoughts causing them great distress, contributing to the symptomatology of their OCD tendencies (Berle & Starcevic, 2005). Consequently, these feelings of guilt may contribute to an individuals desire to neutralize or make attempts to suppress such feeling (Zucker et al., 2002). Because of this attempted suppression, TAF may allow normal intrusive thoughts to become pathological (Berle & Starcevic, 2005). According to Wegner, Schneider, Carter, and White (1987), thought suppression may be counter-productive, actually intensifying intrusions rather than lessening in intensity, thus, exacerbating the symptoms of OCD. Likelihood TAF is a belief that having a thought about an event can make it more likely that event will occur. For example, if I think about stabbing my neighbor, it makes it more likely that I will follow through with it (Thompson-Hollands, Farchione, & Barlow, 2005). Moral TAF is a belief that thinking about an action or behavior is the moral equivalent of performing the behavior. For example, thinking about stabbing my neighbor is as morally wrong as stabbing them (Thompson-Hollands et al., 2005). According to previous research, (e.g. Abramowitz et al., 2003; Shafran and Rachman, 2004), there is not a reliable relation of moral TAF with OCD symptoms even when it has been shown to be related to depression. Yet, several studies have found a positive correlation between likelihood TAF and OCD symptom level (Amir, Freshman, Ramsey, Neary, & Brigidi, 2001; Rassin, Diepstraten, Merckelbach, & Muris, 2001; Shafran, THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 19 Thordarson, & Rachman, 1996). Moreover, there is evidence suggesting an individual diagnosed with OCD will have higher levels of likelihood TAF (Thompson-Hollands et al., 2005). Attitudes Towards Intrusive Thoughts Taboo intrusive thoughts, typically violent or sexual, often are more socially rejected compared to other types of intrusive thoughts (Steinberg & Wetterneck, 2016; Ponzini & Steinman, 2022). Even though intrusive thoughts are on a continuum and are normative in nature, those with OCD are less likely to disclose certain obsessional themes (i.e. taboo thoughts)(Simonds, 2001). These obsessional themes include taboo thoughts, as there may be shame and fear of negative social consequences if shared (Laura M. Simonds & Thorpe, 2003). Cathey and Wetterneck (2013) found that after reading vignettes about either a significant other or a friend disclosing an intrusive thought that individuals are more socially rejecting of a friend who disclosed an intrusive thought compared to a significant other with the same intrusive thought. Even clinicians show some biases in treating OCD and intrusive thoughts. Clinicians were more likely to socially reject contamination, violent, and sexual taboo thoughts in patients compared to other intrusive thoughts like scrupulous obsessions (Steinberg & Wetterneck, 2017). They also found that clinicians, if experiencing sexual obsessions, were less likely to reveal to others compared to other types of taboo thoughts (Steinberg & Wetterneck, 2017). People may think that because someone has the thought that means they will want to act out on the obsessional thoughts. People who experience violent, religious, and/or sexual obsessions appear to be particularly vulnerable and susceptible to stigma and shame surrounding treatment of their symptoms (Glazier, Wetterneck, Singh, & Williams, 2015). For psychotherapists, taboo thoughts are significantly less recognizable as OCD symptomatology compared to contamination and THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 20 symmetry (Canavan, 2022). Clinicians also showed greater levels of stigma toward clients with aggressive and pedophilic taboo thoughts compared to symmetry and contamination (Canavan, 2022). Violent intrusive thoughts (e.g. stabbing yourself or your sibling) are more provoking, most likely because they are perceived as particularly threatening (Simonds & Thorpe, 2003). Simonds and Thorpe (2003) conducted a study with three separate vignettes showing three different types of OCD symptomology presentations. The presentations were a compulsive washer, a compulsive checker, or a person with violent thoughts. The presentation with the violent thoughts was seen as most negative by the participant sample (Simonds & Thorpe, 2003). Another study, by Corcoran and Woody (2008), found religious intrusive thoughts to be the least negatively appraised of violent, sexual, and religious taboo thoughts. Corcoran and Woody (2008), as well as Levine and Warman (2016), utilized vignettes to analyze how individuals with differing levels of OC tendencies appraised taboo intrusive thoughts. These two studies found evidence that, for taboo thoughts, people view violent thoughts most negatively, sexual thoughts second most, and blasphemous least negatively (Corcoran & Woody, 2008; Levine & Warman, 2016). Simonds and Thorpe (2003) found that people believe that others with violent obsessions would feel guilt and because of this would not likely share this information. A non-clinical sample determined those with violent obsessions were lower in social evaluation and were perceived as more dangerous (Simonds & Thorpe, 2003). Not surprisingly, professionals in the mental health field tend to show less stigmatizing attitudes than non-mental-health professionals (Smith & Cashwell, 2011). Even within the mental health field, however, it has been shown that professionals who are uneducated about sexual obsessions often misdiagnose patients with THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 21 pedophilia rather than a more appropriate diagnosis of OCD (Gordon, 2002). Unfortunately, this problem is not exclusive to just sexual intrusive thoughts (SIT). Glazier, Swing, and McGinn (2015) with mental health providers used vignettes that included an individual experiencing violent intrusive thoughts, and Schizophrenia was misdiagnosed by the mental health providers in 31.3% of cases. In general, many people associate mental illness with dangerousness, unpredictability, and weakness (Reavley & Jorm, 2011). Smith and Cashwell (2011) showed that, compared to mental health professionals, the general public holds more negative attitudes about and desires greater social distance from the mentally ill. Also, within the general population, greater social distance is typically desired from others who have sought professional help (Jorm & Oh, 2009). Interestingly, of those who have more knowledge about mental health, greater distance social distance is sometimes desired if the other person has not sought professional help (Jorm & Oh, 2009). Overall, personal experience with mental disorders was associated with lower social distance scores from others diagnosed with a mental disorder (Jorm & Oh, 2009). Cathey and Wetterneck (2013) suggest providing education as a way to decrease stigma and increase the seeking of treatment for mental health professionals. There is now increasing research to back this claim. For example, Warman, Phalen, and Martin (2015) had participants read a vignette describing a target with violent intrusive thoughts as either being diagnosed with schizophrenia, OCD, or no diagnosis and assessed attitudes towards the targets. Then a brief education was given to participants about OCD and participants were asked their attitudes towards the target again. Before the education was given, OCD was not considered a credible diagnosis to participants. However, after education, OCD became a credible diagnosis and negative attitudes toward the target decreased. Snethen and Warman (2018) conducted a very similar study but examined pedophilic thoughts. Results were also similar in that before THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 22 education OCD was not a credible diagnosis, but after education OCD became a credible diagnosis and negative attitudes toward the target significantly decreased. These studies demonstrate that lack of knowledge helps foster negative attitudes many people have about taboo thoughts associated with OCD. Disclosing sexual intrusive thoughts is associated with more social rejection from peers compared to disclosure of contamination related intrusive thoughts (Cathey & Wetterneck, 2013). In line with this, individuals were also less likely to report they would be willing to disclose sexual intrusive thoughts compared to contamination intrusive thoughts (Cathey & Wetterneck, 2013). Given the findings, it is likely that disclosing sexual intrusive thoughts are more stigmatizing than disclosing contamination thoughts (Cathey & Wetterneck, 2013). Moreover, it may also be likely that individuals will still avoid disclosing sexual obsessions even after disclosing other types of intrusive thoughts (Cathey & Wetterneck, 2013). This may be because, compared to taboo violent and blasphemous thoughts, if the thought occurred at a high frequency, participants were found to attach the most personal significance to the sexual target thought in a study by Corcoran and Woody (2008). The frequency of the taboo thought was found to be a mediator for attaching the most personal significance to the sexual taboo thought. It is probable there was something particular about the intrusive sexual thoughts about a child that affected participants of the study more so compared to the violent and blasphemous intrusive thoughts (Corcoran & Woody, 2008). Perhaps, the vignettes pertaining to sexual themes produced more emotional salience toward more distressing emotions (e.g. fear, shock, disgust) (Corcoran & Woody, 2008). Additionally, McCarty, Guzick, Swan, and McNamara (2017) found, in non-clinical samples, there were lower levels of recognition of taboo intrusive thoughts as OCD compared to contamination intrusive thoughts. Unfortunately, the stigma related to OCD THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 23 may help explain why those diagnosed with OCD have very low rates of seeking help from mental health professionals (Mayerovitch et al., 2003). The Present Study Aims The aim of the present study was to better understand how level of OC tendencies in an individual influences appraisal of a taboo thought of another individual versus acting out that thought within a non-clinical sample. Participants were randomly assigned to either a thoughts or an actions vignette set. They were shown 3 vignettes: one with a religious, one with a sexual, and one with a violent thought or action (Foa et al., 2002). Participants level of OC tendencies was measured using the Obsessive-Compulsive Inventory-Revised (OCI-R), a measure of various Obsessive Compulsive symptoms that has been utilized in a number of studies researching nonclinical populations including Abramowitz, Lackey, and Wheaton (2009), Corcoran and Woody (2009), Dar et al. (2019), Magee and Teachman (2012), and Wahl, Huelle, Zurowski, and Kordon (2013). Attitudes towards the targets in the vignette were determined using the Social Distance Scale (Link et al., 1987), a popular assessment to determine participants attitudes toward targets in vignette studies. Several studies have utilized both vignettes and SDS concurrently including Cathey and Wetterneck (2013), McCarty et al. (2017), Reavley and Jorm (2011), Snethen and Warman (2018), and Thibodeau (2016). Hypotheses OC level was expected to be a significant predictor of social distance, such that it was expected individuals higher in OC levels would desire more social distance from the targets, regardless of their group assignment - thought or action. Thought vs action was not expected to THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 24 be a significant predictor as it was expected that OC level would moderate the relationship between social distance and group assignment (thought vs action.) Specifically, it was expected that individuals lower on the continuum of OC tendencies would see vast differences between the targets who had only thoughts and targets who were detailed to have problematic (violent, sexual, or blasphemous) actions. As a result, for individuals lower on the continuum of OC, it was expected social distance would be far greater in the action as opposed to the thoughts condition. For individuals higher in OC, it was expected, due to the concept of "thought-action fusion," that they would see thoughts and actions similarly. Specifically, it was expected participants with higher OC levels would desire the same amount of social distance from vignette targets in the thought and in the action vignettes. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 25 Chapter 2 Methods Participants Participants provided informed consent before participating in the study. Research participants were a minimum of 18 years old at the time of the study and be able to speak English fluently. All participants were recruited through the crowdsourcing marketplace Amazon Mechanical Turk (MTurk) and were given compensation in the amount of $4.00 for their involvement in the present study, funded by a University of Indianapolis internal grant awarded to Debbie Warman, the advisor for this project. Materials Obsessive-Compulsive Inventory-Revised (OCI-R). The OCI-R was used in the present study to determine participants level of OC tendencies. This is a self-report measure used to determine the frequency and amount of distress of OCD symptoms an individual is experiencing using 18 items with each item on a 5-point Likert scale. The OCI-R has excellent test-retest reliability (r=.82; Foa et al., 2002). Moreover, it has internal consistency of r=.88 for non-clinical samples (Hajcak, Huppert, Simons, & Foa, 2004). The OCI-R is a measure that has been used in a number of studies assessing OC symptoms on a continuum in non-clinical populations including (Abramowitz et al., 2009; Corcoran & Woody, 2009; Dar et al., 2019; Magee & Teachman, 2012; Wahl et al., 2013). The Cronbachs Alpha for the OCI-R in this study was .956, which is excellent. Vignettes. A total of 6 vignettes were utilized in this study to determine evaluations of a hypothetical target with: 1) a violent taboo thought, 2) a person acting out that violent taboo thought, 3) a person having a sexual taboo thought, 4) a person acting out that sexual taboo THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 26 thought, 5) a person having a blasphemous taboo thought, and 6) a person acting out that blasphemous taboo thought. This study utilized the three taboo thought vignettes used by Levine and Warman (2016) for the thought condition. For the action condition, the vignettes were modified to indicate the action had been carried out. A number of studies have also used vignettes to research taboo intrusive thoughts including Cathey and Wetterneck (2013), Corcoran and Woody (2008), Corcoran and Woody (2009), McCarty et al. (2017), Levine and Warman (2016), Snethen and Warman (2018), Steinberg and Wetterneck (2017), and Warman, L. Phalen, and Martin (2015). Vignettes for Action 1. Joe is a very religious person. While engaged in silent prayer, he urinated on the Bible. 2. While helping his niece use the bathroom, Alex performed sexual acts with the child. 3. While stopped at a crosswalk waiting for an elderly pedestrian to cross the street, Larry decided to run them over in his car and drive away from the scene. Vignettes for Thought 1. Joe is a very religious person. Several times per week while engaged in silent prayer, he has a sudden, terrible image of urinating on the Bible. Joe is very upset about having this thought. 2. Several times per week while helping his niece use the bathroom, Alex has a sudden, intrusive sexual thought about his niece. Alex is very upset about having this thought. 3. Several times per week while stopped at a crosswalk waiting for an elderly pedestrian to cross the street, Larry has a sudden, horrific impulse to run them over in his car. Larry is very upset about having this thought. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 27 Social Distance Scale. The Social Distance Scale is a 7 item self-report measurement used to determine attitudes toward individuals with mental illness. Its most current version was created by Link, Cullen, Frank, and Wozniak (1987). All 7 items are measured using a five-point Likert scale, 0 = definitely willing and 4= definitely unwilling. Higher scores on the measure show a desire for greater distance from the individual targeted in the scale. The measure has good internal consistency reliability, ranging between .079 and 0.92 (Angermeyer et al., 2014; Link et al., 1987; Von Dem Knesebeck, Angermeyer, Kofahl, Makowski, & Mnich, 2014), and good construct validity (Link et al., 1987). The social distance scale is a popular way to assess attitudes towards individuals with various presenting problems, including OCD (McCarty et al., 2017; Reavley & Jorm, 2011; Schomerus et al., 2016; Snethen & Warman, 2018; Thibodeau, 2016; Warman et al., 2015; Wiesjahn et al., 2016). In this study, the Social Distance Scale was used to collect data on the dependent variable. The Cronbachs Alpha for the Social Distance Scale in this study was .971, which is excellent. Manipulation Check. To ensure participants had attended to materials, all participants engaged in a manipulation check. Participants in the thought condition were asked to endorse which of the following thoughts they did not view in a vignette: running someone over with a car, engaging in sexual activity with a child, urinating on the bible, or thought of leaving dirty dishes on the counter. Participants in the action condition were asked to endorse which of the following actions they did not view in a vignette: running someone over with a car, engaging in sexual activity with a child, urinating on the bible, or leaving dirty dishes on the counter. Procedure. Data for this study was collected online using the Qualtrics survey system. The survey was presented to participants through MTurk. Participants first gave consent to participate in the study. Next, they were administered the OCI-R to determine level of OC tendencies. The THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 28 participants were randomly assigned to either be shown vignettes describing three taboo thoughts (sexual, violent, blasphemous thoughts group) or assigned vignettes describing the three taboo thoughts as actions (action group). Participants then were asked to complete the Social Distance Scale about the targets they read about after they read each vignette. Lastly, they completed a manipulation check for content type. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 29 Chapter 3 Results Power Analysis. A power analysis was conducted with a presumed effect size of .15 and power set to .8. A total sample size of 77 particpants was determined to be required. Ultimately, 271 particpants were recruited to protect against missing data. 84 participants were eventually dropped from the study for reasons including not successfully completing the manipulation check (69 participants), not thoroughly completing the procedures (11 participants), and representing outliers (4 participants). Demographic data of the remaining 187 participants is shown in Table 1. Table 1 Sample Demographics Group Sex Male Female Thought N % N % 58 37 61.1 38.9 44 48 47.8 52.2 76.8 23.2 SD 10.97 70 22 M 37.22 Race White 73 Non-white 22 M Age 36.93 Action 76.1 23.9 SD 11.45 Testing of Assumptions. Several tests of assumptions for moderation analyses were conducted including testing for homogeneity, homoscedasticity, outliers, multicollinearity, and a normal distribution of the data. After checking for outliers using distance measures of Mahalanobis, Cooks, and leverage values, two participants were found to be outliers and were dropped from the primary analyses. The histogram of standardized residuals for each content type indicated THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 30 that the data contained approximately normally distributed errors, as did the normal P-P plot of standardized residuals, which showed points that were not completely on the line, but still correlated with it. The scatterplot of standardized predicted values showed that the data met the assumptions of homogeneity of variance and linearity. There did not appear to be any issues with multicollinearity. Preliminary Analyses. A number of demographic variables were examined to determine if they needed to be added to the primary analyses as covariates. Specifically, age, gender, and race were examined to determine their relationships to the dependent variables of the study: social distance desired from the sexual, violent, and blasphemous vignettes. The relationship of age and the dependent variables were examined through correlational analyses. Age did not have a significant impact on social distance for all three content types, blasphemous (n = 187, r = .04, p = .61), sexual (n = 191, r = .05, p = .47), and violent (n = 191, r = .05, p = .52). To determine any differences in the dependent variables across diffferent genders (male and female) a t-test was used. There appeared to be a significant difference between genders for the sexual content type (p = .024) and, thus, was included in the primary analysis as a covariate for the sexual vignettes. To determine any differences in responses to dependent variables across races, one-way ANOVAS were conducted. Due to insufficient participants in racial categories other than White, it was determined there was only enough representation to create white and non-white groupings. There were no significant relationships found between white and non-white participants desired social distance from the targets (all p-values >.09). Primary Analyses. Regression analyses were conducted to test the hypotheses of the current study. The hypotheses are repeated here for clarity: OC level was expected to be a significant predictor of social distance, such that it was expected individuals higher in OC levels would THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 31 desire more social distance from the targets, regardless of their group assignment - thought or action. Thought vs action was not expected to be a significant predictor as it was expected that OC level would moderate the relationship between social distance desired from the targets and group assignment (thought vs action). In terms of the expected moderation, it was expected that individuals lower on the continuum of OC tendencies would see vast differences between the targets who had only thoughts and targets who were detailed to have problematic (violent, sexual, or blasphemous) actions. As a result, for individuals lower on the continuum of OC, it was expected social distance would be far greater in the action as opposed to the thoughts condition. For individuals higher in OC, it was expected, due to the concept of "thought-action fusion," that they would see thoughts and actions similarly. Specifically, it was expected participants with high OC levels would desire the same amount of social distance from vignette targets in the thought and in the action vignettes. To test these hypotheses, three separate moderation analyses were conducted, one for each type of content - sexual, violent, and blasphemous. Using Hayes PROCESS Macro, moderation analyses were conducted with thought vs. action as the predictor, OC tendencies as the moderator and social distance as the outcome. For the sexual content type, gender of the participant was entered as a covariate. The continuous variable was centered, Model I with 5,000 bootstrap samples. Where the moderation was found to be significant, simple slope analyses were conducted. For the violent content type, the overall model was found to be significant [F(3, 183) = 44.23 p < .001, R2 = .42]. Thought vs action was a significant predictor, [b = -10.58, t(183) = 8.68, p < .001], such that participants desired less social distance from the target with the violent thought than they did the target with the violent action. OC tendencies was also found to be a significant predictor, [b = -.12, t(183) = -5.44, p < .001], such that, counter to hypothesis, THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 32 participants with higher OC tendencies desired less social distance from the vignette targets than did participants with lower OC tendencies. Moreover, the interaction between thought vs. action and OC tendencies was significant [b =.19, t(183) = 4.25, p < .001]. Examination of simple slopes indicated that for each level of OC (low, average, and high), participants desired more social distance from targets who acted on thoughts as opposed to targets who exclusively had thoughts. However, the difference was more pronounced for low and average OC participants than it was for high OC participants (p < . 001 for both high and average OC tendencies, compared to p = .04 for high OC tendencies in terms of their relationship to social distance desired from the target when considering thought vs. action) (see Figure 1). Figure 1 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 33 Table 1 Regression Model Violent Content Type coeff 16.7559 se .6091 t 27.5090 p .0000 LLCI 15.5541 ULCI 17.9576 T_Coded -10.5795 1.2182 -8.6845 .0000 -12.9831 -8.1760 constant OCISum -.1228 .0226 -5.4375 .0000 -.1674 -.0783 Int_1 .1920 .0452 4.2505 .0000 .1029 .2812 For the sexual content type, the overall model was found to be significant [F(4, 182) = 21.20, p < .001, R2 = .32]. Thought vs action was a significant predictor, [b = -6.01, t(182) = 5.30, p < .001], such that participants desired less social distance from the target with sexual thoughts than the did the target with sexual actions. In addition to thought vs action, OC tendencies was also found to be a significant predictor, [b = -.12, t(182) = -5.57, p < .001] such that, consistent with the violent condition and counter to hypotheses, high OC individuals desired less social distance from the vignette targets than low OC individuals. The interaction between thought vs. action and OC tendencies was significant as well [b = .09, t(182) = 2.22, p = .03]. Much like the violent content type, examination of simple slopes indicated that for each level of OC (low, average, and high), participants desired more social distance from targets who acted on thoughts as opposed to targets who exclusively had thoughts. Again, the difference was more pronounced for low and average OC participants (p < .001 for both) than it was for high OC participants (p = .06), see figure 2. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 34 Figure 2 Table 2 Regression Model Sexual Content Type constant coeff 18.3017 se .6582 t 27.8046 p .0000 LLCI 17.0029 ULCI 19.6004 T_Coded -6.0094 1.1348 -5.2954 .0000 -8.2486 -3.7703 OCISum -.1165 .0209 -5.5671 .0000 -.1578 -.0752 Int_1 .0928 .0419 2.2173 .0278 .0102 .1754 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION gendernu coeff 1.2258 se .7113 t 1.7233 p .0865 LLCI -.1777 35 ULCI 2.6293 For the blasphemous content type, the overall model was found to be significant [F(3, 183) = 23.51 p < .001, R2 = .28]. Thought vs action was a significant predictor, [b = -8.36, t(183) = -6.52, p < .001], indicating that, similarly to the violent and sexual conditions, participants desired more social distance from the vignette targets who engaged in a blasphemous action than they did the blasphemous thought. Unlike for the violent and sexual conditions, for the blasphemous condition, OC tendencies was not found to be a significant predictor, [b = -.03, t(183) = -1.30, p = .19], indicating no significant difference between levels of OC tendencies in participants and their desired social distance from targets. The interaction between thought vs. action and OC tendencies was significant [b = .10, t(183) = 2.08, p = .04]. Examination of simple slopes indicated that, similar to the violent and sexual content types, for each level of OC (low, average, and high), participants desired more social distance from targets who acted on thoughts when compared to targets who exclusively had thoughts. Likewise, the difference was more pronounced for low and average OC participants (p < .001 for both while t = -6.87 and t = -8.05 respectively) than it was for high OC participants (p = .001 and t = -3.28), see figure 3. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 36 Figure 3 Table 3 Regression Model Blasphemous Content Type constant coeff (b) 12.7548 se .6412 t 19.8923 p .0000 LLCI 11.4897 ULCI 14.0199 T_Coded -8.3617 1.2824 -6.5205 .0000 -10.8919 -5.8316 OCISum -.0309 .0238 -1.3010 .1949 -.0779 .0160 Int_1 .0988 .0476 2.0769 .0392 .0049 .1926 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION Table 4 Conditional effects of thought vs. action on social distance at values of the moderator: OCISum Effect 3.0000 -8.0654 se 1.1748 t -6.8651 p LLCI .0000 -10.3834 ULCI -5.7474 18.0000 -6.5838 .8183 -8.0458 .0000 -8.1982 -4.9693 42.0000 -4.2131 1.2844 -3.2802 .0012 -6.7473 -1.6790 37 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 38 Chapter 4 Discussion The present study investigated appraisal of an intrusive thought of a hypothetical individual (i.e., a vignette target) vs. acting out the behavior of the thought while comparing OC tendencies in a non-clinical sample population. Participants were randomly assigned to either be shown vignettes describing three taboo thoughts (sexual, violent, blasphemous; thoughts group) or assigned vignettes describing the three taboo thoughts as actions (action group). Participants were given the OCI-R as a means to measure OC tendencies (Foa et al., 2002). Social distance from the target was then measured as a way to determine the participants attitudes towards the vignette targets. It was predicted that individuals with higher OC levels would desire more social distance from targets, regardless of their group assignment thought or action. This expectation was based on previous research showing that individuals with higher levels of OC had stronger appraisals to taboo thoughts compared to individuals with lower OC tendencies (Corcoran & Woody 2008). Quite unexpectedly, participants with higher OC levels were actually found to desire the least social distance from targets across each content type compared to participants with average and lower OC tendencies. Cocoran and Woody (2008) collected data from participants who were undergraduate students. The present study, however, collected data from a general population. Although both non-clinical samples, this may be at least partially responsible for the unexpected results. This may indicate differences in OCD symptomatology and/or its expression between college students and the general population which might be worth exploring further. Although participants were not formally diagnosed with OCD, the cognitive model posits that OCD symptoms are on a spectrum (Wang & Clark, 2002). Thus, those with high OC THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 39 tendencies likely have experiences similar to those diagnosed with OCD, while those lower on the spectrum likely have fewer such experiences. A previous study also found that personal experience of mental disorders is associated with less social distance from those with mental disorders (Jorm & Oh, 2009). Those with OCD that score higher on obsessions subscales tend to also have higher scores on taboo thoughts symptom dimension scales (Brakoulias et al., 2013). Moreover, those who experience blasphemous, sexual, and/or violent taboo thoughts seem to be particularly vulnerable and prone to stigma and shame regarding treatment of their symptoms (Glazier, Wetterneck, Singh, & Williams, 2015). This may indicate a need to assess and provide education particularly for violent and sexual taboo thoughts. This education would likely be valuable across the continuum of OC levels and even in clinicians, as even clinicians have been found to have greater levels of stigma toward clients with aggressive and pedophilic taboo thoughts (Canavan, 2022). Previous research also found that knowledge of mental disorders is associated with less social distance (Jorm & Oh, 2009). On the other hand, participants with lower OC tendencies may be less familiar with mental disorders compared to participants with higher OC tendencies and, thus, evaluate them more harshly. Individuals with greater mental health literacy have also been found to have greater empathy which may have lead participants in the study with higher levels of OC to be more forgiving toward the target (Furnham & Sjokvist, 2017). Given these research findings, it could be possible those with higher OC tendencies in this study experienced taboo thoughts themselves and, thus, were more forgiving of the experience of the target. This may help explain the variation found between OC tendency levels in participants across the sexual and violent content types. Additionally, Corcoran and Woody (2008) found that participants appraised taboo thoughts similarly regardless of whether the person in a vignette experiencing the thoughts was THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 40 detailed to be the participant themselves or a friend. However, Hezel et al. (2019) conducted a study exploring whether TAF bias is unique to ones own thoughts or if it is also applicable to how those with OCD evaluate others thoughts. They utilized a revised version of the Thoughtaction Fusion Scale (TAF Scale; Shafran et al., 1996). The study found that people with certain anxiety disorders, including those with OCD, tend to evaluate their own thoughts as more dangerous than other peoples thoughts (Hezel et al., 2019). Also, a study conducted by Berman et al. (2011) regarding TAF showed results indicating that thinking of a relative being diagnosed with cancer significantly increased distress, urges from the individual to neutralize the thought, mentally neutralizing behaviors, and feelings of likelihood that the thought would manifest into a real life occurrence compared to thinking of a stranger. Although previous research has shown that people with OCD appraise taboo thoughts more negatively than the normal population, because the target in the vignette was a stranger, this perhaps lessened some of the negative appraisal (i.e. increased desired social distance) that was anticipated by participants who had higher levels of OC regardless of content type (Brakoulias et al., 2013; Corcoran & Woody, 2008; Rachman, 1997). There was also an expectation that OC tendencies would moderate the relationship between social distance desired from targets in the thoughts vs actions conditions. Specifically, it was expected that individuals lower on the continuum of OC tendencies would see vast differences between the targets who had only thoughts and targets who were detailed to have problematic (violent, sexual, or blasphemous) actions. As a result, for individuals lower on the continuum of OC tendencies, it was expected that social distance would be far greater in the action as opposed to the thoughts condition. This was predicted due to the expectation that those with lower OC levels would not experience TAF, as is consistent with previous research. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 41 Analyses showed that OC tendencies did moderate the relationship between thought vs action and social distance in that participants with lower OC tendencies desired greater social distance from the target in the action condition compared to the thought condition for each content type. As mentioned above, these findings are most likely attributable to lower level OC participants not experiencing effects of TAF, consistent with the theory of TAF and cognitive model of OCD. Because there was anticipation that OC level would moderate the relationship between social distance and group assignment (thought vs action), thouhgt vs. action was not expected to be a significant predictor. For individuals higher in OC, it was expected, due to the concept of "thought-action fusion," that they would see thoughts and actions similarly. Specifically, it was expected participants with higher OC levels would desire the same amount of social distance from vignette targets in the thought and in the action vignettes. This study, however, found that thought vs action was a significant predictor across all content types. Contrary to what was predicted, participants with higher OC levels also desired greater social distance from the action condition as relative to the thought condition. Consistent with previous research, it was found that for participants with lower levels of OC, their desired social distance from the target increased in the action condition compared to the thought condition as they likely did not experience TAF. As mentioned, it appeared individuals with higher levels of OC also had significant differences between the thought condition and the action condition for each of the content types. Yet, the differences in levels of desired social distance between thought and action were less pronounced for those who were high OC. This is consistent with previous research on the theory of TAF (Berle & Starcevic, 2005; Shafran & Rahman, 2004), though the effect did not emerge as powerfully as was predicted. These findings lead to a reasonable suspicion that the THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 42 effects of TAF are positively correlated with OC tendencies as Berle and Starcevic (2005) suggest. Individuals tend to be more concerned about the potential consequences of a taboo thought if they feel responsible for the experience as opposed to believing someone else is actually responsible (Menzies, Harris, Cumming, & Einstein, 2000). This may have dampened some of the effects of TAF in participants with higher OC tendencies in the present study without eliminating the effect completely, perhaps explaining why there appeared to be a subtle TAF effect forparticipants with higher OC levels. There is also evidence that non-clinical sample populations endorse TAF statements to some extent (Rassin, 2001; Rassin, Merkelbach et al., 2001; Shafran et al., 1996), though clinical samples score higher on the TAF scale. It is important to note, however, that overlap between clinical and non-clinical samples does occur (Abramowitz, Whiteside, Lynam, & Kalsy, 2003; Shafran et al., 1996). Since scores on the TAF Scale are variable between clinical and non-clinical populations, its likely that TAF can affect those with higher levels of OC who are not necessarily part of a clinical population. Pertaining to this study, participants with higher OC levels would then presumably experience higher levels of TAF while participants with average and lower levels of OC would not experience any effects of TAF. This may help explain the differences in social distance desired between thought vs action within differing levels of OC. Given the confusing findings, it would likely be beneficial for research to delve deeper into TAF and how it differs across the continuum of OC tendencies and not only those diagnosed with OCD. Unlike the violent and sexual content types, surprisingly, OC level was not a significant predictor of social distance for the blaspehmous content type. Previous research has shown that blasphemous thoughts are not appraised as negatively as the sexual and violent intrusive THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 43 thoughts (Corcoran & Woody, 2008; Levine & Warman, 2016). Typically violent or sexual taboo thoughts are more socially rejected compared to blasphemous intrusive thoughts (Ponzini & Steinman, 2022; Steinberg & Wetterneck, 2016), which may be why OC level was not a significant predictor perhaps the blasphemous thought was simply not that provocative in general. Relationships have also been found between religiosity and obsessive-compulsive symptoms (Hutchinson, Patock-Pekham, Cheong, & Nagoshi, 1998; Sica, Norvara, & Sanavio, 2002). For example, there is evidence to show that people who are religious more strongly endorse TAF compared to nonreligious people (Rassin & Koster, 2003). Yorulmaz et al. (2004) claimed that differing patterns in religiosity between Western and Turkish cultures were why their results showed elevated TAF moral scores compared to TAF likelihood scores between participants. Studies have also shown that individuals who have higher levels of intrusive thoughts related to religion tend to also be more religious in both clinical and non-clinical populations (Abramowitz et al., 2004; Abramowitz et al., 2002; Greenberg & Shefler, 2002; Lewis & Maltby, 1995; Moron et al., 2022; Nelson, Abramowitz et al., 2006; Okasha et al., 1994; Sica, Novara, & Sanavio, 2002; Siev & Cohen, 2007; Steketee, Quay, & White, 1991). This highlights the importance of assessing for blasphemous intrusive thoughts in treatment when a client mentions identification with religion or spirituality. Although affiliation with religion is increasing across the globe, in the United States, religious affiliation is currently declining with an increase in individuals who identify as atheist or agnostic (Pew Research Center, 2015). With these findings and religious trends in mind, perhaps participants in this study were not particularly religious. Participants coming from a country with decreasing religiosity may have led to the decreased likelihood of TAF as well as THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 44 decreased negative appraisal of blasphemous content and, thus, differences in social distance to occur for the blasphemous content type. It will remain unknown at this time as this study did not collect data on participants religious identity or their level of religiosity. As Corcoran and Woody (2008) point out, although the vignettes contradict social norms, some of the vignettes may have violated participants personal values more than others. What appears to cause distress with taboo thoughts is how much the thought deviates from valued aspects of the self (Rowa & Purdon, 2003). The vignettes from the violent and sexual content types involve an identified victim who is personally harmed by a target. In the blasphemous vignettes, however, the disturbing act/thought does not have a specific identifiable victim. In this content type, the victim is more abstract and involves disrespect to a personal belief system and physical damage to an object. Considering that there is no identifiable victim and that participants were likely not particularly religious, this may have weakened their negative appraisal of the blasphemous content. Limitations Although this study had enough participants to run analyses, having an increased sample size could have allowed for anlysis of more specific demographic variables rather than dichotomous variables such as male/female and white/non-white. Increased sample size may have also allowed for more power to find significant relationships that this particular study was not able to. Although mTurk has become popular as a means to collect participant data, particularly for its ease of access and administration (Aguinis, Villamor, & Ramani, 2021), it does not come without drawbacks. The sample population from mTurk is not immune to limitations including self-misrepresentation, high attrition, and social desirability bias (Aguinis, Villamor, & Ramani, 2021). Additionally, a manipulation check can only go so far into THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 45 determining whether participants answered questions with intent; the anonymity of mTurk may have created a situation where participants were less honest and thus less accurate in their responses. Moreover, vignettes have limited ability in replicating how someone may react in person compared to answering to prompts provided via the internet (Link, Yang, Phelan, & Collins, 2004). Content validity is difficult to measure for vignettes as there is a sizeable amount of variability in how they are constructed. For example in the sexual vignettes the victim was the targets niece. There may have been a different effect found if the victim had been a stranger (Berman et al., 2011). Also, in the informed consent, participants are told the target is hypothetical. Perhaps, this had an influence on participants appraisal of the target compared to a real life target. Additionally, there may have been a confound in not including guilt felt by the target in the action vignettes unlike the thought vignettes. This could have influenced findings because the emotional impact of the experience was not balanced across the vignettes. Lastly, not collecting demographic data on religiosity of participants was a limitation of this study as it could not then be used as a variable to determine if it was related to social distance and should be considered a covariate in the moderation analyses. The mixed findings in this study iterate the necessity of future research in this area in order to clarify our understanding of OC tendencies, TAF, and attitudes towards intrusive thoughts as well as the relationships they have and do not have with each other. Future research should attempt to reduce some of the limitations this study had as a way to create results that are more robust. Although studies examining individuals lower on the continuum of OC traits is a popular way of inferring these processes in individuals with OCD (Corcoran & Woody, 2008; Lee & Kwon, 2003; Levine & Warman, 2015; Rachman & de Silva, 1978), it is important to note THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 46 that if this study were conducted with a clinical sample population, entirely different findings may emerge. Conclusion The purpose of this study was to broaden the scope of understanding of the cognitive model, OCD, TAF, stigma, and intrusive thoughts. OCD and intrusive thoughts can cause distress in both clinical and non-clinical samples which necessitates the importance of increased knowledge regarding this subject of research. This can be further exacerbated through stigma and attitudes towards intrusive thoughts. In this study, OC tendencies did moderate the relationship between thought vs action and social distance, though effects were not as pronounced as was hypothesized. Future research appraising actions in others while exploring TAF and comparing clinical OCD and non-clinical samples may shed light on the findings of the current study. THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 47 References Aardema, F., OConnor, K. 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ACTION IN A NON-CLINICAL POPULATION 63 Appendices Appendix A: Obsessive-Compulsive Inventory Revised (OCI-R) The following statements refer to experiences that many people have in their everyday lives. Circle the number that best describes HOW MUCH that experience has DISTRESSED or BOTHERED you during the PAST MONTH. The numbers refer to the following verbal labels. 0 Not at all 1 A little 2 Moderately 3 A lot 4 Extremely 1. I have saved up so many things that they get in the way. 0 1 2 3 4 2. I check things more often than necessary. 0 1 2 3 4 3. I get upset if objects are not arranged properly. 0 1 2 3 4 4. I feel compelled to count while I am doing things. 0 1 2 3 4 5. I find it difficult to touch an object when I know it has been touched by strangers or certain people. 0 1 2 3 4 6. I find it difficult to control my own thoughts. 0 1 2 3 4 7. I collect things I dont need. 0 1 2 3 4 8. I repeatedly check doors, windows, drawers, etc. 0 1 2 3 4 9. I get upset if others change the way I have arranged things. 0 1 2 3 4 10. I feel I have to repeat certain numbers. 0 1 2 3 4 11. I sometimes have to wash or clean myself simply because I feel contaminated. 0 1 2 3 4 12. I am upset by unpleasant thoughts that come into my mind against my will. 0 1 2 3 4 13. I avoid throwing things away because I am afraid I might need them later. 0 1 2 3 4 14. I repeatedly check gas and water taps and light switches after turning them off. 0 1 2 3 4 15. I need things to be arranged in a particular way. 0 1 2 3 4 16. I feel that there are good and bad numbers. 0 1 2 3 4 17. I wash my hands more often and longer than necessary. 0 1 2 3 4 18. I frequently get nasty thoughts and have difficulty getting rid of them. 0 1 2 3 4 THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 64 Appendix B: Social Distance Scale Please answer the following questions about Larry, the person you just read about. Definitely Probably Unwilling Unwilling How would you feel about renting a room in your home to someone like Larry? How about working on the same job as someone like Larry? How would you feel having someone like Larry as a neighbor? How about as the caretaker of your children for a couple of hours? How about having your children marry someone like Larry? How would you feel about introducing Larry to a friend? How would you feel about recommending someone like Larry for a job working for a friend of yours? Probably Willing Definitely Willing THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 65 Please answer the following questions about Alex, the person you just read about. Definitely Probably Unwilling Unwilling How would you feel about renting a room in your home to someone like Alex? How about working on the same job as someone like Alex? How would you feel having someone like Alex as a neighbor? How about as the caretaker of your children for a couple of hours? How about having your children marry someone like Alex? How would you feel about introducing Alex to a friend? How would you feel about recommending someone like Alex for a job working for a friend of yours? Probably Willing Definitely Willing THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 66 Please answer the following questions about Joe, the person you just read about. Definitely Probably Unwilling Unwilling How would you feel about renting a room in your home to someone like Joe? How about working on the same job as someone like Joe? How would you feel having someone like Joe as a neighbor? How about as the caretaker of your children for a couple of hours? How about having your children marry someone like Joe? How would you feel about introducing Joe to a friend? How would you feel about recommending someone like Joe for a job working for a friend of yours? Probably Willing Definitely Willing THOUGHT VS. ACTION IN A NON-CLINICAL POPULATION 67 Appendix C: Vignettes Thought 1. Several times per week while stopped at a crosswalk waiting for an elderly pedestrian to cross the street, Larry has a sudden, horrific impulse to run them over in his car. Larry is very upset about having this thought. 2. Several times per week while helping his niece use the bathroom, Alex has a sudden, intrusive sexual thought about his niece. Alex is very upset about having this thought. 3. Joe is a very religious person. Several times per week while engaged in silent prayer, he has a sudden, terrible image of urinating on the Bible. Joe is very upset about having this thought. Action 4. While stopped at a crosswalk waiting for an elderly pedestrian to cross the street, Larry decided to run them over in his car and drive away from the scene. 5. While helping his niece use the bathroom, Alex performed sexual acts with the child. 6. Joe is a very religious person. While engaged in silent prayer, he urinated on the Bible.  ...

... (IL)LIBERAL BIAS IN ACADEMIA: INVESTIGATION OF THE GRIEVANCE STUDIES AFFAIR A Doctoral Dissertation Presented to The Graduate Department of Clinical Psychology University of Indianapolis In partial fulfillment of the requirement for the degree Doctor of Psychology Graham Clayton Husick, M.A. April 11, 2023 ii (Il)liberal Bias In Academia: Investigation of the Grievance Studies Affair The signatures below certify that the Doctoral Dissertation of Graham Clayton Husick, M.A. has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial Fulfillment of the requirements for the degree of Doctor of Psychology Approved: Accepted: _____________________________ ___________________________ Mason Burns, Ph.D. Committee Chair Dissertation Advisor John Kuykendall, Ph.D. Dean, College of Applied Behavioral Sciences 4/13/2023 _____________________________ ____________________________ William Essman, Ph.D. Committee Member Date _________________________ James Lindsay, Ph.D. Committee Member 4/13/2023 Date iii ABSTRACT In 2018, a team of academics succeeded in publishing studies with critically flawed methodologies, crass language, and unsupported conclusions in major Social Science academic journals such as Hypatia, Fat Studies, and Sex Roles. One paper was even awarded as leading scholarship. The hoaxers hypothesized that their success was due to political bias in peer review, specifically a prioritization of politically-correct conclusions in these fields over scientific rigor. An ideologically- and politically-motivated methodology called Critical Social Science does appear to be influencing academia as a whole, particularly in the Social Sciences, and likely affects peer review as well. Critical Social Science explicitly presupposes conclusions and actively rejects critique, thus rejecting the entire paradigm of academic research and the scientific method itself. We sought to evaluate what individual differences might influence an individual to subscribe to this ideology including Liberal Ideology (LI) and Paranoid Egalitarian Meliorism (PEM). We presented 169 MTurk participants with summaries of the hoax articles and measured their agreement with the arguments as well as their willingness to share the articles. Then, we presented them with scientific rebuttals of the hoax arguments and measured changes in attitudes towards the original article, as well as towards the rebuttal researchers. We found that: confirmation bias most likely predicted high-LI individuals desire to disseminate the hoax articles, that high PEM individuals were far more denigrating towards simulated rebuttal researchers, and that high PEM individuals were far less likely to agree with or share the rebuttals. These findings implicate a possible individual difference explanation for the success of the Hoax Project and appear to identify an individual trait (PEM) that indicates rejection of iv scientific principles. The implications of high rates of PEM individuals in academic fields are discussed. TABLE OF CONTENTS TITLE PAGE.i SIGNATURE PAGE.ii ABSTRACT..iii TABLE OF CONTENTS..iv Chapter I: Introduction and Review of the Literature7 The Hoax, Discovered.....7 The Paradigm Wars........................................................................................................8 Value-Laden Study..........................................................................................................10 The Purpose of Science.................................................................................................. 12 Bad Actors.......................................................................................................................15 Bad Science, Real Consequences...................................................................................17 The Hoaxers Hypothesis...............................................................................................22 What About Good Faith Mistakes?..............................................................................26 Separating Bad Actors from Biased Liberals..............................................................29 Liberal Feminist Ideology...................................................................................30 Paranoid Egalitarian Meliorism.........................................................................31 Overview of the Present Research................................................................................33 Hypotheses......................................................................................................................35 Chapter II: Research Design and Method...............................................................................37 Participants....................................................................................................................37 v Procedure........................................................................................................................38 Chapter III: Planned Analyses and Expected Results............................................................41 Transformations of Data.............................................................................................41 Pre-Rebuttal Results....................................................................................................41 Mediation Analysis............................................................................................41 Post-Rebuttal Results...................................................................................................43 Researcher Critique.....................................................................................................44 Rebuttal Reactions........................................................................................................45 Hypotheses Results Summary.....................................................................................46 Chapter IV: Discussion............................................................................................................47 Limitations....................................................................................................................48 Self-Correction?...........................................................................................................51 Possible Solutions.........................................................................................................53 Improve Peer Review........................................................................................53 Abandon Peer Review.......................................................................................56 Why Does This Matter?...............................................................................................59 References.................................................................................................................................62 Appendix A...............................................................................................................................78 Hoax Article Argument/Conclusion Sets with Rebuttals.........................................78 Appendix B................................................................................................................................82 Dependent Measures....................................................................................................82 Agreement with Arguments and Conclusions..................................................82 Evaluation of Logical Quality...........................................................................82 vi Willingness to Read More/Share......................................................................82 Agreement with Rebuttal...................................................................................83 Willingness to Read More/Share (Rebuttal)....................................................83 Denigration of Rebuttal Researchers...............................................................83 Liberal Feminist Ideology (Morgan, 1996)......................................................84 Liberal Racial Ideology (Adapted from Morgan, 1996)..................................84 Paranoid Egalitarian Meliorism (Winegard, Clark, Hasty, & Baumeister, 2018).................................................................85 Social/Economic Conservatism........................................................................86 Appendix C...............................................................................................................................88 Descriptives and Interrelations Between Measures..................................................88 7 Chapter I: Introduction and Review of the Literature The Hoax, Discovered In October of 2018, the Wall Street Journal discovered a possible scandal in academic integrity: the author of a scholarly article titled Human reactions to rape culture and queer performativity at urban dog parks in Portland, Oregon, did not seem to exist (Melchior, 2018). Helen Wilson, the supposed author, apparently a faculty member at the Portland Ungendering Research Initiative (also non-existent), was contacted to answer for her alleged academic dishonesty. Instead, a man named James Lindsay answered. He explained that he was posing as Helen Wilson, the paper was in fact a hoax, and that it was not the only one: four hoax papers had been published in major academic journals, seven total had been accepted for publication, and even more were in the final stages of review. Despite being complete fabrications, these hoax papers made their way through the supposedly rigorous peer review process at top journals in various academic disciplines and were welcomed with acclaim. For instance, their Dog Park paper, which argued for publicly and suddenly yelling at men when they show sexual interest in a woman a la canine shock training as a method to reduce rape, was even honored with an award as leading scholarship by the journal (Wilson, 2015). Indeed, every accepted paper as part of this Hoax Project received rave reviewer comments, including papers that argued that humor should be exclusively reserved for social justice purposes, that rewrote a chapter of Mein Kampf to be in line with feminist principles, and that even advocated for reducing homophobia by the use of anal sex toys for straight men. Lindsay and his two colleagues, Dr. Peter Boghossian and Helen Pluckrose, had duped major scholarly journals including Hypatia; Gender, Place, and Culture; Sexuality & Culture, and others into publishing studies with critically flawed methodologies, crass language, 8 and unsupported conclusions (Lindsay et al., 2018). Upon discovery of this hoax, the studies were promptly retracted by the hoaxers, but the embarrassing question remained: how did these critically flawed studies pass peer review in the first place? The Paradigm Wars To explain this supposed lapse in academic integrity, it is necessary to begin by reviewing some philosophy of science, particularly as it applies to the Social Sciences. During the late 1960s to early 1970s, Social Science underwent a significant overhaul in fundamental assumptions of its work. These evolving assumptions centered on the nature of humanity, the meanings of truth (i.e., validity), what constitutes good evidence, and when social and/or political values can/should enter the scientific process (Neuman, 1991). Three main schools of thought emerged from this debate: the Positivist, Interpretive, and Critical Social Science approaches. The Positivist approach has been the predominant approach to much of the Social Sciences and assumes that social reality contains preexisting objective facts that manifest in ordered patterns, much like the rules of mathematics patterned in the physical world (Turner, 1985). In a Positivist approach to Social Science, hypotheses are to be formulated a priori to avoid biasing observations and tested using statistical techniques, which must be replicable across time and studied populations. Positivism also dictates that the social scientist should strive to separate themselves from their work as fully as possible, keeping the scientific process separate from their own values and biases (Neuman, 1991). In a word, the Positivist approach is a Quantitative approach to science and is the foundation of much of the past 50 years of Social Science research. However, despite the explosion of high-quality science in the past half-century due to the adoption of Positivism, significant criticisms of its inherent weaknesses have led to differing 9 approaches. One major criticism of the Positivist technique is that it reduces all human experience to quantifiable measurements, which risks losing the full richness of human life in favor of exacting statistical accuracy. Furthermore, by having researchers develop research questions, hypotheses, and instruments before data collection, Positivism is critiqued for overemphasizing the researcher and neglecting the perspectives of the research subjects (Neuman, 1991). In response, the Interpretive approach to Social Science takes a subjective approach, emphasizing the differences between the way individual humans can experience the same events and interactions. The Interpretive approach may include hypotheses, but these are confirmed using largely narrative-driven, non-mathematical approaches that prioritize the depth of experience of the population studied (Neuman, 1991). Within the Interpretive approach, social and political values are meant to be analyzed and brought to the forefront as a recognition of their influence on both the researcher and the researched. However, the Interpretive social scientist typically does not assume that any one value is more valid or better than any other, and thus avoids taking explicit activist or political roles during research (Neuman, 1991). In a word, the Interpretive approach is a Qualitative method of Social Science research. One can see how both the Positivist and Interpretive approaches contribute significantly to greater understanding of humans and their social landscape, while also accounting for each others shortcomings. One can also see, if combined in a mixed-methods design, how Social Science can discover the facts of human nature and interactions while also allowing for more personalized, emotionally meaningful, and collaborative data. However, these two approaches do not satisfy all criticisms of the social scientific research status quo. The Critical Social Science (CSS) approach, birthed by Karl Marx and Postmodern thinkers, views the Positivist tradition as reductive and the Interpretive approach as 10 too passive in its aims (Neuman, 1991). CSS does not regard there to be both universal truths and subjective experiences, in fact outright rejecting the idea that unique individuals can interact richly with a universal reality. Instead, the Critical approach believes that all claims to truth are value-laden constructs of culture (Lindsay & Pluckrose, 2020, p. 32). This belief is also referred to as a radical form of Social Constructivism and is a significant departure from the Positivist and Interpretive methods. In this approach, what is considered truth is purely dictated by how society defines the concept of truth and who was involved in producing it (Sensoy, zlem, & DiAngelo, 2012). Thus, truth is simply the dominant narrative put forward by those in the position to define societys perception of truth and has nothing to do with a universal reality. In fact, the idea of a universal reality is itself disputed (Thompson, 2015, p. 192). Indeed, much of this thinking can be seen in recently developed school curricula, where even the statement 2 + 2 = 4 is deemed to be a subjective narrative claim to truth, rather than a basic rule of a reality governed by mathematical rules (Young, 2020). Value-laden Study The Critical approachs attitude towards values and politics is also a central component of its methodology. As opposed to Positivism or the Interpretive approaches that regard all values as either threats to validity or as subjects of careful and balanced study, CSS intentionally prioritizes certain values over others and explicitly advocates for their use within research and application of the research, typically for the liberation of oppressed peoples (Prilleltensky & Fox, 1997). CSS is firmly activist in its orientation and advocates that science should serve a political purpose at every level of its practice (Sayer, 1992). This purpose is then organized around what Lindsay and Pluckrose (2020) identify as the central uniting variable of interest for Critical Social Science: power. Within a Critical viewpoint, society is seen as in a constant 11 struggle for power wherein those in privileged positions exert power over the disadvantaged, and Positivist or Interpretive (i.e. mainstream) science is seen as attempting to maintain this unjust status quo (Prilleltensky & Fox, 1997). However, CSS departs from its origins in the Marxist view of a class struggle in which those with economic class privilege directly and intentionally oppress those in lower classes (Habermas, 1973). The Critical view regards the social landscape of humanity as a constant and sometimes unconscious power struggle between identity groups that is enacted at every level of society, from as broad as federal policy to as narrow as momentary personal interactions (Lindsay & Pluckrose, 2020). This view does not require malicious intent by the oppressive perpetrators, but instead relies on systemic definitions of oppression and power imbalances, typically pointing out demographic disparities as evidence of oppression. Most importantly, truth is seen only temporarily as what those in powerful and privileged identities (typically White, heterosexual, thin, able-bodied, Christian males) determine to be the truth (McIntosh, 1988; Sensoy, zlem, & DiAngelo, 2012). Since the world is seen as inherently oppressive, the truth is supposedly constructed and then used by these powerful identity groups to keep the disadvantaged from attaining positions of power. Therefore, as the Critical approach argues, there is a moral mandate for the scientific fields to be used to emancipate and improve conditions for the oppressed (Marcuse, 1969). The Critical Social Science approach, in summary, views truth as entirely socially constructed and through the lens of power, and is meant not to be factually true but strategically useful: in order to bring about its own aims, morally virtuous and politically useful by its own definitions (Pluckrose & Lindsay, 2020, p. 39). It should not be overlooked then that Critical Social Science contains an internal contradiction, borne of its postmodern roots: it views there to 12 be no truth except that which is constructed by power, but regards its own perspective as true enough as to require focused and organized action. Additionally, it presupposes the singular truth of power and oppression and enters scientific inquiry with a foregone conclusion in mind: the question is not whether a particular form of oppression such as racism has occurred, but rather how it has manifested in whatever is studied (DiAngelo, 2012). Critical Social Science methods promote proudly carrying ones own assumptions into hypothesis formation, as well as assuming the content and meaning of the results before inquiry even begins: all analysis will find oppression in some form, and that oppression must be understood and interpreted through a Critical lens. The Critical approach may be correct in its criticism that Positivist and Interpretive methods may still be inherently biased, but it attempts to resolve this issue by wholeheartedly embracing its own bias instead. In the Hoax Project, the hoaxers intentionally infused biased values and perspectives into their faux-scholarship and predicted that CSS value-consistent papers would be published and praised despite dire flaws in their work. The hoaxers tested this hypothesis by attempting to publish massively flawed research that was nonetheless in-line with CSS principles and conclusions, and succeeded in doing so. Although the hoaxers established that flawed, but valueconsistent findings were supported, they did not investigate whether value-inconsistent findings were opposed. To address this limitation, our research expanded upon the hoaxers project by investigating what individual differences might contribute to both supporting CSS-consistent arguments as well as denigrating CSS-inconsistent arguments. The Purpose of Science The primary issues with Critical Social Sciences methodology concern the purpose of Science itself. Social Psychologist Jonathan Haidt, in his 2016 lecture at Duke University, lays 13 out the case for the purpose of science by addressing the Aristotelian concept of Telos: the purpose or end goal of something. Haidt first makes the point that if the Telos of a knife is to cut, and it does not cut, then it is not a good knife. He then translates this concept to more complicated areas, such as that of the profession of a physician, whose Telos is to heal. He also makes the point that the Teloses of different areas, such as applied medicine and medical research, can serve to benefit each other if kept separate but in constructive interaction. Unfortunately, as Haidt explains, if Teloses blend, such as when fields like medicine and business meld in hospital settings, the profession of the physician becomes corrupted and loses its Telos to the influence of another Telos; in this case, to that of maximizing profit. In the end, this hurts those who could have been better served by the field of medicine. The Telos of Science and the scientific method, Haidt argues, is Institutionalized Disconfirmation: the potential for bad science to be caught and filtered out due to the expectation that every scientists work will be analyzed for error. In Haidts words, this was the genius of science. Its not the scientist whos so rational; its that science is a community of scholars that critique each others work (Haidt, 2016). Unfortunately, it appears that Critical Social Sciences methods and presuppositions represent an attempt to blend the Teloses of Science and Activism. Much like when medicine and business collide, it appears that one Telos overwhelms the other: Critical Social Science embraces the Telos of Activism while corrupting the original Telos of Science. This risk appears to already have come to fruition: a rejection of Institutional Disconfirmation is evident in prominent Critical Social Science literature. When the presuppositions of Critical Social Science are challenged in the scientific arena, accusations of privilege-preserving epistemic pushback are levied against those who dare to do so (Bailey, 14 2017). Privilege-preserving epistemic pushback is defined in the literature as a form of resistance to CSS ideas as a form of worldview protection that preserves ones place of power within society. In simpler terms, CSS explains away critiques of its ideas by means of ad hominem attacks against those who challenged them. A litany of other accusations is charged against those who might disagree with Critical Social Science including Willful Ignorance (i.e., not knowing and not wanting to know about the Critical view of the world; Tuana, 2006), Internalized Dominance (i.e., internalizing and acting out power dynamics by critiquing CSS; Sensoy & DiAngelo, 2017), or False Consciousness (i.e., if one is considered to be in an oppressed group and acting against their own interests by critiquing CSS; Delgado & Stefancic, 2017). One might even be accused of committing epistemic violence against the scientist being critiqued if that Critical Social Scientist is a member of an oppressed group (Dotson, 2011). Perhaps the most popular CSS books at the time of this writing is White Fragility (DiAngelo, 2016), which accuses Whites who do not agree with CSS principles of being irrational and reactionary. In another popular CSS book, How to be an Antiracist by Ibram X. Kendi (2021), Kendi divides people into a binary in which one can only be a Racist or an Anti-Racist. In his model, there is no in-between safe space of not racist. The claim of not racist neutrality is a mask for racism (Kendi, 2021, p. 9). Kendi therefore creates a trap for any critics of his simplistic model, shoehorning those that might substantively disagree with him into the ruinous category of racist. In all of these ways, Critical Social Science builds an inability to accept critique into its own methodology, decrying any criticism as insidious efforts to enact oppressive power dynamics. Thus, Critical Social Science fully and explicitly rejects the Telos of Science. Instead of being considered Science, one would be more precise in considering CSS to be a form of Institutionalized Activism. 15 Science is always in a constant state of evolution, being changed, shaped, and improved upon by subsequent researchers. Therefore, even if unduly value-laden science is produced by researchers, this does not mean that this science will go unchallenged. However, as the hoaxers argue, CSS is unequipped and/or unmotivated for this type of corrective effort. Indeed, the hoaxers pre-established a time to retract all the papers since they were being awarded instead of rejected, and it took an independent journalist outside of academia to catch them before that date. The present research investigated how value-laden scientific output is resistant to efforts to correct value-laden findings. Bad Actors Although Critical social scientists have historically made up only a small fraction of working social scientists (Neuman, 1991), their fast-growing influence on academia, the research literature, and public trust in the Social Sciences warrants scrutiny of their methods. Within the Critical Social Science literature, one can find explicit tactics meant to undermine traditional science for its own political and moral aims. From as early as the 1920s, foundational Critical Studies scholars such as Antonio Gramsci, later expanded on by Rudi Dutschke and Herbert Marcuse in the 1970s, have advocated for a long march through the institutions, a term meant as an homage to the Maoist Chinese communist movement (Kimbal, 2001). This long march, as defined by Marcuse, requires working against the established institutions while working within them, but not simply by boring from within, rather by doing the job (Marcuse, 1972, p. 55). By doing the job, Marcuse refers to subverting the current institution, seen as promoting and continuing societal oppression, by taking advantage of their weaknesses from within. Rather than working politically to rescind funding from these institutions, it is seen as more effective to instead corrupt them from within, with the end result of either institutional 16 death (Nayna, 2019) or, if done right, an ideological takeover of the institution itself (Marcuse, 1972, p. 56-57). Marcuse also names the Universities specifically as the primary institution from which all other institutions may be captured, since they can be restructured to train countercadres (Marcuse, 1972, p. 56). Put more plainly, Marcuse proposes ideologically capturing the Universities to use them as training grounds for the next generation of Critical Studies thinkers who could further subvert other industries. The plan to subvert the institutions from within has not lost steam since the musings of Marcuse; activist scholars have continued to call for further implementation of this model. Entire instructional books have been published on the plan and its implementation in modern times (Perna, 2018, as cited in Lindsay & Pluckrose, 2020). Scholar Sandra Grey explicitly calls for professors to push their students to take up activist roles and for rigorous research carried out for a cause to be regarded as legitimate science on par with the current Positivist-inspired methods of knowledge production (Grey, 2013, p. 208, as cited in Lindsay & Pluckrose, 2020). Most dubiously, some scholars even compare their Grievance Study field of Womens Studies to the HIV/AIDS virus in its ability to exploit the vulnerabilities and weaknesses of the systems it attacks (Fahs & Karger, 2016, as cited in Lindsay & Pluckrose, 2020). These scholars advocate that Womens Studies programs should aim to train students who can settle into corporate universities and regenerate themselves through the education of students and by manipulating portions of the academy under their control, thereby mimicking viral replication in human cells. The most important point these scholars make is that these students are intentionally unleashed to infect the formerly isolated and protected, traditional disciplines (e.g., History, Mathematics, Physics, Psychology, and so on) with principles of critical feminist analysis, with the ultimate goal that the corporate university begins to integrate, bit-by-bit, 17 portions of feminist pedagogies into its own ideology [and] as the perpetual expansion of the corporate university builds upon itself, it carries these alien blueprints into new domains (Fahs & Karger, 2016, as cited in Lindsay & Pluckrose, 2020). The Critical fields of study state their own goals plainly: they aim to take over every University department to be used as activist factories for their own political ideology. Critical Social Scientists who implement these strategies seem to be achieving their goal effectively; fields of scientific study that traditionally study apolitical topics such as Mathematics, Physics, and even Astronomy increasingly find themselves defending against efforts to inject them with Critical Studies material (Brown University Department of Physics, 2021; Math Equity Toolkit, 2021; Sullivan, 2021). The long march marches on and threatens to either capture institutions of rigorous knowledge production or, if they cannot be captured, kill them instead. These are dire circumstances for academia as a whole, but many open questions remain as to specifically how bad-faith science is spread and exactly who is spreading it. The hoaxers cannot be completely sure that the reviewers of their hoax papers accepted their flawed papers because of their value-laden conclusions, nor can they be completely sure that the reviewers themselves were bad actors. For instance, the hoaxers flawed papers may have been accepted either by bad actors seeking to proliferate value-laden findings or accepted by good actors with ideological blind spots suffering from confirmation bias. The present research sought to disentangle these possibilities by investigating the individual differences underlying the acceptance of flawed, but value-laden, research findings. Bad Science, Real Consequences If Critical Social Science and its machinations were simply unenacted theories swirling 18 around the minds of academics, their impact would be minimal. Unfortunately, the persecutorial, strategic, power hierarchy-based mindset has appeared to have infected even the Positivist wings of scientific knowledge production. Specifically, when Positivist scientists produce substandard work, it may be praised and proliferated due to appealing to CSS values rather than its inherent quality. One example is the construct of Implicit Bias, purportedly measured by the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998; see https://implicit.harvard.edu/implicit/takeatest.html). Implicit Bias as a construct is typically described as an unconscious preference for or against any number of different identity categories including race, weight, and gender. Supposedly, if one holds an implicit bias, that individual might act in a discriminatory manner without even knowing they are doing it or that they have the bias in the first place. The IAT then purports to measure ones implicit bias by measuring ones reaction time to pairing good or bad valanced words with the identity category in question. Clearly, this construct is in line with some of the core tenets of the Grievance Fields and Critical Social Science: if individuals can discriminate against others of a different identity class without even knowing it, the claim that oppression is ever-present and can exist without conscious intention is bolstered. However, the construct and measurement of Implicit Bias and the Implicit Association Test (IAT) appear to be so rife with ambiguity and insufficient validity that the entire enterprise is called into question. Firstly, as Jussim, Careem, Goldberg, & Honeycutt (2021) explain, there is no one definition for the construct that is used in the Implicit Bias literature. Implicit Bias is described as a behavior, a mental association, a decision-making process, and even as the seemingly unavoidable influence of cultural stereotypes (Jussim et al., 2021). Simply put, Implicit Bias cannot be all of these at the same time. Psychological constructs require a greater 19 degree of specificity, and certainly necessitate a consensus on whether they are artifacts, behaviors, or social constructions before attempting to measure them. Schmader, Dennehy, & Baron (2021) point out that the confusions in definitions for Implicit Bias are found in both scientific literature and in public discourse, leading to further confusion about its scientific basis. Even if the term were to be accurately defined, the measures used to assess it are dubious. The variance within results appears to be over 80% due to both methodological and random error, with less than 20% of the variance due to identifiable trait variance (Chequer & Quinn, 2021). With this level of error, Schimmack (2019) has calculated that within the Black racial IAT, a participant who scores at the mean level could have an extreme pro-Black bias or an extreme pro-White bias; clearly, the result of the test means little for the individual who took it. Along with a host of other methodological problems including inflated effect sizes and reliance on a monomethod approach (Jussim, et al., 2021), the IAT appears to measure a poorly defined construct, and measures it poorly at that. If Implicit Bias and the IAT are so fraught, one would imagine that they should be relegated to the questionable theories category of psychological research or at least constrained in practical use until more research can be conducted to improve them. Instead, the field of assessing ones Implicit Bias (coined Unconscious Bias in Diversity Training Programs) utilizing the IAT is booming to the tune of between $8-10 billion every year (Kirkland & Bohnet, 2017). By late 2015, approximately 17 million IAT tests had been taken online, the majority of which were likely taken by individuals in institutional settings undergoing Diversity Training (Goldhill, 2020). Though the content of these trainings varies, the overwhelming shared message is that the world is biased against oppressed groups and that current disparities between identity groups can largely be explained by discrimination fueled by Implicit Bias 20 (DiAngelo, 2021). The IAT is used as the primary form of evidence in these trainings and is meant to highlight to everyones supposed unavoidable, secret biases. Once each individual has been revealed to have unconscious biases using the IAT, these trainings follow a similar pattern: the participants are subjected to ideologically-charged activities such as privilege walks and evaluations of their positionality (status as an oppressor or oppressed identity), asked to identify episodes of Implicit Bias in work-related vignettes, and given the take-home message that one must always be focused on how their Implicit Bias may reinforce systems of oppression (Kirwan Institute, 2017; Project READY, 2021; DSHS, 2021). It appears that Diversity Trainings, using the IAT as scientific bolstering, push largely ideological and unproven ideas and techniques. Thus, it is perhaps unsurprising that these Diversity Trainings appear to do little to reduce discrimination, are ineffective at shifting either Implicit or Explicit Biases, and may in fact increase conflict and division in workplaces (Burns, Monteith, & Parker, 2017; Cooley et al., 2019; Forscher et al., 2019; Lai et al., 2016; Paluck, Porat, Clark, & Green, 2021; Vorauer, 2012). If the IAT and Diversity programs are unreliable, invalid, and ineffective, how do they persist so pervasively in use? One could make the argument that this is just another instance of shoddy psychological science making its way into the public sphere and being notoriously difficult to excise; after all, the legacies of Power Posing (Cuddy, 2015), Multiple Intelligences (Gardner, 2006), Grit (Duckworth, 2018), and others still persist in many institutional consultants programs despite their use being largely debunked and/or unsupported by evidence (Glazzard, 2015; Singal, 2021). None of the researchers or authors of Power Posing, Multiple Intelligences, or Grit appear to be engaging in intentional or politically-motivated bad science. Instead, it appears that their research was methodologically sub-par but was still picked up by 21 popular media, influencing wide-spread acceptance before institutional disconfirmation could run its course. However, there are a number of these flawed theories and constructs that have failed to replicate in larger studies including Implicit Bias, Microaggressions (Cantu & Jussim, 2021; Lillienfield, 2017), and Stereotype Threat (Jussim, Crawford, Anglin, & Stevens, 2016) that appear importantly different: each of these theories appeals to the ideological framework that is Critical Social Science, even if they were produced within Positivist methodologies by Positivist researchers. For example, Stereotype Threat presupposes a belief of absolute equality in desirable traits between racial, gender, and other groups to make its claims, despite decades of unresolved scientific debate on this very topic (Hernstein & Murray, 1996; Weisberg, DeYoung, & Hirsh, 2011). Each of these theories begins with assumptions of social oppression and injustice, purports to measure a facet of the oppression, and prescribes a doctrine of how to recognize and theoretically eliminate them. In reality, these theories begin with ideologically motivated presuppositions which lead to scientifically invalid constructs that fail to be reliably measured. Nevertheless, each of these theories has been translated into consultation programs that purport to solve problems they identify for hefty prices. In short, bad science appears to be given a methodological pass since it fits into a Critical Social Science ideological framework and thus promotes the favorable political viewpoint. With this pass, ideologues are set loose upon academic, corporate, and governmental institutions, backed by illusory science, to spread their particular political prescriptions. This is not science; this is Institutionalized Activism given the veneer of scientific credibility (Jussim, 2021). The hoaxers themselves appear to have exploited this pathway from scientifically-veneered ideology to publication and fame: they hypothesize that by writing articles that were in line with CSS ideology, their intentionally and 22 blatantly flawed work was able to be published and even awarded. Because the hoaxers were caught when they were, it is impossible to know what impact their hoax articles would have had on their respective fields. Would they have been heavily cited and influential, or would their flaws have been recognized by other researchers and their papers forgotten? We attempted to better investigate the consequences of value-laden research by measuring not only participants agreement with the value-laden conclusions but also their desire to share and spread flawed research. In doing so, we attempted to extend the hoaxers project by investigating the downstream consequences of value-based decisions surrounding the acceptance of flawed, but fashionable, research. The Hoaxers Hypothesis Peter Boghossian, one of the hoaxers, refers to the process described above as Idea Laundering, a term originally coined by evolutionary biologist Bret Weinstein (Boghossian, 2019). Idea Laundering begins when CSS academics inject their political opinions into academic papers, which are collected into scientific peer-reviewed journals. Since CSS rejects the typical process of institutionalized disconfirmation (upon which the entire system of peer review is based), Idea Laundering contends that CSS hijacks the legitimacy of peer review by prioritizing publishing papers that support its own political view, rather than prioritizing academic rigor. Given that peer reviewers are typically academics from the very fields from which the work is produced, the hoaxers hypothesized that the reviewers possess shared ideologies and values. Soon, there are entire scientific journals built upon political ideologies and opinions, but which have the exterior veneer of legitimate knowledge production. Idea Laundering does not stop there. Rather, institutions then begin to create entire departments devoted to these supposedly rigorous studies, named for the oppressed identity 23 groups which they study and advocate for: Womens Studies, African-American Studies, LGBTQIA+ Studies, Fat Studies, and so on. Lindsay, Pluckrose, and Boghossian have nicknamed these fields the Grievance Studies for their proclivity to refer to themselves as [something] Studies and for their Critical focus on the grievances of their particular identity group (Lindsay, Boghossian, & Pluckrose, 2018). As with all academic fields, these Grievance fields grow over time. If, as the hoaxers hypothesize, these Grievance fields are engaging in Idea Laundering, it then follows that the CSS scholars within these fields benefit from academic systems such as tenure and the ability to hire others that share their view. Courses are designed around this material, with students graded on how well they conform to the values prescribed within the discipline. Eventually, in line with the HIV/AIDS comparison, these students burst forth into the world with political opinions they believe are scientific facts, going on to influence the academic, corporate, and governmental institutions into which they are hired. The life cycle of Idea Laundering is alive and well in modern universities. For example, the academic field of Critical Dietetics is still in its infancy but appears to be well on its way to adoption in several Canadian universities. In 2009, a collection of academics met for the firstever conference on Critical Dietetics, otherwise known as the Critical Social Science approach to the study of diet and nutrition. At this conference, the academics united together under a declaration of the foundational principles and aims of Critical Dietetics. In this declaration, the academics announced that the field of Critical Dietetics was to be founded on the principles that the ways of knowing (i.e. epistemology) of the current Dietary scientific field were insufficient and that it would require a Critical lens to give voice to the unspoken, reveal and explore power relations, and acknowledge that there are no value-free positions in Dietary Science 24 (Gingras & Brady, 2019, p. 5). The authors of the declaration explicitly state the goal for their discipline: rather than seeking any kind of as-yet-undiscovered truth in nutritional study (a worthy challenge to extant knowledge), Critical Dietetics nakedly attempts to create space for an emancipatory (i.e., liberating and socially just) scholarship (Gingras & Brady, 2019, p. 6). It is important to keep in mind that emancipatory or liberating scholarship traces its roots directly back to Herbert Marcuse and his goal of institutional capture, as described previously. The authors also describe two of the founding tenets of Critical Dietetics as a Commitment to Anti-oppression and a Commitment to Critical Praxis, with Praxis defined as reflection and action directed at the structures to be transformed (Brady & Gingras, 2019, p. 22). In sum, it appears that scholars in Critical Dietetics follow the same structure of other Critical fields: they declare that current knowledge in a scientific discipline is insufficient and biased, that power is the dominant factor in current society related to the scientific field, and that their efforts as a Critical field are explicitly to embrace bias towards these assumptions and seize the power for themselves to work towards emancipatory aims. Two of the founders of the field (and the authors of the work cited above) are both prolific in their collection of published works, most of which are published in peer-reviewed journals such as Fat Studies (which itself published a hoax paper), Fat Studies in Canada, and most importantly, the fields own Journal of Critical Dietetics. With their prolific publication records in journals that are explicitly biased in favor of emancipatory scholarship, the authors have become influential professors at Canadian universities, with Dr. Jacqui Gringas serving as the Undergraduate Program Director for the Sociology department at Toronto Metropolitan University and Dr. Jennifer Brady working as the Director of the School of Nutrition and Dietetics at Acadia University. Both of them teach courses where students are 25 assumedly graded on their adherence to the nakedly biased tenets of Critical Dietetics, most notably in Dr. Gringas Sociology 493: Making Social Change course in which students are to learn how their sociological perspective and skills can be used to create social change where power, equity, and diversity are central themes (Toronto Metropolitan University, 2022). In sum, a 2009 conference of biased academics birthed a quasi-scientific academic field by publishing amongst themselves enough to launder their own biases into the veneer of scientific rigor, thereby creating a discipline where students can be trained in Critical Praxis intended to emancipate (i.e. capture) the current Positivist and Interpretive Dietary scientific fields. The hoaxers project was a test of one of the postulates laid out in the theory of Idea Laundering: that of the corrupted peer review process. Characteristic of the Hoax Project was the quality that each hoax study shared: no matter the shoddiness of the methodology or how ridiculous the premises, each paper came to a politically fashionable conclusion. In these cases, fashionable means conforming to the orthodoxy of the CSS field and to traditionally left-leaning politics: their Dog Park paper forwarded the theory of a pervasive Rape Culture, which has received much attention within academic feminist thinking for decades (Whisnant, 2017) by applying the concept to canine culture. Additionally, their Fat Bodybuilding paper claimed that fatphobia was more dangerous than the health risks of obesity, reflecting a core tenet within Fat Studies regarding labels as more impactful on the individual than ones physical health (Bacon & Severson, 2019). With the vast majority of academics in these fields on the political left (Langbert, 2018), these conclusions were more than likely consistent with the reviewers moral and political beliefs. The hoaxers claimed that their papers passed through peer review, not because of the merit of their scholarship, but because the conclusions appealed to the political beliefs of Critical Social Science academics who purport to guard the gates of academic 26 discourse. Of course, finding flaws in the peer review process is not sufficient to support the overall Idea Laundering argument. Furthermore, the hoaxers cannot know for certain that their hoax papers were accepted, despite their flaws, on the basis of their fashionable conclusions. Although the Hoax Project establishes serious issues in the publishing and dissemination of scholarship with maximal external validity, there are many lingering questions. Chief among them, were the hoax articles accepted on the basis of their fashionable conclusions? What About Good-Faith Mistakes? Despite the strong argument of the hoaxers given the previous evidence, the hoaxers hypothesis is potentially muddied by the nuances of the world of academia. Given that the peer review process was blind, the hoaxers knew little-to-nothing about the reviewers other than their academic discipline. As a result, the hoaxers do not know for sure the political values of any particular reviewer, whether the reviewer identified as a critical social scientist, or whether the fashionable conclusion was the reason the hoax papers were accepted. These unknowns serve as the basis of the present research. Were the reviewers all bad actors working in the service of an activist ideology, or could the papers have slipped through scientifically honest reviewers for other reasons? A review of the typical Social Science academic offers some initial insight into the likely characteristics of these reviewers. Specifically, a great deal of evidence suggests an overwhelmingly Liberal bias in academia, particularly in the Social Sciences. For instance, the field of Social Sciences are overwhelmingly Liberal: between 58-66% of professors in these fields identify as political Liberals, while only 5-8% identify as Conservative, with self-identified Democrats outnumbering Republicans by at least 8:1 (Gross & Simmons, 2007; Klein & Stern, 27 2009; Rothman & Lichter, 2008). In fields like Psychology, the disparity is even greater, with 84% identifying as liberal and with a 10.5:1 Liberal to Conservative ratio in the field (Gross & Simmons, 2007; Rothman & Lichter, 2008). At the time these measures were taken, the Liberal to Conservative ratio in the United States as a whole sat at 1:2 (Gallup, 2010). While this ratio has shrunk to about 1:1.4 in 2020 (Saad, 2021), the point persists: the Social Sciences are overwhelmingly Liberal, out of proportion to the country at large. Therefore, we can infer that the reviewers were more than likely politically Liberal. Duarte et al. (2015), specifically investigating the effects of political skew in Social Psychology, proposed that these overwhelmingly skewed ratios are a cause for great concern. Importantly, none of the authors of the paper identify as Conservative or Republican, demonstrating that non-CSS Liberals can and will effectively critique their own fields political biases/blind-spots even when these critiques align with their political values. They point out three ways in which Liberal bias might degrade scientific inquiry. Firstly, they propose that Liberal values and assumptions become embedded in research design such that the research itself is invalidated. They point out several examples of this in published research where ideological and/or political statements are treated as the truth and observed deviation from that truth is treated as error (Duarte, 2015, p. 9), such as when environmentalist opinions were treated as environmental realities in prominent research (Feygina et al., 2010). Next, Duarte et al. identify a long-standing trend in Social Science research in which topics that might invalidate or challenge politically Liberal assumptions go largely unstudied, leaving many important areas of research completely hidden from scientific view. They propose that some important topic areas, such as Stereotype Accuracy, go largely unresearched due to a Liberal bias; in this case, the biased view that all stereotypes are inaccurate and mean-spirited. 28 However, once a self-identified Conservative researcher took the initial leap to study this uncomfortable topic, Stereotype Accuracy was and has continued to be one of the strongest and most replicable effects in Social Psychology (Jussim, 2012). In this case, Liberal bias appears to have delayed valuable research until someone was willing to risk discovering uncomfortable data, leaving one to wonder what other vital areas might remain unstudied due to Liberal bias. This resistance to challenge Liberal assumptions creates a homogenous literature wherein future research may be evaluated on the basis of fit, thereby facilitating the proliferation of fashionable results and suppression of unfashionable results. Finally, Duarte et al. (2015) propose that Liberal bias in the study of Conservatives and other political outgroups groups can warp and distort research due to Liberal stereotypes of those groups. Because Liberals view Conservatives as more judgmental and dogmatic than themselves, research tends to be conducted that supports this hypothesized difference (Altemeyer, 1996). However, when the same methodologies are turned against Liberals using slightly modified scenarios, Liberals are found to be equally guilty of the same accusations (Crawford, 2012). Thus, the results are reached primarily due to the method of study, rather than the characteristics of the group being studied. In short, Liberal researchers can confirm their own negative stereotypes of outgroups by using unintentionally biased methods. None of these instances of bias affecting research require nefarious intentions or bad actors; they can occur because of the lack of Institutionalized Disconfirmation in an overwhelmingly politically one-sided academe. When Liberal bias creates poor research, these errors are unlikely to be caught by Liberal peer reviewers who have parallel biases (Gampa et al., 2019). Duarte et al. (2015) point out that this process demonstrates an instance of Confirmation Bias, in which it is common for someone to seek out evidence that confirms their own views and 29 disconfirms views that run against them. When there are practically no individuals of an ideological minority (e.g. Conservatives) that might catch and counter the Confirmation Biases of the Liberal majority, such as in the Social Sciences, there is no regulating mechanism to prevent runaway distortions of research. Bias, transformed into inaccuracy, is enshrined in the literature by peer reviewers who fail to account for their own shortcomings. Taken together, we can reasonably presume that the reviewers of the Grievance Studies Hoax were Liberal themselves. Is this what enabled the Grievance Studies Hoax to succeed? Was it the nefarious workings of bad-actor Critical Social Studies activists laundering ideas into academia for their own aims through biased peer review, or did unintended, runaway Liberal biases affect honest researchers who intended to provide high quality evaluation of good-quality science? To rescue the Social Sciences from losing the trust of the public, it is imperative to distinguish between those who prioritize their own political ideology from those that simply fall prey to their own biases while attempting to generate knowledge in good faith. Accordingly, the present research expanded upon the Hoax Project to better understand the causes of the proliferation of value-laden research, how acceptance of value-laden science can translate to the sharing of value-laden science, and the obstinance of value-laden science to challenge. Separating Bad Actors from Biased Liberals Sometimes, a simple survey allows for a rough estimate of the problem. In 2007, 43% of Social Sciences and Humanities faculty considered themselves to be radicals, activists, or Marxists (Gross, 2007). This number has likely grown since then as the subfields have become more Liberal and, at the same time, more infused with CSS ideology. These academics, or at least a great majority of them, might fairly be considered those who would prioritize their politics over scientific rigor. However, we the researchers aimed to be more precise in 30 identifying those who might intentionally, versus unintentionally, corrupt the Telos of science. Even if the vast majority of social scientists are self-identified Liberals, we reasoned it unlikely that all Liberals suffer to the same extent from these confirmation biases. Accordingly, we sought to identify if there might be a way to reliably identify an underlying belief system that might predict if an individual would prioritize politics over rigor when evaluating research. Furthermore, we sought to evaluate if its effects might extend into increased dissemination of bad science, just as the hoax papers made their way into established journals. Liberal Feminist Ideology To be certain, there are innumerable within-group variations among Liberals and academic Liberals more specifically. In order to capture what type of Liberal academic might best explain why the Grievance Studies Hoax succeeded, we first focused on Liberal Feminist Attitude and Ideology Scale (LFAIS; Morgan, 1996), specifically its Discrimination/Subordination subscale. We chose to use the Discrimination/Subordination subscale because it reflects a central aspect of Liberal ideology, namely that particular groups (in this case, women) are aggrieved, unfairly discriminated against, and treated unfairly in society. Items in this subscale include even though some things have changed, women are still treated unfairly in todays society and women in the U.S. are treated as second-class citizens. To be clear, while a view of the world as oppressive against certain identity groups is central to CSS ideology, a fair and balanced evaluation of societal imbalances is an essential component of traditionally liberal/left ideology and is not incompatible with a rational, scientific approach (Graham et al., 2012). Additionally, there is little reason to think that this measure is unique to attitudes toward woman, sexism, or feminism. Instead, items from this subscale appear highly adaptable to all 31 groups central to the Grievance fields. For instance, a pilot study we conducted had participants complete the Discrimination/Subordination subscale in its original form focusing on women and an adapted form focusing on African Americans. Results revealed that these two versions were highly related, r(141) = .83, p < .001, verging on redundancy. Furthermore, the sex- and racebased Discrimination/Subordination subscales were highly related to basic Liberalism, r(141) = .59, p < .001 and r(141) = .63, p < .001 respectively, but are far from completely overlapping constructs. Put another way, not all Liberals in our sample endorsed the beliefs captured in the Discrimination/Subordination subscale. Thus, by using this subscale, we are attempting to capture a certain subset of liberals who see aspects of society as oppressive (a potential source of ideological bias) while not necessarily subscribing to CSS ideology. That is, we are attempting to measure those liberals who, when evaluating evidence, might succumb to their own ideological biases towards societal aggrievement while not engaging in intentional bad-faith behaviors as CSS ideology prescribes. In sum, we chose the Discrimination/Subordination subscale because it appears to measure a central, defining characteristic of political Liberals (sensitivity to unfairness and/or imbalance on a societal level) while also appearing to capture a subset of Liberals who might fall prey to confirmation bias. In theory, this subset of Liberals might be able to modify their beliefs when presented with sound evidence that contradicts their current stance. However, a further measurement was required to discriminate between those with this ideology who retain an ability to logically evaluate evidence (albeit with the possible interference of bias) and those who intentionally predetermine the conclusion of their analysis based on their ideology. Paranoid Egalitarian Meliorism In addition to Liberal ideology, we considered that Liberals likely varied in Paranoid 32 Egalitarian Meliorism (PEM, Winegard, Clark, Hasty, & Baumeister, 2018). PEM describes an underlying ideology that likely predetermines conclusions to analyses. A PEM scale has been validated by the inventors of the construct, with excellent internal reliability and a one-factor solution in a principle components analysis (Winegard, Clark, Hasty, & Baumeister, 2018). To define the term, Egalitarians in this case are those who believe that all groups (sex, racial, etc.) are relatively equal in desirable traits (intelligence, creativity, athleticism, etc.). Next, Meliorists are those who believe that humanity can architect a fairer and more just world if enough people were able to strive hard enough in that direction and declare that those actions are a moral imperative. Thus, Egalitarian Meliorists are those who believe that if humans strived hard enough, all sociocultural disparities between any racial group or the sexes could be eliminated. Paranoid, in this conceptualization, indicates an exceptional sensitivity to threats to this worldview and indicates a willingness to ascribe negative motives to those who might challenge it, much like those who work from a CSS perspective. The developers of the scale argue that if a critical mass of Social Science academics in a given discipline subscribe to the Paranoid Egalitarian Meliorist worldview, it would explain why they typically: (a) study topics that are related to perceived injustices (stereotyping, prejudice, hierarchies, immorality of the wealthy, obedience); (b) ignore topics that are perceived to threaten egalitarianism (heritability, stereotype accuracy, possible benefits of conformity/hierarchy); and (c) become hostile/biased against research which suggests that some outcome differences among individuals and/or groups are at least partially caused by differences in personal traits rather than by discrimination or social oppression (e.g., that sex differences in science, technology, engineering, and mathematics (STEM) fields are partially caused by the cognitive differences and the different occupational 33 preferences of men and women and thus not entirely caused by unjust hiring practices or prejudices) (Winegard, Winegard, & Geary 2015, found in Hasty, 2016). If someone were to score high in PEM, it indicates a worldview that is so central to their view of humanity that it would be inseparable from their reasoning, as Positivism demands. Additionally, it indicates a moral imperative to act on this worldview, as well as a willingness to denigrate those who might challenge this worldview as sexists or racists, which violates the principles of the Interpretive approach. Items on the scale that support this include when people assert that men and women are different because of biology, they are usually trying to justify the status quo, racism is everywhere, even though people say they are not racist, and people often use biology to justify unjust policies that create inequalities. Thus, if someone were to score highly in both LFAIS and PEM, it would indicate an individual who is prone to see society as oppressive, conclude that all disparities between groups are the result of discrimination, who believes that enough action in the right direction could eliminate these disparities, and who believes that certain nefarious others are attempting to maintain this state of affairs. In sum, these two scales appear to uniquely tap into the assumptions underlying Critical Social Science and the hoaxers critiques of Critical researchers. However, if one were to score high in LFAIS but low in PEM, it would indicate an individual with strong left-leaning opinions without the illogical, activist-oriented baggage of a Paranoid Egalitarian Meliorist worldview. As a result, PEM (and LFAIS) may serve as useful tools in identifying bad, versus good, actors impacting the legitimization and spreading of bad science. Overview of the Present Research Our research sought to evaluate and extend the claims made by the original hoaxers. Specifically, the hoaxers claimed that their fake papers passed through peer review due to the 34 CSS-friendly conclusions they crafted, rather than the quality of the study. While the hoaxers were able to account for an excellent amount of external validity by getting the studies published and awarded in real, well-respected academic journals, there were several gaps in their research we hoped to fill. Firstly, there was no experimental control group, as the hoaxers did not submit articles with conclusions that were unfashionable to the CSS worldview. In a series of pilot studies, we presented participants with conclusions that are both fashionable and unfashionable to the CSS worldview, inspired directly from the hoax articles themselves. High LFI predicted significantly higher agreement, higher willingness to share, and higher desire to learn more about the fashionable hoax articles, while it did not predict the agreement and desire to share of the unfashionable articles. Thus, we have already established that the articles and conclusions alignment with CSS principles explained the articles positive reviews/acceptances among people high in LFI. Second, when the hoax articles were reviewed, no measurements were taken of the reviewers themselves, thus leaving the motivations and attitudes of the reviewers up for debate. While one can logically deduce the reviewers political leanings from the review comments they submitted (Lindsay, Boghossian, & Pluckrose, 2018), our research measured individual differences (LFI, PEM) in order to determine if there are specific qualities of individuals that lead to intentionally or unintentionally biased evaluations. Third, though the comments left by the peer reviewers enable a face valid analysis of their agreement with the fake articles publication worthiness and desire to share the material, no measurement was taken to specifically evaluate their level of ideological agreement. In our research, we specifically measured level of agreement with the conclusions of the articles. 35 Fourth, it is unclear if these patterns of behavior and individual differences are unique to scholars in the Grievance Study fields. Thus, it is important to determine if the CSS worldview affects more than those deeply steeped in CSS literature. In our research, we used laypeople as samples. Finally, while some of the hoax papers continue to be cited in new research despite being retracted by the authors themselves, the Hoax Project did not demonstrate whether the fake articles would have impacted the field as laid out by Peter Boghossians Idea Laundering hypothesis. Since many academic articles are published and never cited, their hoax articles could have similarly been lost to the trove of published but ultimately insignificant and unused research. Furthermore, these articles were retracted once the Hoax Project was discovered, which could be taken as evidence of the self-corrective nature of science. In our research, we measured desire to share and spread the content within the articles, while also analyzing this measured desire in relation to level of agreement and level of LFI and PEM. We also investigated participants agreement and desire to share the article even in the face of information calling into question the articles veracity. Consistent with our argument of ideologically-motivated reasoning, we hypothesized that participants high in LFI and PEM would continue to agree with and share fashionable conclusions even in the face of critique and contradictory information. Hypotheses Our hypotheses were as follows: 1. A main effect of PEM on the agreement/evaluation of logical quality/desire to share the hoax articles such that higher levels of PEM predict higher scores in each of these dimensions across measurements. 2. A main effect of PEM such that higher levels of PEM will predict higher levels of critique 36 towards the rebuttal researchers. 3. A main effect of LI (Liberal Ideology) on the agreement/evaluation of logical quality/desire to share the hoax articles such that higher levels of LI predict higher scores in each of these dimensions across measurements. 4. An interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the hoax articles will be significantly higher in all three of these dimensions for participants high in LI and PEM compared to participants high in LI but low in PEM. 5. An interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the hoax articles pre- and post-rebuttal presentation will be significantly higher in all three of these dimensions for participants high in LI and PEM compared to participants high in LI but low in PEM. 6. An interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the rebuttals will be significantly lower in all three of these dimensions for participants high in LI but low in PEM compared to participants high in both LI and PEM. 37 Chapter II: Research Design and Method Participants According to our pilot studies, which investigated the interrelations between focal measures and perceptions of politically fashionable conclusions, the effect of the Discrimination/Subordination subscale of the LFI on agreement with the fashionable article/conclusion pairs was strong, meta-analytic r = .54. An a priori power analysis specifying bivariate correlations indicated we would need between 19 (one-tailed) and 24 (two-tailed) participants to detect a comparable effect with 80% power. However, we also anticipated that this effect would be made stronger post-rebuttal relative to pre-rebuttal among participants also high in PEM. Using modern conventions to estimate the required sample for attenuated effects, we required approximately 7x the number of participants needed to detect our estimated prerebuttal effect, or between 133 and 168 participants. To account for potential poor data, unanticipated exclusions, and other data collection issues we recruited 177 participants from Amazons Mechanical Turk online data collection service. The only preemptive exclusion criteria was a requirement to live in the United States, which accounts for most cultural and potential language barriers. Per Leiner (2016), we calculated a speed factor by dividing the overall samples median completion time (in seconds) by each participants completion time. Scores of 1.75 or greater indicated that participants completed the study 1.75x faster than the median completion time, and were to be excluded. Eight participants had a score of 1.75 or greater and were excluded. Finally, 33 participants failed the attention check item included in the study. However, the results did not change following depending on whether these participants were excluded, and therefore these participants were retained to maximize our sample size and statistical power to detect effects of 38 interest. After excluding implausibly fast responders, 169 participants were retained. Although MTurk has a Liberal bias in their participants (Berinsky et al., 2012; Huff & Tingly, 2015), other research suggests that MTurk is a valid instrument for ideology-related research (Clifford et al., 2015). Participants were compensated $0.40. Participants were over age 18, and of any gender. Participants were primarily middle-aged (M = 43.19, SD = 13.70) and non-Hispanic (91.1%, 8.9% Hispanic). The most common racial/ethnic group was White (80.5%), followed by African-American (10.7%), Asian-American (7.1%), and Middle Eastern (1.2%), with 1.2% identifying as Other. Participants included slightly more women (52.7%) than men (46.2%). Participants also ranged in education from Some High School (1.7%) to Doctorate Degree (5.3%), with the most common level being 4-Year College Degree (33.7%). Procedure Participation was completed online. The study was described as being interested in participants opinions of academically-published arguments and conclusions, and they were required to sign an informed consent form before continuing. Participants were led to believe that the article summaries they were reading were from authentic published articles. In reality, these were our summaries of two Grievance Study hoax articles and, in one case, an original hoax summary of our design. These hoax articles cover the Grievance Study Fields of Fat Studies, Womens Studies, and Critical Race Theory (see Appendix A). Participants were shown the hoax argument/conclusion sets one-at-a-time. Each argument/conclusion set presented the article summary as a bulleted list with 3-4 arguments followed by a conclusion statement (see Appendix A for full argument/conclusion stimuli and additional details surrounding the creation of stimuli). After each summary, participants then 39 indicated their agreement with the articles conclusions across 5 items (e.g., I find myself agreeing with the arguments.) and logical evaluation of the argument/conclusion sets they just read across two items (e.g., The conclusion logically follows from the argument.). Items were averaged to form an index of agreement (M = 3.28, SD = 1.42, = .96). Finally, participants indicated their desire to share the article across three items (M = 2.89, SD = 1.53, = .92; e.g., I would share the original article with a friend.) and two items assessing participants desires to learn more about the article (M = 3.32, SD = 1.62, = .88; e.g., I want to read the original article.). All responses were made on 1 (strongly disagree) to 7 (strongly agree) scales (see Appendix B for full scale information). The presentation of the three argument/conclusion pairs was randomized across participants. After responding to all three argument/conclusion sets, participants were informed that these articles were being debated within their respective academic disciplines. Participants were then shown each argument/conclusion set that they just considered along with a corresponding rebuttal (see Appendix A), with the preface that the rebuttal was written by prominent scientists in the field. These rebuttals provide the typical critiques of CSS conclusions found in the real world, as well as legitimate contradictory research. Again, each argument/conclusion set and rebuttal was displayed one-at-a-time. Participants were then asked to re-indicate their agreement (M = 3.97, SD = 1.30, = .94), desire to share (M = 3.25, SD = 1.50, = .91), and desire to learn more about the article (M = 3.78, SD = 1.59, = .79) across the same items as previously described. Participants also indicated their agreement and willingness to share the rebuttal information across 8 items (M = 3.77, SD = 1.19, = .92; e.g., This statement changed my opinion of the initial article.) Finally, participants indicated their perceptions of the rebuttal and the researchers behind the 40 rebuttal across five items (M = 3.40, SD = 1.42, = .93; e.g., I question the motives of the researchers who wrote this statement.). Again, responses were made on 1 (strongly disagree) to 7 (strongly agree) scales (see Appendix B for full scale information, and see Appendix C for prompt-specific response descriptives.) After the conclusion of the final set, each participant was asked to complete the Liberal Feminist Ideologys Discrimination/Subordination measure (e.g., Women in the U.S. are treated as second-class citizens), its Racial Adaptation (e.g., The achievements of racial minorities in history have not been emphasized as much as those of White people), and the Paranoid Egalitarian Meliorism (PEM) scale (e.g., We should strive to make all groups equal in society). Responses were made on 1 (Strongly Disagree) to 6 (Strongly Agree) scales for the LFI measures, which were averaged to form an overall index of Liberal Ideology (M = 4.72, SD = 1.36, = .96). The PEM items were scored on a 1 (Do Not Agree At All) to 7 (Agree Completely) scale (M = 4.75, SD = 1.13, = .90). Finally, participants completed demographic items, including political ideology measured with a 1 (Very Liberal) to 11 (Very Conservative) scale (M = 5.31, SD = 3.23) as well as a measure of social (M = 3.14, SD = 1.32, = .79) and economic (M = 3.13, SD = 1.22, = .82) conservatism that was scored on a 1 (Strongly Disagree) to 7 (Strongly Agree) scale (see Appendix B for full measure information). After the completion of the study, the participants were provided with a debriefing form that explained the main questions and hypotheses of the study, as well as information about why deception was used in the study and what components used deception. The participants were provided the name and email of both researchers and provided the opportunity to withdraw their data if they wished. Once the predetermined number of participants to be collected was reached, the study was removed from MTurk. 41 Chapter III: Results Transformations of Data Items from the LFI and LRI measures were averaged to form a Liberal Ideology (LI) index, since pilot testing suggested that the construct of Liberal Ideology is not exclusive to either feminist or racial topics. Additionally, the researcher denigration measure was administered once for each rebuttal prompt and was combined into an average denigration score for each participant. Pre-Rebuttal Results Hierarchical linear regressions were run predicting pre-rebuttal outcome variables from LI, PEM, and their interaction. In predicting pre-rebuttal agreement, only the main effect of LI was significant, t(165) = 2.90, B = 0.81, p = .004. The same was found for pre-rebuttal willingness to share, t(165) = 2.70, B = 0.85, p = .008, and pre-rebuttal desire to learn more, t(165) = 2.63, B = 0.86, p = .009, with no other significant effects. This result was partially expected, as LI has previously shown to predict these outcome measures in pilot studies and was predicted to do the same in Hypothesis 3. However (in accordance with Hypothesis 1), PEM was expected to also predict these outcome measures, which it did not. This finding, when combined with LI and PEMs significant bivariate correlation (see Appendix C), indicates that despite a significant overlap, LI and PEM are distinctly separate constructs in their degree of influence over the hoax article evaluations. This pattern preliminarily suggests that PEM only factors in when there is a finding which contradicts some aspect of Egalitarian Meliorism, which was not characteristic of the hoax article summaries. Mediation Analysis Consistent with our pilot studies, a mediation analysis was run using LI to predict 42 conclusion agreement, which would in turn predict desire to share (see Figure 1). Unique to this experiment, PEM was included as a covariate in order to test if LI-driven confirmation bias, rather than any bad-actor PEM motivations, would predict this pathway. Liberal ideology, as in our pilot studies, predicted agreement with the articles conclusions pre-rebuttal, t(166) = 3.13, B = 0.41, p = .002. In turn, pre-rebuttal agreement significantly predicted pre-rebuttal desires to share the article, t(165) = 19.96, B = 0.94, p < .001. The inclusion of the mediator rendered the direct effect of Liberal Ideology on pre-rebuttal desires to share nonsignificant, p = .657, indicating full mediation. Most importantly, the indirect effect was significant, B = 0.39, 95% CI[0.14, 0.63]. Figure 1 Pre-Rebuttal Mediation Model This finding replicates the pattern seen in pilot studies and demonstrates that agreement with the conclusion (confirmation bias), rather than simply ones ideology, predicts ones desire to disseminate the hoax articles. Additionally, although PEM correlated with pre-rebuttal measures at the bivariate correlational level (see Appendix C), it is clear that LI is vastly more important in predicting these initial pre-rebuttal outcomes. This finding is consistent with our predictions given that PEM is more characteristic of a hostility towards perceived anti-egalitarian research and dissenting voices and should factor much more into evaluations of the rebuttal, only 43 contributing to pre-rebuttal evaluations to the degree that it overlaps with LI. Post-Rebuttal Responses Hierarchical linear regressions were run predicting post-rebuttal outcome variables from LI, PEM, and their interaction. When predicting post-rebuttal Agreement, the interaction was significant, t(165) = 3.15, B = -0.17, p = .002 (Figure 2). Among those low in liberal ideology (1 SD), the effect of PEM was not significant, p = .909. However, among those high in liberal ideology (+1 SD), high PEM participants agreed with the article less than low PEM participants, t(165) = 2.47, B = -0.44, p = .015. Neither the slope among low PEM participants nor high PEM participants was significant, ps > .068. Agreement; Post-Rebuttal Figure 2 Interaction between PEM and liberal ideology on post-rebuttal agreement 7 6 5 4 -1 SD PEM 3 +1 SD PEM 2 1 -1 SD +1 SD Liberal Ideology This finding was the opposite of what we predicted. Participants high in both PEM and LI were expected to agree with the hoax articles post-rebuttal more than anyone else, rather than less. This same pattern was largely repeated when analyzing participants willingness to share, where the interaction was significant, t(165) = 2.44, B = -0.15, p = .016. The pattern also repeated when analyzing participants desire to learn more, where the interaction was significant, 44 t(165) = 2.87, B = -0.19, p = .005. Among participants high in liberal ideology, greater PEM predicted less desire to learn more, t(165) = 2.22, B = -0.48, p = .028. Among participants low in Liberal Ideology, the effect of PEM was not significant, p = .894. Among low PEM participants, greater liberal ideology predicted greater desire to learn more, t(165) = 2.83, B = 0.48, p = .005. Among participants high in PEM, the effect of liberal ideology was not significant, p = .753. The explanation for this unexpected pattern likely lies in the bivariate correlations (see Appendix C). Specifically, post-rebuttal agreement, post-rebuttal desire to share, and postrebuttal desire to learn more were all positively correlated with rebuttal agreement. If one agreed with the rebuttal, thus exposing the weaknesses of the original hoax article, why would one persist in rating the original article highly? Participants who agreed with the rebuttal were predicted to rate the original articles lower and thus produce a negative correlation, or at least express ambivalence with a non-significant correlation. These positive bivariate correlational results, taken together with the post-rebuttal hierarchical linear regression results, led us to conclude the following: the participants, who were asked to voice opinions about the original hoax articles post-rebuttal, were instead responding to the rebuttal itself. Consequently, the postrebuttal hoax article perceptions were unfortunately unable to be interpreted. Thus, we were unable to evaluate the effects of the rebuttal on high PEM/high LI participants opinions of the original article, meaning that Hypothesis 5 was unable to be tested. However, PEM effects on researcher critique (Hypothesis 2) and reactions to the rebuttals themselves (Hypothesis 6) were still able to be tested. Researcher Critique The interaction was not significant, p = .444, nor was the main effect of Liberal Ideology, p = .148. However, the main effect of PEM was significant such that as PEM increased so too 45 did critiques of the rebuttal researchers, t(165) = 2.32, B = 0.63, p = .021. This result was predicted by Hypothesis 2. Rebuttal Reactions In response to previous participant confusion and in an effort to reduce possible systematic error, all rebuttal reactions (agreement, willingness to share, desire to learn more) were combined into a single scale. The interaction was significant, t(165) = 3.18, B = -0.10, p = .002 (see Figure 3). Among participants low in LI, greater PEM predicted less positive reactions overall, t(165) = 2.68, B = -0.27, p = .008. Among participants high in LI, as PEM increased, positive reactions to the rebuttal overall decreased, t(165) = 5.11, B = -0.55, p < .001. Although PEM predicted negative reactions across LI, the effect was about twice as large at high levels LI. Among people low in PEM, the effect of Liberal Ideology was not significant, p = .918. However, among participants high in PEM, greater liberal ideology predicted less positive reactions to the rebuttal overall, t(165) = 2.52, B = -0.22, p = .013. These findings were predicted in Hypothesis 6. Figure 3 Interaction between PEM and liberal ideology on overall rebuttal perceptions 7 Rebuttal Reactions 6 5 4 -1 SD PEM +1 SD PEM 3 2 1 -1 SD +1 SD Liberal Ideology 46 Hypotheses Results Summary In sum, Hypothesis 1 (a main effect of PEM on the agreement/evaluation of logical quality/desire to share the hoax articles such that higher levels of PEM predict higher scores in each of these dimensions across measurements) was not confirmed. Hypothesis 2 (a main effect of PEM such that higher levels of PEM will predict higher levels of critique towards the rebuttal researchers) was confirmed. Hypothesis 3 (a main effect of LI on the agreement/evaluation of logical quality/desire to share the hoax articles such that higher levels of LI predict higher scores in each of these dimensions across measurements) was confirmed. Hypothesis 4 (an interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the hoax articles will be significantly higher in all three of these dimensions for participants high in LI and PEM compared to participants high in LI but low in PEM) was not confirmed. Hypothesis 5 (an interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the hoax articles pre- and post-rebuttal presentation will be significantly higher in all three of these dimensions for participants high in LI and PEM compared to participants high in LI but low in PEM) was unable to be tested. Hypothesis 6 (an interaction effect between LI and PEM such that agreement/evaluation of logical quality/desire to share the rebuttals will be significantly higher in these dimensions for participants high in LI but low in PEM compared to participants high in both LI and PEM) was confirmed. 47 Chapter IV: Discussion The Grievance Studies Hoax project concluded in late 2018, but its impact continues to ripple across academia. Though the hoaxers were able to demonstrate excellent external validity by actually getting their papers past peer review and into scholarly journals, some central questions remained. Firstly, if these hoax articles were not ethically withdrawn by their authors, would they have impacted scholarly inquiry and the outside world or would they have languished in relative obscurity? Through our mediation analysis, we found that Liberal Ideology (LI) predicted agreement with the hoaxes, which in turn significantly predicted a participants willingness to disseminate them. Combined with the real-world external validity demonstrated by their Dog Park paper receiving a designation as leading scholarship, as well as their Conceptual Penis paper continuing to be cited 16 times despite its retraction (Lindsay & Boyle, 2017), we argue that a disturbingly unknown amount of low-quality work is likely to have been (and continues to be) published, cited, and shared as long as its conclusions fall in line with Liberal Ideology. Given that the hoax articles represent the highest ideological-fidelity but lowest scientific-quality work designed to be rejected on grounds of rigor, it is impossible to know just how many genuinely-written but poor-quality articles have been published, cited, and shared due to their ideological fashion. In other words, it appears that ideological opinions have been granted the veneer of scientific rigor (Jussim, 2021) by passing through a biased and motivated peer review process. This is the definition of Bret Weinsteins concept of Idea Laundering (Boghossian, 2016) and is a core tenet of the hoaxers claims. Additionally, how did these papers make it past assumedly experienced peer reviewers? In our research, we were able to demonstrate that Liberal Ideology, and thus a type of Confirmation Bias, likely contributed to participants initial positive evaluations of the hoax articles. This 48 result was unsurprising, and previous research has also demonstrated the relevant negative effects of an overwhelmingly Liberal/Left-leaning academe (Duarte et al., 2015). However, our research took this question one step further in attempting to parse participants falling prey to Confirmation Bias from those specifically acting in the service of an ideology (Paranoid Egalitarian Meliorists/PEMs). We found that PEMs not only degraded the rebuttals but in fact attacked the supposed rebuttal researchers for suspected dubious motives, whereas participants high in LI but low in PEM were able to evaluate the rebuttals without resorting to ad hominem attacks against those who wrote them. Importantly and contrary to our hypotheses, it appeared that PEM did not factor into participants evaluations of the hoax articles, instead only coming into play when the articles received pushback in the form of rebuttals. In sum, these findings provide support for the argument that PEMs are resistant to engage in scientifically sound inquiry and exchange, instead demonstrating ideologically-motivated (rather than scientifically-based) attacks toward those who might disagree with them. Thus, it would seem a likely explanation that Liberal Ideology produced a blind spot for some peer reviewers, while other reviewers may have been acting in scientific bad faith, allowing ideologically-fashionable papers to bypass standards for rigor. These reviewers may be distinguished by their comments on the hoax articles, such as a Feminist Theory journal reviewers nakedly ideological comment: I am very sympathetic to the core arguments of the paper, such as the need for solidarity and the problematic nature of neoliberal feminism or a Hypatia journal reviewers explicit praising of a papers especially nice connection of pedagogy and activism (Lindsay, Boghossian, & Pluckrose, 2018). Limitations We are able to identify several important but justifiable limitations within this study. 49 Firstly, though we have justified the use of MTurk for collecting participants for this study, our preferred participant pool would have been Social Science researchers and professors themselves since they were the population implicated by the original Grievance Studies Affair Hoax Project. If we were able to sample Social Science researchers and professors, we could have more easily drawn a link between the results of our study and the claims of the Hoaxers. However, Gross 2007 study that found 43% of Social Sciences and Humanities faculty considered themselves to be radicals, activists, or Marxists allows us to infer that high-PEM individuals are likely found in high concentrations in academia. Additionally, given that PEM is likely not found exclusively within individuals in academia, we believe that sampling non-academic Liberals was sufficient to find adequate levels of PEM, particularly in an era where Critical theories and their practical applications are ascendent in the popular culture. Additionally, given the rising effect that social media has in academic discourse and its products, laypeople now play a significant role in the spread of potentially bad science, amplifying it far beyond the academy. Thus, this study contributed to our understanding how PEM outside of academia can still shape academia and society for the worse. Secondly, the use of a subscale adapted from a measure meant to assess Feminist ideology and attitudes to assess Liberal Ideology might be called into question. Within social and political science, a standard measure of political ideology has never been established, and as a result, the construct of political orientation is likely captured in wildly varying ways across all studies that claim to measure it (Azevedo, 2022). In our study, we neither aimed to capture the entire construct of political orientation, nor even measure the entirety of Liberal Ideology. Instead, we simply attempted to capture one critical piece of Liberal Ideology: sensitivity to group differences. As Graham et al. (2012) explain, the moral foundation of Fairness is one of the two 50 most relied-upon dimensions of morality for self-described Liberals when evaluating any number of issues within both personal and societal domains. Thus, our choice to use the Discrimination/Subordination subscale has merit: this subscales items are intended to measure ones perceptions of a societal unfairness, and the adapted racial version does the same for racial issues. Likewise, the PEM scale does the same, albeit with its items couched in pre-determined explanatory power and accusatory language (e.g., people often use biology to justify unjust policies that create inequalities). In sum, we believe that the use of the adapted Discrimination/Subordination subscale is theoretically relevant and appropriate given that we aimed to differentiate between Liberals who are simply aware of and concerned by group imbalances from those who fervently believe they already understand their origins and solutions. Though we found that LI and PEM are overlapping constructs, we were still able to provide valuable insight into the specific ways that LI and PEM differently affect an individuals ability to evaluate arguments and counterarguments. Thirdly, we recognize that writing one of the hoax prompts ourselves (Racism Redux: Police slayings of Black men repeats slavecatcher history) might introduce some inconsistency, given that the other two hoax prompts were derived directly from the Grievance Studies Hoax Project. Nevertheless, this decision is justified. We determined that including prompts from multiple Critical fields of study (Fat Studies, Womens Studies, and Critical Race Theory) would best capture the breadth of Critical Social Science and decrease our reliance on any one Critical field of study. Additionally, it was essential to include a hoax paper based on racial subject matter given the focus on race within the PEM scale. However, the Hoax project only included one paper written primarily from a Critical Race Theory perspective which did not easily translate into argument/conclusion summary format and was also too complex for a simple 51 rebuttal. Thus, given our own knowledge of the tenets of Critical Race Theory and the contemporary debate around police use of force against Black and White Americans, we wrote our own hoax prompt and rebuttal using primary sources. We attempted to keep this prompt and rebuttal as close to both the primary sources and Hoax project format as possible. Additionally, our pilot studies demonstrated that our overall method of distilling articles to argument/conclusion sets resulted in acceptable reliability and validity. In sum, we believe that the potential risk to validity of writing our own hoax prompt and rebuttal outweighed the risk to validity of not including a racially-focused hoax prompt. Finally, we recognize that participant confusion impacted our ability to test our fifth hypothesis. In a future study and/or replication, it would be important to modify the format and instructions of the prompts to clarify the intent of the measures. This could involve reducing the amount of text per page and highlighting the particular prompts we desired the participants to evaluate; modifications could additionally involve using an alternative to Qualtrics, which can sometimes present prompts in a visually confusing manner. Self-Correction? As the Hoax Project and current research exposes academias serious problem with bias, one might hope that academia could attempt some form of self-correction. Unfortunately, there appears to be little hope for an effective response. Multiple fields replication crises have been well-documented (Baker, 2016) including in Psychology where many of its most famous studies and findings (e.g., the Stanford Prison Experiment, Milgram Shock Experiments, Robbers Cave findings, Stereotype Threat, Power Posing, Multiple Intelligences, Grit, and others) have been found to either fail replication attempts or to have failed standards for scientific rigor altogether (Le Texier, 2019; Griggs, 2017; Haslam, 2018; Jussim, 2015; Cuddy, 2015; Gardner, 2006; 52 Duckworth, 2018; Glazzard, 2015; Singal, 2021). If academia could be self-correcting, studies and findings that fail to replicate or to meet standards for rigor would cease to be cited and repeated, but recent findings show that papers which fail to replicate are cited more than papers that do and that citation patterns largely do not change even after replication attempts fail (SerraGarcia & Gneezy, 2021). Additionally, even if academia attempts to self-correct its blind spots and unintentional bias problem, there will still be academics who regard the political Critical Social Science approach to knowledge production as equally scientifically legitimate and valuable as the Positivist and Interpretive approaches. There is perhaps no more relevant example than the responses the hoaxers received from Dr. Geoff Cole, a Cognitive Science researcher (Cole, 2020). In a series of commentaries on the Hoax Project, Cole argued most centrally that the Hoax Project was fundamentally flawed because the papers (specifically the Fat Bodybuilding paper), though questionable in rigor, advanced opinions that might be considered reasonable. Cole argued that therefore, papers like Fat Bodybuilding should be reinstated because regardless of the authors motivations, it simply comes down to a matter of opinion as to whether fat bodybuilding is ludicrous (Cole, 2020). This hyper-relativist perspective on matters of scientifically-informed opinion flies in the face of all three of the Positivist, Interpretive, and Critical approaches to science. To use the example of Fat Bodybuilding, Obesity is the construct of interest. The Positivist tradition would attempt to understand the effects of Obesity through experimentation and measurement (and in fact has done so in extant medical literature, finding almost universally negative health outcomes), the Interpretive approach would attempt to understand the experience of those who are Obese, and the Critical approach would attempt to subvert both other methods by deeming them oppressive and replacing them with its own 53 theories about how to use Obesity to deconstruct supposed societal power dynamics. Each of these approaches informs opinion about the reality of Obesity. However, only the Critical approach is resistant to outside critique and assumes its opinion and evaluation of the construct a priori, while denigrating any other method as oppressive. This is the key difference between academias previous failures and the issue at hand: while replication crises and poor research integrity can emerge due to a mixture of perverse incentives and honest mistakes, the Critical approach appears to encourage reductions in rigor if the research can be ideologically consistent and politically useful. To make matters worse, the Critical approach explicitly seeks to eliminate the Positivist and the Interpretive methods. Unlike the healthy tension between the Positivist and Interpretive methods, the Critical approach cannot coexist with others, seeking to take them over for its own ideological uses (Fahs & Karger, 2016, as cited in Lindsay & Pluckrose, 2020). Dr. Coles tepid response, which boils down to the argument everyone is entitled to their own opinion, fails to appreciate the immensely powerful tool that Science can be (if used correctly), and fails to recognize the threat that Critical approaches present to proper Science. Along with replication crises and overall poor quality, Social Sciences newfound CSS dogmatism has culminated in cratering credibility for the field. Social Science Academia must therefore decide which approaches are more legitimate in establishing fact and informing opinion, and act accordingly. Possible Solutions How might academia respond to the risk that is the Critical approach? Given that this paper focuses on peer review, we suggest two major directions in this area. Improve Peer Review The first path would be to focus on improving peer review as it currently stands. In the 54 past, peer review has bestowed an air of academic rigor to papers that made it through its gatekeeping, and not without justification; papers that have made it through peer review in major journals have (at least hypothetically) fewer major errors and pass field-wide standards for rigor. However, these field-wide standards are exactly the issue at hand with the Critical approach to scholarship: as both the Hoax Project and the present research demonstrate, rigor appears to fall down the list of priorities in favor of ideological conformity. As rigor in peer review is regarded as less important or, even more dubiously, as a form of epistemic oppression (Berenstain et al., 2021), the quality of the work produced will plummet (as the Hoax Project has already demonstrated). In order to protect rigor as the top priority in knowledge production, a clearer delineation approach could work to improve the current state of peer review. Firstly, academics could produce and adhere to a clear demarcation between fields and journals that utilize the different approaches to knowledge production. The Critical fields have already accomplished this to a great extent: any field that explicitly uses the word Critical (e.g. Critical Dietetics) is self-identifying, while the vast majority of fields that end in the word studies (e.g. Fat Studies, Disability Studies, Gender Studies) could reasonably be shown and have admitted to be rooted in Critical theories and methodology (Pluckrose & Lindsay, 2020). Simultaneously, the non-Critical fields could work to sanitize and protect themselves from the intrusions of Critical methodology which explicitly seeks to colonize the non-Critical fields (Fahs & Karger, 2016, as cited in Lindsay & Pluckrose, 2020). In all likelihood, this approach would not decrease the amount of study that each topic receives. To use the example given above, Fat Studies could apply a Critical methodology to the question of Obesity, while the more empirical and qualitative methodologies of the Positivist and Interpretive approaches could examine Obesity in their own ways. One could see how the topic of Obesity would actually 55 receive more well-rounded and multifaceted attention from three different approaches, likely leading to a better quality of understanding. Additionally, the peer review process could look different in each of these systems. Whereas the Critical fields may deem the current state of affairs as acceptable (given that scholarship can be published in its major journals if it is ideologically fashionable), the Positivist/Interpretive approaches could choose to be more stringent in their peer review processes in order to provide the most rigorous results. Given that the current state of much of the Social Sciences is overwhelmingly left-leaning (Langbert, 2018), guidelines in this area could include several proposed by Duarte et al. (2015) including: expanding the number of peer reviewers who identify as conservative, moderate, and libertarian; developing strategies to encourage and support research training to attract and retain non-left-leaning students and early career professionals; and supporting adversarial (left- and right-leaning) scholarly collaborations. These proposals would work to solve the confirmation bias issues that come with Liberal Ideology. Additionally, the Positivist/Interpretive peer review boards could include a verification process in their methods in order to ensure that the reviewers were committed to rigor over ideological outcome, which could include administering the PEM measure and designating a cutoff score. Lastly, the demarcation between the Critical and Positivist/Interpretive methods could even become structural, with entirely different institutions housing each camp. This structural approach has been proposed by Jonathan Haidt in his 2016 discussion on the Teloses of universities where he describes differentiating between a Social Justice University and a Truth University, and a similar approach is being piloted in Florida to reinvigorate a Classical College (Downey, 2023). However, it will take significant effort from inside academia to 56 realize this potential. In the end, though other agents like policy makers and the media also bear responsibility for the proper use of scientific findings, Social Science academia could get its own house in order by separating itself from Critical methods, thereby resuscitating its own reputation and function as producers of knowledge. Abandon Peer Review While improving on an existing system may be the most desirable decision, some systems may be so fundamentally broken that removing them entirely could be the best outcome. Many challenges have been raised against the current system of peer review beyond the problems addressed in the present research. For example, peer review appears to perform poorly in detecting fraud, as data are typically assumed to have been collected properly (such as in the Hoax Project). Additionally, plagiarism is difficult to catch, especially when images or diagrams can be tweaked to avoid easy detection, leaving these issues to be caught after papers have already been published (Shen, 2020). In some instances, peer review itself has been the source of fraudulent enterprise as authors have been caught reviewing their own papers or forming backroom deals to reciprocally positively review each others work (Ferguson, Marcus, & Oransky, 2014). This issue continues to plague peer review as even large publishers like Springer have needed to retract over 100 papers as recent as 2017 for these reasons alone (Marcus & Oransky, 2017). Additionally, the peer review process is an extremely costly and time-consuming affair. In 2019, peer reviewers globally were estimated to have worked 100 million hours, and in the U.S., the estimated value of time spent peer reviewing exceeded 1.5 billion dollars (Aczel, Szaszi, & Holcombe, 2021). Given that much of peer review time is donated voluntarily, and that publishers make significant profit from subscriptions and sales of the papers that are peer 57 reviewed, some argue that the peer review process is exploitative (Allen, Reardon, Crawford, & Walsh, 2022). To make matters worse, peer reviews notoriously sluggish pace can mean that cutting-edge research can languish in the system for months or even years. Even after the immense cost and delay, the quality of the reviews can range from excellent to negligent with reviewers contradicting one another in their recommendations, leading some to argue that passing peer review can more be attributed to luck than quality (Smith, 2006). Even worse, the gatekeeping function of peer review can sometimes be used to intentionally prevent groundbreaking or paradigm-shifting research from entering a field on the grounds that it may be too disruptive to the status quo (Weinstein, 2019). Papers can also be maliciously rejected and their ideas stolen for later publication by the reviewers (Weinstein, 2020). These are considered the untransparent, black box problems of peer review. Clearly, peer reviews supposed filtering role is faulty, slow, and costly at best, while elevating fraud and corruption at worst. Abandoning the current system of peer review could resolve many of its issues, but what system could replace it? Though the scope of this question is larger than this paper can answer, several prototype solutions have already presented themselves in recent years. Researchers.one is a website where authors of papers can submit their work to non-anonymous peer review as many times as they wish, and when the authors deem the paper publishable, the authors (rather than journal editors or peer reviewers) publish it. This allows for the responsibility of quality to fall squarely on the authors shoulders, allowing for rigor to be judged by the public and scholarly reputation to be built on paper quality rather than the rubber stamp approval of publication in a journal (Crane & Martin, 2018). This system could provide a solution for many of the issues with current peer review listed above, as papers could be published without the black box problems and without the risk of uncaught poor quality or fraudulent science being rubber stamped as 58 good-quality work. In fact, a system like this could reinvigorate the scientific environment of a culture of doubt in which healthy skepticism detects errors and inspires innovation, as opposed to the current peer review system that exacerbates the impact of bad science that leaks through its filter (Crane and Martin, 2018). Additionally, this system would allow for scientific papers to be freely available to the public as opposed to behind exorbitantly expensive paywalls. With close to nine billion taxpayer dollars given to universities for research in 2020 alone (Duffin, 2023), it is a wonder that the public would then need to pay even more to be granted the privilege to view and evaluate the results of that work. Another similar solution presented itself in the midst of the SARS-COV-2 pandemic: a drastic increase in postings on scientific pre-print servers (Fraser et al., 2021). Given that a large amount of research attention turned to studying the virus and its effects, and given that there was not enough time on the urgent matter to go through the normal peer review process, authors began publishing much more of their work in pre-print servers. With this explosion in non-peerreviewed literature, it is reasonable to assume that a good deal of bad science was initially disseminated. However, the papers that were pre-published were able to be scrutinized by anyone who chose to do so, and lively scientific debate arose around many subjects including masking, vaccination, prophylactic medication, and more. This allowed for more scrutiny than most peer reviewed papers ever receive, advancing knowledge and discounting poor work at a much faster pace than normal (Kwon, 2020). Additionally, this also allowed the public to view a proper scientific debate in action, as opposed to the black box of current peer review, although this debate was conducted in many different formats including Substack blogs, YouTube videos, podcasts, and more. One could see how, if pre-print servers allowed for written (or even audio/video recorded) commentary and critique, the debate could be centralized and located at 59 the same access point as the paper. Overall, the pre-print servers provide another look into a possible peer review alternative that demonstrates true review by peers, a seemingly preferable process over formalized peer review (Weinstein, 2020). While abandoning peer review would not completely solve academias serious problem with Critical methodology, it could address the issue of Idea Laundering. It is clear that peer review has been institutionally captured by Critical scholars who approve articles based on ideological conformity, rather than rigor. An articles status of being peer reviewed is one of the markers of the overused descriptor gold standard, giving some papers the previously described veneer of scientific credibility (Jussim, 2021). Thus, peer review as it currently exists seems to exacerbate the impact of bad science, the opposite of its supposed intent. If peer review were voluntarily abandoned by every field, the Critical scholars may hold on to the process and attempt to preserve its power as a legitimization machine. However, with all other pieces removed, this would mean that their approach to peer review could be revealed as the nakedly ideological process that it is. Why does this matter? Why did we focus our research on ideologys intrusion into science? Recent history provides a disturbing example of what can happen when ideology perverts scientific rigor: Lysenkoism. In Soviet Russia, Trofim Lysenko was promoted to lead Soviet agriculture efforts (Kean, 2017). Lysenko was not particularly accomplished in agriculture or biology, but his promotion was instead based on his radical rejection of Mendelian genetics, which he deemed to be reflective of a Capitalist mindset that reinforced an unjust status quo. Instead, Lysenko combined Marxist social theory with genetic theory, believing that the environment a crop experienced was the determining factor of its ability to prosper. Thus, he believed that he could 60 remake plant behavior by simply educating the plants to the frigid Russian environment (a chilling echo of Soviet reeducation camps.) He also believed that plants from the same class would not compete with one another, meaning that seeds could be planted as close together as possible (again, a direct injection of Marxist class theory). These beliefs were the result of attempting to force reality to fit an ideology (specifically, a direct ancestor ideology to current Critical methods), rather than allowing careful study of reality to inform opinion and action. The result of perverting science with ideology was the complete collapse of Soviet food production, with widespread starvation killing more than 30 million people (Kean, 2017). Soviet citizens were forced to eat anything they could find, sometimes resorting to cannibalizing their own children (Vardy & Vardy, 2007). One might hope that after this catastrophic failure, the Soviet Union would have self-corrected. But instead, many scientists who had studied agriculture using Positivist methods, and thus better knew the reality of agricultural production in Russias climate, were either dismissed from their posts and left destitute or simply jailed and executed (Kean, 2017). Stalin then banned the use of the words famine, hunger, or starvation, even preventing doctors from diagnosing malnutrition, and blamed the failures on enemies of the state (Follett, 2020). This example is not an attempt at hyperbolic fearmongering. The central findings from our research resound in Lysenkoism: Ideology took precedent over rigor in scientific fields, resulting in real-life consequences on a genocidal scale. Instead of self-correcting, the Ideologues simply rejected critique and blamed others for their failures. The Hoax Project, combined with our research, strongly indicates that this process has already instantiated itself in modern scientific institutions. Evidence for this claim abounds: the Critical methods-inspired goals of Diversity, Inclusion, and Equity (with the apt acronym DIE) have become the ideological filter through 61 which research must pass in order to become part of the scientific literature (Brookings Institute, 2022; Ricci, 2021; BJS and BJS Open Editorial Teams, 2023; British Medical Journal, 2023; Taylor & Francis, 2021; Elsevier, 2023; Nature Medicine, 2021; National Science Foundation, 2023), and through which doctors and clinicians must pass in order to become part of the medical and helping professions (Association of American Medical Colleges, 2023; University of Minnesota Medical School, 2018; American Psychological Association, 2023). Those that critique DIE find themselves harassed, punished, or even fired (including the author of this research) (Friedersdorf, 2015; Kabbany, 2021; Nayna, 2019). We sit at a precipice. 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Zell, E., & Bernstein, M. J. (2013). You may think youre right young adults are more liberal than they realize. Social Psychological and Personality Science, 5(3), 326333. https://doi.org/10.1177/1948550613492825 78 Appendix A Hoax Article Argument/Conclusion Sets with Rebuttals These argument/conclusion sets were distilled from the retracted hoax articles and involved directly quoting and/or paraphrasing their main points. One of the hoaxers, Dr. James Lindsay, was on the dissertation committee for this study and raised no objections to our framing. 1. Who are they to judge? Overcoming anthropometry through fat bodybuilding, published in Fat Studies (Baldwin, 2018). i. People who inhabit fat bodies are constantly judgedmorally, aesthetically, physically, emotionally, economically, and in other ways that undermine their dignity. ii. Stigma and Fatphobia are more harmful to peoples health than fat itself. iii. The best way to reduce stigma and Fatphobia is to include fat people in spaces that are traditionally fat-exclusionary. iv. The current focus of Bodybuilding (dieting, weight loss, etc.) creates a fatexclusionary space within the health community. Conclusion: A new category of Bodybuilding should be introduced called Fat Bodybuilding, which will serve to normalize fat, encourage fat body-positivity, and eliminate the idea of fat as unhealthy. Rebuttal: Recently, a group of prominent researchers put out a statement outlining their concerns about the validity and rigor of the article summarized above. Specifically, they said that unlike the building of muscle which requires a great deal of self-regulatory control over ones diet and exercise regime - becoming obese is a self-regulatory failure 79 that is in large part a lifestyle choice and is extremely unhealthy. In fact, we worry that by celebrating it, the authors of this paper are encouraging irresponsible, dangerous behavior that will slowly kill people over time. Therefore, it should not be celebrated or promoted in any way. The researchers have requested that the article have a comment added to it explaining their concerns. 2. Rubbing one out: Defining metasexual violence of objectification through nonconsensual masturbation (Written by Lindsay, Boghossian, & Pluckrose, 2018). i. Sexual violence is not only physical, but also includes things like sexual harassment and locker-room talk. ii. Non-physical sexual violence contributes to proven harms such as objectification and Rape Culture. iii. When a man sexually fantasizes about a woman while masturbating, he is depersonalizing her into solely a sexual object for the purpose of his pleasure. iv. When a man fantasizes about a women while masturbating, he is usually doing it without her consent. Conclusion: A man sexually fantasizing about a woman while masturbating, without her consent, is committing a form of sexual violence. Rebuttal: Recently, a team of prominent researchers put out a statement regarding their concerns about the article above. Specifically, these concerned researchers said that individual masturbation done in private is far from a form of sexual misconduct. Next, they cited their own research that found that over half of women (~57%) reported 80 frequent fantasies in which they are forced into sex against their will (sometimes referred to as consensual non-consent). Secondly, and more importantly, if women are having sexual fantasies about having sexual violence done to them as our research consistently finds - then having men masturbating to thoughts of them without their consent is indeed the best, safest way to satisfy womens sexual fantasies related to force. Therefore, we should not discourage men masturbating to thoughts of women they know. They have requested that the original article include a comment explaining their argument. Note: This rebuttal is based on research by Critelli & Bivona (2008) that found the cited rate of fantasies of consensual non-consent. Additionally, the argument/conclusion set will be provided with author names replaced with invented names, as the hoaxers did not invent a fake author for this paper. 3. Racism redux: Police slayings of Black men repeats slavecatcher history (Written by Husick & Burns). i. Systemic racism is everywhere in the United States, especially in institutions of power. ii. Some of the worst systemic racism is found in police departments, which originated from the groups that would hunt down escaped slaves who were wanted dead or alive. iii. Police shoot and kill Black men by the hundreds every year. iv. People who commit racist acts sometimes dont even know that they are doing it; this is referred to as unconscious bias. Conclusion: Police shoot and kill hundreds of black men every year because they are unconsciously continuing their departments original goal of hunting down slaves. 81 Note: This argument/conclusion set was written based on a combination of both unconscious bias (Greenwald, McGhee, & Schwartz, 1998) and existing historical analyses that utilize Critical Race Theory methodology (NAACP, 2020; Lepore, 2020; Hassett-Walker, 2021). Author names will be replaced with invented names. Rebuttal: Recently, a group of scientists who study police shootings released a statement regarding their concerns with the article above. Specifically, they said that Violent crimes often lead to legally justifiable police shootings, and sociological evidence finds that Black men proportionally commit more violent crimes than other demographic groups in the country. Therefore, Black men are shot more, not because of racist police officers, but because they commit more violent crimes. They have requested that the original article have a comment added to it explaining their concerns. Note: This rebuttal was written using statistics and arguments from Miller et al., 2017 and Fryer, 2019. 82 Appendix B Dependent Measures Agreement with Arguments and Conclusions For each argument/conclusion set and before being presented with the rebuttal, participants will be asked for their level of agreement with the arguments and conclusions. Participants will be asked to indicate their level of agreement with the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. I find myself agreeing with the arguments. 2. Any reasonable person would agree with this argument. 3. I wish more people would write arguments like these. 4. I agree with the conclusion. 5. I find myself agreeing with the conclusion. Evaluation of Logical Quality For each argument/conclusion set and before being presented with the rebuttal, participants will be asked to indicate their level of agreement on the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. The conclusion logically follows from the argument. 2. The arguments build on each other well. Willingness to Read More/Share For each argument/conclusion set and before being presented with the rebuttal, participants will be asked to indicate their level of agreement on the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. I would share the original article with a friend. 83 2. I want to read the original article. 3. I would post a link to this article on social media. 4. I would like to read more on this topic. 5. If these topics came up in conversation, I would probably mention these findings. Agreement with Rebuttal For each rebuttal, participants will be asked to indicate their level of agreement on the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. I find myself agreeing with this statement. 2. Any reasonable person would agree with this statement. 3. I wish more people would write statements like this. 4. This statement changed my opinion of the initial article. 5. If my opinion of the initial article changed, do you agree more or less now? Willingness to Read More/Share For each rebuttal, participants will be asked to indicate their level of agreement on the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. I would like to read more on this topic. 2. If these topics came up in conversation, I would probably mention this statement. 3. I would post a link to this statement on social media. Denigration of Rebuttal Researchers In line with the predictions of Paranoid Egalitarian Meliorism, participants will be asked to indicate their level of agreement on the following statements on a 1 (strongly disagree) to 7 (strongly agree) scale. 1. These researchers are (fatphobic/sexist/racist.) 84 2. This statement is using scientific theories to justify discrimination. 3. Statements like this are just trying to justify (fatphobia/sexism/racism). 4. These researchers are biased against (fat/female/black) people. 5. I question the motives of the researchers who wrote this statement. Liberal Feminist Ideology (Morgan, 1996) Participants will rate their agreement with the following statements on a 7-point Likert scale from 1 (Strongly Disagree) to 7 (Strongly Agree). 1. Even though some things have changed, women are still treated unfairly in todays society. 2. Women have been treated unfairly on the basis of their gender throughout most of human history. 3. The achievements of women in history have not been emphasized as much as those of men. 4. Men have too much influence in American politics compared to women. 5. People who complain that pornography treats women like objects are overreacting (reverse coded). 6. Men still dont take womens ideas seriously. 7. Women are already given equal opportunities with men in all important sectors of their lives (reverse coded). 8. Women have fewer choices available to them as compared to men. 9. Women in the U.S. are treated as second-class citizens. Liberal Racial Ideology (Adapted from Morgan, 1996) Participants will rate their agreement with the following statements on a 7-point Likert 85 scale from 1 (Strongly Disagree) to 7 (Strongly Agree). 1. Even though some things have changed, racial minorities are still treated unfairly in todays society. 2. Racial minorities have been treated unfairly on the basis of their race throughout most of human history. 3. The achievements of racial minorities in history have not been emphasized as much as those of White people. 4. White people have too much influence in American politics compared to racial minorities. 5. White people still dont take racial minorities ideas seriously. 6. Racial minorities are already given equal opportunities with White people in all important sectors of their lives (reverse coded). 7. Racial minorities have fewer choices available to them as compared to White people. 8. Racial minorities in the U.S. are treated as second-class citizens. Paranoid Egalitarian Meliorism (Winegard, Clark, Hasty, & Baumeister, 2018) On a scale from 1 to 7 (1 = strongly disagree, 7 = strongly agree), how much do you agree with the following statements? 1. The only reason there are differences between men and women is because society is sexist. 2. Differences between men and women in society are caused by discrimination. 3. Differences between ethnic groups in society are caused by discrimination. 4. Most people are not biased and racism is not a problem anymore.* 5. When people assert that men and women are different because of biology, they are 86 usually trying to justify the status quo. 6. People often try to conceal their racism and sexism but they act that way anyways. 7. People often use biology to justify unjust policies that create inequalities. 8. Racism is everywhere, even though people say they are not racist. 9. Sexism is everywhere, even though people say they are not sexist. 10. People use scientific theories to justify inequalities between groups. 11. Men and women have equal abilities on all tasks (for example, mathematics, cooking, nursing). 12. All ethnic groups have equal abilities on all tasks (for example, mathematics, sports, creativity). 13. Some differences between men and women are hardwired.* 14. Although things are unequal now, if we work really hard, we can make society better and more equal. 15. We should strive to make all groups equal in society. 16. We should strive to make men and women equally represented in science fields. 17. If we work hard enough, we can ensure that all ethnic groups have equal outcomes. 18. Differences among ethnic groups in social outcome are at least partially biologically caused.* *Reverse coded items Social/Economic Conservatism (Zell & Bernstein, 2013) On a scale from 1 to 7 (1 = strongly disagree, 7 = strongly agree), how much do you agree with the following statements? 1. There need to be stricter laws and regulations to protect the environment. 87 2. The government should help more needy people even if it means going deeper into debt. 3. The growing number of newcomers from other countries threaten traditional American customs and values. 4. I never doubt the existence of God. 5. Business corporations make too much profit. 6. Gays and lesbians should continue to be allowed to marry legally. 7. The government needs to do more to make health care affordable and accessible. 8. One parent can bring up a child as well as two parents together. 9. Government regulation of business usually does more harm than good. 10. Abortion should be illegal in all or most cases. 11. Labor unions are necessary to protect the working person. 12. Poor people have become too dependent on government assistance programs. 88 Appendix C Table 1 Descriptives and interrelations between measures, Study 3 Variable M SD 1 2 1. Liberal Ideology 4.72 1.36 .96 2. PEM 4.75 1.13 .90 .83 3. Social Conservatism 3.14 1.32 .79 -.54 -.59 4. Economic Conservatism 3.13 1.22 .82 -.75 -.70 5. Conservatism (12-item) 3.13 1.17 .87 -.70 -.69 6. Agree; Pre 3.28 1.42 .96 .43 .37 7. Agree; Post 3.97 1.30 .94 -.02 -.06 8. Share; Pre 2.89 1.53 .92 .34 .29 9. Share; Post 3.25 1.50 .91 .03 .01 10. Learn; Pre 3.32 1.62 .88 .39 .32 11. Learn; Post 3.78 1.59 .79 .15 .09 12. Researcher Critique 3.40 1.42 .93 .50 .53 13. Rebuttal Agreement 3.77 1.19 .92 -.31 -.35 14. Overall Rebuttal 4.04 0.94 .91 -.51 -.56 Note. Correlation coefficients in bold are significant at p < .05 at least. 3 4 5 6 7 8 9 10 11 12 13 .71 .93 -.07 .28 .07 .36 -.02 .22 -.13 .52 .50 .92 -.22 .21 -.12 .16 -.20 .02 -.28 .38 .46 -.15 .27 -.02 .28 -.12 .14 -.22 .49 .52 .32 .86 .50 .78 .53 .59 .18 -.15 .37 .69 .31 .63 .22 .48 .30 .68 .82 .58 .57 .33 -.01 .47 .73 .39 .64 .34 .68 .53 .21 -.09 .38 .49 .22 -.04 -.54 .87  ...

... The Daughter Defense: Fathers of Daughters and the Denial of Sexual Misconduct Alexandria N. Hamilton A Masters Thesis presented to The Department of Psychological Sciences, University of Indianapolis, in partial fulfillment of the requirements for the degree of Master of Science in Psychology Submitted for review in April, 2023 ii The Daughter Defense: Fathers of Daughters and the Denial of Sexual Misconduct The signatures below certify that the Thesis of Alexandria N. Hamilton has been approved by the Department of Psychological Sciences of the University of Indianapolis in partial fulfillment of the requirements for the degree Master of Arts in Psychology Approved: Accepted: _____________________ _____________________ Mason Burns, Ph.D. John Kuykendall, Ph.D. Thesis Advisor Dean, College of _____________________ Applied Behavioral Sciences Kathryn Boucher, Ph.D. Committee Member 5/5/2023 _____________________ _____________________ Hui Zhang, Ph.D. Date Committee Member 4/28/2023 _____________________ Date iii Abstract The Daughter Defense, the act of a man invoking ones daughter(s) when defending themselves of gender/sexual misconduct allegations (Demopoulous, 2021; Bennett, 2020; Hesse, 2018, Schultz, 2021), is frequently used by powerful men (i.e. Brett Kavanaugh, Andrew Cuomo) accused of sexual misconduct. However, little is known about whether the Daughter Defense is an effective strategy against these accusations I investigated whether the Daughter Defense affected perceptions of men accused of sexual harassment in one study (N = 295). Participants varying in conservatism read two vignettes about two men (either Republican or Democrat politicians) accused of sexually harassing a female employee. One vignette had the accused perpetrator use the Daughter Defense and the other did not. Participants reported their perceptions of the alleged perpetrator and their perceptions of the defense used. As hypothesized, as conservatism increased, perceptions of the alleged perpetrator became more positive, regardless of the alleged perpetrators political affiliation or response type. However, contrary to hypotheses, but consistent with prior research (Lizzio-Wilson et al., 2022), the Daughter Defense improved perceptions of the alleged perpetrator and the alleged perpetrators response relative to the control defense. Discussion surrounds implications for understanding a common, and effective, rhetorical strategy used by alleged perpetrators to cast doubt on alleged victims allegations. WC: 207 1 Table of Contents Signature Page................................................................................................................................ii Abstract...........................................................................................................................................iii Table of Contents............................................................................................................................1 Introduction.....................................................................................................................................2 Reactions to Sexual Harassment Allegations..................................................................................3 The Daughter Defense as Effective Counterimaging......................................................................5 The Daughter Defense Backfiring...................................................................................................7 Individual Differences and Daughter Defense Receptivity.............................................................9 Overview of the Present Research.................................................................................................11 Method...................................................................................................................13 Participants.....................................................................................................................................13 Design............................................................................................................................................13 Procedure.......................................................................................................................................14 Measures........................................................................................................................................17 Perception of the Alleged Perpetrator and Victim.................................................................17 Perceptions of the Defense.....................................................................................................17 Conservatism..........................................................................................................................18 Demographics........................................................................................................................18 Results............................................................................................................................................19 Preliminary Results........................................................................................................................19 Anticipated Results .......................................................................................................................19 Primary Results..............................................................................................................................19 Analytic Plan..................................................................................................................................19 Perpetrator Guilt............................................................................................................................20 Perpetrator Responsibility.............................................................................................................20 Victim Perceptions.........................................................................................................................21 Victim Responsibility....................................................................................................................21 Evaluation of Response.................................................................................................................21 Perceived Defensiveness...............................................................................................................22 General Discussion........................................................................................................................22 Limitations and Future Directions.................................................................................................24 Conclusion.....................................................................................................................................26 REFERENCES..............................................................................................................................28 APPENDICES...............................................................................................................................33 APPENDIX A: Perception of the Alleged Perpetrator and Victim Items.....................................34 APPENDIX B: Perceptions of the Defense Items.........................................................................35 APPENDIX C: Social/Economic Conservatism Items..................................................................37 APPENDIX D: Demographic Items..............................................................................................38 2 The Daughter Defense: Fathers of Daughters and the Denial of Sexual Misconduct On August 21st, 2021, then New York Governor Andrew Cuomo resigned from his position following numerous allegations of sexual harassment by female staffers. In his resignation, Cuomo cited his three daughters as central to his character as a man who would never intentionally mistreat a woman. Earlier, in 2020, Congressman Ted Yoho was overheard referring to Congresswoman Alexandria Ocasio-Cortez with sexist/misogynist language. In his defense against allegations of sexism/sexual harassment, Yoho said that he respects and treats women well, a claim he supported by referencing being the father of daughters. Specifically, Yoho stated, Having been married for 45 years, with two daughters, I am very cognizant of my language. In response, Ocasio-Cortez said, I believe having a daughter does not make a man decent. Following the #MeToo movement of 2017, increased public attention has been placed on holding powerful men accountable for their treatment of women, resulting in more and more men having to publicly respond to allegations of sexual misconduct. Anecdotally, a common tactic adopted by many of these men involves explicit references to their daughter(s) as a means of casting them as supporters of female empowerment and/or allies against sexism/mistreatment of women (Demopoulos, 2021). Although common, the so-called Daughter Defense has been met with incredulity by many who argue that simply having daughters does not make men allies (Bennett, 2020; Hesse, 2018, Schultz, 2021). Nevertheless, examples of men using the Daughter Defense to appear as an ally to women continue to mount and beg the question, is the Daughter Defense effective at protecting the image of men accused of sexual misconduct? The present research seeks to understand the Daughter Defense, determining whether alleged perpetrators who invoke their daughters are perceived as more innocent/blameworthy than men who deny 3 sexual misconduct allegations without referencing female family members. Furthermore, the present research investigated how partisanship influences perceptions of the Daughter Defense in order to reflect the partisan context in which real world instances of the Daughter Defense occur. Reactions to Sexual Harassment Allegations Past research on perceptions of sexual harassment/misconduct scenarios has primarily focused on how characteristics of the victim, characteristics of the perpetrator, and characteristics of the situation affect perceptions of perpetrator guilt/innocence. For instance, endorsement of myths related to the victim (e.g., victims promiscuity; Lonsway et al. 2008), the quality of evidence posed against the accused (Bhattacharya & Stockdale, 2016), and the degree of certainty that the sexual misconduct took place (Lizzio-Wilson et al., 2022) can all impact perceptions of sexual harassment scenarios. Recently, Lucarini and colleagues (2020) investigated whether sexual harassment claims were perceived as more or less credible depending on if the sexual harassment was reported immediately or after several years. Results revealed that victims who immediately report harassment were perceived more positively than victims who reported harassment years later, and that this effect was stronger among political conservatives. Less research, however, has investigated perceptions of alleged perpetrators responses following sexual misconduct allegations (but see Craig & Cossette, 2020; Nigro et al., 2020; Schumann & Dragotta, 2020). Of this work, focus has been placed primarily on what types of apologies are perceived as more, or less, authentic (Kirchoff & Cehajic-Clancy, 2014). For instance, Schumann and Dragota (2020) investigated how people perceive various types of apologies, finding that the content of the apology, the severity of the allegations, and participant gender influenced participants' reactions to their statements. Similarly, response tone impacts 4 perceptions, with angrier responses/defenses increasing perceptions of guilt, even in the case when the alleged perpetrator is innocent of any wrongdoing (DeCelles et al., 2021). Beyond apologies, Craig and Cossette (2020) investigated other types of responses, including denials and counterimaging, or a response to allegations of wrongdoing that reframe the perpetrator in a positive light without necessarily apologizing or denying the allegation (see also Perry et al., 2019 for a comparison of perceptions of people who apologize versus deny allegations of interpersonal wrongdoing). Counterimaging is a unique response to sexual misconduct allegations in that it allows alleged perpetrators to deny allegations while casting themselves in a positive light and without needing to reference to accuser. For instance, a man accused of sexual misconduct might respond, I was shocked and disappointed to learn that my well-intentioned actions were sometimes perceived as threatening and lewd, this is not who I am or how I was raised, and it will certainly never happen again. The present research investigated the Daughter Defense as a counterimaging strategy because this defense involves men portraying themselves as family men who can be assumed to have a track record of treating women well. Although not specific to the Daughter Defense, there is some evidence that counterimaging and deflection (i.e., changing the topic away from the sexual misconduct allegation) improve perceptions of the alleged perpetrator more than simply denying the allegations altogether (Craig & Cossette, 2020; Johnson, 2018; von Sikorski, 2018). To date, no empirical research has investigated the Daughter Defense, specifically, to ascertain whether this defense effectively reduces perceptions of perpetrator guilt. Accordingly, the present research investigated how the Daughter Defense may be be a useful counterimaging tactic (Bennett, 2020; Hesse, 2018; Shultz, 2021), investigating whether the Daughter Defense affects perceptions of men accused of sexual misconduct. Specifically, I considered two 5 possibilities. On the one hand, the Daughter Defense may improve perceptions of men accused of sexual misconduct by effectively presenting the accused as a male ally against mistreatment of women (Lizzio-Wilson et al., 2022). Such a finding would support the use of the Daughter Defense as has been observed in real world instances of sexual misconduct allegations. On the other hand, there is evidence that the Daughter Defense is unpersuasive to many political journalists (Demopoulous, 2021; Bennett, 2020; Hesse, 2018, Schultz, 2021). In this case, the Daughter Defense may be perceived more negatively than a simple denial that does not mention the accused perpetrators daughter. In particular, the Daughter Defense may backfire to the extent their defense comes off as inauthentic (Hornsey et al., 2020), defensive (Schumann, 2014), performative (MacLachlan, 2015), or suggest a moral violation (Schumann & Dragotta, 2020). The Daughter Defense as Effective Counterimaging There are many reasons to suspect the Daughter Defense may be an effective defense against allegations of wrongdoing and reduce peoples perceptions of perpetrator guilt. For instance, using the Daughter Defense does not require the accused perpetrator to admit to the sexual misconduct accusation, apologize for any wrongdoing, and does not require reference to the alleged victim at all. Prior research has found that denials, versus apologies, are effective at reducing negative evaluations of alleged perpetrators of wrongdoing (Perry et al., 2019). Although not necessarily requiring a denial, the Daughter Defense is a type of counterimaging, which is used to avoid criticizing the victim while also not admitting wrongdoing (Craig et al., 2014). As a counterimaging tactic, the Daughter Defense may cast the alleged perpetrator as a family man who treats women well (e.g., his daughters), while simultaneously avoiding saying anything negative about the victim (or saying anything about the victim at all). Prior research 6 suggests that counterimaging, relative to denials or apologies, can be particularly effective in mitigating an alleged perpetrators perceived guilt (Craig et al., 2014). Further, recent research has found that male allies, or men who present themselves as allies against sexism, accused of sexual harassment were given the benefit of the doubt and perceived as more innocent/less guilty (Lizzio-Wilson et al., 2022). Specifically, Lizzio-Wilson and colleagues (2022) found that, regardless of the level of certainty that sexual harassment occurred, perpetrators presented as allies were evaluated more positively than non-ally perpetrators. Interestingly, non-ally perpetrators were judged more negatively only when there was strong evidence to support that the sexual harassment allegation, whereas the ally perpetrator was judged more positively regardless of the evidence, lack thereof, or ambiguity of the allegation. Thus, the more ambiguous the allegation, perpetrators who can present themselves as allies may be perceived as less guilty. The Daughter Defense, therefore, may effectively reduce perceptions of perpetrator guilt to the extent that invoking ones daughter(s) casts an alleged perpetrator as an ally of women broadly. Similarly, by informing respondents that the man has a daughter(s), the Daughter Defense also presents accused perpetrators as having women in their close social orbit. Prior research has found that when advantaged group members (e.g., Whites, men) are described as having diverse social networks, they are perceived more positively, less biased, and more likely to be allies (Wout et al., 2010; 2014). Thus, referencing ones daughter in response to sexual misconduct allegations may act as a safety cue to other women, and in turn suggests that fathers of daughters are less likely to be guilty of sexual harassment allegations. Finally, the Daughter Defense may be an effective counterimaging strategy given research that finds that men with daughters are, in reality, less sexist than men without daughters 7 (Washington, 2008), particularly when a daughter is a mans first child (Sharrow et al., 2018). For instance, Washington (2008) found that male legislators voting record on womens health issues (e.g., reproductive rights) became less conservative following the birth of a daughter. This shift toward more feminist beliefs appears unique to having daughters given other research showing that having sons (Prokos et al., 2010). To the extent people are aware that fathers of daughters typically possess fewer sexist beliefs, referencing ones daughter may signal to onlookers that they are more egalitarian and more likely to treat women fairly/respectfully (Warner & Steel, 1999). Taken together, it is possible that people perceive fathers of daughters as less likely to be guilty of sexual harassment allegations, a belief akin to a sexual harassment myth regarding who is, versus is not, likely to sexually harass a woman (Feild, 1978). Specifically, this research suggests that women tend to view men who rape women as inherently different from men who do not. Thus, men who reference their daughters may do so to portray themselves as an ally, possessing a diverse social network, and/or avoid directly attacking the credibility of the accuser. The Daughter Defense Backfiring Of course, there are also reasons to expect the Daughter Defense to be ineffective and perhaps even backfire, increasing perceptions of perpetrator guilt. Although denials of wrongdoing are oftentimes perceived more positively than apologies, certain types of denials (e.g., deflections) are perceived particularly negatively (Schumann & Dragotta, 2020). Given that the Daughter Defense is a defense that does not directly address the accusations, the Daughter Defense is a deflection. Additionally, while having a diverse social network (i.e., a man having women in their immediate family) can serve as a safety cue for other women, accusations of sexual misconduct may serve as threat cues that undermine the safety cues (Wout et al., 2014). 8 Specifically, safety cues can be undermined by the cooccurrence of threat cues, or cues that signal that prejudice and discrimination may occur more easily. However, any ambiguity (e.g., lack of evidence) surrounding the sexual misconduct will surely have an impact on the perception that a threat cue is even present (Lizzio-Wilson et al., 2022). Thus, men with daughters may be perceived as unlikely to mistreat women in the abstract (i.e., a safety cue), but this may not benefit them when an allegation has been made (i.e., a threat cue). Furthermore, men with daughters who are accused of mistreating other women may be perceived as moral hypocrites based on the sex of their children (Lizzio-Wilson et al., 2022) and evaluated more harshly than men without daughters. For instance, men with daughters may be perceived as unlikely to mistreat women but, following an allegation, perceived as morally hypocritical to the extent the accusation is believed by perceivers. Put another way, fathers of daughters may be expected to know how to treat women well and be perceived as particularly guilty following a credible allegation. Additionally, by framing themselves as parents, accused fathers of daughters may also be priming perceivers with family values, which can result in perceivers making more punitive moral judgments to perceive moral violations when considering an outgroup member (Eibach et al., 2009). Thus, if the accusation is believed, presenting oneself as a man who ought to know better (e.g., fathers of daughters should know better than to mistreat other women) and encouraging perceivers to consider their own families and family values may result in greater perceptions of perpetrator guilt relative to defenses that do not reference female family members. Finally, research on responses to wrongdoing have found that responses that appear insincere (MacLachlan, 2015) and angry/defensive (DeCelles et al., 2021; Schumann, 2014), are perceived negatively relative to more authentic sounding, calm, and other-focused defenses. 9 Thus, the Daughter Defense may increase perceptions of perpetrator guilt if such a defense comes across as insincere, angry/defensive and emotionally charged relative to other defenses. Taken together, there are reasons to expect that the Daughter Defense may backfire, both by framing the accused perpetrator as a moral hypocrite but also by presenting their defense as inappropriate. The present study attempts to investigate whether the Daughter Defense might work at reducing perceptions of guilt for high profile men, who might find the Daughter Defense convincing, and why such a defense may reduce perceived guilt among these perceivers. I considered both possibilities that the Daughter Defense may reduce perceptions of guilt relative to a defense without referencing ones daughter, or that the Daughter Defense used in isolation of other types of defenses may backfire and increase perceptions of guilt. Individual Differences and Daughter Defense Receptivity There is evidence to suggest that the Daughter Defense may be more, or less, effective at reducing perceived perpetrator guilt across individuals varying in numerous individual differences. Of particular interest to the present research, I investigated how reactions to the Daughter Defense differ across political conservatism. In real world instances of the Daughter Defense, sexual misconduct allegations often occur in highly partisan contexts. For instance, Brett Kavanaugh was a conservative Supreme Court nominee nominated by a Republican president, and many attacks came from liberal political rivals. Similarly, Andrew Cuomo, a Democratic governor, faced backlash, oftentimes from Republican counterparts. Accordingly, a persons political affiliation likely impacts how sexual misconduct allegations are perceived. In general, political conservatism is associated with more negative attitudes toward women. Christopher & Mull (2006) found that social dominance, and right-wing authoritarianism all predicted sexism. More directly, Lucarini and colleagues (2020) found that 10 greater conservatism predicted less perceived guilt for a male alleged perpetrator of sexual harassment. Thus, political affiliation may moderate the effect of the Daughter Defense on perceptions of perpetrator guilt and/or victim responsibility. Relatedly, Lisneck and colleagues (2022) investigated how conservatism affected participants perceptions of the #MeToo movement and believing women who claim to have been sexually harassed. Specifically, conservatives reported greater perceived male victimization when reading about womens accounts of sexual harassment than liberals. Interestingly, participant gender did not moderate results, suggesting that political affiliation impacts perceptions of sexual misconduct accusations for both men and women. Although liberals/Democrats tend to view alleged perpetrators as more guilty than conservatives/Republicans (Craig & Cossette, 2022; Lisneck et al., 2022; Nasarella et al., 2021; van der Linden & Panagopoulos, 2019), evidence suggests that the political affiliation of the perpetrator shapes these partisan perceptions. Specifically, Democrats and Republicans do not seem to differ in their levels of bias during social interactions, showing preference for political ingroup members over outgroup members (Balliet et al., 2018). In the case of sexual misconduct, research has shown that Republicans are more supportive of Republican perpetrators than Democratic perpetrators, and vice versa (Craig & Cossette, 2022; Nasarella et al., 2021; van der Linden & Panagopoulos, 2019). Thus, conservatives may find the Daughter Defense compelling when used by a conservative perpetrator, but not a liberal perpetrator, and vice versa. However, other research suggests that reactions may differ across participants orientation. Specifically, van der Linden and Panagopoulos (2019) found that while conservatives were generally more forgiving of men accused of sexual misconduct, conservatives expressed more forgiveness for conservative perpetrators relative to liberal 11 perpetrators. In contrast, liberals were similarly unforgiving of both conservative and liberal perpetrators. Additionally, people tend to judge their political ingroup members less harshly, making more external attributions for their ingroup members while making more internal attributions for their outgroup members (Munro et al., 2010). When presented with a push for a policy change, participants were more likely to attribute the reason for the policy change as having ulterior motives when judging a political outgroup member as opposed to an ingroup member. In the case of the Daughter Defense, liberals may perceive another liberal invoking their daughter as authentic and sincere but perceive a conservative invoking their daughter as more rehearsed and performative. Therefore, it is possible that reactions to the Daughter Defense may depend on the interaction between participants political affiliation and the alleged perpetrators political affiliation. I considered these possibilities and investigated how the match, versus mismatch, of participants and perpetrators orientation affected perceptions of the Daughter Defense. The Present Research I investigated the Daughter Defense in the context of politicized allegations of sexual harassment. Specifically, participants varying in political affiliation read about two politicians accused of sexual harassment, either two Democrats or two Republicans. The design was withinsubjects, as participants may have perceived the Daughter Defense and a control response differently when faced with both responses. In one vignette, the accused politician used the Daughter Defense while the other simply denied the allegation without referencing their children/families. Participants then indicated their perceptions of the accused perpetrators and of the alleged victims. I expected that, overall, conservatives would be more skeptical of the allegations relative to liberals. However, I expected reactions to the Daughter Defense would 12 depend on the (mis)match between the participants political affiliation and the alleged perpetrators political affiliation. Specifically, I hypothesized that the Daughter Defense would increase the accused perpetrators perceived innocence when the perpetrator and participants shared a similar political affiliation/orientation relative to the control defense. In contrast, I hypothesized that the Daughter Defense would backfire relative to the control defense when the participant and perpetrator differed in their political affiliation/orientation. 13 Method Participants Based on earlier studies in this program of research, I estimated small effect sizes for the interaction between participants social conservatism (continuous), perpetrator political affiliation (between-subjects), and defense used (within-subject). Based on a power analysis performed using G*Power, I determined that approximately 300 participants were needed to detect interaction effects with 80% power. Participants (N = 295) were recruited from Amazons Mechanical Turk (MTurk). Participants were compensated up to $2.00 for their participation depending on the estimated time to complete the study (15-20 minutes) and market norms. Participant data was excluded from analyses if they reported living in the United States for less than 5 years to ensure an adequate familiarity with American social classes and labels. Per recent methodological suggestions (Leiner, 2019), participants who completed the study 1.75 times faster than the overall sample median were also excluded to eliminate potentially meaningless data. Participation was not restricted based on other demographic information (e.g., gender, race, political orientation) and no quotas will be set for any response type. Specifically, we did not restrict on the basis of other demographics because we had no a priori reason to expect results to differ on the basis of participant demographics. Of course, we investigated potential differences across demographics for exploratory reasons. Design Participants were randomly assigned to a 2 (Perpetrator Affiliation: Democrat vs. Republican) x 2 (Response Type: Daughter Defense vs. Control) mixed model. Perpetrator Affiliation was a between-subjects factor while Response Type was the within-subjects factor. Participants conservatism varied continuously. 14 Procedure Participation was through the Qualtrics online survey platform. After confirming that they are 18 years or older and consenting to participate in the study, participants were told that the study is interested in their attitudes toward sexual harassment. Participants read two vignettes describing two men credibly accused of sexual harassment. For each participant, one vignette described the perpetrator defending themself against the allegations using the Daughter Defense. In the other vignette, the perpetrator defended themselves against the allegations, but did not reference their daughter or any female family member. Two things were counterbalanced. First, I counterbalanced whether participants saw the vignette with Andy or the vignette with Ken first. Second, I randomized whether participants saw the Daughter Defense or control defense first. Based on random assignment, the two men were either be described as Democratic or Republican politicians. Specifically, one vignette read (Political Affiliation differences are separated by backslashes): Alicia Johnson, an intern at the congressional office of Republican/Democratic Congressman Andrew Hales (R/D - NV) accused Congressman Hales of sexual harassment. Her allegation asserts that Andrew Hales inappropriately touched her (rubbed her shoulders) in front of other staff members and frequently asked her about her private sex life (despite her discomfort). Although the alleged behaviors occurred over the past year, she only reported the Republican/Democratic congressman now because she feared losing her position. When interviewed, Congressman Hales denied sexually harassing Alicia. 15 Based on random assignment to the Daughter Defense condition, participants read the alleged perpetrators defense as either referencing his daughters or not. In the Daughter Defense condition, participants read: Alicia Johnson, an intern at the congressional office of Republican/Democratic Congressman Andrew Hales accused Hales (R/D NV) of sexual harassment. Her allegation asserts that Andrew Hales inappropriately touched her in front of other staff members, frequently asked her about her private sex life (even after she expressed her discomfort in doing so), and inappropriately commented on her dress/appearance. Although the alleged behaviors occurred over the past year, she only reported Congressman Hales now because she feared losing her position. When interviewed, Congressman Hales denied sexually harassing Alicia. In the Control condition, participants read: Republican Congressman Hales (R/D - NV) claimed he would never sexually harass a woman and denied the allegation. Specifically, Hales said the following at a press conference outside the Nevada Republican/Democratic Party Headquarters: Having spent years working with other people and taking care of my employees who I respect deeply I would never dream of harassing or mistreating any woman. I want people to know that I would never treat any woman in the way I am being accused. For the second vignette, participants first read about a second man accused of sexual harassment. The political affiliation of the alleged perpetrators was kept consistent across both vignettes. Specifically, participants read (Political Affiliation differences are separated by backslashes): 16 Amber Jones, a city employee, has accused Republican/Democratic Mayor Kenneth Guidry of sexual harassment. Jones alleges that Mayor Guidry (R/D) frequently commented on her appearance in a manner that made her uncomfortable. Additionally, Jones alleges that Mayor Guidry touched her inappropriately and unprofessionally, including insisting on giving her unwanted hugs to greet her in the morning. Additionally, Jones alleges that Guidry frequently commented on her appearance in a manner that made her uncomfortable. She notes that with male employees, he would simply shake their hands. Jones was hesitant to report these incidents, fearing for her future in Republican/Democratic political roles, but eventually did report the incidents after encouragement from female coworkers. As with the first vignette, participants then read the alleged perpetrators response. Participants who read the Daughter Defense response for the first vignette read the control defense response for the second vignette, and vice versa. Participants reading the Daughter Defense response read: In response, Mayor Guidrys (R/D) office released the following statement: As the father of two daughters, I am very aware of how my words and actions can affect women. This has all been an unfortunate misunderstanding, and I am innocent of any alleged wrongdoing. Participants in the Control condition read: In response, Mayor Guidrys (R/D) office released the following statement: I am aware of how my words and actions can affect women. This has all been an unfortunate misunderstanding, and I am innocent of any alleged wrongdoing. After each vignette, participants completed a questionnaire assessing their perceptions of the perpetrator (e.g., perpetrator guilt/innocence), the victim, and perceptions of the 17 defense used. After all primary measures were completed, the participants were then asked to recall the political affiliation of the perpetrator as a manipulation check. Finally, participants indicated their political affiliation before being debriefed about the purpose of the study, thanked for their participation, and dismissed. Measures Perception of the Alleged Perpetrator and Victim After each vignette, participants indicated their perceptions of the alleged perpetrator and his defense on a 0 (not at all responsible) to 100 (extremely responsible) scale (Lucarini et al., 2020). Additionally, participants completed a six-item measure assessing perceptions of the perpetrators guilt (e.g., Andrew/Kenneth (the alleged perpetrator) was guilty of harassment.) on 1 (strongly disagree) to 7 (strongly agree) scales (MAndrew = 4.97, SDAndrew = 1.08, Andrew = .64; MKenneth = 4.97, SDKenneth = 1.16; Kenneth = .67). Similarly, participants indicated their perceptions of the victim (e.g., From the previous scenario, it seems that the alleged victim was only trying to tarnish Andrew's/Kenneths (the alleged perpetrator) reputation.) on 1 (strongly disagree) to 7 (strongly agree) scales for each of the vignettes (MAndrew = 5.28, SDAndrew = 1.11, Andrew = .76; MKenneth = 5.44, SDKenneth = 1.08; Kenneth = .79) See Appendix A for scale information. Perceptions of the Defense Taken from prior research (Schumann & Dragotta, 2020), participants indicated their perceptions of the perpetrators defense across 25-items that assess the responses perceived authenticity (e.g., This statement seems sincere.), effectiveness (e.g., This statement improves my perceptions of Andrew/Kenneth.), and completeness (e.g., This statement is insufficient.) on 1 (strongly disagree) to 7 (strongly agree) or 1 (not at all) to 7 (to a great degree) scales 18 depending on item wording (MAndrew = 4.37, SDAndrew = 0.93, Andrew = 0.91; MKenneth = 4.21, SDKenneth = 0.97; Kenneth = 0.92). See Appendix B for scale information. Although these items were designed to tap into different perceptions of the responses, prior research has found these items to be highly related and suggests combining them into a single measure. Perceived Defensiveness Participants also indicated how angry the perpetrators seemed across two items (e.g., In the scenario you read, how angrily did Kenneth/Andrew (the alleged perpetrator) react to the accusation?) on 1 (strongly disagree) to 7 (strongly agree) scales (MAndrew = 3.46, SDAndrew = 1.44, Andrew = .60; MKenneth = 2.84, SDKenneth = 1.33, Kenneth = .45). Conservatism Participants indicated their own political orientation in three ways (Appendix C). First, participants completed a 12-item measure assessing their conservative policy attitudes. Six items assessed social conservatism (M = 3.21, SD = 1.23, = .71; e.g., One parent can bring up a child as well as two parents together.) and six assessed economic conservatism (M = 3.16, SD = 0.96, = .65; e.g., Government regulation of business usually does more harm than good.). Scores were made on 1 (strongly disagree) to 7 (strongly agree) scales. Second, participants rated themselves on a single 1 (very liberal) to 11 (very conservative) item (M = 6.06, SD = 3.16). Finally, participants rated themselves on a single 1 (Democrat) to 6 (Republican) item (M = 3.16, SD = 1.71). Demographics After all primary measures were completed, the participants were then asked to recall the political affiliation of the perpetrator as a manipulation check. Next, participants indicated their political affiliation and completed a series of demographic items (e.g., gender and race). Included 19 in these items were items asking participants to indicate whether they have any daughters themselves and, if so, how many. Prior studies in this program of research (not included in this manuscript), has found inconsistent results related to the predictive power of participant sex and number of daughters on results. Nevertheless, these items were included for exploratory purposes. Finally, participants were debriefed about the purpose of the study, thanked for their participation, and dismissed. Results Preliminary Results Vignette Comparisons A series of paired-samples t-tests revealed that participants rated Kenneth and Andrew similarly responsible, p = .539, and guilty, p = .961, suggesting the wording of the vignettes did not affect these perceptions. However, Andrews response (M = 4.37, SD = 0.93) was rated more negatively than Kenneths response (M = 4.21, SD = 0.97), t(294) = 2.36, p = .019, regardless of if the response included the Daughter Defense or not. This effect is small, inconsistent with guilt and responsibility results, and likely does not impact results meaningfully. Finally, perceptions of the vignettes did not differ among men and women, ps > .419. Primary Results Analytic Plan To account for non-independence across responses to the Daughter Defense and control defense, we conducted a series of mixed model analyses using jamovi (The jamovi project, 2021). Specifically, we predicted outcomes from social conservatism1 (continuous), perpetrator 1 I also analyzed results with the single item conservatism measure and political affiliation items in place of the social conservatism measure. Results did not differ depending on how partisanship was measured. I focused on social conservatism herein given prior results in this program of research that similarly focused on social conservatism as a focal predictor. 20 affiliation (between-subjects), vignette order (between-subjects), and Defense (within-subject) and their interactions. We fit an overall model with fixed effects of all main effects and all interactions, and random intercepts. Perpetrator Guilt The order the scenarios were presented predicted guilt perceptions, t(286) = 2.03, B = 0.20, p = 044, and participants rated the perpetrators more guilty (M = 5.07, SD = .0.93) when they read the scenario about Mayor Kenneth Guidry first than when they read about Congressman Andrew Hales first (M = 4.86, SD = 0.94). It is unclear why this effect emerged and this effect was rather small. Therefore, I suspect it was spurious. Nevertheless, order effects were controlled for in all analyses. Relatedly, order did not interact with any other variable to predict perpetrator guilt perceptions, ps> .085. Consistent with hypotheses, the main effect of social conservatism was significant t(286) = 7.35, B = -0.25, p < .001, and as social conservatism increased, perceived guilt decreased regardless of the perpetrators political affiliation and defense used. A main effect of defense was also found such that the perpetrator who used the Daughter Defense (M = 4.21, SD =. 94) was perceived as less guilty than the perpetrator who used the control defense (M = 4.37, SD = 0.96). t(286) = 2.46, B = -0.16, p = .014. No other effects, nor interactions, were significant, ps > .110. Perpetrator Responsibility Consistent with guilt responses, the effect of social conservatism was significant, t(286) = 5.42, B = -5.65, p < .001, such that as social conservatism increased perceptions of the perpetrators responsibility decreased. Additionally, a main effect of defense was present such that the Daughter Defense (M = 74.94, SD = 25.89) resulted in the perpetrator being perceived 21 as less responsible than the control defense (M = 78.31, SD = 24.17), t(286) = 2.69, B = 3.53, p = .008. No other main or interactive effects were significant, ps> .183. Victim Perceptions Consistent with prior studies (not included in this manuscript), social conservatism predicted perceptions of the alleged victims, t(286) = 4.53, B = -0.20, p < .001, and greater conservatism predicted more negative evaluations of the alleged victims regardless of perpetrator affiliation or the defense used. The effect of conservatism was not moderated by perpetrator affiliation or defense used, ps > .302. Victim Responsibility Only a main effect of social conservatism was significant, t(286) = 8.19, B = 11.28, p < .001, such that as conservatism increased perceptions of the victims responsibility increased. This effect emerged regardless of the perpetrators affiliation or defense used. No other effects were significant, ps > .088. Evaluation of Response Order of scenario presentations did not predict response evaluations, p = .713, nor did order interact with any other variable to predict response evaluations, ps > .110. Consistent with my hypothesis, there was a main effect of conservatism, such that as social conservatism increased, perceptions of the alleged perpetrator became more positive regardless of the alleged perpetrators political affiliation or response type t(286) = 7.35, B = -0.25, p < .001. There was a main effect of Response Type, however, in the opposite direction than hypothesized. The Daughter Defense improved perceptions of the alleged perpetrators response, and participants rated the Daughter Defense (M = 4.37, SD = 0.96) more positively than the control defense (M = 4.21, SD = 0.94) regardless of the perpetrators affiliation or participants self-reported social 22 conservativism, t(286) = 2.46, B = -0.16, p = .014. Unexpectedly, main effects were not qualified by any interaction, ps > .435. Participants rated the alleged perpetrator who used the Daughter Defense as less guilty regardless of whether the perpetrators affiliation matched their own selfreported social conservatism or not. Perceived Defensiveness As with prior results, the main effect of social conservatism was significant such that greater conservatism predicted greater perceived defensiveness, t(286) = 2.21, B = 0.12, p = .028. Additionally, the main effect of order was significant such that participants who evaluated Kenneth before Andrew rated the averaged defensiveness higher (M = 3.29, SD = 1.11) than participants who evaluated Andrew before Kenneth (M = 3.00, SD = 1.11), t(288) = 2.22, B = 0.29, p = .027. Finally, the main effect of Defense was marginally significant such that the Daughter Defense was rated as less negative (M = 3.05, SD = 1.43) than the control defense (M = 3.25, SD = 1.40), t(288) = 1.95, B = -0.20, p = .052. However, this main effect is significant when omitting nonsignificant variables from the model and is consistent with other results. No other effects or interactions were significant, ps > .201. General Discussion Consistent with prior studies, which are not included in this manuscript, greater conservatism predicted more negative evaluations of the alleged victims overall, regardless of the defense that was used or the alleged perpetrators affiliation. This is not surprising, as previous research has demonstrated that conservatives tend to take sexual misconduct allegations less seriously than more liberal people do (Agiesta & Sparks, 2018). As hypothesized, as conservatism increased, perceptions of the alleged perpetrator became more positive, regardless of the alleged perpetrators political affiliation or response 23 type. This is in line with prior research, where Democrats were more likely than Republicans to believe that a victim of sexual misconduct should be taken at their word (Craig & Cossette, 2020). Contrary to my hypothesis, the Daughter Defense improved perceptions of the alleged perpetrators response relative to the control defense. The Daughter Defense was rated more positively than the control defense regardless of both the perpetrators political affiliation and the participants conservatism. These results were unexpected, as prior results from this program of research found that in a between-subjects design, the Daughter Defense led to more guilty perceptions than the control defense (Study 2). Thus, I considered the possibility that the Daughter Defense would backfire. However, the present research was a within-subjects design, and participants considered both a perpetrator who used the Daughter Defense and a perpetrator who used the control defense. This design changes things from looking at the Daughter Defense in isolation to being forced to make a relative comparison between the Daughter Defense and the defense in which no relationship to a female is mentioned. This is consistent with prior work related to the admission or denial of bias by Perry and colleagues (2019). Specifically, they found that relative to people who deny having bias based on sex, people who admit to their bias are evaluated more harshly. However, when participants viewed the denier or admitter in isolation of each other, the denier is evaluated more harshly, suggesting that participants may have been viewing evidence of bias at face value. What I found is consistent with research done by Lizzio-Wilson and colleagues (2022) that revealed that males who present themselves as allies are given the benefit of the doubt when they are accused of sexual misconduct. Herein, I found that the perpetrator was evaluated as less guilty when they referenced their daughter in their defense versus when they did not. Given pilot 24 data finding that men with daughters are viewed as less sexist and more in favor of gender equality, these results indicate that the Daughter Defense may signal to perceivers that the perpetrator is an ally and, in turn, reduce guilt perceptions. This is also, in retrospect, consistent with our initial correlational studies related to the Daughter Defense. Specifically, I investigated whether fathers of daughters were perceived more positively than men without daughters, finding that indeed they were, thus finding initial evidence that the Daughter Defense might work to increase positive perceptions of an alleged perpetrator. This research phrased items using relative comparisons, for instance, one item read Relative to men without daughters, fathers of daughters are more supportive of gender equality. Thus, it may be the case that the Daughter Defense improves perceptions of men relative to other defenses, but backfires when perceived in isolation. Future research is needed to know if this is indeed the case. Limitations and Future Directions One limitation of this study is that the vignettes I used were not thoroughly tested before including them in this study. It is possible, then, that participants could perceive the actions of Andrew (rubbing her shoulders and asking about her sex life) as more or less serious than the actions of Kenneth (hugging her and making sexual jokes). However, although I found a difference between the Kenneth and Andrew vignettes, specifically that Andrews response was perceived more negatively than Kenneths, no other differences emerged and, in particular, no differences emerged related to the alleged actions. On the hand, the lack of differences may indicate that our vignettes were perceived comparably. On the other hand, there may exist unaccounted for differences between them. Future research is necessary to more fully understand how participants perceived the scenarios provided, irrespective of the defense used. 25 Additionally, our manipulation of the perpetrators political affiliation was subtle and could have been overlooked. Nonetheless, excluding participants who incorrectly identified the perpetrators political affiliation did not change results. Future research is needed to better understand whether having the same political affiliation as the alleged perpetrator matters. Other research that has investigated partisan reactions to political sexual harassment scandals often use more overt manipulations, yet I purposefully designed subtle scenarios in order to observe variability in responses. However, it is uncertain how serious participants perceived these events to be, and it is possible that reactions could depend on the seriousness of the allegations. The reactions I saw were coming from a more ambiguous form of harassment, like Andrew Cuomo in the real world, yet some men who have used the Daughter Defense (e.g., Brett Kavanaugh) were accused of attempted rape, which some may perceive to be a bigger moral violation. Thus, it could be the case that the Daughter Defense is perceived differently depending on the perceived severity of the sexual misconduct. Further, the mechanism through which the Daughter Defense affected perceptions remains unclear. However, additional research is necessary to replicate the present findings and determine the process through which fathers of daughters are perceived as less guilty than men without daughters. Another explanation is that fathers of daughters are perceived as allies, and thus are given the benefit of the doubt when it comes to sexual misconduct allegations that have not been definitively proven (Lizzio-Wilson et al., 2022). Future research should replicate these unexpected findings while also investigating the process through which they occur. In addition to this, future research should include other potentially relevant individual differences, such as feminist identification, attitudes toward sexual harassment, and measures of both hostile and benevolent sexism. Although I do not expect these specific individual differences would affect 26 participants reactions based on prior studies in this program of research, getting this information about participants could help inform this discussion. Other individual differences may need to be measured as well. For instance, it is possible that the Daughter Defense backfires primarily among people who have heard this defense used by accused men repeatedly, as they might already have the idea that the accused man is only mentioning his female family member in order to look like an already-established ally to women. Thus, instead of looking at the match/mismatch between the political affiliations of the participant and the perpetrator, perhaps future research should look at participants news consumption to get a sense of whether participants differ based on how often they have seen this phenomenon play out in the news. I would expect more politically nave participants, less politically active participants, and/or participants completely unfamiliar with the Daughter Defense, to all differ from participants who have seen the Daughter Defense be used by a real politician or talked about in the news. In addition to this, the reliability scores for several items were lower than expected, so results should be interpreted with caution. Future work ought to use improved measures in order to ensure items are fully reliable. Conclusion As I expected, as conservatism increased, perceptions of the alleged perpetrator became more positive, regardless of the alleged perpetrators political affiliation or response type. Contrary to my hypotheses but supported by some prior research (Lizzio-Wilson et al., 2022), the Daughter Defense improved perceptions of the alleged perpetrator and the perpetrators response relative to the control defense. Thus, presenting oneself as a father of a daughter may serve as an effective strategy for men accused of sexual misconduct. Furthermore, results indicate that perceiving fathers of daughters as less guilty of sexual harassment allegations may 27 constitute a novel sexual harassment myth (Lonsway et al., 2008). These findings highlight the importance of understanding how alleged perpetrators present themselves as indirect, subtle, means of defending themselves. Despite these findings, many have called out the so-called Daughter Defense as a cynical attempt to use ones daughters as shields against accusations (Bennett, 2020), and it remains to be seen whether the Daughter Defense will be an effective strategy moving forward. If the Daughter Defense loses its utility for accused men, this program of research highlights the importance of understanding the rhetorical means through which alleged perpetrators cast doubt on the voices of alleged victims. 28 References Agiesta, J., & Sparks, G. (2018, October 11). CNN poll: Two-thirds call sexual harassment a serious problem in the US today. CNN. Retrieved from https://www.cnn.com/2018/10/11/politics/sexua l-harassment-poll/index.html Balliet, D., Tybur, J. M., Wu, J., Antonellis, C., & Van Lange, P. A. M. (2018). Political orientation, trust, and cooperation: In-group favoritism among republicans and democrats during a US national election. Journal of Conflict Resolution, 62(4), 797818. https://doi.org/10.1177/0022002716658694 Bennett, J. (2020, July 25). A.O.C. and the daughter defense. The New York Times. Retrieved September 29, 2022, from https://www.nytimes.com/2020/07/25/sunday-review/aocdaughters-ted-yoho.html Bhattacharya, G., & Stockdale, M. S. (2016). Perceptions of sexual harassment by evidence quality, perceiver gender, feminism, and right wing authoritarianism: Debunking popular myths. Law and Human Behavior, 40(5), 594609. https://doi.org/10.1037/lhb0000195 Christopher, A. N., & Mull, M. S. (2006). Conservative Orientation and Ambivalent Sexism. Psychology of Women Quarterly, 30(2), 223230. https://doi.org/10.1111/j.14716402.2006.00284.x Craig, S. C., & Cossette, P. S. (2022). Eye of the beholder: Partisanship, identity, and the politics of sexual harassment. Political Behavior, 44(2), 749777. https://doi.org/10.1007/s11109-020-09631-4 Craig, S. C., Rippere, P. S., & Grayson, M. S. (2014). Attack and response in political campaigns: An experimental study in two parts. Political Communication, 31(4), 647674. https://doi.org/10.1080/10584609.2013.879362 29 DeCelles, K. A., Adams, G. S., Howe, H. S., & John, L. K. (2021). Anger damns the innocent. Psychological Science, 32(8), 12141226. https://doi.org/10.1177/0956797621994770 Demopoulos, A. (2021, August 11). Lets Retire the Daughter Defense Once and For All With Governor Cuomo. Daily Beast. https://www.thedailybeast.com/lets-retire-the-daughterdefense-once-and-for-all-with-governor-cuomo Edwards-Levy, A. (2017, November 15). Most Hillary Clinton voters think the allegations against Bill Clinton are credible. Huffington Post. https://www.huffpost.com/entry/mosthillary-clinton-voters-think-the-allegations-against-bill-clinton-arecredible_n_5a0ca041e4b0c0b2f2f76f79 Eibach, R. P., Libby, L. K., & Ehrlinger, J. (2009). Priming family values: How being a parent affects moral evaluations of harmless but offensive acts. Journal of Experimental Social Psychology, 45(5), 11601163. https://doi.org/10.1016/j.jesp.2009.06.017 Feild, H. S. (1978). Attitudes toward rape: A comparative analysis of police, rapists, crisis counselors, and citizens. Journal of Personality and Social Psychology, 36(2), 156. https://doi.org/10.1037/0022-3514.36.2.156 Fiske, S. T., & Glick, P. (1995). Ambivalence and stereotypes cause sexual harassment: A theory with implications for organizational change. Journal of Social Issues, 51(1), 97115. https://doi.org/10.1111/j.1540-4560.1995.tb01311.x Hesse, Monica. (2018, July 11). What men are trying to say when they show off their Female Relationship Rsum. The Washington Post. https://www.washingtonpost.com/lifestyle/style/what-men-are-trying-to-say-when-theyshow-off-their-female-relationship-resume/2018/07/11/f58e414a-8391-11e8-8f6c46cb43e3f306_story.html 30 Hornsey, M. J., Wohl, M. J., Harris, E. A., Okimoto, T. G., Thai, M., & Wenzel, M. (2020). Embodied remorse: Physical displays of remorse increase positive responses to public apologies, but have negligible effects on forgiveness. Journal of Personality and Social Psychology, 119(2), 367. Johnson, T. (2018). Deny and attack or concede and correct? Image repair and the politically scandalized. Journal of Political Marketing, 17(3), 213234. Kirchhoff, J., & ehaji-Clancy, S. (2014). Intergroup apologies: Does it matter what they say? Experimental analyses. Peace and Conflict: Journal of Peace Psychology, 20(4), 430. Leiner, D. J. (2019, December). Too fast, too straight, too weird: Non-reactive indicators for meaningless data in internet surveys. Survey Research Methods (Vol. 13, No. 3, pp. 229248). Lisnek, J. A., Wilkins, C. L., Wilson, M. E., & Ekstrom, P. D. (2022). Backlash against the# MeToo movement: How womens voice causes men to feel victimized. Group Processes & Intergroup Relations, 25(3), 682-702. Lizzio-Wilson, M., Klas, A., & Clarke, E. J. (2022). When good guys do bad things: Evaluations of sexual harassment allegations against male allies. Group Processes & Intergroup Relations, 13684302221094432. Lonsway, K. A., Cortina, L. M., & Magley, V. J. (2008). Sexual harassment mythology: Definition, conceptualization, and measurement. Sex Roles, 58(9), 599-615. MacLachlan, A. (2015). Trust me, Im sorry: The paradox of public apology. The Monist, 98(4), 441-456. 31 Munro, G. D., Weih, C., & Tsai, J. (2010). Motivated suspicion: Asymmetrical attributions of the behavior of political ingroup and outgroup members. Basic and Applied Social Psychology, 32(2), 173-184. Naseralla, E. J., Baker, S. G., & Warner, R. H. (2021). The influence of political partisanship on perceptions of sexual assault. Analyses of Social Issues and Public Policy (ASAP). https://doi.org/10.1111/asap.12273 Nigro, G., Ross, E., Binns, T., & Kurtz, C. (2020). Apologies in the #MeToo moment. Psychology of Popular Media, 9(4), 403411. https://doi.org/10.1037/ppm0000261 Perry, S., Skinner-Dorkenoo, A. L., Wages, J., & Parzonka, J. (2019). Ambivalent reactions to people who deny or admit their gender and racial biases. Prokos, A. H., Baird, C. L., & Keene, J. R. (2010). Attitudes about affirmative action for women: The role of children in shaping parents interests. Sex Roles, 62(5), 347-360. Schultz, C. (2021, August 13). Powerful men, their enablers, and the victims, like me, who are harassed. USA Today. https://www.usatoday.com/story/opinion/columnist/2021/08/13/sexual-harassmentvictims-cuomo-enablers-trap-victims/5547313001/ Schumann, K. (2014). An affirmed self and a better apology: The effect of self-affirmation on transgressors' responses to victims. Journal of Experimental Social Psychology, 54, 8996. Schumann, K., & Dragotta, A. (2020). Is moral redemption possible? The effectiveness of public apologies for sexual misconduct. Journal of Experimental Social Psychology, 90, 104002. 32 Sharrow, E. A., Rhodes, J. H., Nteta, T. M., & Greenlee, J. S. (2018). The first-daughter effect: The impact of fathering daughters on mens preferences for gender-equality policies. Public Opinion Quarterly, 82(3), 493523. https://doi.org/10.1093/poq/nfy037 The jamovi project (2021). jamovi (Version 1.6) [Computer Software]. Retrieved from https://www.jamovi.org van der Linden, S., & Panagopoulos, C. (2019). The O'Reilly factor: An ideological bias in judgments about sexual harassment. Personality and Individual Differences, 139, 198201. von Sikorski, C. (2018). The aftermath of political scandals: A meta-analysis. International Journal of Communication, 12, 31093133. Warner, R. L., & Steel, B. S. (1999). Child rearing as a mechanism for social change: The relationship of child gender to parents commitment to gender equity. Gender & Society, 13(4), 503517. https://doi.org/10.1177/089124399013004005 Washington, E. L. (2008). Female socialization: how daughters affect their legislator fathers. American Economic Review, 98(1), 311-32. Wout, D. A., Murphy, M. C., & Barnett, S. (2014). When having Black friends isnt enough: How threat cues undermine safety cues in friendship formation. Social Psychological and Personality Science, 5(7), 844-851. Wout, D. A., Murphy, M. C., & Steele, C. M. (2010). When your friends matter: The effect of White students' racial friendship networks on meta-perceptions and perceived identity contingencies. Journal of Experimental Social Psychology, 46(6), 1035-1041. 33 APPENDICES 34 Appendix A Perception of the Alleged Perpetrator and Victim 1. Using the following scale, how much was Alicia/Amber (the alleged victim) responsible for the harassment? a. 1 (not at all responsible) to 100 (completely responsible) 2. Using the following scale, how much was Andrew/Kenneth (the alleged perpetrator) responsible for the harassment? a. 1 (not at all responsible) to 100 (completely responsible) 3. Andrew/Kenneth (the alleged perpetrator) was guilty of harassment. a. 1 (strongly disagree) to 7 (strongly agree) 4. Andrew/Kenneth (the alleged perpetrator) was innocent of harassment. a. 1 (strongly disagree) to 7 (strongly agree) 5. Andrew/Kenneth (the alleged perpetrator) misused his authority over the alleged victim. a. 1 (strongly disagree) to 7 (strongly agree) 6. From the previous scenario, it seems that the alleged victim was only trying to tarnish Andrew's/Kenneths (the alleged perpetrator) reputation. a. 1 (strongly disagree) to 7 (strongly agree) 7. The alleged victim seemed trustworthy. a. 1 (strongly disagree) to 7 (strongly agree) 8. Alicia/Amber (the alleged victim) seemed sincere. a. 1 (strongly disagree) to 7 (strongly agree) 35 Appendix B Perception of the Defense 1 (strongly disagree) to 7 (strongly agree) 1. In the scenario you read, how angrily did Andrew/Kenneth (the alleged perpetrator) react to the accusation? 2. In the scenario you read, how calmly did Andrew/Kenneth (the alleged perpetrator) react to the accusation? 3. I believe that Andrew/Kenneth will commit similar acts in the future. 4. Nothing Andrew/Kenneth could say would be able to change my opinion of him. 5. Andrew/Kenneth seems guilty of the allegations against him. 6. Andrew/Kenneth seems like a good person. 7. Andrew/Kenneth seems like an immoral person. 8. Andrew/Kenneth seems like he could change for the better. 9. Andrew/Kenneth disgusts me. 10. I feel compassion for Andrew/Kenneth. 11. I feel anger toward Andrew/Kenneth. 12. I feel forgiving toward Andrew/Kenneth. 13. The allegations against Andrew/Kenneth are unforgivable. 14. This statement seems sincere. 15. This statement is insufficient. 16. This statement is satisfying. 17. This statement is worthless. 18. This statement improves my perceptions of Andrew/Kenneth. 36 19. This statement worsens my perceptions of Andrew/Kenneth. 20. I believe what Andrew/Kenneth says in his statement. 1 (not at all) to 7 (a great deal) 21. Should Andrew/Kenneth be forgiven by his accuser for his actions? 22. Should Andrew/Kenneth be legally punished for his actions? 23. Should Andrew/Kenneth be morally redeemed in the eye of the public? 24. Should Andrew/Kenneth be removed from the position he held at the time of this allegation? 25. Should Andrew/Kenneth be allowed to work in a similar position in the future? 37 Appendix C Social/Economic Conservatism 1 (strongly disagree) to 7 (strongly agree) 1. There need to be stricter laws and regulations to protect the environment. 2. The government should help more needy people even if it means going deeper into debt. 3. The growing number of newcomers from other countries threaten traditional American customs and values. 4. I never doubt the existence of God. 5. Business corporations make too much profit. 6. Gays and lesbians should continue to be allowed to marry legally. 7. The government needs to do more to make health care affordable and accessible. 8. One parent can bring up a child as well as two parents together. 9. Government regulation of business usually does more harm than good. 10. Abortion should be illegal in all or most cases. 11. Labor unions are necessary to protect the working person. 12. Poor people have become too dependent on government assistance programs. Single-Item Orientation Measure 1. On the following scale, please indicate your political orientation: a. 1 (very liberal) to 11 (very conservative) Single-Item Affiliation Measure 1. On the following scale, please indicate your political affiliation: a. 1 (Democratic) to 6 (Republican) 38 APPENDIX D Demographics 1. Please indicate your age (in years): 2. Please indicate your race: - Selected Choice a. White/Caucasian b. African American c. Asian/Asian American d. Latina/o e. Native American f. Middle Eastern g. Other (please specify) h. Mixed (please specify) 3. How long have you lived in the United States (in years): 4. Please indicate your sex: a. Male b. Female c. Transgender d. Nonbinary 5. Do you have any children? a. Yes/No 6. If you selected, "yes" to the previous item, please indicate the number of sons and/or daughters you have: a. Sons: 39 b. Daughters: c. N/A; No Children  ...

... CBT TREATMENT IN AN ADOLESCENT REFUGEE EFFECTIVENESS OF COGNITIVE-BEHAVIORAL THERAPY FOR ANXIETY AND DEPRESSION IN AN ADOLESCENT REFUGEE: A CASE STUDY A Doctoral Dissertation Presented to the School of Psychological Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Psychology Rachel Walters May 2022 CBT treatment in an adolescent refugee 2 EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY FOR ANXIETY AND DEPRESSION IN AN ADOLESCENT REFUGEE: A CASE STUDY The signatures below certify that the Doctoral Dissertation of Rachel Walters has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: Debbie Warman, Ph.D. Dissertation Advisor John Kuykendall, Ph.D. Dean, College of Applied Behavioral Sciences 5/2/2023 Katie Kivisto, Ph.D. Committee Member Marlyssa Fillmore, Ph.D. Committee Member 5/2/2023 Date Date CBT treatment in an adolescent refugee 3 Abstract Refugee mental health has been very under-researched in terms of the impact and implications their experiences have for treatment (Kim & Keovisai, 2016; Trieu & Vang, 2015). Burmese refugees, specifically, are even less present in refugee mental health research despite being one of the largest groups to relocate in the past 20 years, and the largest to relocate to the United States in the past 10 years (Kim, 2018; Kumar, 2020; Ngo-Metzer et al., 2010). Adolescent mental health has also been relatively under-researched despite this being a common age of onset, the chronicity of disorders, and psychosocial impact of mental health disorders when left untreated (Baker et al., 2021; Kendall et al., 1989; Kendall & Peterman, 2015; Strauss et al., 1987). The overall lack of research of refugee and adolescent mental health is reflected in treatment outcome studies. To date, there is no treatment outcome study for adolescent Burmese refugees in a Western country. The effectiveness of cognitive-behavioral treatment for generalized anxiety disorder and major depressive disorder in an adolescent refugee was examined. The patient, an adolescent Burmese refugee, was selected from an integrated primary care clinic in a Midwestern city. The patient received cognitive-behavioral therapy (CBT) for a diagnosis of generalized anxiety and major depressive disorder. Effectiveness of treatment was measured by comparing pre- and post-treatment scores on the Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7. The data was analyzed for statistical and clinical significance using the reliable change index (RCI). The calculated RCI did not suggest a significant change in the patients pre- and post-treatment scores. Treatment suggestions based on Chomdens treatment outcome and future research directions are presented. CBT treatment in an adolescent refugee 4 TABLE OF CONTENTS TITLE PAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i SIGNATURE PAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Construct Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Internal Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 External Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Value of a Case Study to Evaluate Psychotherapeutic Effectiveness . . . . . . . . . . . . . .9 Complex Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Flexible Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Research Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Case Study Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Time-Series Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Percentage of Non-Overlapping Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Reliable Change Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 PATIENT DESCRIPTIVE MATERIAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 REVIEW OF PSYCHOLOGICAL LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Generalized Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Cognitive-Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Mindfulness-Based Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Major Depressive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Cognitive-Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Interpersonal Psychotherapy for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . 27 Attachment-Based Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Refugee Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Ethnic Burmese and Chin Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 CLINICAL RESEARCH QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 METHODS/RESEARCH DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Generalized Anxiety Disorder-7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Patient Health Questionnaire-9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 CASE FORMULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Case Conceptualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 TREATMENT PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 COURSE OF TREATMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Session 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Session 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 CBT treatment in an adolescent refugee 5 Session 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Session 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Session 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Session 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Session 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Session 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Session 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Session 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Session 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 EMPIRICAL FINDINGS WITH ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 CBT treatment in an adolescent refugee 6 Introduction Single-subject case studies have played a key role in the development of theory of personality and behavior within clinical psychology (Widdowson, 2011). However, it was not until recently that they started to gain respect as a valuable research contribution, often being undervalued and overlooked as a true methodology (Perdices & Tate, 2009; Smith, 2012). Case studies were acknowledged for their heuristic value, but not for the ability to draw scientific inferences (Kazdin, 1981). This perception can be traced back to the lack of methodological rigor that impacted findings and ability to form valuable inferences. However, if methodological rigor is ensured, case studies may act as valuable contributions to research. The four criteria that are often used as a measure of rigor are reliability, construct validity, internal validity, and external validity (Crow, 2011; Gibbert et al., 2008; Kazdin, 1981; Schell, 1992; Tsang, 2013). Threats to validity and reliability within a case study will be discussed, and solutions posed by the literature to resolve these issues will be put forth. Reliability Reliability refers to the replicability and consistency of a measure or study. A study is said to have high reliability if future clinicians perform the same study and obtain similar results repeatedly (Kirk & Miller 1986). When engaging in single-case study designs, researchers should create a case study protocol and database. A case study protocol is a report specifying exactly how the case study was conducted. A case study database includes notes, documents, and narratives collected during the case study (Gibbert et al., 2008). By utilizing these tools, it increases the accuracy in which future researchers can replicate the case study. Construct Validity CBT treatment in an adolescent refugee 7 Construct validity refers to the quality of the conceptualization, or the operationalization, of the relevant concept (Gibbert et al., 2008). In the instance of research, construct validity refers to the study investigating what it claims to investigate and that the methods lead to an accurate portrayal of reality (Denzin & Lincoln, 1994). The use of subjective measures may drastically impact construct validity. In order to ensure construct validity, it is recommended that the researchers triangulate data, meaning they use different sources or types of data (Gibbert et al., 2008; Schell, 1992; Turner et al., 2017). For example, it is recommended to use multiple methods such as interviews, performance tasks, and rating scales, as well as multiple reporters, for example, client self-report, collateral reports of the client, or observer reports. Internal Validity Internal validity is the ability to determine a clear, causal relationship between two variables while ruling out random error and influence from external variables (Patino & Ferreira, 2018). It is more difficult to establish internal validity within case studies because the researcher is less able to determine if the change is due to treatment or another variable, as they typically do not control for external variables as tightly as group-designs. Without being able to rule out threats to internal validity, a case study cannot be considered to produce scientific inferences. Kazdin (1981; 2019) provides recommendations to rule out threats to internal validity within non-experimental designs. First, the researcher should utilize consistent, objective assessment outcomes (e.g., the same self- or collateral-report measures, carefully documented behavioral observations), as opposed to relying on anecdotal information alone. It is near impossible to draw scientific inferences from anecdotal evidence, as it is often based on impressions, clinical judgement, or assessments with poor validity that increase the likelihood of operating from cognitive heuristics or biases (Kazdin, 2019). In fact, Kazdin (1981, p. 185) noted the CBT treatment in an adolescent refugee 8 overreliance of anecdotal evidence as being the problem associated with case studies, rather than the use of a single subject. Second, outcome assessment should be continuous. Collecting only pre- and post-treatment data makes it more difficult to confidently say change was due to treatment and not an external variable. By collecting data continuously (e.g., daily or a few times per week), extrapolations for future behavior can be made and compared to the effects of treatment, and the data can be used to rule out alternative hypotheses. Lastly, the more immediate the therapeutic change as measured by symptom improvement, the higher the likelihood that it is due to treatment (Kazdin, 1981). External Validity External validity, or generalizability, is the ability for theories to apply not only to the situation being studied, but also to the population at large (Tsang, 2013). Low levels of external validity have been noted as the most profound issue for case studies (Yin, 1999). The critique of low generalizability derived from case studies stems from the small-N problem (Gerring, 2007; Tsang, 2013). However, the small-N problem does not monopolize deficits in generalizability, as these deficits may be observed within group designs as well. For example, the improvement of each individual subject is not provided. Instead, the aggregate effect of the group is given and thus researchers must generalize from it (Perdices & Tate, 2009). Yin (1999) provides a conceptual solution to the issue of generalizability. He states that if one views a case study as a single unit, then it can be considered equivalent to an experiment, as a unit. Researchers may improve external validity by having multiple subjects, ideally three to four (Borckardt et al., 2002; Kazdin, 1981). In the case where multiple subjects cannot be used, the researcher can improve external validity by providing a clear rationale for the case study selection and details CBT treatment in an adolescent refugee 9 on the case study context so the reader can fully understand the sampling choice (Gibbert et al., 2008). The lack of methodological rigor is not inherent to case studies, but rather a side effect of the lack of research protocol development. When methodological rigor is ensured, single subject case studies can yield valuable scientific inferences (Schell, 1992). These contributions are specifically relevant for psychotherapy outcome research. Value of Case Study to Evaluate Psychotherapy Effectiveness Case studies are a valuable tool when evaluating the effectiveness of psychotherapy and change over time. Psychotherapy effectiveness case studies, specifically, are the most represented in literature (Moeyaert, 2018; Morgan & Morgan, 2001; Shadish, 2014). Psychotherapy effectiveness refers to questions regarding if the intervention is working when administered to a specific client under real world conditions (Singal et al., 2014). Case studies are better equipped to handle questions of effectiveness opposed to efficacy, the performance of an intervention under controlled conditions, which is better measured by group designs like RCTs (Borckardt et al., 2002; Singal et al., 2014). By looking at questions of effectiveness, case studies are able to say for who and how psychotherapy works (Borckardt et al., 2008). They yield valuable information relevant to psychotherapy outcomes because they retain real-life contextual factors, have flexibility, and provide specific benefits relevant to research. Each of these areas is described below. Complex Contexts Case studies are well equipped to answer complex, psychotherapy outcome questions within their real-life context (Flyvbjerg, 2006; Gibbert et al., 2008; Schell, 1992; Yin, 1999). In contrast, group design studies often strip various contextual factors like comorbidities, diversity, CBT treatment in an adolescent refugee 10 and treatment as usual delivery in order to increase internal validity (Tsang, 2013; Widdowson, 2011). While this is needed to determine correlations and causality, it rids the participant and the study of real-life contextual factors. In comparison, case studies retain these uncontrollable differences. Case studies are able to address broad, complex questions within their context, opposed to removing and isolating these questions in a controlled laboratory setting (Yin, 1999). For example, several mental health surveys found that 45-60% of patients with a diagnosable mental illness also met criteria for one or more additional mental illnesses (Bourdon et al., 1992; Kessler et al., 1997; Kessler et al., 2005). Upwards of half the patients surveyed had a comorbid mental illness yet many group design treatment efficacy studies state comorbid mental illnesses in their exclusion criteria (Halvorson & Humphreys, 2015). While this is needed to determine efficacy for treating a specific disorder with a specific intervention, it may make the results of less interest to clinicians in the community where comorbidities are common. In contrast, case studies are able to recognize and include comorbidities because they focus on the individual at hand. By not controlling for as many external variables, the treatment more accurately represents what treatment as usual looks like for clinicians in the community. This is especially beneficial for those clinicians as the case study would accurately reflect their experience, possibly making the findings more relevant and of greater interest to them (Perdices & Tate, 2009). By retaining these variables, case studies remain flexible while recognizing and embracing the uniqueness of each individual (Borckardt et al., 2002). Flexible Implementation Case studies have a level of flexibility that make them well equipped to evaluate treatment effectiveness (Tate et al., 2008). In a group design, the treatment is often rigidly manualized and there is little to no room for change throughout the course of treatment. CBT treatment in an adolescent refugee 11 Additionally, statistical analyses of the outcomes are not performed until the end of the study. While case studies may adhere to a principle-based or detailed manual, the continuous assessment of treatment effectiveness in a single-case design provides the clinician with the ability to adapt and make changes to the treatment as needed if it is not yielding the desired change (Anderson & Kim, 2003; Tate et al., 2008). This makes case studies exceptionally well at coping with uncertainty that inevitably presents during treatment in a community setting (Crow, 2011). Research Benefits RCTs are the cornerstone of psychotherapy outcome research, and should be, however they should not overshadow the valuable contributions that well-designed single-subject research can bring to the field. RCTs provide powerful statistical procedures that allow researchers to confidently find aggregate effects. Single-subject designs should not replace RCTs in this regard, but rather advance the field beside them in the place of research they hold evaluating effectiveness of treatments for an independent client. By engaging in and promoting the use of well-performed case studies, clinicians can enhance the research of treatment effectiveness. They are a critical link in the chain of research, as they are the first step in testing a hypothesis (Crow, 2011). Once the hypothesis has been further explored with group-design studies, a case study uses these results to clarify findings and provide further guidance for other researchers (Borckardt et al., 2008). The applicability of case studies promotes clinicians in the community to function as scientist-practitioners, contributing to the body of research and further enriching the building knowledge of behavioral and psychological sciences (Anderson & Kim, 2003). Case Study Methods CBT treatment in an adolescent refugee 12 There are various ways to measure and analyze client change within a case study. Three methods of measuring change within single-subject designs are time-series analysis, percentage of non-overlapping data, and reliable change index. While each of these methods provides both benefits and limitations, there has yet to be an agreement in the field of which is best to statistically summarize treatment effects (Beretvas & Chung, 2008). These methods, how they are conducted, and the pros and cons of each will be discussed. Time-Series Analysis Time-series designs are often used in group designs (e.g., randomized controlled trial) and are now commonly used in single-subject case studies (Smith et al., 2013). Time-series designs measure a variable equally over time (Crabtree et al., 1989). By continuously tracking client outcomes throughout the duration of treatment and comparing this to a baseline, practitioners can yield valuable information about responses to psychotherapeutic interventions (Nash et al., 2011). Single-case time-series designs answer two types of psychotherapy questions questions of improvement and of process of change (Borckardt et al., 2008). Questions of improvement are generally interested in if there is meaningful change from the pre- to post-treatment phase, and if so, is the change statistically significant? For example, Mariotti et al. 2021 conducted a case study exploring the effectiveness of the Unified Protocol for Children (UP-C) in preadolescents with subthreshold emotional problems. In their case study they were able to monitor anxiety and depression and provide evidence that the UP-C was effective in treating subthreshold emotional disorders. In addition, patterns of response to an intervention can be detected (i.e., delayed, temporary, gradual, and cyclic effects; Crabtree et al., 1989). Questions of process of change are interested in how change occurs and can be either univariate or multivariate. Univariate process CBT treatment in an adolescent refugee 13 change requires the tracking of a single variable (i.e., symptom). This question may be, when does the client start improving? Multivariate process questions of change simultaneously track two or more variables. These questions are capable of addressing mechanism of change or sequencing, the order in which improvement occurs. A case-study by Crane et al. (2003) used multivariate questioning to explore the symptom severity and bi-directional relationship between irritable bowel syndrome (IBS) and bipolar disorder. Their study was able to identify an unusual occurrence where an increase in self-reported depression was associated with less severe IBS symptoms. One protocol for a single-case time-series was developed by the University of Tennessee Psychology Clinics Practice-Research Integrative Project (Nash, 2005), and adopted by Borckardt et al. (2008). To begin, the clinician must first choose a research question and determine which symptom(s) will be tracked. These symptoms can be cognitive (e.g., concentration difficulties), emotional (e.g., depression), or behavioral (e.g., medication adherence). The client is then instructed to rate the chosen symptom on a Likert scale every day, during the baseline and treatment phase. Self-report questionnaires may also be utilized as a measure of symptom severity and change. The baseline phase should yield between seven and 14 data points and the treatment phase must yield a minimum of 35 data points. During analyses, clinical researches must account for autocorrelation inherent in repeated measures. Due to the strict requirements of minimal data collection, time-series does not provide much flexibility in this aspect. In order to accurately gauge the change in outcome variables, observations must be evenly spaced (Borckardt et al., 2008). The intervals between measures must be the same throughout the entire study, either daily, weekly, etc. This is done to prevent statistical artefacts, CBT treatment in an adolescent refugee 14 when the bias in the collection of data interferes with the results (Scott & Marshall, 2005). Collecting equally spaced data on a single-subject allows for valuable data to be collected without the cost associated with other group-designs (Crabtree et al., 1989). Time-series analysis is an empirically grounded method to determine the effectiveness of an intervention. It allows the researcher to ask questions beyond simple intervention effectiveness and ask those of process change. While it proposes many scientific benefits, these are compounded with practical difficulties. When using time-series analysis it is necessary to collect data evenly throughout the treatment, and every day during the baseline phase. If a single day of rating is incomplete, time-series analysis can no longer be used. Percentage of Non-Overlapping Data Percentage of non-overlapping data (PND) is a method developed by Scruggs & Mastropieri (1987) used frequently in single-subject behavior research to measure meaningful change (Beretvas & Chung, 2008; Kazdin, 2006). PND provides a non-parametric (i.e., does not assume the data is normally distributed) descriptor of the data by analyzing the percentage of data in the treatment phase that falls below the lowest point in the baseline phase (if the intended direction of change is negative; Beretvas & Chung, 2008; Parker et al., 2011). To calculate the PND, the clinician needs to identify the intended change and choose an appropriate method of collecting data to measure said change. Similar to time-series analysis, the variable of interest may be cognitive, emotional, or behavioral. The clinician may also opt to use specific brief outcome measures, like the Patient Health Questionnaire 9. Once the data has been collected, the lowest data point within the baseline phase is identified if the intended direction of change is negative. A line is drawn from this point through the treatment phase and all data points below this line are counted. The PND is then calculated by dividing the number of CBT treatment in an adolescent refugee 15 data points below the lowest point in the baseline phase by the total number of data points in the treatment phase (Beretvas & Chung, 2008). PND scores of 90% are regarded as very effective, 70 to 90% are regarded as effective, scores of 50 to 70 are questionable, and scores below 50% are regarded as ineffective. The PND visually displays this meaningful data about the treatment effectiveness (Scruggs & Mastriopieri, 1998). The calculations simplicity does not take away from the applicability and meaningfulness of measuring the effectiveness of treatment outcomes. Overlap between baseline and treatment phases have been noted as an essential measure in evaluating outcomes (Scruggs & Mastropieri, 1998). When there is low overlap between the baseline and treatment phase, the effect is considered reliable (Kazdin, 1978). PND measures have been found to correlate with expert ratings of treatment effectiveness when the reliability of their ratings was also high (Mastropieri & Scruggs, 1985-1986). Using PND to calculate treatment effectiveness replicates benefits similar to time-series design. It requires the same level of planning prior to meeting the client but allows for slightly more flexibility. Compared to the time-series design, PND data points do not need to be collected daily, or in equal intervals, though a baseline does need to be established. This alleviates many of the practical constraints placed on the clinician. PND displays data in a way that allows researchers to readily interpret it (Olive & Franco, 2008). The ease of interpretation may allow for more clinicians in the community to act as researchers. Additionally, it is capable of handling small data sets, which is necessary when using single-subject case studies. However, PND is limited in the types of questions that can be answered, as it is only capable of analyzing treatment effectiveness. The analysis can also be heavily influenced by extreme data collection in CBT treatment in an adolescent refugee 16 the baseline phase which can lead to type 2 errors, which is a potential issue with the approach (Lenz, 2013). Reliable Change Index Statistical comparison between mean changes is often utilized to measure treatment effects. Jacobson & Truax (1991) note two limitations with this method. First, information on the variability of response to treatment is lost. Second, the presence of treatment effects in the statistical sense has little to do with clinical significance of the effects. The simple presence of statistically significant change does not indicate if that change was clinically meaningful to the patient. The example of a weight loss study for obese patients is put forth. A net weight loss of 2 lbs may be statistically significant compared to a control group that lost no weight, however losing two lbs may not put the patient outside the obesity range. In this example, the posttreatment change does not present as meaningful for the patient, which statistical treatment effect does not capture. In contrast, clinical significance by definition captures this type of meaningful change. Clinically significant change occurs when the change is statistically significant (i.e., at least as likely the change did not occur by random error or chance) and the change moves the individual closer to the typical or normal population (Kendall et al., 1999). One method that captures both statistical and clinically significant change is the Reliable Change Index (RCI). The first step in calculating the RCI is determining if the change that occurred between pre- and posttest scores is statistically significant (Lambert et al., 2008). The formula used to calculate statistical significance is RCI = x2 x1 /Sdiff , where x2 is the individuals posttest score, x1 is the individuals pre-test score, and Sdiff is the standard error of difference between the two scores. To calculate the standard error of difference, the following formula is used Sdiff = 2S2E. The standard error of difference is the spread of scores that would be expected if no change CBT treatment in an adolescent refugee 17 occurred (Jacobson & Truax, 1991). Knowledge of the test-retest reliability of the measure being used and standard deviation of the test scores is necessary to calculate the standard error of difference (Unicomb et al., 2016). An RCI of 1.96 is indicative of statistically significant change at the 0.05 significance level, with the valence indicating the direction of change (Jacobson & Truax, 1991). The presence of a positive or negative RCI depends on the measure being used and the targeted change. For example, if the BDI-II was used as the measure, then a negative RCI would be expected, as a significant change would result in a lower posttest score compared to the pre-test score. The final step is to determine if clinically significant change has occurred. To measure clinically significant change, a cutoff point needs to be set (Jacobson & Truax, 1991). The cutoff point refers to the point the client must cross at the post-treatment assessment to be classified as changed to a clinically significant degree. The cut-off point is determined by obtaining normative data for the disordered and normal populations (Unicomb et al., 2016). If the posttest score moves out of the range of the disordered population and into that of the normal population, then clinical change occurred. There are several strengths associated with using RCI to measure treatment outcomes in terms of clinically significant improvement. The use of clinical significance to measure treatment outcomes operationalizes recovery in a relatively objective and unbiased way (Jacobson & Truax, 1991). The definition of recovery is not tied to any one diagnosis and can be used for a variety of different disorders. The wide applicability of the approach gives it the potential to grow within psychotherapy research which could yield comparisons between studies and additional information on variability in treatment outcomes (Jacobson & Truax, 1991). This method may also encourage more clinicians to engage in psychotherapy research due to the CBT treatment in an adolescent refugee 18 emphasis it places on clinically significant change, which is of the utmost importance to working clinicians. Lastly, it is especially useful in small sample studies like a single-case study, as it allows an individual to be tracked across conditions and time (Zahra & Hedge, 2010). Despite its strengths there are limitations to this method which are worth noting. First, it assumes that functional and dysfunctional distributions are normal, which may not always be the case. Second, the assumption that recovery indicates the return into normal functioning may not be accurate depending on the diagnosis. For example, recovery for autism or schizophrenia will look quite different compared to depression or anxiety due to the nature of the disorders (Jacobson & Truax, 1991). Third, because it compares only pre- and post-treatment data, it limits the types of questions that can be asked. This approach would not be able to accommodate process of change questions, only questions regarding if the therapy did or did not work. Lastly, without the use of a psychometrically reliable psychotherapy outcome measures you cannot perform the calculation. Patient Descriptive Material The patient, who from this point forward will be referred to by the pseudonym Chomden, was a 17-year-old Chin female who was referred for therapy by her primary care physician after complaints of anxiety and depression. At her PCP appointment, her GAD-7 score was 8 out of 21 (mild) and PHQ-9 score was 13 out of 27 (moderate). After receiving the referral, the clinician met with Chomden and her father. Chomden was born in Burma (Myanmar) to her mother and father and was the second oldest daughter of four. She has one older sister (19 years old) and two younger sisters (12 and 8 years old). When she was four years old, her family left Burma and moved to Malaysia due to the civil unrest particularly aimed at ethnic minorities including Chin. Her family stayed in CBT treatment in an adolescent refugee 19 Malaysia for several years until relocating again to the United States at age eleven. She described not being able to speak any English when she first moved and that she experienced a lot of bullying in middle school. Her family had lived in the greater Indianapolis area from ages 11 and older. At the time of intake, she was living at home with her mother, father, and two younger sisters. Her older sister had moved out to go to college previously that year. At the time of the intake Chomden was a junior in high school. She was very active in her academics and extracurricular activities, like art club. She described having a small group of friends with whom she was close. However, upon further investigation she explained that while she considers them very close, she is quite reserved around them and does not share much emotional content. Chomdens medical history was positive for well-controlled exercise induced asthma and dysmenorrhea. At the time of intake she was prescribed Zoloft 50mg, which she started one month prior. She denied previous significant medical procedures, surgeries, traumatic brain injury, or seizures. She denied a family history of mental health disorders. Her developmental history was largely unremarkable. She achieved developmental milestones at her expected ages and never had a regression in development. Chomden was asked questions that aligned with DSM-5 criteria of generalized anxiety disorder. She endorsed feeling restless or on edge, being easily fatigued, and difficulty concentrating or mind going blank. She denied experiencing racing thoughts, irritability, muscle tension, and difficulty falling or staying asleep. Although denying experiencing racing anxious thoughts, throughout the intake she described experiencing what would be racing thoughts. Chomden stated that she had experienced several panic attacks before. During these panic attacks she endorsed experiencing shortness of breath, light headedness, nausea, crying, and increased CBT treatment in an adolescent refugee 20 heart rate. She stated that she worries about a variety of things including talking in class, being around a lot of people, failing in school, and pressure from setting high academic standards. She reported that she first started noticing symptoms of anxiety approximately a year prior and that it significantly impacts her socially and academically. She was asked about previous attempts to cope with anxiety, explaining she has tried walking outside to clear her mind which had been mostly successful. She endorsed several symptoms that align with DSM-5 criteria of major depressive disorder including depressed mood most days, loss of interest in pleasure or activities, low energy, loss of appetite and weight loss, hypersomnia, psychomotor retardation, and passive suicidal ideation. She reported that she first started experiencing symptoms of depression when she was 12 years old and that she experiences these symptoms kind of often. She provided further insight into how her depressive symptoms impact her. She reported not being able to eat much because she lacks appetite and it has caused her to lose weight. She stated that when she does eat, she cannot eat much, and she often feels nauseas after. Additionally, she sleeps up to 12 hours a day including at night and daytime naps. She discussed feeling very frustrated by these two symptoms and the way they impact her. When asked about her goals for therapy she explained that she would like to nap less, eat more, talk more to people during class, and talk more to people in general. Review of Psychological Literature Anxiety and depression are the most common mental health problems in children and adolescents today (Farrell and Barrett, 2007). These two mental health problems have been demonstrated to be associated with attention and concentration deficits, academic difficulties, poor peer relations and low self-esteem (Kendall et al., 1989; Strauss et al., 1987). Many CBT treatment in an adolescent refugee 21 disorders emerge during teen years, indicating that this age group deserves special attention in treatment and outcome studies (Kendall & Peterman, 2015). This section will review the current literature on effective treatments for generalized anxiety disorder and major depressive disorder in adolescents. It will also address the current literature and findings on the impact and implications for treatment for refugees. Generalized Anxiety Disorder Anxiety disorders are the most common psychiatric disorders in children and adolescents, with prevalence rates ranging from 6-20% (Baker et al., 2021; Costello et al., 2004; Creswell et al., 2020; Salkosky & Birmaher, 2008). Generalized anxiety disorder (GAD), specifically, is the most common disorder in adolescents (Imran et al., 2017). Adolescence is an essential time for intervention due to the negative impact anxiety disorders can have on psychosocial functioning including social interactions and school achievement (Van Ameringen et al., 2003). If left untreated, anxiety disorders tend to take a chronic course, persisting into adulthood (Hill et al., 2016). Despite the high prevalence rate and critical period of intervention, many studies do not address GAD specifically, but rather anxiety disorders in general or primary separation anxiety disorder (Creswell et al., 2020). The current review of treatment will reflect this issue and provide support based on treatment for anxiety disorders. The effectiveness of cognitive behavioral therapy and mindfulness-based therapies for the treatment of GAD in adolescents will be presented. Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT) is a gold standard treatment for anxiety disorders, including GAD (David & Cristea, 2018). This extends to the treatment of adolescents with GAD. It is a well-established, treatment of choice for GAD in adolescents (Compton et al., 2004; Higa- CBT treatment in an adolescent refugee 22 McMillan et al., 2016) given it is the most studied and has the most empirical support (Baker et al., 2021; Creswell et al., 2020; Salkosky & Birmaher, 2008). CBT for anxiety disorders, including GAD, has several key components: psychoeducation, relaxation training, cognitive restructuring, practicing problem-solving skills, and exposure to feared stimuli (Kendall & Peterman, 2015; Salkosky & Birmaher, 2008; Velting et al., 2004). It has demonstrated to be efficacious and effective in producing short- and long-term improvement in anxiety symptoms. CBT produces effective short-term outcomes treating adolescent anxiety. It has been found to be superior to waitlist or non-treatment control conditions. In one study evaluating the effectiveness of CBT in anxiety disorders, both individual and group formats were superior to the waitlist control condition (Villabo et al., 2018). A separate study found large treatment effects in adolescents with anxiety disorders, however they noted heterogeneity in their findings (James et al., 2020). Meta-analyses and reviews on the status of CBT provide excellent support for short-term outcomes. A 2008 meta-analysis reviewed over 20 RCTs evaluating the effectiveness of CBT for pediatric anxiety disorders and found substantial evidence for acute treatment (Salkosky & Birmaher, 2008). A 2015 review of 16 RCTs provided support for the efficacy and effectiveness of CBT for anxiety disorders in adolescents (Kendall & Peterman). In efficacy studies, clinical improvement rates were between 60-80%. For a more conservative rate of improvement, remission rates were between 50-70%. Brief CBT, specifically, yielded medium to large effect sizes posttreatment. Effectiveness studies were less impressive while significant improvements in symptoms were found, the effect sizes were lower than efficacy trials. In sum, they concluded that approximately two-thirds of children and adolescents receiving CBT showed clinical improvement, in both laboratory and community settings. It is important to note that of studies CBT treatment in an adolescent refugee 23 including mixed children and adolescent age groups, there were no significant differences in the outcomes between age groups. CBT yields effects that persist long-term. In a study looking at the long-term effects of CBT in 139 youths (ages 11-21), they found significant reductions in all anxiety symptom measures and loss of primary anxiety diagnosis in 63% at a long-term follow-up of an average of 3.9 years posttreatment (Kodal et al., 2018). A meta-analysis of over 20 RCTs found long-term efficacy for CBT in treating anxiety (Salkosky & Birmaher, 2008). In the same 2015 review mentioned previously, they found that the medium to large effect sizes persist into the 6-month follow-up after brief CBT (Kendall & Peterman, 2015). Mindfulness-Based Therapy Mindfulness has become increasingly popular in treating mental health problems (Odgers et al., 2020). Mindfulness, a practice originating from the Buddhist religion, is the intentional acceptance and non-judgmental noticing of an individuals emotions, thoughts, and sensation in the present moment (Zgierska et al., 2009). Mindfulness-based therapies (MBTs) are widely used to treat anxiety (Virgili, 2015). MBTs have been demonstrated to be effective in treating anxiety in adolescent populations (Cheung et al., 2021). The limited data available demonstrates good to mixed results in using MBTs to treat adolescent anxiety (Wehry et al., 2015). MBTs demonstrate efficacy and effectiveness in treating adolescent anxiety. Mindfulness-based stress reduction (MBSR) was found to be superior to control conditions in a 2020 meta-analysis of 14 RCTs evaluating the efficacy of mindfulness-based stress reduction (MBSR) in adolescents (Zhou et al., 2020). There was a significant reduction in anxiety symptoms compared to control conditions. However, the authors noted the significance may be affected by treatment duration with short-term interventions of 8-weeks or less showing less CBT treatment in an adolescent refugee 24 significant outcomes. A separate quasi-experimental study from 2016 compared MBSR to notreatment control group and found significant reductions in generalized anxiety symptomology, anxiety sensitivity, and intolerance of uncertainty (Alimehdi et al.). While these results are promising, limitations to note about the study are the small sample size (n = 30), and that it took place in Iran therefore the results may not generalize to treatment in Western countries. Lastly, a 2020 meta-analysis observed the efficacy of mindfulness-based interventions (MBIs) in 20 studies (Odgers et al., 2020). While they found a small effect size on posttreatment anxiety compared to controls, this was limited to children and was not observed in adolescents. Despite the high occurrence of GAD in the adolescent population, they have typically been underrepresented in treatment outcomes studies (Baker et al., 2021). Moreover, additional support is needed for more diverse populations (Creswell, 2020). While CBT is not the sole treatment for adolescent anxiety, RCTs on other modalities are quite limited and this review reflects that lack of literature (Creswell, 2020). Based on the current data available, while studies regarding MBIs are promising, CBT maintains the most substantial support for treating GAD in adolescents. Major Depressive Disorder Depressive disorders are a common mental health problem in adolescents, with prevalence rates ranging from 2-12% (Stikkelbroek et al., 2013; Walter et al., 2021). While it is less common than adolescent anxiety, it is nonetheless a significantly debilitating and interfering condition (Crowe & McKay, 2017). Depressive disorders that present in adolescence take a chronic course, where risk of recurrence in clinical samples have been reported as high as 5070% in a five-year span (Dunn & Goodyer, 2006). The debilitating nature and chronicity of the disorder lead to poor psychosocial functioning that can persist into adulthood (Avenevoli et al., CBT treatment in an adolescent refugee 25 2008; Maughan et al., 2013). These characteristics emphasize the need of effective intervention for adolescent depression (Weersing et al., 2016). This section will review the current literature on effective interventions in treating adolescent depression, specifically CBT, interpersonal psychotherapy (IPT), and attachment-based family therapy (ABFT). Cognitive Behavioral Therapy CBT is a treatment of choice and the most widely researched treatment for depression in adolescents (Compton et al., 2004; Spirito et al., 2011). The key components are similar to that of anxiety treatment and include psychoeducation, coping skills, social problem solving, participation in pleasant activities, behavioral activation, cognitive restructuring (Kazdin & Weisz, 1998). CBT is an efficacious and effective treatment of depression in adolescents capable of producing short- and long-term benefits. The efficacy of CBT for adolescent depression is well-established as evidenced by several meta-analyses and treatment reviews. In a 2016 meta-analysis, 14 RCTs observing the effects of individual CBT in depressed adolescents demonstrated to be a well-established treatment (Weersing et al., 2016). Seven of the RCTs demonstrated statistically significant effects against the control conditions. The authors note that many of these studies included more stringent control conditions like alternate psychosocial treatments. They did, however, find that the other seven studies included found that CBT failed to demonstrate statistical significance compared to control conditions. These trials also compared CBT to more stringent control conditions. However, none of these studies found a negative effect of CBT which is worth noting. In a 2015 systematic review of 52 studies observing treatments for depressed children and adolescents, CBT was determined to be superior to most control conditions and other CBT treatment in an adolescent refugee 26 psychosocial interventions including play therapy, psychodynamic therapy, and problem-solving therapy (Zhou et al., 2015). CBT did not retain this significance at the long-term follow-up. The authors concluded that CBT should be considered one of the best available psychotherapies for depression in children and adolescents. Lastly, a 2004 evidenced-based review of 21 RCTs evaluating the effects of CBT on both anxiety and depression in children and adolescents found that CBT showed medium to large effects for symptom reduction in comparison to wait-list, inactive controls, and active controls (Compton et al., 2004). The authors concluded that CBT was the current treatment of choice for child and adolescent anxiety and depression. Brief CBT is effective when administered in a collaborative, primary care setting. Richardson et al. (2014) examined the effects of brief CBT in depressed adolescents compared to pharmacotherapy, combined brief CBT and pharmacotherapy, or usual care. 101 adolescents were randomly selected for either the collaborative care condition (e.g., brief CBT, pharmacotherapy, or combined treatment) or usual care. Those in the collaborative care condition self-selected which treatment they received. 38% of the total 101 adolescents received CBT alone. At the 12-month follow-up the collaborative care condition had clinically and significantly higher response rates to treatment as defined be a 50% reduction in symptoms. CBT retains its effectiveness when administered under routine care conditions. A 2021 observational study examined the effectiveness of usual-care CBT in adolescents ages 11-18 years with a depressive disorder (Walter et al.). These participants were compared to a historical control group that received treatment as usual from a previous study (Weisz et al., 2009). Their results showed highly significant reductions in depressive symptoms, with effect sizes ranging CBT treatment in an adolescent refugee 27 from small to large across measures. The authors concluded that CBT is effective for adolescents with depressive disorders when administered until routine care conditions. There is evidence to suggest that CBT is a durable treatment for adolescent depression, maintaining treatment effects long-term. A 2018 meta-analysis observing the effects of 101 studies examining the posttreatment and long-term effects of CBT for adolescent depression, anxiety, and posttraumatic stress found that CBT had durable treatment effects (Rith-Najarian et al.). They found large effect sizes at posttreatment, 1-month, 3-month, 6-month, 1-year, and 2+ years follow-up. While the meta-analysis included other presenting problems like anxiety and posttraumatic stress, the effect sizes did not differ significantly by diagnoses. The authors did note, however, that effect sizes diminished across later follow-up assessments and effect sizes were smaller when reported by caregiver or youth respondents compared to evaluator reported. These results provide initial support that CBT has durable effects, but more research in this area is needed. Interpersonal Psychotherapy Interpersonal psychotherapy (IPT) is a manualized psychotherapy that was initially used to treat depression in adults (Duffy et al., 2019). Since its development, it has been expanded to other disorders and populations, including adolescents. IPT for adolescents (IPT-A) is used to treat acute depression in youths between the ages of 12 and 18 over a period of 12-16 sessions. The focus of IPT-A is on relationship issues and how they relate to ongoing depression and its symptoms (Weissman et al., 2008). The goal of IPT-A treatment is to help the adolescents recognize their feelings, increase understanding as to how interpersonal relationships and conflicts affect their mood, and build adaptive interpersonal skills (Miller et al., 2016). IPT-A is an effective treatment for adolescent depression, often yielding treatment effects similar to CBT. CBT treatment in an adolescent refugee 28 IPT-A is effective as evidence by several meta-analyses, reviews, and RCTs. IPT-A is effective when compared to treatment as usual. A 2004 RCT compared IPT-A to treatment as usual in school-based mental health clinics in 63 depressed adolescents (Mufson et al., 2004). Compared to those who received treatment as usual, those who received IPT-A showed greater symptom reduction and improvement in functioning. The authors conclude that IPT-A is an effective treatment for adolescent depression. In a 2019 meta-analysis of 20 studies examining the effects of IPT-A on depression, they found that overall participants experienced large improvements in depressive symptoms postintervention and some evidence that these gains were maintained for up to a year (Duffy et al., 2009). When compared to other psychosocial interventions, IPT-A showed a medium significant effect compared to less-structured, active control conditions. When compared to CBT, there were no differences in postintervention depressive symptoms. These results are also demonstrated when observing remission rates. When compared to non-CBT active controls, IPT-A showed significantly higher remission rates. The authors conclude that IPT-A is an effective intervention for adolescent depression. In the same 2015 systematic review by Zhou et al. previously mentioned, they found that IPT yielded similar results to CBT. IPT was also significantly more effective than control conditions and active control conditions including play therapy, psychodynamic therapy, and problem-solving therapy. Additionally, IPT was the only treatment that remained significant at the long-term follow-up. The authors concluded that along with CBT, IPT is one of the best available psychotherapeutic treatments for adolescent depression. In the same 2016 review by Weersing et al. previously mentioned, the authors conclude that IPT is a well-established intervention for adolescent depression based on the evidence of CBT treatment in an adolescent refugee 29 efficacy from multiple trials. They also note that there is a smaller size of IPT literature which may have impacted their findings. Attachment-Based Family Therapy Attachment-based family therapy (ABFT) is a process-oriented, structured therapy that uses theories from family therapy and attachment theory to understand adolescent depression and suicidality. The creators, Diamond et al. (2014), posit that poor attachment bonds, conflict, harsh criticism, and low affective attunement can lead to physical or emotional neglect, abuse, and abandonment. This negative family environment inhibits children and adolescent from developing internal and interpersonal coping skills needed to buffer against stresses, which can lead to or exacerbate depression (Rudolph et al., 2000). The process of change for this therapy is to then improve the insecure attachment that has formed between caregiver and child (Diamond et al., 2016). While there is some evidence to suggest that ABFT is an effective treatment for depressed adolescents, the results are overall mixed. There are mixed results when comparing ABFT to treatment as usual. A 2010 study evaluated the effects of 14 weeks of ABFT compared to enhanced treatment as usual in 66 depressed, suicidal adolescents (Diamond et al.). The results showed that in comparison to enhanced treatment as usual, those in the ABFT group significantly improved as measured by decreased suicidal ideation during treatment. In a 2013 study observing the effectiveness of ABFT compared to treatment as usual, 20 adolescents were randomly assigned to 12 weeks of either condition (Israel & Diamond, 2013). The results showed significantly greater improvements on depressive outcome measures for the ABFT group. A more recent study compared ABFT to treatment as usual in 60 adolescents diagnosed with MDD (Waraan et al., 2021). While the participants in both groups reported reduced depressive symptoms, the majority CBT treatment in an adolescent refugee 30 were still in a clinically significant range. ABFT was not superior to treatment as usual as evidenced by low remission and response rates for both groups. There is evidence that ABFT is more effective than CBT, specifically when major depression is comorbid with a history of sexual trauma. In a 2012 study observing the effectiveness of ABFT with major depression in individuals with a history of sexual trauma, 66 adolescents were randomly assigned to either ABFT or enhanced care as usual (ECU; Diamond et al., 2012). The results demonstrated ABFT to be more effective than EUC in individuals with or without a history of sexual trauma. ABFT was then compared to CBT in the treatment of adolescents with depression and history of sexual trauma. Using data from the Treatment of Adolescents with Depression Study (TADS; 2004), Lewis et al. (2010) observed the impact that history of sexual trauma had on the treatment outcomes in the TADS study. When comparing the effect sizes from the Diamond et al. (2012) and Lewis et al., (2010) studies, Diamond et al. (2012) found that ABFT outperformed CBT in individuals with a history of sexual trauma. Refugee Status The world is currently experiencing some of the highest rates of displaced individuals since The United Nations High Commissioner for Refugees (UNHCR) started keeping record in 1951 (Kim, 2018). Over 25 million people who are displaced can be categorized as a refugee, or someone who has fled war, violence, conflict, persecution for reasons of race, nationality, membership of a particular social group, or political opinion and have crossed international borders seeking safety in another country (UNHCR, 2001). This is the highest refugee population in the past 20 years (Kumar, 2020). The United States plays an essential role in the resettlement of approximately 70% of refugees annually (Kim, 2018). One of the largest groups of refugees that have resettled in the U.S. are Burmese refugees (Kumar, 2020). CBT treatment in an adolescent refugee 31 Burmese refugees are the largest group to have resettled in the U.S., with over 160,000 coming in a ten-year span (Kim, 2018; Tan et al., 2014). Indiana is home to one of the largest Burmese populations within the U.S. (Asian Learning Center of Indiana, 2011). Approximately 35,000 Burmese people reside in Indiana, many of whom hold a refugee status. Indianapolis has the largest community approximately 24,000, as of 2020 (Contreras, 2021). Many of these refugees belong to one of Burmas major ethnic minorities Karen, Karenni, or Chin, with Chin making up approximately 83% of the population in Indiana (Indiana State Department of Health, 2014). Refugee status has numerous implications for an individuals mental and physical health. Overall, they are at a higher risk for physical and psychological distress (George, 2010). Reasons for relocation may have directly caused trauma or instances of violence, both of which increase their risk of developing mental health disorders including anxiety, depression, and posttraumatic stress (Bolton et al., 2014). In fact, they experience depression at a higher rate than the general population at a rate of 30.8% (Steel et al., 2009). Apart from mental health problems due to violence and trauma, the relocation itself can lead to decreased mental health functioning from the drastic shift in culture (Noom & Vergara, 2011). This can cause culture shock and a rapid need for acculturation. The acculturative stress that Burmese adolescents, specifically, experience has been shown to lead to suicidal ideation and low self-esteem which was correlated with anxiety, hopelessness, and depression (Hovey & Magana, 2002; Noom & Vergara 2011; Sonderegger et al., 2004). One study found that isolation was a leading cause for an increase in psychological illness (Burnett & Gebremikael, 2005). This point is especially relevant now, with isolation at an all-time high from the COVID-19 pandemic and subsequent necessary lockdowns, quarantine, and social distancing (Hwang et al., 2020). CBT treatment in an adolescent refugee 32 Female Burmese refugees are at an even greater disadvantage when it comes to declining mental health. In one study, being female was found to be significantly positively associated with symptoms of depression, anxiety, and PTSD (Kim, 2018). In a separate study, women who resettled in Western countries were found to have had a tenfold risk of developing PTSD compared to their same-aged female counterparts in the general population (Kirmayer et al., 2011). This provides additional insight into how the location after resettlement can influence mental health. While the literature shows that the refugee population can experience overall declines in mental health, knowledge on the mental health experiences of the group is significantly lacking (Kim & Keovisai, 2016; Trieu & Vang, 2015). Burmese refugees are one of the most understudied minority groups with relatively few studies on their mental health and overall health status (Hickey, 2007; Ngo-Metzer et al., 2010). While there are few studies on overall mental health, there are even fewer that look at how to treat mental health concerns most effectively in this population. One study observed the effectiveness of Common Elements Treatment Approach (CETA) in Burmese refugees relocated in Thailand (Bolton et al., 2014). The elements of this treatment were engagement, psychoeducation, anxiety management (relaxation), behavioral activation, cognitive coping/restructuring, suicide risk assessment, and alcohol/substance use assessment/intervention. The results demonstrated that CETA was effective in reducing symptoms of depression, anxiety, and posttraumatic stress. Part of what makes this group specifically so unique is the ethnic and religious diversity. This diversity poses additional need for a significantly greater understanding of their mental health. In one study, ethnicity was a main factor that was consistently associated with the majority of the behavioral health outcomes (Kim, 2018). Additionally, much of what is known of CBT treatment in an adolescent refugee 33 this group is from refugees who relocated to Eastern countries, for example Thailand or Malaysia. While this remains an important contribution in the understanding of this group, it neglects the experience of those who have resettled in the U.S. The unique experience of Burmese refugees in the U.S. should be of interest given the role it has played during their resettlement and the implications it has on their mental health. In sum, there remains a significant need to treat behavioral health concerns with limited understanding or guidance on how to do so (Kim, 2018; OMahony & Donelly, 2010). Ethnic Burmese and Chin Culture Myanmar, formally Burma, is currently the center of the one of the largest refugee crises in the world (Lewis, 2019). For the purpose of this dissertation, the country will be referred to as Myanmar, while people who are from the country are referred to as Burmese, a distinction that is consistent in the literature (Steinberg, 2013). Note that Burmese is different from Burman, which is the ethnic majority in Myanmar. Myanmar is one of the worlds most ethnically diverse countries, with more than 130 different ethnic groups (Fike & Androff, 2016). While majority of the population is ethnically Burman and practices Buddhism, the ethnic minorities make up nearly 40% of the 50 million people who reside in Myanmar (Kramer, 2015). There are eight nationally recognized races in Myanmar Burman (Bamar), Chin, Kachin, Kayah (Karenni), Kayin (Karen), Mon, Rkhine (Arakan), and Shan (Stokke, 2019). The country is divided into seven Burman regions in the center area of the country, with seven ethnic states along the border of the country (Stokke, 2019). Along with ethnic diversity, Myanmar is also rich in religious and linguistic diversity. The main religions that are practiced include Buddhism, Christianity, Islam, and Hinduism. CBT treatment in an adolescent refugee 34 Christianity is especially prevalent within the ethnic minorities, for example Chin (Stokke, 2019). The official language of the country is Burmese, however there are over 118 languages spoken throughout the country (Simons & Fennig, 2017). The Chin state is a very independent, remote part of Myanmar (Lalhriatpuii & Shyamkishor, 2019). It has been politically, socially, and economically discriminated against and isolated from the rest of the country (Bawi, 2015). Chin culture emphasizes family and community. Family, ethnic identity, community, and religion are all vital to their values and identity (Bawi, 2015; Thein, 2015). Myanmars ethnic diversity is central to the refugee crisis that has persisted for decades. The refugee crisis in Myanmar can be traced back to the civil war and ethnic conflict that has afflicted the country since gaining independence in 1948. Many minorities, including religious, ethnic, and political, have been persecuted and displaced by the military regime leading to need to seek refuge (Alexander et al., 2017). The state of conflict worsened after the military coup in 1962 when the country changed from a democracy to military rule, and minorities were further minimized and oppressed (Kramer, 2015). Military seize of power within the country has persisted, with the most recent coup occurring in February of 2021 (Thein-Lemelson, 2021). This conflict, which has given rise to ethnic and religious violence, can be traced back to numerous factors including trauma from colonialism, poverty, transition from a military government to a democratic state, and the global war on terror (Harvard Divinity School, 2018). Decades of civil war has contributed toward the breakdown of education and healthcare systems, militarization, food insecurity, discrimination, and human rights violations (Kramer, 2015). As a result, people of Myanmar started relocating in large numbers to the United States in 2008, however more than 3 million have relocated to the U.S. in the past 40 years (Ballard et al., 2020; Wang, 2022). CBT treatment in an adolescent refugee 35 The decades of war, persecution, and violence has contributed toward violence, suffering, and trauma for ethnic minorities in Myanmar (Kim et al., 2021; Kramer, 2015). The traumatic experiences begin in their home country from persecution; however, they persist at refugee camps and even after resettlement (Kim et al., 2021). These experiences contribute toward a substantial need for mental health care, however there are many barriers that exists some of which are related to the perception of mental health in Burmese culture. There are many cultural barriers that exist and prevent Burmese refugees from seeking treatment. Stigma of mental health has been identified as one of the largest barriers to accessing mental health treatment (Morris et al., 2009). Part of the stigmatization of mental health in Myanmar is due to language and lack of information of mental health (Kim et al., 2021; Saechao et al., 2012). Mental health is often a new concept for Burmese individuals who have relocated to the United States. In Myanmar, the construct of mental health is typically related to being crazy, or is for crazy people (Kim et al., 2021). There is no appropriate translation for the term mental health in languages that are spoken in Myanmar. Individuals are even further dissuaded from bringing mental health up, as it is highly taboo and shameful to discuss. By openly talking about mental health, they jeopardize their face or reputation (Kim et al., 2021). Because family is extremely important in Burmese cultures, and families have a collective face, the possibility of losing face for ones family is avoided (Evason, 2017). Clinical Research Question There is an evident lack of literature focusing on refugees and adolescents with mental health problems. In an attempt to narrow this gap, this case study will address the research question will a female adolescent Burmese refugee with generalized anxiety disorder and major depressive disorder be better off after receiving CBT treatment in a primary care setting? CBT treatment in an adolescent refugee 36 This will be assessed by examining the patients pre- and posttreatment scores on validated assessments for statistical and clinical significance. In order to test this question, a reliable change index will be computed. This method of analysis permits addressing the primary question of study improvement in treatment while also focusing on validated measures that have been used in prior research of depression and anxiety (Delgadillo et al., 2017; Islam et al., 2020; Mewton et al., 2012; Richardson et al., 2009; Richardson et al., 2014) Methods/Research Design Procedure This case study was conducted in an integrated primary care clinic located in the greater Indianapolis area. The patient was selected from a pool of referrals provided to the clinicians from the medical residents in the clinic. The selected patient was seen for weekly, in-person psychotherapy sessions, approximately 30 minutes each, for 13 sessions excluding the intake evaluation. The clinician obtained consent from the patients father at the intake. Both the patient and her father spoke fluent English therefore no interpreter was needed. He was debriefed on limits of confidentiality, expectations for possible audio/video recording, and possibility of patient materials being used for academic/research purposes. The patient was also informed of such information and the patient provided assent for this purpose. Outcome Measures Brief outcome assessment measures were administered in-person pre- and posttreatment at the beginning of the intake interview and termination session. The selected brief outcome measures are the Generalized Anxiety Disorder 7 (GAD-7) and the Patient Health Questionnaire 9 (PHQ-9). Both measures were developed to screen for generalized anxiety CBT treatment in an adolescent refugee 37 disorder and major depression, respectively, in a primary care population (Arroll et al., 2010; Kroenke et al., 2001; Spitzer et al., 2006). Generalized Anxiety Disorder-7 The GAD-7 is a 7-item self-report assessment measured designed to screen for and assess the severity of Generalized Anxiety Disorder in practice and research (Spitzer et al., 2006). Each item assesses the extent to which the individual has been bothered by a symptom of GAD in the past two weeks (e.g., trouble relaxing, feeling nervous, anxious, or on edge, etc.). Each of the seven items is scored on a scale ranging from 0 (not at all bothered) to 3 (bothered nearly every day), with a total score ranging from 0 to 21. The GAD-7 has cut-off scores that differentiate minimal (0-4), mild (5-9), moderate (10-14), and severe (15-21) generalized anxiety. The selected cut-off score of 10 has a sensitivity of 89% and specificity of 82%. The internal consistency of the GAD-7 is well over the acceptable range (Cronbach = 0.92). The test-retest reliability was good (intraclass correlation = 0.83). To determine convergent validity the GAD-7 was compared to the Beck Anxiety Inventory and the anxiety subscale from the Symptom Checklist-90. Convergent validity was determined to be good based on its correlations with the two measures, r = 0.72 and r = 0.74, respectively. The norms for the GAD-7 were calculated from a total of 965 patients in 15 primary care sites. The mean (SD) GAD-7 score was 14.4 (4.7) for those diagnosed with GAD (n = 73) and 4.9 (4.8) for those without GAD (n = 892). The GAD-7 was validated for adolescent populations in primary care. 40 adolescents ages 12-17 were administered the GAD-7 and scores of 11 or higher had a sensitivity of 97% and specificity of 100% at detecting moderate levels of generalized anxiety symptoms (Mossman et al., 2017). The authors concluded the GAD-7 is a measure that should be utilized by clinicians to quickly assess symptom severity in adolescents with GAD. CBT treatment in an adolescent refugee 38 Patient Health Questionnaire-9 The Patient Health Quesionnaire-9 (PHQ-9) is a self-report assessment measure designed to assess the severity of depression in the primary care setting (Kroenke et al., 2001). Each of the nine items corresponds to one of the nine DSM-5 criteria for depression. The individual is instructed to indicate how bothered they were by each symptom, ranging from 0 (not at all bothered) to 3 (bothered nearly every day), with a total score ranging from 0 to 27. The PHQ-9 has cut-off scores to distinguish minimal (0-4) mild (5-9), moderate (10-14), moderately severe (15-19) and severe (20-27) depression. A cut-off score of 10 has a sensitivity of 88% and specificity of 88% for major depression. Internal consistency of the PHQ-9 was acceptable (Cronbachs = 0.89). The test-retest reliability was excellent between scores of the initial primary care visit and 48 hours later with a mental health professional (r = 0.84). The norms were calculated from 580 patients interviewed by a mental health professional after completing the PHQ-9 at a primary care or obstetrician/gynecologic clinic. The mean (SD) of PHQ-9 score for patients (n = 41) diagnosed with major depressive disorder was 17.1 (6.1), 10.4 (5.4) for the patients (n = 65) diagnosed with other depressive disorder, and 3.3 (3.8) for the patients (n = 474) with no depressive disorder. While the PHQ-9 was designed for adults it has been validated with adolescent populations. 442 adolescents ages 13-17 were administered the PHQ-9 and a score of 11 or higher had a sensitivity of 89.5% and specificity of 77.5% for detecting youth meeting DSM criteria for major depression (Richardson et al., 2010). The authors noted that while the optimal cut-off score was slightly higher, the PHQ-9 remained an excellent choice for screening depression among adolescents in primary care settings. CBT treatment in an adolescent refugee 39 Case Formulation The case conceptualization was developed using the cognitive-behavioral model for generalized anxiety and depression. This model places emphasis on early learning and experiences which contribute to current problems, underlying rules and beliefs, ways in which they have coped with their dysfunctional beliefs (e.g., cognitive, affective, and behavioral mechanisms), and current stressors which contribute to their current problems or their ability to solve such problems. (Beck, 2020). Additionally, various distortions of anxiety are present including hypervigilance, false alarms, loss of objectivity, generalization of danger, and no tolerance for uncertainty (Beck et al., 1985; Beck, 2005). Special consideration was given to her experiences as a Burmese refugee including immigrant/refugee status, experiences as a minority, and level of acculturation. In addition, cultural factors were used as essential context throughout the entire conceptualization including increased mental health stigma and family dynamics. Conceptualization of Chomdens anxiety was supplemented using the avoidance model of worry (AMW) and the metacognitive model of worry (MCM). The AMW was developed by Borkevec et al. (2004) which posits that worry functions as an ineffective problem-solving skill to minimize aversive emotional and somatic experiences. Worry becomes negatively reinforced as the avoidance of anxiety-inducing stimuli decreases negative emotional and somatic experiences. Furthermore, worry is reinforced by positive beliefs such as worry is helpful in problem-solving, motivating performance, and avoiding negative outcomes. (Behar et al., 2009). The MCM of GAD developed by Wells (1995) posits that individuals experience two types of worry. The first is Type 1 worry which occurs when they are faced with an anxietyinducing stimuli, coupled with the belief that worry will help them cope with the situation. CBT treatment in an adolescent refugee 40 Individuals then begin to worry about their experience of type 1 worry, where they fear their worry is uncontrollable, also known as Type 2 worry. Case Conceptualization Chomdens relationship with her parents and experiences as an immigrant/refugee played a significant role in the development of her negative core beliefs. She recalled her early life in Burma and feeling as though she was the only child who was not raised by her parents, as she was raised by her grandparents. She explained that her parents were consistently home when both her older and younger sister were young. She recalled feeling as though this was unfair, and that she was unable to develop a relationship with her parents the same way her sisters were. This led to her feeling as though there is something inherently wrong with her such that she was not worthy of a relationship with her parents, or that she did not deserve it. Throughout her life, she reported not feeling loved by her parents, which further contributed to negative beliefs about herself and her inherent worth. She recalled experiencing a significant amount of praise when she was younger. This praise was often related to her performance in academics or extracurriculars. This praise even came from other family members, being told by others that she was gifted. As she became older, the ample praise from her parents stopped. Additionally, she remembered being questioned by the same family members that previously called her gifted, who were now asking what happened to her? such that her achievements were no longer as impressive. This experience confirmed her current assessment of herself, such that she was previously worthy of love and praise but she fell from grace and was no longer worthy. She recalled experiencing her parents praise and attention as love, but that since she was no longer receiving this praise, she no longer felt loved by them. This further confirmed her perception of having a fall from grace in which something about CBT treatment in an adolescent refugee 41 herself inherently changed, ultimately changing her worth. These experiences also connected academic performance with overall worth and being deserving of love. Chomdens early experiences in the United States contributed toward negative beliefs of herself and others. She recalled experiencing bullying in middle school for not knowing English, feeling very embarrassed as a result. This further confirmed previous negative beliefs about herself, in addition to beliefs that other people and social interactions are dangerous and rejection is likely to occur. Lastly, Chomden experienced a significant amount of parentification, or when children assume adult roles and are expected to meet the needs of family members (Early & Cushway, 2002). She recalled learning English much quicker than her parents and is overall more proficient. This is especially relevant with her mother, who does not speak English. As a result, she often interpreted for her parents (i.e., language brokering), and translated and helped manage bills. Language brokering is a common occurrence when there is an acculturation gap between parent and child (Titzman, 2012). Brokering has been found to be associated with higher psychological distress and depression (Oznobishin & Kumar, 2009; Williams & Francis, 2010). Additionally, because her parents were not around very often when she was younger, she felt there were many times where she had to parent herself or help parent her younger sister. At the time of treatment, she felt the responsibility to parent herself. During older adolescence, she experienced emotional parentification from her mother. Her mother vented to her about her father, either complaining about him or saying she regretted marrying him. All of these experiences, in conjunction with the already established belief that she is not worthy or deserving, contributed toward a tendency to minimize or look past her own needs in favor of others, most significantly her parents. CBT treatment in an adolescent refugee 42 The belief that she must minimize or ignore her own needs in favor of others was reinforced culturally, as the Burmese culture highly emphasizes deep respect for elders and it is considered highly inappropriate to challenge or argue with someone of senior status (Evason, 2017). This would make it extremely difficult to question or challenge her parents requests for help, as it goes against social norms. Additionally, it is very common in the Burmese culture to be constantly mindful of how ones actions could offend, embarrass, or inconvenience others. This is referred to as the concept of ah-nar-de, or the feeling of not having the heart to say or do something that may affect another persons feelings (Evason, 2017). This contributes to a significant consideration for others feelings, which Chomden demonstrated in relationship to her parents, in that she often placed their needs higher than hers. Additionally, the conflict of having her own needs increase related to her mental health, with feeling unworthy and placing others needs above her own lead to her feeling as though she is a burden to others. As a consequence of Chomdens early life experiences, she developed the following core beliefs: I am unlovable, I am a burden, I am unworthy, I will be rejected, I am worthless, I will embarrass myself around others, and others are dangerous. As a way to cope with these negative beliefs about herself and others, she developed the following assumptions and rules for living (i.e., intermediate beliefs): 1) if I succeed in school, then my parents will love me, 2) if I am perfect, then my parents will love me, 3) If I decline my parents wants, then they will never love me, 4) if I share my own struggles, then I will scare others away or be rejected, 5) if I struggled when trying to succeed, then the outcome will be more impressive, 6) if I speak to others, then I will embarrass myself, and 7) if I worry, I will be motivated to do well. Chomdens view of her worry aligns with the avoidance model of worry and metacognitive model of worry, as she had positive beliefs of her worry. Chomden explained CBT treatment in an adolescent refugee 43 feeling as though her worry and subsequent negative self-talk motivate her to do well and are significantly responsible for her success. Therefore, she has the belief if she does not worry then she will not succeed. Because her parents love was contingent on her academic success, losing her worry meant losing her parents love. This led to school being a significant cause of anxiety for Chomden. Her early experiences of once being deemed gifted which changed to falling from grace, led to Chomden developing perfectionistic tendencies. She placed a significant amount of pressure to succeed and be the best. This is likely due to the emphasis on external validation and achievement during her childhood. Her increased motivation for success reinforced her positive belief related to worry, such that worry will help her to be perfect. Increased self-criticism plays a similar role in this situation. She believed criticism will act to increase her motivation, improving the outcome of events. The increase of self-criticism, in turn, reinforced depressive symptoms. Additionally, because such large emphasis was placed on her success and outcomes, she believed that if she was able to perform while being hindered by anxiety, the outcome is that much greater, or more impressive. This further reinforced her positive belief of worry, impacting her willingness to decrease worry. Chomdens belief of being a burden and unworthy of love, in conjunction with sacrificing her own needs, negatively affected her ability to seek social support. She would often bottle-up her feelings which increased anxiety and decreased her mood. This behavior occurred with both parents and friends. With her parents, she acted as a martyr sacrificing her own needs. With her friends, she would not open up to them about her mental health or significant stressors, despite wanting to. Her lack of social support, internalization of feelings, and dismissal of personal needs increased depressive and anxiety symptoms. CBT treatment in an adolescent refugee 44 Chomdens early experiences being bullied and feeling embarrassed in social situations led to her developing a fear of social interactions. She explained she did not fear social situations prior moving to the United States and experiencing bullying. While she did not report feeling this anxiety with her close friends, she reported significant anxiety talking to other people or raising her hand in class. She explained wanting to speak to other peers and teachers more often, but that her anxiety of the outcome and possible embarrassment or rejection interfered. In behavioral terms, her anxiety decreased when she avoided social situation, thus her avoidant behavior was negatively reinforced, and, thus, increased in frequency. Additionally, she viewed her perceived inability to talk to others as a personal flaw, acting as additional evidence for being unworthy or undeserving of love. Chomdens intermediate beliefs influenced the automatic thoughts she had in response to triggering events. Triggering events that occurred frequently were parentification, stress from school, social interactions, and social comparison. The following is an example of how Chomdens core and intermediate beliefs influence her automatic thoughts and behavior: Chomden receives a 92% on an exam. She has the automatic thought, you are an idiot and a failure. As a result, her depressed mood increases, and she begins to worry about her grade in the class. The following is another example: She enters the classroom and sees her teacher. She has the automatic thought, if you say hello you will make a fool of and embarrass yourself, and she is going to laugh at you. She then feels anxious and avoids initiating conversation with her teacher. Treatment Plan Chomdens treatment plan was developed considering her diagnoses, personal goals for therapy, and sociocultural factors. Chomdens personal goals for therapy were to nap less, eat CBT treatment in an adolescent refugee 45 more, talk to more people during class, and talk to more people in general. The clinician and Chomden collaboratively identified the following goals at the beginning stage of treatment: 1) decrease hypersomnia, 2) increase food consumption, 3) decrease overall social anxiety, 4) decrease perfectionistic tendencies and distorted thoughts related to unrealistic expectations for herself, and 5) increase ability to seek social support. In order to meet these goals, a CBT treatment plan was adapted utilizing the main components of CBT treatment including psychoeducation, behavioral activation, cognitive restructuring, and exposures (Leahy et al., 2011; Wehry et al., 2015). First, psychoeducation was provided on anxiety, depression, sleep hygiene, and later, cognitive distortions. Because mental health is highly stigmatized in the Burmese culture and non-severe mental health if often less understood, additional time was spent on psychoeducation. This included providing education on the symptoms of anxiety and depression, how they reinforce each other, and prevalence to normalize her experience. As decreasing hypersomnia was a personal goal of Chomden, and likely worsened her depressive symptoms, psychoeducation on sleep hygiene was also given special attention. Specific relevant items included reducing daytime napping and not laying in bed except to sleep at night. Lastly, education on cognitive distortions was provided to enhance her ability to identify, and ultimately challenge, maladaptive thoughts. In order to improve depressive symptoms which would positively contribute to goals one and two, which were both very important to Chomden, behavioral activation was used. Chomden identified going on walks as an adaptive coping skill she had used before. She was encouraged to continue to use it as a coping skill but also as behavioral activation to decrease depressive CBT treatment in an adolescent refugee 46 symptoms. A specific behavioral intervention used to target goal two was to increase snacking throughout the day. Cognitive restructuring and behavioral experiments were used to target Chomdens anxiety in social situations. This was achieved during and outside of sessions as homework. In session, Chomden was encouraged to identify and challenge maladaptive thoughts. Specific cognitive interventions used to achieve this were evidence for and against a thought, examining the logic of a thought, and best/worst/most realistic scenario. For example, a maladaptive thought may be, If I say hello to my teacher, she is going to laugh at me. In order to challenge this thought, Chomden was encouraged to provide evidence for and against this thought. One piece of evidence against this thought is that the teacher has never laughed at a student for saying hello. A piece of evidence supporting the thought is that people have laughed at Chomden in the past. As homework, Chomden identified specific behavioral experiments to target and challenge this thought, for example, say hello to her teacher one day in a week. Cognitive restructuring was used to challenge maladaptive thoughts and beliefs which reinforced her anxiety and depression. After psychoeducation was provided on the various cognitive distortions, Chomden was encouraged to practice identifying maladaptive thoughts outside of session as homework, which would then be discussed during session. During session, cognitive interventions were used to challenge her maladaptive thoughts and beliefs as well as encourage her to explore new perspectives. The most predominant type of maladaptive thoughts was related to her perfectionistic tendencies. An example of how her perfectionist tendencies manifested was harsh self-criticism due to not meeting extremely high standards set for herself. Her maladaptive perfectionistic thoughts often arose in response to school and academic achievement. Specific cognitive interventions that were used to challenge maladaptive thoughts CBT treatment in an adolescent refugee 47 were evidence for and against a thought, role playing as the defense attorney, testing a double standard by applying it to a friend, examining the logic of thought, defining the terms, and vertical descent. Vertical descent was often used, specifically, to aid Chomden in identifying her core beliefs or other maladaptive beliefs she has about herself or others. Lastly, cognitive restructuring and behavioral experiments were used to increase Chomdens ability to seek social support from her friends. Maladaptive thoughts, such as, I am a burden, were challenged during sessions. Specific cognitive interventions used were evidence for and against a thought, testing a double standard by applying it to a friend, and testing predictions. Once Chomdens ability to recognize and challenge her maladaptive thoughts increased, she was encouraged to test her predictions as behavioral experiments for homework between sessions. An example of one self-identified behavioral experiment was seeking social support from her friends about her anxiety and depression. Chomdens experience as a refugee as well as the Burmese culture were heavily considered throughout the treatment plan. For instance, the clinician checked in with Chomdens understanding more frequently since Chomden was less likely to speak up to the clinician due to the power imbalance. Similarly, the clinician offered the opportunity to disagree with the clinician when challenging maladaptive thoughts, again due to the stark power imbalance and subsequent decreased likelihood that Chomden would openly disagree with the therapist. The clinician often checked her understanding with Chomden to ensure the clinician had an appropriate understanding of how Burmese ideals were enforced specifically in Chomdens family. Lastly, in order to ensure traditional Western ideals were not being forced on Chomden by the clinician, supervision was frequently sought. On occasion, the clinician and Chomden would openly discuss and balance Chomdens personal needs and her culture. For example, CBT treatment in an adolescent refugee 48 although it is normalized in Burmese culture not to share personal struggles as other peoples feelings are highly considered, this was negatively impacting Chomdens anxiety and depression (Evason, 2017). The pros and cons of sharing her struggles with friends were discussed with Chomden, along with assessing her personal values. For example, Chomden stated that she valued her friends as social support and therefore wanted to increase her ability to confide and share personal information with them, despite it contradicting aspects of traditional Burmese culture. This is an example of how cultural considerations were made while also keeping the individual in mind. Course of Treatment This section will describe each session of therapy and highlight important differences or deviations from the previously described treatment plan. Chomden had a total of 13 sessions and each will be described. Session 1 Chomden and the clinician discussed her eating and sleeping habits. The clinician provided psychoeducation on depression and anxiety, and how both can affect sleep and appetite. The clinician collaborated with Chomden to problem-solve ways to increase food intake and decrease hypersomnia. Chomdens homework was to decrease daytime napping and increasing snacks throughout the day. The clinician noticed rapport with Chomden was very low and it was challenging for Chomden to offer insights unprompted. Session 2 Chomden followed-up on homework, reporting she did not nap during the day and ate more snacks. This was a large improvement from previous napping habits, which was to take a three to four hour nap each day. Chomden began discussing her expectations of her academic CBT treatment in an adolescent refugee 49 performance and how it negatively affected her. She also began to discuss her relationship with her friends, avoidance of emotional closeness with them, and the ways this impacts her. The clinician continued to provide psychoeducation on anxiety and began to introduce the different types of cognitive distortions. The clinician asked direct and open-ended questions to explore and discuss the importance Chomden placed on academic success and intelligence. For example, why is it important to receive all As? and what would happen if you got a bad grade? Chomdens homework was to practice identifying maladaptive thoughts and cognitive distortions. Session 3 Chomden completed the homework and reported that identifying cognitive distortions was helpful. She discussed upcoming academic events that increased her anxiety. Chomdens idealization of perfectionism was discussed, including how it is unachievable. The clinician continued to provide psychoeducation about cognitive distortions. The clinician aided Chomden in identifying and challenging her black-and-white thinking in regard to her perfectionistic expectations of her academic performance. Chomdens homework was to continue identifying cognitive distortions but to add in a reframe/challenge of the negative thought. By the third session, rapport had significantly increased. The clinician noticed Chomden feeling more relaxed and less anxious during session, as well as the session feeling more collaborative. Session 4 Chomden discussed upcoming events that were increasing her anxiety. Throughout the discussion she was able to identify cognitive distortions with the aid of the clinician. Chomden continued to discuss her perfectionistic tendencies. She reported noticing how her perfectionism impacts other areas of life besides academics, as well as how it contributed to anxiety. The CBT treatment in an adolescent refugee 50 clinician aided Chomden in identifying her cognitive distortions in session. Other cognitive techniques used were discussing the worst-case scenario, and evidence for and against a thought. Chomdens homework was to practice challenging negative thoughts on her own using the techniques practiced in session (i.e., evidence for and against, worst case scenario, etc.). Session 5 Chomden followed-up on her homework, providing examples where she effectively identified and challenged negative thoughts. She discussed improvements in her napping and appetite. She explained that her napping continued to improve because her parents no longer let her sleep during the day. Chomden also said she noticed having midnight cravings, which was an improvement because would often not feel hungry. Chomden discussed her social anxiety and specific situations that trigger it. The clinician asked questions to explore Chomdens anxiety in social situations. For example, what is the worst possible outcome, how would you ideally act in social situations, and what prevents you from acting this way? Homework for the next session was a behavioral experiment they collaboratively set say good morning to her teacher one time within the next week to test her expectation that she would embarrass herself or be made fun of. Session 6 Chomden discussed her homework and the impact it had on her social anxiety. She discussed how she was able to say good morning to her teacher three times throughout the week instead of one, exceeding her goal. Chomden reported how her anxiety significantly decreased from the first time she said hello compared to the third time. She discussed how her social anxiety increased negative self-talk, for example, labeling herself as inadequate or a failure for feeling anxious in social situations. She was able to identify the purpose of the negative self-talk CBT treatment in an adolescent refugee 51 as a way to motivate herself to improve. The clinician aided Chomden in identifying the purpose of negative self-talk by asking questions such as what do you believe would happen if you didnt talk to yourself that way?. Chomdens homework was another behavioral experiment of her choice targeted at decreasing social anxiety. Session 7 Chomden reported her homework, which she chose to initiate conversation with classmates more, was effective in decreasing anxiety. This was the first session where Chomden discussed her family dynamics. She explained her relationship with her mother and the ways in which her mother emotionally parentified Chomden. She reported not feeling as though she had a relationship with her father. The clinician introduced the idea of setting boundaries to decrease emotional parentification, to which there was significant resistance. In order to increase emotional connectedness and social support, Chomdens homework was to confide to a friend about something small, but more than what she normally would. Session 8 The homework was discussed Chomden confided to her friends that she was going to therapy for anxiety. She explained her friends were very understanding and supportive which made her happy that she told them. Chomden continued to open up about her family dynamics and how it contributed to her mental health. She provided other examples of parentification such as language brokering which made her feel burdened. She explained that she did not feel loved by her father and identified academic success as a way to receive acceptance and praise from her parents. The clinician aided Chomden in identifying core beliefs by using the downward arrow technique. When talking about automatic thoughts, the clinician would ask questions such as what would that say about you if it were true? and what would that mean if it were true? Her CBT treatment in an adolescent refugee 52 homework was to write a compassionate letter to herself identifying her successes and as a way to provide internal validation and increase sense of acceptance. Session 9 Chomden discussed that although she completed the letter, she noticed it increased negative self-talk. Chomden did not discuss her family but rather focused on topics related to perfectionism. This included her reasoning for holding herself to a high standard and having high expectations. She discussed her perspective on achievements, explaining a single large achievement is better than accomplishing several realistic achievements, even when the outcome is the same. The clinician used the cognitive technique pros and cons to explore the cost and benefit of engaging in realistic standards. Chomdens homework was to role play as the defense attorney and provide sound reasoning why setting unrealistic goals are better than realistic goals. The clinician noticed a significant increase in resistance during this session compared to previous. Additionally, Chomdens insight into her anxiety and maladaptive thoughts had decreased significantly. The clinician hypothesized this was a reaction and subsequent regression of insight due to discussing the very sensitive topic of her family the previous sessions. This information was used by the clinician to aid her conceptualization of Chomden. Session 10 Chomden discussed her family, explaining there were no changes at home. Chomden continued to be hesitant in setting boundaries with her mother. Relevant cultural factors that impacted Chomdens ability to set boundaries were discussed. During the session, she identified and discussed her core belief of being unworthy of love. Chomden identified relevant history that contributed to the formation of the core belief family members previously described her as gifted and then several years later talked negatively about her. Chomden identified other core CBT treatment in an adolescent refugee 53 beliefs including I am a disappointment, and I am a failure. The clinician provided psychoeducation on core beliefs and the ways they impact beliefs and thoughts. The metaphor of minds doing mental gymnastics was introduced as a way to communicate the extent to which core beliefs can influence our thoughts. Session 11 Chomden reported a decrease in her overall mental health, as she had an argument with her parents since the last session and was not speaking to them. She discussed the argument, explaining it felt as though she had bottled-up her emotions for too long so she finally exploded. Chomden identified aspects of her relationship with her father that she was not happy with, and the ideal version of their relationship. Chomden and the clinician discussed differences in parental-child relationships within the Burmese culture. The clinician aided Chomden in identifying different options she had in order to have her emotional needs met. The clinician introduced acceptance as a way to cope with unfulfilling relationships with her family. As homework, Chomden was encouraged to use problem-solving strategies to create a plan of action to get her emotional needs met. Session 12 Chomden reported she was talking to her mother again but that she was no longer talking to her father. She discussed the different options she had to navigate her relationship with her parents, providing pros and cons of each course of action. Chomden discussed the ways negative treatment from others impacts her sense of self-worth. She reported wanting to be a good role model for her sisters, and that she feared they would pick up on her negative qualities. The clinician asked questions to aid Chomdens exploration of her negative self-worth as a justification for how others treat her for example, it is okay if they treat me badly because I am CBT treatment in an adolescent refugee 54 a bad person. Examples of questions the clinician asked are, why do you not deserve to be treated with respect? and if all people deserve to be treated with respect, why are you different? Chomdens homework was to list positive attributes of herself that she would want her sisters to have. Session 13 During the termination session, Chomden read aloud the list of positive attributes she would want her sisters to have. While processing termination of the therapeutic relationship, Chomden reported wishing she had discussed her family sooner. The clinician prompted Chomden to identify progress she made in therapy, which she then discussed. Summary At the time of referral, Chomdens case presented as uncomplicated anxiety and depression. At the mid-point of therapy, Chomden disclosed dissatisfaction within her family, which changed the trajectory of the therapeutic focus. Chomdens anxiety and depression appeared to be directly correlated with her family dynamics and feeling unloved by her parents in the way she would like. Chomden also directly expressed her feelings toward her familial relationship as being the root of her anxiety and depression. This was also reflected in her core beliefs, which related to her evaluation of her self-worth based on feeling unloved by her parents. While many aspects of the previously set treatment plan were implemented as intended, the clinician shifted the focus of treatment to Chomdens relationship with her parents and the impact it had on her overall mental health. Empirical Findings with Analysis The data was collected at two time points, the start and end of treatment. The reliable change index (RCI) was used to measure clinically and statistically significant change between CBT treatment in an adolescent refugee 55 start and end of treatment. A RCI was calculated for both measures used, the PHQ-9 and GAD-7. The RCI was calculated using the calculation recommended by Jacobson and Truax (1991). Normative data of clinical and non-clinical populations, including test-retest reliability, for the PHQ-9 was used from Kroenke et al. (2001). For the GAD-7, normative data from Spitzer et al. (2006) was used. The standard error of measurement (SE) and standard error of difference (Sdiff) were first computed. SE was calculated using the following equation, SE = SD(1-r), where SD is the standard deviation of the non-clinical population and r is the test-retest reliability of the measure. To calculate Sdiff the following equation was used, Sdiff = 2(SE)2. The RCI was then calculated using the following equation RC = (X2 X1)/Sdiff. According to Jacobson and Truax (1991), if the RCI is greater than or equal to 1.96 reliable change has occurred. An improvement on both the PHQ-9 and GAD-7 would produce a lower post-treatment score, leading to a RCI of -1.96. Using the data from Kroenke et al., (2001) and Spitzer et al., (2006) for the PHQ-9 and GAD-7, it was determined that the change in Chomdens scores at the end of treatment were not statistically significant (see Table 1). Table 1 Reliable Change Index Determination of PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006) Assessment PreTest Score (X1) PostTest Score (X2) Standard Deviation of non-clinical group Test-Retest Reliability PHQ-9 13 15 3.8 GAD-7 9 12 4.8 SE Sdiff RCI Reliable Change? (1.96) 0.84 1.52 2.15 0.93 No 0.83 1.98 2.80 1.07 No CBT treatment in an adolescent refugee 56 To measure clinically significant change, a cut-off point was computed using the method determined by Jacobson and Truax (1991). The following equation was used: Cutoff score = (SDnonclinical x xclinical)x(SDclinical x xnonclinical)/SDclinical + SDnonclinical. Using the data from Kroenke et al. (2001) and Spitzer et al. (2006) for the PHQ-9 and GAD-7, it was determined that Chomdens scores did not achieve the cutoff score by the end of treatment (see Table 2). This indicates that Chomdens scores did not move closer to the mean of the nonclinical population than the clinical population. The calculated RCI and cutoff score comparing Chomdens scores before and after treatment were not statistically or clinically significant. This indicates that there was no meaningful change that occurred for her anxiety and depression after treatment. It is important to note that although the RCI is approaching 1.96, which would suggest approaching statistical significance, Chomdens scores worsened after treatment. Improvement of her scores would produce a negative RCI due to the assessments used to measure change. Table 2 Cutoff Score Determination Using Normative Data for the PHQ-9 (Kroenke et al., 2001) and GAD-7 (Spitzer et al., 2006) Assessment Mean of Mean of nonclinical clinical population population Standard deviation of nonclinical population Standard Cutoff deviation score of clinical population Post- Cutoff Test score Score achieved by patient? PHQ-9 3.3 17.1 3.8 6.1 8.6 15 No GAD-7 4.9 14.4 4.8 4.7 9.7 12 No CBT treatment in an adolescent refugee 57 Discussion At the time of literature review, there were no studies that observed the effectiveness of mental health treatment for Burmese refugees who relocated to the United States. Due to the saliency of Burmese mental health treatment in the United States, understudied nature of this group, and known negative outcomes associated with refugee relocation, further research on mental health intervention is needed (George, 2010; Hickey, 2007; Kim & Keovisai, 2016; NgoMentzer et al., 2004). Because of the increased stigma and minimal mental health psychoeducation within this population (Morris et al., 2009; Saechao et al., 2012), it may be particularly beneficial to observe treatment effects in primary care, as primary care physicians provide a significant proportion of mental health care (Jetty et al., 2021; Olfson, 2016). Additionally, racial and ethnic minorities are more likely to receive mental health services in primary care settings (Chapa, 2004; Henry et al., 2020). This case study sought to determine if 13 sessions of CBT administered in a primary care setting would effectively treat Chomdens generalized anxiety and major depressive disorder, as determined by decreased PHQ-9 and GAD-7 scores. The treatment was not found to be effective, as the RCI calculation did not reach significance. Although her scores did not significantly change by the end of treatment, to indicate improvement or decline, it is important to note her scores were higher after treatment, in the direction of an increase in symptoms, relative to the beginning of treatment. Hypersomnia and lack of appetite were particularly distressing symptoms for Chomden; however, these symptoms did not significantly decrease as determined by items on the PHQ-9. When considering why treatment was ineffective, it is important to consider the therapeutic alliance. The therapeutic alliance between the therapist and patient is one of the most CBT treatment in an adolescent refugee 58 important common factors related to treatment outcomes, regardless of length of session or treatment modality (Gergov et al., 2021). Various factors could have hindered the development of the therapeutic alliance between Chomden and the clinician, including personality traits and attachment style. Perfectionism has been demonstrated to negatively impact the development of the therapeutic alliance (Lingiardi et al., 2005; Miller 2017). Additionally, in patients who are high in perfectionism, there are smaller increases in the therapeutic relationship over the course of treatment (Zuroff 2000). The effect perfectionism has on the therapeutic alliance is an important factor to consider when treating Burmese individuals, given that studies have shown that Asian Americans demonstrate perfectionistic tendencies (Peng & Wright, 1994). In fact, stress of meeting parental expectations of high academic achievement, as well as living up to the model minority stereotype has been shown to be a common source of stress for Asian Americans (Lee et al., 2009). This unique stress that Asian Americans experience may have negative consequences for the development of the therapeutic alliance, and ultimately treatment outcomes. Long-term, as opposed to short-term CBT may produce more desirable outcomes when perfectionism is present. Studies have found that individuals high in perfectionism view their therapist as less empathetic and understanding early in therapy (Hewitt et al., 2008; Miller et al., 2017). It is possible the patient needs a longer time in therapy to develop trust in and create an emotional bond with the therapist (Miller et al., 2017). While this has not been observed specifically with CBT, long-term therapy has been more effective for other treatment modalities (Blatt, 1992; Blatt & Ford, 1994). Additionally, the therapist can help the patient develop selfcompassion by creating a compassionate and accepting therapeutic environment which may then CBT treatment in an adolescent refugee 59 be internalized (Gilbert, 2009). It is possible treatment was too short for Chomden to benefit given her perfectionism and that longer-term therapy would have been a better match for her. Chomdens perfectionism may have made it difficult to engage in self-compassion. Selfcriticism is highly associated with perfectionism (Gilbert et al., 2006). Chomden reported viewing her self-criticism as a motivating tool that enabled her to perform to her perfectionistic standards. This aligns with the AMW where worry, or in this case self-criticism, is viewed positively by the patient as a motivating tool (Behar et al., 2009). Self-compassion may have been particularly difficult for Chomden, as she may have feared that self-compassion would lower her standards and decrease her motivation. Studies suggest this negative view of selfcompassion is a common barrier (Kelly et al., 2021). This perspective is particularly relevant with perfectionistic individuals, such that they fear self-compassion (Gilbert & Procter, 2006). One definition of self-compassion is noticing ones suffering, then responding in an accepting and non-judgmental way with motivation to decrease ones suffering, all while tolerating difficult emotions (Gilbert, 2010). Self-compassion is not accepting yourself as you currently are with no desire to change or improve. In fact, there is evidence that self-compassion increases motivation following failure and promotes adjustment after failure to achieve a goal, which contradicts the perfectionistic fear of self-compassion (Breines & Chen, 2012; Miyagawa et al., 2018). In Chomdens treatment, providing more psychoeducation on self-compassion, and explaining it as an approach of non-judgement and curiosity may have been more tolerable and thus improved her willingness to let go of self-criticism and increase self-compassion (Gilbert, 2010). Attachment style, or the way in which a person relates to others as formed by early childhood experiences and relationships, can impact the development of the therapeutic alliance CBT treatment in an adolescent refugee 60 (Bowlby, 1988). Specifically, insecure attachment styles have been shown to be negatively associated with the development of the therapeutic alliance (Bachelor et al., 2010). Some theorize that the patients attachment style is then projected onto the therapist-patient relationship, which ultimately impacts the development and formation of the alliance (Bowlby, 1988; Smith et al., 2009). An insecure attachment style can delay the formation of the therapeutic alliance and can contribute to an overall less positive therapeutic alliance (Smith et al., 2009). Burmese refugees may be more vulnerable to this issue through direct pathways, such as the inherently traumatic experience of being displaced, and through indirect pathways, like intergenerational trauma. Some studies have found a link between adverse childhood experiences and attachment style, such that those with childhood traumas were more likely to have an insecure attachment style (zcan et al., 2016). Traumas related to refugee experiences, specifically, have also shown an association with insecure attachment styles (Morina et al., 2016). Within refugee families, parental trauma has been shown to contribute to insecure attachment and diminished parental emotional ability (Flanagan et al., 2020). Other studies have found maternal traumatic experiences and attachment style impact their childs attachment style, suggesting intergenerational transfer (Cooke et al., 2019; zcan et al., 2016). Although Chomdens attachment style was not assessed during treatment, the clinician reflected after treatment and speculated that Chomden likely demonstrated an avoidant attachment type. Those with an avoidant attachment type may suppress and deactivate emotions when caregivers are unable to meet their needs, leading to long-term consequences of becoming overwhelmed by emotions and repressing or dissociating for difficult emotions (Mikulincer et al., 2003). Chomden longed for close relationships with others but feared rejection. This is demonstrated in her relationship with her friends, where she was close with them but greatly CBT treatment in an adolescent refugee 61 feared confiding in them about intimate details of her life and experience. While she considered them close, emotionally they were kept at a distance. This relational pattern aligns with the avoidant attachment style (Akhtar, 2012). Chomdens experiences of rejection in childhood bolster the clinicians hypothesis of Chomdens avoidant attachment style. Chomden experienced repeated rejection from her parents, for example being the only sibling to be parented by her grandmother and having a fall from grace where she no longer received praise. Chomden was also rejected in middle childhood, where she was bullied and made fun of in middle school when first moving to the US. Additionally, she perceived her parents as less warm and reported not feeling loved by them. Repeated rejections and lack of warmth from parents are both core features of an avoidant attachment style (Akhtar, 2012). Chomdens avoidant attachment style may have hindered the development of the therapeutic alliance. As previously stated, it is expected that a persons attachment style is projected onto the patient-therapist relationship (Bowlby, 1988; Smith et al., 2009). In treatment, Chomdens avoidant attachment style may have manifested as a lack of trust of the clinician, difficulty forming trust in the clinician, or a fear of rejection from the clinician, as mistrust and fear of rejection are core features of avoidant attachment (Akhtar, 2012). In order to minimize the negative effects an insecure attachment has on the therapeutic relationship, some suggest assessing for attachment style prior to treatment (Shorey & Snyder, 2006). Self-report measures are often used in clinical settings, as narrative measures take much longer to complete (Smith et al., 2009). A self-report inventory such as the Adult Attachment Inventory (Simpson et al., 1992) may be used to quickly, in conjunction with information gathered during the intake interview, assess attachment style. If the therapist is aware of the patients attachment style, and potential problems that may arise in therapy as a result, the CBT treatment in an adolescent refugee 62 therapist can be more attentive to the development of such issues (Smith, 2009). Additionally, the therapist may benefit from monitoring the therapeutic alliance for signs of distance or discontent, and preemptively repair the alliance as needed (Diener & Monroe, 2011). These recommendations have been made for treatment modalities where relational processes are not the main focus, for example, CBT (Taylor et al., 2015). For the present patient, no assessment of attachment style was done. It is possible that doing say may have improved the course of treatment by incorporating this information, therefore benefiting Chomden. The duty to save face for the collective family may negatively impact therapeutic outcomes (Covelman & Covelman, 1993). Family is extremely important in Burmese culture. As such, so is the collective reputation or face of the family. Because families have a collective face or reputation, the act of an individual in the family can impact the perception of the family unit as a whole (Evason, 2017). This, in conjunction with mental illness remaining highly stigmatized, results in hiding feelings of anger, shame, or other negative emotions that may undermine their face (Chung, 2016). As part of saving face, there is a strong boundary within the family structure to not share family issues with outsiders (Epstein et al., 2012). Sharing such details with a clinician may be seen as increasing the probability of losing face (Anderson et al., 2012). To share personal details to a therapist that could lose face may be very stressful and lead to difficulty opening up in therapy (Liu et al., 2014). Chomden disclosed in session she had wanted to talk about her family dynamics sooner, but that she was hesitant to speak about it, which may be interpreted as an attempt to save face for the family. If the fear of losing face was not present, her family conflict may have been discussed sooner, potentially leading to more desirable outcomes. CBT treatment in an adolescent refugee 63 To combat the fear of losing face and increase sharing in session, it is essential to build trust early in the therapeutic relationship. One way to build this trust is to clearly communicate privacy and confidentiality limits, and openly address any concerns the patient may have (Anderson et al., 2012; Yeung & Ng, 2011). This helps to ensure their understanding that personal information will not be shared outside of the therapeutic settings. Others have found that therapist self-disclosure of personal information helps to build trust and can be important in the development of the therapeutic alliance when working with Asian American patients (Epstein et al., 2013; Jim & Pistrang, 2007). Therapeutically appropriate self-disclosure may build trust and the therapeutic alliance, as the sharing of personal information is an important symbol of trust (Epstein et al., 2013). Although self-disclosure in therapy is controversial amongst clinicians, research further suggests it has the potential to increase positive outcomes (Hill & Knox, 2002). Studies have found it to have an immediate, positive effect such that patients rate their therapist as more helpful (Hill et al., 2001). Other studies have found it to be effective in lowering levels of symptoms distress and improved therapeutic relationship such that those patients liked their therapist more (Barrett & Berman, 2001). Additionally, the use of metaphor, both patient and therapist, may improve the patients ability to discuss family conflicts. Communicating through metaphor allows the patient to communicate this information in an indirect and safe way, increasing their willingness to share (Liu et al., 2014). While the limits to confidentiality and privacy were discussed with both Chomden and her father, it is possible that taking additional time to discuss such limits and emphasizing that information shared with the therapist would not be shared to outside sources would have improved the trust with the therapist. Additionally, the clinician did not strategically use self-disclosure to build trust, which if done in a therapeutically appropriate manner, may have also increased trust and ultimately CBT treatment in an adolescent refugee 64 Chomdens comfort to share information. Lastly, metaphors were occasionally used in session to convey complex ideas in a simplified way, however Chomden was not encouraged to also use metaphors. If the use of metaphor was more frequent and Chomden was also encouraged to use metaphor, she may have felt more comfortable to share information related to family conflict sooner in therapy. One possibility, considering the number of the issues described above, is that familybased interventions, as opposed to individual, may have produced more positive outcomes for Chomden. Although there is a shortage of literature focusing on family interventions for refugees, the research that does exist suggests positive outcomes. Given the impact of trauma exposure and intergenerational transmission of trauma, there is a great need for family support (Slobodin & de Jong, 2015). In addition to trauma exposure, relocation and acculturative stress add additional difficulties to parenting and family relations which may contribute to parent-child conflict or parental withdrawal (Ballard et al., 2020; Lewig et al., 2010). There is preliminary evidence to suggest parent training interventions produce positive outcomes while considering the complex experiences of refugees (Ballard et al., 2018). Culturally relevant parent training interventions for Karen Burmese refugees decreased mental health concerns for parents and children ages 5-13, while positively changing parenting practices. This shift in parenting practices may have enabled parents to support better emotional health. Chomdens experience of feeling unloved, emotionally unsupported, and possible parental emotional withdrawal suggest parent training interventions may have produced more positive outcomes. In addition to directly improving parent-child relationships, parent training may also improve perfectionism. In Asian American families, an increase in parental support and decrease in parental criticism, particularly as it relates to academic achievement, may also serve to CBT treatment in an adolescent refugee 65 decrease perfectionism (Greenberger et al., 2000; Yoon & Lau, 2008). This indicates that parent training interventions may directly improve adolescent mental health, while indirectly improving it via decreases in perfectionism. Additionally, decreases in perfectionism would also improve the therapeutic relationship in individual therapy. It is important to discuss the differences between patient and therapist characteristics and the possible impact it had on treatment outcomes. Chomden was a Burmese, Christian, heterosexual female. The clinician identified as a white, heterosexual female. Patient preferences in regard to therapist characteristics are especially important to consider when working with individuals who have experienced marginalization and other disparities, which Chomden had reported (Jackson, 2015). Some studies have found that Asian Americans are more likely to utilize mental health services when clinicians are the same ethnicity or race (Wu & Windle, 1980). Asian Americans who do show preferences for same-race therapist are more likely to have additional vulnerability factors such as being female, foreign-born, or low acculturation (Jang et al., 2021). Additionally, Asian Americans who adhere highly to Asian cultural values have been found to view Asian American therapists as being more credible and approachable, compared to their white counterparts (Atkinson et al., 1978; Kim & Atkinson, 2002). Despite showing preferences for same-race or ethnicity clinicians, there is not consistent evidence to suggest it significantly impacts treatment outcomes (Ilagan & Heatherington, 2022). Although treatment outcomes may not significantly differ, it is possible that therapy engagement, therapeutic alliance, and retention significantly improves with race/ethnicity-matching for Asian Americans (Smith & Trimble, 2016). In terms of gender matching, female patients show higher preferences for and report greater comfort self-disclosing to female clinicians (Kuusisto & Artkoski, 2013; Landes et al., CBT treatment in an adolescent refugee 66 2013). Similar to race-matching, gender-matching demonstrates inconsistent findings in regard to improving treatment outcomes (Ilagan & Heatherington, 2022). This suggests that while Chomden having a female clinician may have improved self-disclosure and sharing, it is unlikely to have significantly affected overall treatment outcomes. Additionally, having a clinician who was also Asian American may have improved other therapeutic factors such as engagement and alliance; however, the literature suggests that it is unlikely it would have directly, significantly improved treatment outcomes for Chomden. However, due to the possibility that the alliance was weakened by other factors, like perfectionism and insecure attachment, a same-race therapist may have improved the alliance enough to improve treatment outcomes. Limitations to this case study include low generalizability, given it is a single-case subject research design (Tsang, 2014). While conclusions can be formed for the effectiveness of treatment for this specific patient, no such conclusions can be formed for Burmese refugees as a whole (Janosky, 2005). Other limitations include that only pre- and post-treatment data was collected, which is less desirable compared to continuous daily or weekly ratings which allow for additional inferences to be formed (Kazdin, 2019). Future studies, both group and case studies, should focus on treatment outcomes for Burmese refugees given the lack of literature that exists for this group. Refugee status and the complex experiences associated with it, such as relocation, acculturative stress, and traumatic experiences, all contribute toward the mental health of these individuals. When considering the state of civil unrest, with the most recent event being the Myanmar (Burma) coup in early 2021, it is likely that these experiences, and need for treatment, will continue (Thein-Lemelson, 2021). 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... Nurturing Nuggets: Trauma-Informed, Sensory-Based Education to Help Children Grow through Connection, Compassion and Community Megan Yingling May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Taylor Gurley, MS, OTR, OTD, CEIM Abstract Safe Families for Children (SFFC) is a national, volunteer-based organization that provides out-of-home care for children whose families are in crisis. By doing so, they are working to keep the children safe and the family together. Because SFFC provides out-of-home care to families in crisis, they often encounter children who have experienced trauma and adverse childhood experiences (ACEs) which sometimes manifests as challenging behaviors in the children. My doctoral capstone project sought to educate on trauma-informed care and sensory processing styles to help the volunteers in SFFC better understand the behaviors of the children that they serve. I led a virtual training session for volunteers, and created video and flyer resources on trauma-informed care and sensory styles. Participants reported an increase in knowledge and preparedness to educate others after the training suggesting that it was effective. Introduction Safe Families for Children (SFFC) is a national organization that hosts children and creates a support system for families in crisis (How Safe Families Works, 2022). Their mission is to keep children safe and families together. Within SFFC, there is unique terminology to identify the different entities involved in creating an extended support system for the family in need. Partnering parent(s) are the families in need or in crisis. Host families temporarily take care of the child(ren) on a volunteer basis. Family coaches are the key connection piece between partnering parents and the host families, working to build relationships and facilitate communication. The volunteer family coaches visit the host family's house and provide support and guidance. They also support the partnering parent in building skills to work on whatever is most important to the partnering parent. Family friends help the partnering parent in ways outside of hosting the children overnight, and resource friends provide tangible items such as beds, clothes, or diapers to help meet the needs of the host family and partnering parent. When discussing common child challenges with the staff and family coaches, it was mentioned that host families oftentimes dont fully understand trauma responses seen in some children within SFFC, and they often struggle with resulting behaviors. Family coaches also mentioned partnering parents struggle with some of their own childs behaviors. To address these challenges, my project consisted of an hour-long training as well as several educational videos and handouts for family coaches. The focus was trauma-informed care and a sensory-approach to behaviors. My hope was that by educating family coaches, I would empower them to educate host families and partnering parents as they see fit. Passing on this education would help all entities better understand the children involved in SFFC and their behaviors, equipping caregivers to provide the best possible care for the children. Background The population primarily served by SFFC is children from birth up to 18 years of age. There is a sociodemographic divide between the partnering parents and the host families which is currently being addressed by SFFC at a national level. The most common sociodemographic seen with the partnering parents are single, Black, female, non-high school graduate, and living at or near poverty level. Meanwhile, the demographics of a typical host family are married, white, higher education, and middle to upper income. This difference is important to note because it directly impacts the relationships SFFC tries to build through an extended support network. To assess what education would be most helpful for SFFC, I talked with both the staff members and family coaches. I asked what they felt they understood about child development, difficult behaviors, and trauma-informed care, as well as if there was any other topic about which they wish they knew more. Responses varied based on the individuals backgrounds, but they felt that short videos covering trauma and resulting behaviors, sensory needs, and trust-based relational intervention would help them. Family coaches mentioned that they would want to share the videos with host families and partnering parents as they saw fit. Therefore, my project background focused on defining the need for these topics. Research exists to define out-of-home care (OOHC) as not only formal foster care, but also informal foster care due to parental inability to provide adequate care at the time, such as the care provided in SFFC (Galvin et al., 2019; Turney & Wildeman, 2017). Children in OOHC have higher rates of mental health disorders, behavioral and emotional problems, and overall health needs, but early intervention is predicted to lead to an overall decrease in those same categories (Galvin et al., 2019; Leloux-Opmeer et al., 2016; Tarren-Sweeney, 2008). My capstone project sought to empower parents to recognize when their child needs early intervention services by educating parents and coaches on typical child development. In addition to early intervention, there is substantial evidence that providing various protective environmental factors to children in OOHC can reduce the effects of their higher adverse childhood experience (ACE) scores and help prevent developmental delays (Gatwiri et al., 2019; Hambrick et al., 2018; Sciaraffa, 2018; Sege & Brown, 2017; von Sneidern, 2017; Yamaoka & Bard, 2018). Children in SFFC have not always been exposed to big traumas in their lives, however, even by being separated from their family for a short period of time, they are exposed to ACEs (Finkelhor et al., 2013). Hambrick et al. (2018) examined brain scans of children that showed a correlation between early trauma exposure and developmental delays. The researchers found that the relational health currently being provided to a child, not the early trauma exposure, was the strongest predictor of developmental outcomes. Hambrick et al. (2018) defined relational health as feeling connected to others such as caregivers, family members, mentors, and others in the community. Another study conducted by von Sneidern et al. (2017) looked at the association between preschoolers ACE scores and developmental scores from a standardized assessment and found no association between ACE scores and developmental delay. Importantly, researchers noted the sociocultural context of the town in which they conducted their study as a community with extensive support networks of aunts/uncles, grandparents, friends, and teachers (von Sneidern et al., 2017). Therefore, they made the claim that the protective childhood development factors, including this extensive social support, were able to encourage healthy development despite ACEs (von Sneidern et al., 2017). SFFC is set up to foster relationships and build community around a family in crisis to keep the children safe and the families together. Therefore, my project will seek to foster these protective factors that already exist within SFFC, incorporate new ones, and educate families on the benefits of all protective factors. Sciaraffa et al. (2018) discussed three categories of protective factors that can help a childs positive adaptation in their environment: (1) helping children build their capacities, (2) helping them develop healthy attachments and a sense of belonging, and (3) building a protective community. Other articles focus on similar factors such as engaging in nurturing, playing, and learning in a safe and stable environment (Sege & Browne, 2017) while others list specifics such as reading together, having a family meal, and storytelling (Yamaoka & Bard, 2018). These protective factors also fall under the realm of trauma-informed care as discussed in the meta-analysis of Bailey et al. (2019). I believed that by including these trauma-informed protective factors in my educational resources, children in Safe Families could have less mental health disorders, behavioral problems, and overall health needs because of ACEs to which they may have been exposed (Risk and Protective Factors, 2021). Finally, while working to incorporate these protective environmental factors to promote healthy development of children in SFFC, I also brought awareness to cultural considerations. Kokaliari et al. (2019) addresses the racial disparities in the foster care system from the perspective of African American parents involved in the child welfare system. As there is a racial disparity between the host families and partnering parents as discussed above, I felt that this was crucial to consider. Kokaliari et al. (2019) found themes mentioned by the 21 African American participants living in poverty that included a profound lack of trust, overwhelming trauma, and a sense of social isolation. Maintaining cultural awareness in my project helped family coaches facilitate trust-building between the host family and the partnering parent, hopefully alleviating some lack of trust and social isolation. Theoretical Background The Person-Environment Occupational Performance (PEOP) Model with Trust-Based Relational Intervention (TBRI) influences guided my clinical reasoning throughout my capstone project development. My focus was on the children of SFFC and fostering their development while considering some of their behaviors. Observing these children from a PEOP perspective allowed me to consider not only the children themselves, but also their environment, occupations, and performance capacities. The most important part of my project was the central overlap seen in Figure 1 - the occupational performance and participation of the children in their desired occupations. The concepts of TBRI are key to my project as well as they guided my approach to educating the SFFC extended support network. Compassionate understanding is crucial to creating a healthy environment for the vulnerable children and their families to grow in the way that is needed. The goal of TBRI is to help children feel a sense of safety and connection with their caregivers and within their environment, both concepts highlighted in the performance bubble of Figure 1. That felt safety and connection in turn manifest as self-regulation and appropriate behaviors in children, concepts seen in the core of Figure 1. Project Design My main goals in designing my Nurturing Nuggets capstone project were (1) to make it accessible to the participants, and (2) to ensure its sustainability. Since the family coaches provide mentorship and education to both host families and partnering parents, I delivered my educational materials to the family coaches. I asked them what format of resources they felt would be easiest for them to work with and decided that short videos and handouts located in a shared Google folder were the most accessible and sustainable. The short videos covered a variety of topics including: (1) different sensory processing styles, (2) behaviors associated with sensory processing styles, (3) managing behaviors from a sensory perspective, (4) caregiver mental health support, (5) trauma-informed care, and (6) trauma and adverse childhood experiences. I also created handouts that reflected the content in the videos for any individuals who preferred reading rather than watching a video. In addition to the handouts and videos, I led a 45-minute educational session for the family coaches over Zoom focused on trauma-informed care and challenging behaviors. The educational session was intended to allow for more direct engagement with the topics, introduce my resources, and give time for discussion. I created a Google forms pre- and post-survey to use as my outcome measure that assessed learning and preparedness to educate host families/partnering parents before and after the Zoom educational session. See Appendix A for a weekly planning guide of my doctoral capstone project and experience. Project Implementation I emailed the family coaches a short description of my Nurturing Nuggets programming as well as a Zoom link to attend. Three family coaches attended the one-hour Zoom programming. I recorded the session for any family coaches who could not attend. The educational content consisted of a short description of occupational therapy, trauma-informed care, and a sensory approach to challenging behaviors. I showed them the shared Google folder that I had created containing the resource videos I had already made and explained the corresponding handouts I planned to make over the following weeks. I asked for feedback on those videos, and ideas of other resources that might continue to help them. I also showed them the sensory handouts from the previous capstone student that I had included in the same folder. I wanted to give the other seven family coaches the same opportunity for discussion and questions, so I decided to offer a second date and time for the same Nurturing Nuggets programming. Four additional family coaches attended the second session. Following the second session, I sent out an email with the recording of the programming for family coaches who had not yet attended a Zoom session, and the link to the shared Google folder with the resources I had created. I also encouraged family coaches to contact me over the following weeks with more needs for videos, handouts, or brainstorming for individual children. Project Outcomes In order to evaluate the effectiveness of my programming, I used pre- and post-surveys before and after the Zoom sessions. I was not able to find an existing outcome measure that would measure the participants knowledge on trauma-informed care and sensory processing styles, as well as their preparedness in educating others on those same topics. To capture the intended data, I chose to construct my own surveys with a 5-point Likert scale. Due to time constraints, I was not able to test for reliability or validity of these measures. I had seven total participants (n=7), and I calculated the average scores of each pre- and post-survey question to gauge if there was an increase in their knowledge and preparedness to educate. The Likert scale used ranged from 1, not at all, to 5, extremely. The averages for each question are listed in Table 1. Participants reported an overall increase in knowledge and preparedness following the training. This improvement was reflected in the participants comments during the training sessions seen in Table 2. The feedback I received from participants during and after the trainings, combined with increase in scores, suggests that my training was effective in educating on trauma-informed care and sensory styles in an accessible way. Summary Safe Families is an organization that helps families in times of crisis by temporarily hosting or caring for the children. With only two staff members in the Central Indiana chapter, it is a volunteer-based organization. Family coaches are the most experienced volunteers who are tasked with education, mentorship, and walking alongside both host families and partnering parents. When I performed a need assessment by talking to family coaches, I learned that they would benefit from educational programming and resources that they could share on traumainformed care and challenging behaviors. Research into these topics showed that providing various protective environmental factors to children in out-of-home care can reduce the effects of their higher adverse childhood experience (ACE) scores (Gatwiri et al., 2019; Hambrick et al., 2018; Sciaraffa, 2018; Sege & Brown, 2017; von Sneidern, 2017; Yamaoka & Bard, 2018). Protective factors included an extensive support network (von Sneidern, 2017), a safe and stable environment (Sege & Brown, 2017), and helping them develop healthy attachments and a sense of belonging (Sciaraffa, 2018). I chose to incorporate these factors into my project by leading a family coach training session I called Nurturing Nuggets: A trauma-informed, sensory-based approach to behaviors and development and creating video and handout resources for the family coaches to share. The videos and handouts included the following topics: (1) different sensory processing styles, (2) behaviors associated with sensory processing styles, (3) managing behaviors from a sensory perspective, (4) caregiver mental health support, (5) trauma-informed care, and (6) trauma and adverse childhood experiences. I used a pre- and post-test survey to measure family coaches knowledge and preparedness before and after the training session. An overall increase was seen in scores suggesting that my training was effective in educating on trauma-informed care and sensory styles in an accessible way. Conclusions During this capstone experience, I learned how important it is to advocate for all that I can do as an occupational therapist. Virginia Stoffel, a past American Occupational Therapy Association (AOTA) president coined the idea of what matters to you? instead of whats the matter with you? During this capstone, I realized that defining occupational therapy (OT) that way opens a lot of doors for us to help individuals. I also learned that it is so important to recognize what is within our scope of practice and when to make referrals for additional help (i.e. mental health, housing insecurity, etc.). As a result of my capstone project, the staff and volunteers of Safe Families learned about sensory styles and are now quick to identify different childrens sensory needs. The volunteers and staff now have additional videos and flyers to use as additional training in trauma-informed care for their family coaches. Family coaches are now equipped with short videos and handouts that they can easily text or email to host families or partnering parents who are struggling with behaviors or needing more information on trauma-informed care as well. I made sure these resources were accessible to all volunteers, using general language that is easily understood, and avoiding any specific occupational therapy terminology. Future implications of my capstone project include occupational therapists (OTs) doing contracted work and continued advocacy with community organizations. OTs may play an especially unique role in community organizations helping children who might show difficult behaviors or different sensory processing styles due to a history of trauma. It is also important to continue to advocate for different roles OT could play within an organization to help them see the benefit of potentially contracting or hiring an occupational therapist. References Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J., & Skouteris, H. (2019). Systematic review of organisation-wide, trauma-informed care models in out-of-home care (OoHC) settings. Health & social care in the community, 27(3), e10e22. https://doi.org/10.1111/hsc.12621 Finkelhor, D., Shattuck, A., Turner, H., Hamby, S. (2013). Improving the Adverse Childhood Experiences Study Scale. JAMA Pediatrics, 167(1), 7075. https://doi.org/10.1001/jamapediatrics.2013.420 Galvin, E., O'Donnell, R., Skouteris, H., Halfpenny, N., & Mousa, A. (2019). Interventions and practice models for improving health and psychosocial outcomes of children and young people in out-of-home care: protocol for a systematic review. BMJ Open, 9:e031362, https://doi.org/10.1136/bmjopen-2019-031362 Gatwiri, K., Mcpherson, L., Mcnamara, N., Mitchell, J., & Tucci, J. (2019). From adversity to stability to integration: How one Australian program is making a difference in therapeutic foster care. Journal of Child & Adolescent Trauma, 12, 387398. https://doi.org/10.1007/s40653-018-0236-6 Hambrick, E. P., Brawner, T. W., Perry, B. D., Brandt, K., Hofmeister, C., & Collins, J. O. (2018). Beyond the ACE score: Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children. Archives of Psychiatric Nursing 33, 238247. https://doi.org/10.1016/j.apnu.2018.11.001 Leloux-Opmeer, H., Kuiper, C., Swaab, H., & Scholte, E. (2016). Characteristics of Children in Foster Care, Family-Style Group Care, and Residential Care: A Scoping Review. Journal of child and family studies, 25, 23572371. https://doi.org/10.1007/s10826-016-0418-5 How safe families works. Safe Families for Children. (2022, February 27). Retrieved March 11, 2022, from https://safe-families.org/about/how-safe-families-works/ Kokaliari, E. D., Roy, A. W., & Taylor, J. (2019). African American perspectives on racial disparities in child removals. Child Abuse & Neglect, 90, 139-148. https://doi.org/10.1016/j.chiabu.2018.12.023 Risk and Protective Factors. (2021). Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/riskprotectivefactors.html Sciaraffa, M. A., Zeanah, P. D., Zeanah, C. H. (2018). Understanding and promoting resilience in the context of adverse childhood experiences. Early Childhood Educ J, 46, 343353. https://doi.org/10.1007/s10643-017-0869-3 Sege, R. D. & Browne, C. H. (2017). Responding to ACEs with HOPE: Health outcomes from positive experiences. Academic Pediatrics 17(7), 79-85. Tarren-Sweeney M. (2008). The mental health of children in out-of-home care. Current opinion in psychiatry, 21(4), 345349. https://doi.org/10.1097/YCO.0b013e32830321fa Turney, K. & Wildeman, C. (2017). Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey. Child Abuse & Neglect, 64, 117-129. http://dx.doi.org/10.1016/j.chiabu.2016.12.009 von Sneidern, E., Cabrera, K. P., Galeano, N., Plaza, M., & Barrios, M. (2017). Association between adverse childhood experiences (ACEs) and developmental delay of preschool children in a rural area of Colombia. Journ Child Adol Trauma, 10, 225232. https://doi.org/10.1007/s40653-017-0179-3 Yamaoka, Y. & Bard, D. E. (2018). Positive parenting matters in the face of early adversity. Am J Prev Med, 56(4), 530539. https://doi.org/10.1016/j.amepre.2018.11.018 Table 1 Averages from the Pre- and Post-Survey Question How well do you feel like you understand trauma-informed care? How prepared do you feel to explain trauma-informed care to host families? How well do you feel like you understand children's behaviors from a sensory perspective? How prepared do you feel to explain possible sensory causes of challenging behaviors care to host families and partnering parents? How prepared do you feel to provide host families and partnering parents with sensory resources to help with their child's behaviors? Pre-Survey (n=7) Post-Survey (n=7) 2.86 3.86 2.71 4 2.71 4 2.43 3.86 2 4.14 Table 2 Family Coach Training Participant Quotes I really like this [training] because I feel like it doesnt elevate the stress or anxiety of what trauma-informed care is, it just makes you understand that it happens in all environments. Youve just made [trauma-informed care] more laymens terms. [The sensory styles explanation] is helpful. I like the pictures and the symbolism [of the different mugs as sensory styles]. I havent been able to attend coach trainingsbut catching up on the sensory video and it so great!!! You did a great job explaining all of thisand the trauma-informed care handout has great info. Figure 1 Theoretical Reasoning Diagram Appendix Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage Orientation Weekly Goal Complete orientation with site and roles by the end of the week Objectives Meet all staff members and some family coaches to introduce myself and explain my project and experience goals Understand dress code, site norms, methods of communication, and usual meetings spots Screening/Evaluation Complete needs assessment Tasks Attend staff meetings Complete paperwork and trainings Create blurb to send out in January newsletter introducing myself Ask for contact info for family coaches and host families Familiarize myself with the database and the appropriate note format Obtain login for database and read through past case notes Finalize questions for needs assessment Determine who to send questions to Contact family coaches to assess need of content in educational programming Date complete 1/13/23 Obtain emails for those individuals and send out email assessing need 1/10/23 2 Screening/Evaluation Understand what the needs of the community are and start getting involved with the community Familiarize myself with hands-on work in Safe Families Meet some family coaches, host families, partnering parents, and children Connect with community organizations for partnership Volunteer as family friend for 2 families 1/20/23 Shadow family coaches and staff on home visits and intakes Read case notes after home visits and intakes Gather feedback from family coaches to help with project planning Attend staff meetings Attend outreach meetings 3 Implementation Plan for Create a plan implementation for the content of the programming Continue connecting with community partners Attend family coach meeting to gather additional feedback on resources Outline plan for educational programming Continue shadowing Attend staff meetings 1/27/23 Attend Creative Youth Housing Collective retreat 4 Implementation Start building educational resources Put together educational resources Set up pre- and post-test surveys Shadow staff in administrative positions Learn paperwork to be able to do recertifications, home assessments, and intakes by week 8 Volunteer as family friend 2/3/23 Participate in host family recertifications, home assessments, and intakes Attend staff meetings Begin drafting Google Slides presentation for education session Communicate with staff about timing of education in week 6 Draft pre- and post-test surveys for educational programming 5 Implementation Continue hands-on experience Continue family friend role Volunteer as family friend Put together educational resources Attend staff meetings Help with outreach Create content for 2 video resources 2/10/22 Finalize educational presentation for family coaches Attend Creative Youth Housing Collective meeting 6 Implementation Deliver programming Deliver educational resources Continue family friend role Administer pre- and posttest surveys to family coaches before and after education session 2/17/23 Create content for 3 more video resources Create handouts to correspond with videos based on feedback Attend staff meetings Shadow intake at hospital Volunteer as family friend 7 Implementation Continue hands-on experience Gather feedback from educational resources Plan additional videos and handouts based on feedback 2/24/23 Continue family friend role Attend staff meetings Help with outreach Volunteer as family friend Attend Creative Youth Housing Collective meeting 8 Implementation Continue hands-on experience Deliver and disseminate educational resources Continue family friend role Administer pre- and posttest surveys to family coaches and other participants before and after education session 3/3/23 Email family coaches the link to shared google folder with resources Attend staff meetings Volunteer as family friend Support family coaches Participate in advocacy for child needing services 9 Implementation Perform data analysis Continue family friend role Attend staff meetings 3/10/23 Analyze preand post-survey data Help with outreach Volunteer as family friend Run descriptive data Attend Creative Youth Housing Collective meeting 10 Discontinuation Perform data analysis Continue family friend role Perform home assessments Plan for dissemination Make changes to resources based on feedback 3/17/23 Discuss dissemination with staff Create feedback survey Attend staff meetings 11 12 Dissemination Dissemination Finalize dissemination plan and ensure sustainability Ensure sustainability Finalize changes in educational resources Send out feedback survey to family coaches Continue family friend role Attend staff meetings Perform home assessments Attend Creative Youth Housing Collective meeting Begin family coaching Family coach for 2 families 3/24/23 3/31/23 Perform home assessments Answer intake line Assess use of resources Analyze results of feedback survey Attend staff meetings 13 Dissemination Wrap up hands-on experience Ensure sustainability of project upon leaving Make all recorded resources easily accessible to staff and family coaches 4/7/23 Attend staff meetings Attend Creative Youth Housing Collective meeting 14 Dissemination Deliver final dissemination Finalize dissemination Present to stakeholders at site Final goodbyes with families Attend staff meetings 4/14/23  ...

... 1 Educational Support Group Implementation for Informal Caregivers of Persons with Dementia Madison Woo May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Patricia Holmes, OTR 2 Abstract Informal caregivers are an exponentially increasing need for older adults and individuals who take on this role report high rates of burnout and a need for community support. This doctoral capstone project evaluated the needs of informal caregivers who provide care for persons with dementia at Clermont Park Life Community across various levels of care through the implementation of a social support group. Data collection included a pre and post-test survey and a weekly qualitative questionnaire to better understand needs of caregivers; observational data is also described in this report. Findings included data on sustaining a support group for caregivers, which provided an outlet for informal caregivers to share and listen to stories from peers. Clermont Park and its patrons benefited from this support group series and received recommendations for the future to continue to support caregivers at this site. 3 Educational Support Group Implementation for Informal Caregivers of Persons with Dementia Clermont Park is the oldest life community campus of the Christian Living Communities brand and offers all levels of care including independent and assisted living, skilled nursing, memory care, and adult day services (Clermont Park, n.d.). Clermont Parks mission is to provide client-centered and dignified care to patrons by facilitating relationships that honor the individual through older adulthood. There are many different types of programming that exist for residents and their family members to help support this mission; one of these programs includes an adult day center. The adult day center at Clermont Park provides stimulating activities and encourages social interaction, providing safe and quality care for loved ones who are community dwelling (Gitlin et al., 2019). The number of members using adult day services has grown in the past year, serving roughly 5 families in 2022 to 30-40 families in 2023. Informal caregivers are increasing exponentially as a form of care used by older adults, as recent trends display older adults living longer and healthier into their older age (CDC, 2019). Many older adults prefer to age in the home in their preferred communities where they can maintain as much independence as possible, a concept termed as Aging in Place (Wiles et al., 2012). While this may be the ideal way to transition to oldest adulthood to many, family caregivers or Informal Caregivers (IC) often take on the responsibilities to provide long-term care for these individuals. Many IC report feelings of unpreparedness and general burden when taking on this role due to the lack of tools, resources, and support to fully thrive in their roles (van der Lee et al., 2017). Prior to the COVID-19 pandemic, Clermont Park offered a support group for IC, but restrictions in group meetings caused the group to dwindle. The purpose of this project is to reimplement a support group for IC and evaluate its impact on creating community, exchanging learned knowledge, and decreasing general caregiver burden. 4 Background Nationally, caregivers of individuals with Alzheimers or related forms of dementia (ARFD) provide an enormous amount of care for the increasing older adult population. In terms of economic value, 11.3 million caregivers of people with dementia provided a combined 16 billion hours of unpaid help (2022 Alzheimers Disease Facts and Figures, 2022). This equates to approximately 271.6 billion dollars of unpaid care for individuals with dementia (2022 Alzheimers Disease Facts and Figures, 2022). In the state of Colorado, the value of unpaid care for caregivers of individuals with Alzheimers or other dementias totaled 3.7 billion dollars (2022 Alzheimers Disease Facts and Figures, 2022). Monetary compensation is far from the only set back IC face, as this population is at high risk to develop feelings of stress, depression, and social depravity (Vos et al., 2021). In addition to a lack of recognition for the work they put into caregiving, IC reported limited amounts of external support, education, and available resources greatly effects the care relationship (Plothner et al., 2019). Clermont Park offers a wide variety of services that benefit the overall health and wellbeing of members, residents, and participants. However, there is a lack of regular support offered to IC through Clermont Park outside of respite care. Prior to the COVID-19 pandemic, Clermont Park hosted a successful caregiver support group; however, according to the life enrichment coordinator of the assisted living sector at Clermont Park, the support group was unable to sustain due to community restrictions and lack of leadership. While the project was originally designed to have educational information topics and a traditional group leader, the issue of sustainability begs the question whether the social support group can remain beneficial if proposed as being led and sustained by the caregivers themselves. Julianne Cooper, Head of Rehabilitation for all outpatient therapy services at Clermont Park 5 suggested this doctoral capstone project act as a way to gain research and insight into what family caregivers at this particular site would find most beneficial (J. Cooper, personal communication, January 26, 2023). For example, asking the participants who attend this social support group questions such as, how would you like to see this program in the future?, what would make this a group meaningful to you?, and assess learning and topic information resonance with a simple questionnaire after each week to evaluate the outcomes of the social support group format, gaining data to support the need of a caregiver support group for Clermont Park beneficiaries. Director of Life Enrichment at Clermont Park, Andrew Sharp, provided insight into the needs of families who use Clermont Park skilled nursing and independent living services. While families who use adult day services might continue to take on the caregiver role with their care recipient continuing to live in the community, a support group should address exhaustion and caregiver burnout, as these families do not cease to be caregivers once their loved one progresses to using skilled nursing services (A. Sharp, personal communication, January 18, 2023). Sharps comment on the needs of families as they progress through the levels of care suggest that this capstone project could be advertised to more families than the adult day care users alone. Caregivers continue to provide care as financial and medical POA, day to day on-call assistance for staff members, and emotional support for their loved ones in long-term care. Caregiver needs are highly rooted in the effects of burnout and social isolation. Creating a traditional social support group would be beneficial in providing IC with a space to speak and relate to others who share their situation. Additionally, according to the social worker for skilled nursing patients, Bobbie Carr, health literacy has decreased, and COVID might have created a disconnect, created a panic mode, between hospital staff and families (B. Carr, personal 6 communication, January 13, 2023). Therefore, maintaining an educational piece to this capstone project may help IC learn medical jargon and address caregiving concepts that may go untouched from the current lack of caregiver support programs. Additionally, becoming an IC can be a major disruption in maintaining health lifestyles that demonstrate occupational balance. According to Wang et al. (2019), IC may find it difficult to address mental health and general motivation to perform tasks. Educational programming may be beneficial in teaching IC tools and skills to maintain occupational balance through reflection of burnout symptoms and their effect on quality of care. In a study by Faw et al. (2021), researchers in Northern Colorado created a social support program titled B-Sharp where members attend social community events with other caregivers in the area. Members who participated in these social events reported reduced feelings of isolation, a restored sense of self, and a more positive view in their identity as a caregiver (Faw et al, 2021). While Clermont Park does not currently offer formal programming specifically for IC, implementing this project can provide data to advocate for social programming. The results of needs assessments suggest that a social support group for family caregivers of individuals who have Alzheimers or dementia related diseases is necessary. Programming for caregivers would be greatly beneficial to help educate and support IC as they transition through levels of care with their care recipients. At Clermont Park, adults are encouraged to progress in the level of care that allows them to age most efficiently and with dignity. IC play a major role in this and are known nationally for being the backbone of long-term care (CDC, 2019, para. 2). This doctoral capstone will attempt to determine the needs and wants of informal caregivers with social support group programming to enhance social participation and decrease the effects of caregiver burden in family caregivers. 7 Theory Occupational therapy models can be helpful for guiding practice and programming in the community. For the proposed programming, the Person-Environment-Occupation-Performance (PEOP) model (see Figure 1) will help integrate occupational therapy (OT) principles to the Clermont Park population. This model provides steps to identifying needs, planning, and evaluating outcomes (Cole & Tufano, 2020). Following this model, the steps to the project are as follows: 1) conduct an needs assessment of the site, 2) Identify how OT can fill those needs, 3) Determine the target population for the project, 4) Identify how goals of the site and OT goals can align, 5) Measure the intrinsic/extrinsic factors that can help with supporting occupational performance, 6) Create a plan, 7) Implement the plan, and 8) Evaluate the outcome (Cole & Tufano, 2020). In addition to these steps, the project will conclude with dissemination to stake holders and other staff members at Clermont Park to advocate for IC and share collected data. Additionally, the Lifespan frame of reference will be used as it can be applied to people of any age who are experiencing transitional phases of life (Cole & Tufano, 2020). IC are often challenged with threats to occupational balance as they take on the caregiving role. OTs can offer tools and resources that support adaptations and modifications to help the caregiver through their care journey. IC may not be familiar with equipment/technology that enhance the safety and quality of life for those with ARFD, which will be addressed in the caregiver support group. Lastly, guiding the facilitator role over the support group is the CARE framework, described by Holliday et al. (2022), which describes how healthcare professionals can address principles of well-being, care planning, and education in ways that reduce burden and build awareness around risk factors that affect caregivers mental and physical health (Holliday et al., 2022). 8 Project Design The project design was produced in collaboration with the Assisted Living and Adult Day Center Director at Clermont Park, Terry Neal, who echoed the needs of Clermont Parks IC. The caregiver support group contains both an educational and a social aspect. Using the Lifestyle Redesign format (Clark, A. F., 2015), the group will begin with a didactic component, followed by a peer exchange and social component, and will close with a personal exploration or selfreflection component. The group is one hour per week for 6 weeks, with a reevaluation at 3 weeks to determine any improvements that can enhance experiences in the support group. To address lack of excess time and associated resources for respite care, support group sessions will occur during adult day care operating times, where caregivers can feel confident that their loved ones are safe while they attend this social support group. Each of the weekly educational topics are chosen based on the 7 dimensions of wellness: occupational, emotional, social, physical, spiritual, environmental, and intellectual (Stoewen, D. L., 2017). Using each of these dimensions, topics are geared towards the common needs of caregivers, including communication and queuing techniques (Petrovsky et al., 2020), burnout prevention/mindfulness (Brown et al., 2016), transitions in care resources, wander/fall prevention, assistive technology, and personhood preservation. Caregivers will be provided with an infographic to summarize information from daily topics. Progress is measured from an initial pre-survey which acts for participants to rate their quality of life, quality of the care relationship, level of support, and confidence in their role as a caregiver, as well as used resources and descriptive questions for current situations. Participants who attend half of the caregiver support group sessions will be asked to complete the survey again to measure improvements in the above-stated items. After each session, participants will be 9 asked open-ended questions in survey format to describe the relevance of daily topics as well as suggestions for improvements to increase the benefit of the caregiver support group. Surveys with both qualitative and quantitative questions will support efficient information gathering and do not require participants to be present every week, as this consistency cannot be guaranteed. The title of this group is the Caregiver Support Series. Advertisement for the caregiver support group will occur through flier handouts to adult day center members, posters in front lobbies of Clermont Park, and signage in high trafficked areas of the main Clermont Park building. Word of mouth will also be encouraged from staff members to share this resource to potential family caregivers who might benefit from participation in the support group. Project Outcomes During the Caregiver Support Series, 7 caregivers attended at least one of the support group sessions with an average of 3 participants in attendance each week; each of the 7 caregivers were administered a pre-test assessment. There were two IC that attended 3+ weeks and were administered a post-test during the 6th support group session. Additionally, two IC communicated interest in participating in the project, however they were unable to attend due to time conflicts. The pre and post- test results are listed in Table 1 and Table 2, respectively. The quantitative results of the pre-test suggest that families who currently use Clermont Park services have general stress from their role as a caregiver, but overall have a positive outlook on their relationship with their care receiver, have some confidence in their role as caregivers, and a generally neutral to positive overall quality of life. Participants reported feeling supported in their role as caregiver. One notable relationship occurred between the stage of dementia of the participants care receiver and the confidence, quality of life, and relationship caregivers have with their care receiver. IC whose loved one was either transitioning into a 10 memory care unit or are already receiving long-term memory care respite services reported lower scores on relationship and quality of life items of the pre-test in comparison to those using only adult day services for respite. These results suggest there may be an inverse relationship between the progress of dementia and the perceived quality of life and quality of care-relationship. Other studies have described this concept as a result of increased burden as the care receiver requires higher intensities of care (Prevo et al., 2018). In the post-tests, one participant rated their care relationship as improving, while the other participant reported a decrease in the care relationship. Regardless of the care relationship status, the perceived quality of life status remained the same between the pre and post-tests for these participants. Neither participant reported a change on items regarding support or confidence in their role as a caregiver. The weekly qualitative questionnaire gathered information on topic relevancy and recommendations for future sessions (see Figure 2). Across all six weeks of support group, participants shared three common thoughts: 1) There is benefit to hearing stories from other caregivers, 2) There is value in articulating personal experiences, and 3) Shared information on educational topics was helpful. One thematically consistent critique across participants was the need for recruitment. During the midterm evaluation, invitations were extended to other life communities; however, no additional participants outside of Clermont Park attended. A few notable observations occurred, including the level of vulnerability shared amongst participants between initial and final weeks of support group. Additionally, as relationships progressed, participants were noted to provide recognition of hardships to peers, a concept called reciprocity which often lacks within the care relationship and increases IC burnout (Koh et al., 2021). These observations support the need for longevity in a support group to continue to cultivate comfort in vulnerability amongst participants. 11 Summary Informal caregivers are an increasing need in many older adults lives; however, the wants and needs of those who provide care to individuals living with dementia may not be satisfied in all communities. This doctoral capstone aimed at addressing this issue at Clermont Park, a life community in the Denver, Colorado metro area. The project was inclusive to all IC who use Clermont Park services; attendants included members using adult day, memory care, and assisted living services. The needs of participants were determined using pre and postsurveys, as well as qualitative questionnaires. The outcomes of this capstone project demonstrate consistent findings with the greater body of literature. IC who are experiencing transitional periods or provide care for people in later stages of dementia report lower perceived quality of life and quality of the care relationship compared to those whose loved ones are in earlier dementia stages. Additionally, participants in this project found the social support group to be beneficial for sharing their stories and advice amongst peers. One limitation of this project includes limited transferability due to a low sample size; however, there is value in the individual circumstances specifically for the purpose of supporting continuation of the caregiver support group at Clermont Park. Participants also reported that educational topics were beneficial to supporting their role as caregivers. Following the 7 dimensions of wellness, caregivers were provided with infographics covering topics including fall risk reduction, wander prevention, assistive technology, and information on dementia stages. Clermont Park received a binder outlining the format of this support group, all infographics created for the support group series, and additional information recommended by IC who attended the support group. The binder will serve as a foundational building block for future facilitators of a support group at Clermont Park. 12 Conclusion Through this doctoral capstone project, Clermont Park staff received information on how the caregiver population who use respite services would benefit from additional programming, specifically in the form of a social support group. The binder containing recommendations for a support group structure as well as informative topics will serve both the informal caregivers of a future support group and the facilitators who lead the group. Occupational therapists are well equipped to address the needs of family caregivers of individuals living with dementia; this project uncovered how caregivers need continued support in their roles and routines, environmental safety, and social interaction outlets-- all of which are within the occupational therapy scope of practice (AOTA, 2020). Overall, this project provided a sustainable and informational support group model, and its continued implementation at Clermont Park has potential for bettering the lives of family caregivers who use this service. 13 References American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi. org/10.5014/ajot.2020.74S2001 Brown, K. W., Coogle, C. L., & Wegelin, J. (2016). A pilot randomized controlled trial of mindfulness-based stress reduction for caregivers of family members with dementia. Aging & Mental Health, 20(11), 11571166. https://doi.org/10.1080/13607863.2015.1065790 Centers for Disease Control and Prevention [CDC]. (2019). Caregiving for family and FriendsA public health issue. U.S. Department of Health & Human Services. https://www.cdc.gov/aging/caregiving/caregiver-brief.html Clermont Park. (n.d.). Senior living in Denver, CO. https://www.clermontpark.org Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Faw, M. H., Luxton, I., Cross, J. E., & Davalos, D. (2021). Surviving and Thriving: Qualitative Results from a Multi-Year, Multidimensional Intervention to Promote Well-Being among Caregivers of Adults with Dementia.International Journal of Environmental Research and Public Health, 18(9).https://doi.org/10.3390/ijerph18094755 Gitlin, L. N., Marx, K., Scerpella, D., Dabelko-Schoeny, H., Anderson, K. A., Huang, J., Pizzi, L., Jutkowitz, E., Roth, D. L., & Gaugler, J. E. (2019). Embedding caregiver support in community-based services for older adults: A multi-site randomized trial to test the Adult Day Service Plus Program (ADS Plus). Contemporary clinical trials, 83, 97108. https://doi.org/10.1016/j.cct.2019.06.010 14 Holliday, A., Quinlan, C., & Schwartz, A. (2022). The hidden patient: The CARE framework to care for caregivers. Journal of Family Medicine & Primary Care, 11(1), 59. https://doi.org/10.4103/jfmpc.jfmpc_719_21 Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: the Well Elderly Study Occupational Therapy Program. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 52(5), 326336. https://doi.org/10.5014/ajot.52.5.326 Koh, Y. S., Koh, G. C.-H., Matchar, D. B., Hong, S.-I., & Tai, B. C. (2021). Examining the Influence of Social Interactions and Community Resources on Caregivers Burden in Stroke Settings: A Prospective Cohort Study. International Journal of Environmental Research and Public Health, 18(23). https://doi.org/10.3390/ijerph182312310 Lifelong Learning with OT. (2015, October 3). Occupational Models: PEOP (PersonEnvironment-Occupation-Performance). https://lifelonglearningwithot.wordpress.com/tag/peop-model/ Petrovsky, D. V., Sefcik, J. S., Hodgson, N. A., & Gitlin, L. N. (2020). Harsh communication: characteristics of caregivers and persons with dementia. Aging & Mental Health, 24(10), 17091716. https://doi.org/10.1080/13607863.2019.1667296 Plthner, M., Schmidt, K., de Jong, L., Zeidler, J., & Damm, K. (2019). Needs and preferences of informal caregivers regarding outpatient care for the elderly: a systematic literature review. BMC Geriatrics, 19(1), 82. https://doi.org/10.1186/s12877-019-1068-4 Prevo, L., Hajema, K., Linssen, E., Kremers, S., Crutzen, R., & Schneider, F. (2018). Population Characteristics and Needs of Informal Caregivers Associated With the Risk of Perceiving a High Burden: A Cross-Sectional Study. Inquiry : a journal of medical care 15 organization, provision and financing, 55, 46958018775570. https://doi.org/10.1177/0046958018775570 Stoewen D. L. (2017). Dimensions of wellness: Change your habits, change your life. The Canadian veterinary journal = La revue veterinaire canadienne, 58(8), 861862. 2022 Alzheimers Disease Facts and Figures. (2022). Alzheimers Association. https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf van der Lee, J., Bakker, T. J. E. M., Duivenvoorden, H. J., & Dres, R.-M. (2017). Do determinants of burden and emotional distress in dementia caregivers change over time? Aging & Mental Health, 21(3), 232240. https://doi.org/10.1080/13607863.2015.1102196 Vos, E. E., de Bruin, S. R., van der Beek, A. J., & Proper, K. I. (2021). " Its Like Juggling, Constantly Trying to Keep All Balls in the Air ": A Qualitative Study of the Support Needs of Working Caregivers Taking Care of Older Adults. International Journal of Environmental Research and Public Health, 18(11). https://doi.org/10.3390/ijerph18115701 Wang, X., Liu, S., Robinson, K. M., Shawler, C., & Zhou, L. (2019). The impact of dementia caregiving on selfcare management of caregivers and facilitators: a qualitative study. Psychogeriatrics, 19(1), 2331. https://doi.org/10.1111/psyg.12354 Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., Allen, R. E. S. (2012). The Meaning of Aging in Place to Older People. The Gerontologist, 52(3), 357366. https://doi.org/10.1093/geront/gnr098 16 Table 1 Pre-test Assessment Participant # Type of Care Relationship (Spouse, Parent, Family, Friend) Average Hours of Care Provided per Week (0-10, 1120, 21-30, 40+) Current Respite Services Used Do you feel supported in your role as a caregiver? Do you feel confident in your role as a caregiver? How would you rate your relationship with your carereceiver? How would you rate your current overall quality of life? Participant Participants Participant #1 #2 #3 Spouse Spouse Spouse Participant Participant Participant Participant #4 #5 #6 #7 Parent Friend Family Family 40+ 40+ 21-30 0-10 0-10 11-20 11-20 Adult Day Adult Day Adult Day Memory Care Assisted Living Memory Care Memory Care Frequently Sometimes Nearly Always Nearly Always Nearly Always Frequently Sometimes 3- Fine 5- Great 2- Poor 2- Poor 3- Fine 4- Good 5- Great 4- Good 3- Fine 3- Fine 3- Fine 4- Good 4- Good 4- Good Sometimes Frequently Sometimes Sometimes Frequently Frequently Frequently 17 Table 2 Post-test Assessment Participant # Do you feel supported in your role as a caregiver? Do you feel confident in your role as a caregiver How would you rate your relationship with your care receiver? How would you rate your current overall quality of life? Participant Participant #2 #1 Frequently Sometimes Frequently Sometimes 4- Good 4- Good 4- Good 3- Fine Figure 1 Person-Environment-Occupation-Performance Model Note. PEOP model initially created by Baum & Christiansen in 1985. From Lifelong Learning with OT (https://lifelonglearningwithot.wordpress.com/tag/peop-model/). 18 Figure 2 Weekly Qualitative Questionnaire 19 Appendix A Week DCE Stage (orientation, screening, evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks Date Complete 1 Orientation Complete orientation by the end of the week Meet site mentor and other staff members to introduce self and project Learn what staff members might be good interviewees for project 1/13 Use staff interviews to format and design caregiver support group Create interview questions 2 Screening/Evaluation Meet with staff to research needs of caregivers by end of week 3 Get contact information for staff members who might assist with logistics 1/20 Email necessary staff members and set up meeting times Take notes during meetings Attend leadership meetings to continue meeting staff members 3 Screening/Evaluation Meet with staff to research needs of caregivers by end of week 3 Plan logistics of support group by Create schedule for support group Plan out support group topics Reach out to potential collaborators for support group Create interest flyer Coordinate with staff members to advertise caregiver support group 1/27 20 end of week 3 Work with activities director to book a space within Clermont Park Work with day center staff on best time/day for day center members 4 Screening/Evaluation Advertise Caregiver Support Series by end of week 4 Create materials for first support group by end of week 4 Start recruitment of potential family caregivers (adult day center, assisted living, skilled nursing, memory care) Prepare for first support group session Post fliers in front lobbies 2/5 Send Voice Friend message to families in all levels of care Meet family members at day center and give fliers Reach out to staff members who work with families and share upcoming support group dates Create first infographic Create pre-test assessment and weekly feedback questionnaire 5 6 Implementation Implementation Create next weeks support group materials by end of week Create infographic Create next weeks support Create infographic Implement support group session Create infographic and send to site mentor for approval 2/7 Create group session questions Create infographic and send to site mentor for approval 2/14 21 group Implement materials by support group end of week session 7 8 9 10 Implementation Implementation Implementation Implementation Create group session questions Create next weeks support group materials by end of week Create infographic Create next weeks support group materials by end of week Create infographic Create next weeks support group materials by end of week Create infographic Plan for final support group session and create materials by end of week. Administer final support group and collect posttest data Prepare for final week of implementation Create post test for final week of implementation Implement support group session Find books on personhood to share with group Implement support group session Implement support group session Implement support group session Create infographic and send to site mentor for approval 2/21 Create group session questions Create infographic and send to site mentor for approval 2/28 Create group session questions Create infographic and send to site mentor for approval 3/7 Create group session questions Create and print posttest to administer to group members Send message out to support group members to remind 3/14 22 them of final support group 11 12 13 14 Discontinuation Discontinuation Discontinuation Discontinuation Create first draft of binder and send to site mentor for corrections by end of week 11 Make corrections to binder by end of week 12 Complete subjects from Introduction and 7 dimensions of wellness Research data to be used on infographics Complete subjects from additional recommendations from staff and caregivers Have site mentor read binder for clarity Finish binder pages to leave with site Create presentation and present to stakeholders by end of week 13. Sign up for Eden Alternative Training by end of week 13. Disseminate to necessary staff and stakeholders and answer questions from staff members regarding project Make thank you cards for site mentor and Attend final days of capstone at Clermont Park and Holly Creek 3/24 Format infographics with cohesiveness Have occupational therapist on site read adaptive equipment/technology pages for recommendations Go through pages and check for spelling/grammar errors Present the binder in PDF view to ensure pages formatting is correct Contact site mentor and life enrichment coordinator regarding Eden training 3/31 4/7 Pull data from final writing assignment to present findings at leadership meeting Print part of binder to have visual aid at leadership meeting Attend graduation party at day center 4/14 23 day center staff. for Eden Training Participate in Eden Alternative Training. Appendix B. Doctoral Capstone Weekly Planning Guide Take notes during eden training to share with classmates and for final voice thread presentation Reach out to necessary staff members for postcapstone contact information  ...

... Equipping and Empowering Vulnerable Parents through Executive Function and Connective Parenting Resources Ashton Williams May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Lori Breeden, EdD, OTR EQUIPPING AND EMPOWERING VULNERABLE PARENTS 1 Abstract Family Hope is an organization that provides childcare hosting to families in vulnerable circumstances. While children are in hosting, support coaches work with their parents to provide resources and offer social support. Support coaches needed additional resources to address parents' occupational wellbeing. Occupational therapy met this need by creating a transition tool of educational resources to empower parents through establishing healthy roles and routines, coach parents on connective, TBRITM parenting techniques, and to equip parents with executive functioning skills to promote family cohesion and occupational balance. The transition tool was piloted including eight sessions with one Family Hope mother. To assess parental competence, self-efficacy, and occupational performance, the Parental Sense of Competence Scale and Canadian Occupational Performance Measure was administered before and after intervention. Overall, parental competence, self-efficacy, occupational performance, and satisfaction improved after intervention. Support coaches will continue to use resources within the transition tool to assist families in need. Keywords: family, occupational performance, trust-based relational intervention (TBRITM), executive function, parenting skills EQUIPPING AND EMPOWERING VULNERABLE PARENTS 2 Equipping and Empowering Vulnerable Parents through Executive Function and Connective Parenting Resources Family Hope is a faith-based, non-profit organization that provides out-of-home hosting opportunities to prevent children from entering the foster care system (Family Hope, 2022). Family Hope offers volunteer placements, called host families, for children to stay when their parents cannot care for them for some time due to undesirable circumstances (Family Hope, 2022). Reunification of children and parents is the goal of this program. At Family Hope, transitions occur when a child is placed in a Host Familys care and when a child returns to their parents. Transitions can be difficult for volunteers, parents, and children, as this process can disrupt a familys daily routines, roles, and mental health. Family Hopes support coaches provide parents with resources, offer connections and support, and mentor parents to improve their quality of life (Family Hope, 2022). Occupational therapy promotes establishing healthy routines, roles, and mental health to improve a familys occupational performance. A transition tool of helpful resources can assist the coaching process. Education is also needed within Family Hope for parents and volunteers to understand trauma-informed care and connective parenting better. Parents and volunteers implement strategies from this education to form a relationship with a child to promote family cohesion, increase resiliency, and reduce adverse effects (Purvis et al., 2009; Nielson, 2014; Razuri et al., 2016). In this scholarly report, I will present the current literature and connect occupational therapy theoretical principles to my capstone project. Next, I will define the transition program while analyzing the programs outcomes and impact. Finally, I will include a synopsis EQUIPPING AND EMPOWERING VULNERABLE PARENTS 3 encompassing the overall capstone experience and a discussion regarding my projects sustainability and future implications. Background Needs Assessment A needs assessment at Family Hope consisted of semi-structured interviews with staff and volunteers, a faceted literature search, and a SWOT analysis. From the interviews, the most significant needs include assisting children and parents with healthy transitions and furthering trust-based parenting education. Parents requiring Family Hope services must clearly define family roles and establish routines within the home. Parents also need help incorporating social opportunities, self-care, and leisure activities into daily routines (Cerny et al., 2017). Foster Care and Family Preservation For children who experience adversity, foster care is available to improve the child's living conditions and safety. Foster care is a state-mandated, out-of-home, temporary service for children who cannot live with their parents or legal guardians (Centers for Disease Control and Prevention [CDC], 2021). The reasons for foster care placement include abuse, neglect, parent incarceration, parent loss, and parent illness (CDC, 20221). Parents and children from these situations often experience trauma, which can negatively manifest as decreased mental health, poor health, and increased risk behaviors (Razuri et al., 2016; Engler et al., 2022). The process of separating a parent and child can also be traumatic and lead to adverse effects on parents and children (Rapsey & Rolston, 2020). The Department of Child Services, the organization overseeing foster care, is overwhelmed due to the extensive number of children entering the system, lack of funding, and difficulty recruiting new foster parents (Howell-Moroney, 2013). EQUIPPING AND EMPOWERING VULNERABLE PARENTS 4 Similar organizations, such as Family Hope, exist to provide alternative solutions while providing services and resources to families in need. Family Hope services families experiencing homelessness, domestic violence, incarceration, unemployment, and poverty. Often, families seeking Family Hope services face a combination of these undesirable situations. Family Hope is unique since their model allows the parent to surrender her children to a host family temporarily and voluntarily. Even though this transition is voluntary, it can still be difficult for the parent and child. Parents using faith-based services reported much higher satisfaction than the national average, and faith-based organizations provide more resources and support to families (Howell-Moroney, 2013). Executive Function in Families Many parents involved with Family Hope have difficulty with their executive functioning skills, as these parents often experience traumatic and stressful situations. Executive function is a group of complex mental processes and cognitive abilities required for daily adaptive behaviors. Examples of these skills include attention, planning, prioritizing, organization, problem-solving, and self-control (Girotti et al., 2018). Many of these skills are required for quality parenting and household management (Deater-Deckard et al., 2012). Executive functioning takes place in a region of the brain called the prefrontal cortex. During stress, neural pathways in the prefrontal cortex can be disrupted, causing impairment in executive functioning skills (Girotti et al., 2018). Relational Interventions to Parents In addition to executive function, more specific trauma-informed parenting techniques are essential to promote parent-child connections. Family preservation aims to keep families together by keeping children with their families instead of placing children in foster care or other EQUIPPING AND EMPOWERING VULNERABLE PARENTS 5 alternative institutions. Parental growth occurs when families can rely on family-like, trust-based, supportive relationships (Rapsey & Rolston, 2020). Through these connective relationships and interventions, parents can improve their self-confidence and feel empowered (Razuri et al., 2016; Rapsey & Rolston, 2020). Trust-Based Relational InterventionTM (TBRITM) is an attachment-based, trauma-informed intervention that is designed to meet the complex needs of vulnerable children (Karyn Purvis Institute of Child Development [KPICD], 2022, p. 1). TBRITM consists of three principles: empowering, connecting, and correcting (Purvis et al., 2009; Razuri et al., 2016). the connecting principle consists of awareness and interaction. The empowering principle includes ecology and physiology to address physical needs, and the correcting principle incorporates proactive and redirective strategies (KPICD, 2022). TBRITM training improves family cohesion, reduces child mental health problems, reduces parental stress, and reduces mental health problems (Nielsen, 2014). Occupational Performance Coaching Occupational Performance Coaching (OPC) is an intervention for parents affected by occupational performance challenges. Occupational therapists use OPC to improve occupational performance in children and parents while improving parents' self-confidence relating to their parenting skills (Graham et al., 2013). OPC provides a strengths-based, goal-oriented, and occupation-based lens to improve maternal mental health and family routines (Graham et al., 2013). The three domains of OPC include emotional support, information exchange, and a structured process (Graham et al., 2013). Family Hope assigns a support coach to each case to build a relationship with the parent(s), provide emotional and social support, and direct parent(s) to available resources. Current research focuses on evaluating children's executive function and EQUIPPING AND EMPOWERING VULNERABLE PARENTS 6 targeting interventions with children; however, my project aims to intervene at the parent level to address household executive functioning and educate on trauma-informed parenting. Theoretical Integration Person-Environment-Occupation (PEO) is an occupation-based model that focuses on maximizing the individual's or group's "fit" (Cole & Tufano, 2008). Occupational "fit" is the balance of an individual's or group's person, environment, and occupation to maximize occupational performance (Cole & Tufano, 2008). At Family Hope, parents seeking services have an unbalanced person-environment-occupation "fit" due to a crisis or decreased occupational performance. This capstone project aimed to improve families' occupational performance and educate parents and volunteers on trauma-informed, connective parenting during transitional periods. The Model of Occupational Empowerment is a frame of reference (FOR) used for individuals or groups in disempowering environments (Cho, 2022). According to this FOR, occupational therapy's role is to provide interventions that empower clients, increase social support, and establish healthy roles and routines (Cho, 2022). At Family Hope, families call the Hope Line when experiencing a time of crisis. Often, families live in undesirable circumstances, making their ability to perform occupations difficult. OT intervention aims to improve self-efficacy, enhance their quality of life, and develop healthy routines and behaviors (Cho, 2022). Specifically, a transition tool was developed to coach parents on establishing healthy roles and routines. The goal of the transition tool was to improve the family's occupational performance and well-being in a sustainable approach.This frame of reference guided the transition tools development, as Family Hope parents could benefit from interventions targeted at understanding healthy household roles, creating family routines, and increasing social support. EQUIPPING AND EMPOWERING VULNERABLE PARENTS 7 Doctoral Capstone Plan Design Following the needs assessment, parents reported needing additional education and resources to address executive functioning and parenting skills during the Family Hope coaching process. Parents using Family Hope services wanted additional support and education regarding best parenting practices. I proposed the idea of creating a transition tool for parents to use with the help of a support coach to address these needs. Specific, evidence-based topics for the tool included: goal-setting, prioritizing needs, problem-solving, understanding parenting roles, establishing structure and routines, and trust-based parenting practices. I researched the effectiveness of including these topics in occupational therapy interventions. Positive and more sustainable outcomes occur when sessions are client-centered, relational, and coach-based (Graham et al., 2013; Razuri et al., 2016; Rapsey & Rolston, 2020; Engler et al., 2022). Applying these topics in occupational therapy sessions has improved parental self-confidence, reduced children's poor behavior, and increased family resiliency and cohesion (Razuri et al., 2016; Rapsey & Rolston, 2020; Engler et al., 2022; Wilburn et al., 2022). When writing the tool, I incorporated parent factors such as accessible language, length, and practical application. Once I completed a draft of the tool, Family Hope staff and an occupational therapist reviewed the tool for usability, clarity, and usefulness. Assessment Tool Selection I aimed to improve parents occupational performance and increase parents' competence and self-confidence through executive functioning activities and trauma-informed, connective parenting education embedded within the transition tool. Two outcome measures were selected and administered as pre-and post-tests to evaluate occupational performance and parental competence. The Canadian Occupational Performance Measure (COPM) assessed participants' EQUIPPING AND EMPOWERING VULNERABLE PARENTS 8 perceptions of their occupational performance and satisfaction. The COPM addressed three domains of occupational performance: self-care, productivity, and leisure. Additionally, the Parenting Sense of Competence Scale (PSOC) assessed participants' competence and self-efficacy regarding their parenting skills (Rodgers & Matthews, 2004). Rogers and Matthews (2004) reported that the PSOC was a reliable and valid tool for measuring parental competence. Implementation After finishing the planning stage, I began the recruitment process by asking support coaches for recommendations of parents who would benefit from transition tool sessions. I also presented my project and passed around an interest form during a Sweet Water ministry event held for mothers involved with Family Hope. From this process, I had one mother named Susan, a pseudonym given to protect privacy, commit to weekly coaching sessions. After Susan agreed to join my DCE program, I planned one-on-one, in-person coaching sessions with her. I piloted the transition tool resources with Susan over the course of eight sessions. We worked together for an hour to an hour and a half on different sections of the transition tool. During each session, I utilized principles of OPC such as encouraging client-directed activities, using a strengths-based lens, and keeping interventions goal-oriented. Additionally, I developed increased confidence and competence in using shared-decision making and therapeutic use of self during one-on-one client intervention sessions through reviewing literature and weekly self-reflection. Assessment To evaluate family occupational performance, I utilized the COPM. During the first transition tool session, one single mother, Susan, completed the assessment tool by discussing her current occupational performance. During administration, I asked Susan to describe her daily roles and routines. She then identified occupational performance problems and rated the EQUIPPING AND EMPOWERING VULNERABLE PARENTS 9 importance of the activities on a scale from 1 (low importance) to 10 (high importance). When administering the COPM, Susan identified six occupational performance deficit areas: self-care, finances, parenting, planning and scheduling, time management, and health and exercise. From these activities, she rated her current performance and satisfaction on a scale from 1 (lowest) to 10 (highest). For the reevaluation, Susan ranked the importance of the activity, her performance, and her satisfaction with each activity again. Then, I administered the PSOC to evaluate Susan's self-efficacy and confidence. The PSOC is a 17-item self-report survey where parents rate how much they agree with a statement using a 6-point Likert scale. Higher scores indicate a high parental sense of competence; scores range from 17 to 102. I administered both the COPM and the PSOC during the initial transition tool session and again during the final session after Susan completed all sections of the tool. Data Analysis After collecting and recording data, I calculated the sum scores for the pretest and posttest PSOC, as reported in Table 1 in Appendix A. When comparing the scores, Susan's PSOC scores increased by five points after transition tool sessions. Next, I compared Susan's posttest scores from the COPM with the pretest scores to assess gain or loss for performance and satisfaction, as reported in Table 1 in Appendix A. Each area increased after intervention by at least two points in terms of her performance. Susan's satisfaction increased in every area by at least one point after the intervention. After reviewing the data, the goals of the transition tool were met, as Susan's perception of her occupational performance improved and her satisfaction improved across all occupational deficit areas. Furthermore, Susan's parental sense of competence, confidence, and self-efficacy improved, as indicated by her PSOC scores after the transition tool intervention. EQUIPPING AND EMPOWERING VULNERABLE PARENTS 10 Summary Family Hope provides families in challenging circumstances with relational support through volunteer childcare hosting opportunities and support coach mentoring. While children are with host families, support coaches work with parents to address immediate needs, create short-term and long-term plans, and provide connection and support. After conducting a needs assessment, support coaches needed additional resources to address parents' holistic needs, as parents often struggled with an unbalanced occupational fit resulting in poor occupational performance. Occupational therapy filled this gap by using techniques from OPC to improve social support, empowering parents by establishing healthy roles and routines, and educating parents on implementing connective parenting with their children. The transition tool contained collaborative, interactive resources to address common occupational performance deficit areas. Implementation included piloting transition tool resources with a Family Hope mother named Susan. Susan and I worked together weekly for eight weeks on transition tool resources. These educational interventions focused on the importance of each section's concept, how to complete activities, and reflection asking her to consider how the concepts learned would apply to her family. During interventions, I educated Susan on the importance of why I created the section, coached her on how to complete the activity, and challenged her to think about how to apply the skill to her family's everyday life. Pre- post- measures of the PSOC and COPM indicate improvements in competence, self-efficacy, and occupational performance. These findings support existing literature, as developing healthy roles and routines improves parents' self-efficacy and occupational performance (Cho, 2022). Additionally, OPC and TBRITM education improves parents' self-confidence and family cohesion (Graham et al., 2013; Nielsen, 2014). EQUIPPING AND EMPOWERING VULNERABLE PARENTS 11 Conclusion During my capstone experience, I produced a transition tool consisting of 11 educational resources covering executive function and trust-based parenting. To develop these resources, I reviewed the current evidence to gain knowledge regarding occupational therapy's role in teaching executive functioning skills, the impact of establishing family roles and routines, and the importance of TBRITM implementation. I spent multiple hours observing Family Hope staff to gain a better understanding of my site and the parents they serve. Before working directly with parents, I applied therapeutic use of self, and I reviewed specific relational techniques such as occupational performance coaching to build rapport and maximize the impact of my program. The doctoral capstone experience improved my communication, leadership, and advocacy skills, effectively building relationships with staff and families, creating and leading a transition tool pilot program, and educating staff and families on occupational therapy's role in non-traditional settings. Family Hope's support coaches will access transition tool resources through a shared virtual drive. Support coaches will utilize these resources throughout the coaching process with parents to improve parents' self-efficacy, confidence, and occupational performance. Family Hope will also include additional education regarding trust-based parenting during volunteer training sessions to maximize volunteers' understanding of evidence-based, trauma-informed parenting. OT intervention can functionally improve the lives of families experiencing vulnerable situations. Creating collaborative, interactive educational resources for clients' needs can improve clients' confidence, self-efficacy, and occupational performance. The knowledge and skills gained from my doctoral capstone project will be applied to my future practice as an occupational therapist. EQUIPPING AND EMPOWERING VULNERABLE PARENTS 12 References Centers for Disease Control and Prevention [CDC]. (2021). About the CDC-Kaiser ACE Study. U.S. Department of Health and Human Services. https://www.cdc.gov/violenceprevention/aces/about.html Cerny, S., Aesoph, M., Green, N., & Johnson, B. (2017). Trauma-informed analysis of family occupational performance. American Journal of Occupational Therapy, 71. https://doi.org/10.5014/ajot.2017.71S1-PO7105 Cho, M. (2022). Model of occupational empowerment. OT Theory. https://ottheory.com/therapy-model/model-occupational-empowerment Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. SLACK Incorporated. Deater-Deckard, K., Chen, N., Wang, Z., & Bell, M. A. (2012). Socioeconomic risk moderates the link between household chaos and maternal executive function. Journal of Family Psychology, 26(3), 391. https://doi.org/10.1037/a0028331 Engler, A. D., Sarpong, K. O., Van Horne, B. S., Greeley, C. S., & Keefe, R. J. (2022). A systematic review of mental health disorders of children in foster care. Trauma, Violence, & Abuse, 23(1), 255-264. https://doi.org/10.1177/1524838020941197 Girotti, M., Adler, S. M., Bulin, S. E., Fucich, E. A., Paredes, D., & Morilak, D. A. (2018). Prefrontal cortex executive processes affected by stress in health and disease. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 85, 161-179. https://doi.org/10.1016/j.pnpbp.2017.07.004 Graham, F., Rodger, S., & Ziviani, J. (2013). Effectiveness of occupational performance coaching in improving childrens and mothers performance and mothers EQUIPPING AND EMPOWERING VULNERABLE PARENTS 13 self-competence. The American Journal of Occupational Therapy, 67(1), 10-18. https://doi.org/10.5014/ajot.2013.004648 Howell-Moroney, M. (2013). Faith-based partnerships and foster parent satisfaction. Journal of Health and Human Services Administration, 228-251. EBSCOhost. https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=8094e6d8-f61a-447 -92d2-d5726902a4f2%40redis Karyn Purvis Institute of Child Development [KPICD]. (2022). Trust-based relational intervention. Texan Christian University. https://child.tcu.edu/about-us/tbri/#sthash.M5yNDd3A.dpbs Nielsen, Lauren E., (2014). Trust-based relational intervention (TBRI) for adopted children receiving therapy in an outpatient setting. Honors Projects. 165. https://digitalcommons.iwu.edu/psych_honproj/165 Purvis, K. B., Cross, D. R., & Pennings, J. S. (2009). Trust Based Relational Intervention: Interactive principles for adopted children with special social-emotional needs. The Journal of Humanistic Counseling, Education and Development, 48(1), 3-22. https://doi.org/10.1002/j.2161-1939.2009.tb00064.x . Rapsey, C. M., & Rolston, C. J. (2020). Fostering the family, not just the child: Exploring the value of a residential family preservation programme from the perspectives of service users and staff. Children and Youth Services Review, 108. https://doi.org/10.1016/j.childyouth.2019.104505 Razuri, E. B., Hiles Howard, A. R., Parris, S. R., Call, C. D., DeLuna, J. H., Hall, J. S., ... & Cross, D. R. (2016). Decrease in behavioral problems and trauma symptoms among at-risk adopted children following web-based trauma-informed parent training EQUIPPING AND EMPOWERING VULNERABLE PARENTS 14 intervention. Journal of Evidence-Informed Social Work, 13(2), 165-178. https://doi.org/10.1080/10888705.2014.950733 Rogers, H., & Matthews, J. (2004). The parenting sense of competence scale: Investigation of the factor structure, reliability, and validity for an Australian sample. Australian Psychologist, 39(1), 88-96. https://doi.org/10.1080/00050060410001660380 Wilburn, V., Huber, M., Senter, D., Stoll, H. (2022). Considerations for occupational therapists in developing community-level interventions for youth with high adverse childhood experiences (ACE). The Open Journal of Occupational Therapy, 10(1), 1-7. https://doi.org/10.15453/2168-6408.1800 EQUIPPING AND EMPOWERING VULNERABLE PARENTS 15 Appendix A Table 1 Findings Before and After Transition Tool Intervention using the PSOC and the COPM Assessment Pre-test Post-test 76 81 PSOC Total score COPM Performance Satisfaction Performance Satisfaction Self-care 4 3 8 7 Finances 2 1 9 8 Parenting 5 7 10 9 Planning & Scheduling 5 2 10 9 Time Management 4 2 10 10 Health & Exercise 5 1 7 6 EQUIPPING AND EMPOWERING VULNERABLE PARENTS 16 Appendix B Table 2 DCE Weekly Planning Guide Week 1 2 3 DCE Stage Weekly Goals Objectives Tasks Orientation - Attended a weekly staff meeting to meet staff and - Complete orientation by the end of educate them on my project. week 1. - Developed supervision - Create a Timely & Weekly Planner plan w/ site coordinator by the end of week 1. - Integrated syllabus into planner - Set up times with key staff members - Ensured all orientation paperwork is signed by the end of the week - Scheduled observation hours for home visits, home evaluations, intake meetings, Sweet Water groups, and more - Created elements of Scholarly Report Drafts Screening/ Evaluation - Complete and submit introduction draft by end of week 2. - Complete literature search by end of week 2. - Create a template draft for transition tool by the end of week 2. - Finalize Needs Assessment by end of week 2. - Attended observation of daily operations - Attended Home Visit - Attended a Home evaluation - Outlined and drafted backgrounds section - Sent template to site coordinator for edits - Attended a weekly supervision hour / site coordinator - Attended weekly staff meeting - Reviewed how to conduct a faceted literature search Screening/ Evaluation - Complete and submit background draft by end of week 3. - Finalize transition tool by the end of week 3. - Create a social story for Intake - Established outcome assessment - Planned introduction transition tool session - Reviewed outcome assessment with capstone coordinator and faculty mentor - Attended weekly staff meeting - Attended weekly supervision hour / site coordinator EQUIPPING AND EMPOWERING VULNERABLE PARENTS 17 transition by end of week 3. - Send transition tool to faculty mentor and Family Hope staff for feedback by end of week 3. 1) Complete and submit design & implementation draft by the end of week 4. 2) Schedule at least 1 transition tool session for next week by the end of week 4. 3) Revise transition tool using feedback by the end of week 4. - Scheduled meetings with Family Hope staff and faculty mentor to discuss feedback - Attended an intake meeting - Began the recruitment process - Attended weekly staff meeting - weekly supervision hour / site coordinator - Attended support coach visits to build rapport with mothers - Attended housing opportunity visit to build rapport with mother - Attend weekly staff meeting - Attended a weekly supervision hour w/ site coordinator - Met with faculty mentor to discuss implementation and assessment - Attended potential parent visit to built rapport with mother 4 Screening/ Evaluation 5 - Implement an introductory transition tool session over goal-setting and prioritizing needs Implementation with a parent by the end of week 5. - Meet with Bethany to learn about the intake process by the end of week 5. - Scheduled and implemented one transition tool session - Attended Sweet Water group to recruit participants & build rapport with mothers 6 - Implement week 2 transition tool session over creating daily and Implementation weekly schedules by the end of week 6. - Scheduled next transition - Attend weekly staff meeting tool session with Susan - Attended weekly supervision hour / site - Attended a home visit with coordinator a support coach 7 - Implement week 3 transition tool session over connective parenting Implementation and TBRITM techniques by the end of week 7. - Scheduled next transition tool session with Susan - Attended Sweet Water to connect with mothers - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Printed more transition tool resources EQUIPPING AND EMPOWERING VULNERABLE PARENTS 18 - Completed midterm evaluation 8 - Complete and submit program: outcomes by the end of week 8. - Implement week 4 transition tool Implementation session over understanding parenting roles by the end of week 8. - Scheduled next transition tool session with Susan - Began drafting program outcomes - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator 9 - Implement week 5 transition tool Implementation session over problem solving skills by the end of week 9. - Scheduled next transition tool session with Susan - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Attended parent and home visit with a support coach - Edited scholarly report draft 10 - Scheduled next transition - Implement week 6 transition tool tool session with Susan session over prioritizing needs part Implementation - Provided consultant II and budgeting by the end of week support to parent and host 10. family - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Attended an intake meeting - Texted and called parents and host family to check on children - Implement week 7 transition tool session over creating visual - Scheduled next transition Implementation checklists to improve routines by the tool session with Susan end of week 11. - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Edited scholarly report draft - Met with faculty coordinator to discuss DCE progress and ask questions regarding APA formatting and data analysis. 11 EQUIPPING AND EMPOWERING VULNERABLE PARENTS 19 12 - Implement final transition tool session to discuss sustainability and reflect on learning by the end of week 12. - Complete data analysis by the end Discontinuation of week 12. - Educate Support Coaches on how to use the Transition Tool resources with parents during the coaching process by the end of week 12. - Scheduled follow-up with Susan - Reviewed data analysis strategies with faculty mentor - Attended a support coach meet-up to educate support coaches on my project 13 - Complete and submit abstract, summary, & conclusion draft by end of week 13. - Create a Family Hope Discontinuation dissemination presentation by the end of week 13. - Finalize a virtual Transition Tool to share with Family Hope staff by the end of week 13. - Rehearsed dissemination presentation - Attend weekly staff meeting - Created a Google folder of - Attended weekly supervision hour / site transition tool resources coordinator - Compiled and organized transition tool resources 14 - Complete scholarly report rough draft of DCE Report by the end of week 14. - Present dissemination presentation to Family Hope staff by the end of week 14. - Complete DCE VoiceThread project by the end of week 14. Dissemination - Combine all sections of scholarly report into one document - Presented to Family Hope staff - Consulted with Sweet Water volunteers regarding TBRITM techniques - Completed DCE - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Created a Support Coach User Manual for the Transition Tool - Attend weekly staff meeting - Attended weekly supervision hour / site coordinator - Called Sweet Water volunteer to discuss future plans - Recorded VoiceThread presentation EQUIPPING AND EMPOWERING VULNERABLE PARENTS VoiceThread presentation 20 EQUIPPING AND EMPOWERING VULNERABLE PARENTS 21  ...

... Community Based Fall Prevention Program for Older Adults Faith Wilkins, OTS May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Beth Ann Walker, PhD, MS, OTR, FAOTA 2 Abstract Falls are a leading cause of injury in older adults attributed to lack of physical activity, social isolation, and health conditions. Fall prevention courses are designed to educate participants on fall safety, increase activity levels and social engagement. The purpose of this capstone experience was to develop and evaluate the effectiveness of implementing educational sessions based upon the evidence-based fall prevention program My Safe and Sound Plan'' delivered to older adults at Flanner House. The value of the group fall prevention courses was assessed by participants through pre/post tests using a Likert scale. All participants reported an increase in engagement in activities they enjoy. Five out of six participants reported feeling more satisfied with life. All participants reported a reduction in fear of falling. Four out of six participants reported an increase in their exercise frequency. Five out of six participants reported an increase in knowledge of fall risks. The results of this capstone project indicate a positive impact on participant knowledge, exercise levels, and fear of falling. 3 Introduction Flanner House is a nonprofit organization that has been serving the Northwest side of the Indianapolis community since 1898. Flanner Houses mission statement is to support, advocate for and empower individuals, children and families by applying educational, social and economic resources that move members of the community towards stabilization, and selfsufficiency (Flanner House, 2022). Flanner House recognizes the lack of innovative, accessible and person-centered services offered in the community. Flanner House offers residents a safe, structured environment for individuals of all ages, abilities, and backgrounds to learn, play and engage with the community around them. The organization analyzes the socio-economic situation of the city's residents to tailor its programs and target key community issues. This year Flanner House is celebrating 125 years of serving thousands of individuals in Indianapolis (Flanner House, 2023). The Senior Program at Flanner House has a variety of programs and activities offered for the older adult guests to promote quality of life and stay engaged. Even a modest increase in social activities can have a significant impact on health and quality of life (Lachman, et al., 2018). Engaging in social and productive activities, like taking an art class or becoming a volunteer in your community, may help to maintain well-being (National Institute of Aging, 2017). Falls in older adults are associated with limitations in activity participation and a loss of personal independence (Leland et al., 2012). According to the CDC (2019), one out of five falls causes a serious injury such as broken bones or a head injury. This indicates the importance of fall prevention interventions for older adults in the community. Implementing an evidencedbased fall prevention program will address specific risk factors and apply targeted interventions to address those risks. 4 Background Occupational Therapy The National Institute on Aging suggests that older adults who participate in meaningful activities, like volunteering in their communities, say they feel happier and healthier (2017). Falls present as barriers to participating in meaningful activities older adults want to do at home and in the community safely. A study completed by Wheeler et al. (2018) showed that occupational therapists demonstrated a 22.2% improvement in implementing evidence-based interventions after completing fall prevention training modules. Elliott and Leland (2018) found that exercise, education on prevention, home safety modifications, and fall prevention programs are effective in reducing the number of falls in older adults. When older persons living in the community received an assessment and multifactorial interventions tailored to their needs, the number of falls was reduced by 25 percent (Van Voast Moncada, 2011). Successful occupational therapy interventions for fall prevention include improving strength, balance, gait through exercise, managing medications, and reducing the fear of falling (Leland, et al., 2012). Occupational therapy practitioners are uniquely qualified to address the multifactorial nature of falls, given their knowledge of factors that influence occupational performance (Peterson & Clemson, 2008). The guidance of an occupational therapist mindset will help to take steps to reduce fall risks and safely increase occupational engagement in activities they value. Falls and Fall Prevention The United States Census Bureau projects that in 2030, one in five Americans will be 65 years old or of retirement age. Falls are a major concern for older adults that lead to injuries, fear of falling, loss of confidence, and a loss of independence when performing daily activities and community participation (Pereira et al., 2008). Many older adults have a higher amount of 5 risk factors resulting in a higher prevalence of falls. Risk factors include weak muscles, poor balance, dizziness, foot injuries, memory issues, vision/ hearing impairments, medications, behaviors, and changes in bladder or bowel (CDC, 2017). The CDC states, in 2019, the emergency department recorded over 3 million visits for older adult falls. Some falls lead to injury and to fear of falling. The psychological impacts of experiencing a fall can result in older adults getting out of the house less often, resulting in lower levels of physical activity, social connection, and occupational participation (Curl et al., 2020). A Fall Prevention program may play an important role in education on fall safety, risks, and increase activity levels and social engagement. Community-based organizations, such as Flanner House, play an important role in promoting the health and well-being of the residents in their community. Many of the services provided by Flanner House help people of all ages maintain healthy lifestyles and improve their quality of life. This includes expanding efforts to reduce falls among older adults while they age in place. Many community settings offer group-based fall prevention programs for older adults. Fall prevention programs are designed to educate individuals on fall safety, with the goal of increasing social participation and activity levels. There is a plethora of evidence-based fall prevention programs such as Healthy Steps in Motion, a Matter of Balance, Healthy Steps for Older Adults, Stay Active and Independent in Life, and others (NCOA, 2021). Thompson et al., (2019) found that exercise interventions aimed at reducing falls in older adults exercise classes containing multiple components (i.e., balance, strength training) exhibited a significant reduction in the relative risk of falls, as well as risk of falling. Valatka et al. (2021) found that 75% of participants who reported falls prior to participating in the fall prevention program Matter of Balance reported a reduction in falls and 71% reported a reduction in fear of falling 6 following the course. Participants in the Fallproof Balance and Mobility Program expressed their experiences of better fall prevention strategies and how the program positively impacted fear of falling, agility, and posture (Osho et al., 2020). Involving physical activity as well as non-exercise-based programs that offer indirect physical benefit and social engagement have been shown to decrease fall levels (Albert & King, 2017). Physical activity and social engagement are valuable for physical health, mental well-being, and satisfaction in community programs. The My Safe and Sound'' Plan: For Staying Falls Free (Howard, 2018) will be used for participants to learn to view falls and fear of falling as controllable, set realistic goals to increase daily activity in their day, change their environment to reduce fall risk factors, and exercise to increase strength and balance. This program consists of group settings covering a range of issues including falls and risk, strength and balance exercises, home hazards, foot care, vision, vitamin D and calcium, heart health, and medication management (Howard, 2018). Prevention of falls is vital to maintain personal independence in older adults. Occupational therapists can use education to change behavior and improve older adults falls self-efficacythat is, their confidence in performing activities without falling (Cheal & Clemson, 2001; Peterson & Murphy, 2002). Using an evidence-based tool, such as My Safe and Sound'' Plan, with content validity increases the likelihood of clear evidence translation and successful occupational therapy intervention outcomes'' (Howard et al., 2019). The goals of the program are to help older adults improve and/or maintain mobility and independence, learn and use health information focused on falls reduction and other health-related behaviors, and socially engage with other older adults. 7 Theory/ FOR The theoretical model for occupational therapy, Person- Environment-OccupationPerformance (PEOP), was used to inform this capstone project. This model focuses on factors and its relationship to successful occupational participation (Cole & Tufano, 2008). It was used to examine multiple factors related to needs and barriers to falls and fall prevention. The PEOP (Figure 1) Model demonstrates the relations of the person, environment, occupation, and performance influence. If one aspect changes, such as the environment, then this can affect the person's occupational engagement or participation. By using this model, occupational therapists can develop fall prevention programs which explore the interaction between person, environment, occupation, and performance to help older adults to make informed decisions to reduce fall risks and promote occupational participation. The Lifespan Frame of Reference works well with the PEOP model because the person, environment, and occupation domains are always interacting, changing and developing across the lifespan. For older adults, the Lifespan reference addresses motivational drives and transitional roles (Cole & Tufano, 2008). Older adults who have a negative perception of aging and have difficulty transitioning through life have higher risk for poor health and functional outcomes (WHO, 2016). This frame of reference will be used as a guide to consider the transitional roles associated with aging to facilitate the delivery of a fall prevention program aimed to enhance participation and engagement in their environment and occupations. The PEOP model and Lifespan Frame of Reference served to provide a framework for better understanding how occupational therapy can be involved at Flanner House to create fall prevention programming that better targets the perceived wants and needs of the older adults the organization serves. 8 Project Design Falls are the leading cause of fatal and non-fatal injuries among older adults. Research shows that falls can be prevented, although falls are commonly seen as a naturally occurring event for older adults. With the growing older adult population, resources for effective fall prevention strategies can benefit the community. Increased fall rates in the older population can be from various issues including social isolation, illness, and lack of activity. The purpose of this Doctoral Capstone Experience (DCE) is to develop and evaluate the effectiveness of educational sessions based upon an evidence-based fall prevention program My Safe and Sound Plan. Participants were surveyed before and after completion of the 4-session course on their selfperceived fear of falling, life satisfaction, and lifestyle habits. The fall prevention program included fall risk assessments, education, exercise, and support for older adults through social engagement. My safe and sound plan includes fall risk assessments such as strength, endurance (30 second chair stand), balance, functional reach, and balance confidence (Howard, 2018). An additional measurement the student included was the Fall Efficacy Scale (FES), an assessment tool based on the construct of self-efficacy, to incorporate behavioral implications (confidence, self-efficacy) as they contribute to choices that can increase or decrease fall risk and fear of falling. Project Implementation This was a single group pretest/posttest project of older adults participating in a group fall prevention program, using My Safe and Sound Plan, in a community setting between February 2023- March 2023. There were four educational sessions consisting of group discussions on various topics related to fall risks encouraging social interaction and storytelling (Refer to Table 1 for schedule and organization). Every session included the teaching of educational concepts, 9 interactive activities, and discussion to engage the participants. The student developed materials including a lesson plan, printed session handouts, informational handouts, and activity worksheets to correspond with each sessions topic. The course was voluntary, at no cost, to the older adults participating in the Senior Program at Flanner House. The program was intended for older adults concerned about falling, restricting activities in daily life due to fear, having a fall history, are 60 years of age or older, or are interested in improving their strength and balance. Challenges in implementation included transportation access and lack of male enrollment. Successes included engagement and participation throughout the program. Project Outcomes A total of six older adults agreed to participate in the Fall Prevention Program. There were five females and one male. The participants were aged 75 years or older. All participants were present during the last three sessions and completed pre and post questionnaires. There were only five participants during the first session. Data collected for information finding included fall frequency, age, social support, assistive device (cane, rollator, etc.), demographic information, fall risks at baseline including a 30 second chair stand, strength, balance screening, taking more than 3 medications, frequency of social activity outside the home, average weekly exercise, and whether the participant had an established exercise routine. Only one senior reported falling six months prior to the start of the program and three other older adult participants had a fall history within the past five years. The 30 Second Chair Stand Test is a physical performance test that was used to measure endurance. The participant, with arms folded across the chest and feet shoulder-width apart, completed as many full stands as possible in 30 seconds. Due to safety concerts, three participants could not complete the 30 second chair stand, indicating a fall risk. The strength test 10 included completing one chair stand with arms folded across the chest and feet shoulder width apart. The balance test consisted of the participants standing in front of a chair, with their feet together, arms folded across their chest and holding their balance for 30 seconds. The FES was used to measure falls self-efficacy. Results show that five out of six participants reported that fear of falling did not have an effect on their life before implementing the program. Although, after implementing the program, participants reported improvements in fear of falling. A five-point Likert scale was used to assess self-reported pre and posttests about the value of group fall prevention courses on fear of falling affecting their ability to participate in activities they enjoy, life satisfaction, comfort openly expressing concerns, exercise frequency, social engagement, and knowledge on fall risks (footwear, vision, medication/ vitamin d, home safety, and exercise/ physical activity). All participants reported an increase in comfort expressing concerns to a healthcare provider about different risks for falling. All participants reported an increase in engagement in activities they enjoy. Only five out of six participants reported feeling satisfied with life. All participants reported a reduction in fear of falling. There were four participants who reported an increase in their exercise frequency and five reported an increase in knowledge of fall risks (vision, footwear, etc.), with the one senior being undecided. Refer to Figures 1-5 for a visual to participants responses using the five-point Likert Scale. To track follow-up behaviors and adherence during the program, a one-page weekly exercise log was used to record participation in strength and balance exercises at home. Only one out of the six participants did not complete their exercises weekly over the 4-week course. After completion of the program, five participants reported that they plan to continue to complete the exercises learned for strength and balance. 11 Summary This capstone project evaluated the effects of a 4-session educational group based on the My Safe and Sound Fall Prevention program on fall frequency, exercise, fear of falling, and life satisfaction in community dwelling older adults by self-report. The program was designed as a tool for fall prevention for older adults living served by Flanner House. The program was designed to encourage most participants to increase their engagement in weekly exercise. Participants were encouraged to continue the exercises they learned after completion of the course. Most of the participants reported some form of exercise prior to the program, but increased frequency was reported following the course. In addition, most of the participants denied fear of falling impacting their engagement in occupations before the program. Although, the participants expressed improvement in fear of falling after completion of the program. The group sessions allowed individuals to share knowledge, strategies, storytelling, and experiences to increase a positive program outcome. The program promoted adherence to a weekly exercise plan to maintain and improve physical mobility and self-efficacy. Falls can have a major impact on an individuals quality of life. Implementing multiple preventive measures early and evaluating them often can facilitate your mobility, reduce your chances of losing balance, and help maintain your quality of life (Manor, 2019). The results of this capstone project indicate a positive impact on participant knowledge, exercise levels, and fear of falling. Conclusion The My Safe and Sound Plan: For staying falls free educational sessions were effective in increasing fall related knowledge to community dwelling older adults and their ability to reduce fall risk factors. Encouraging fall risk reduction and behavior change in older adults is essential in fall prevention due to the multifactor risks and potential issues associated with 12 falling. Participants from Flanner House who participated in this capstone project self-reported decreased fear of falling affecting their everyday engagement in activities, increased exercise frequency, and life satisfaction. Flanner House can use My Safe and Sound Plan to help educate older adults on fall prevention strategies. Occupational therapy plays a critical role in improving safety and emphasizes the importance of reducing fall risks inside the home. Falls are an important area of practice for occupational therapists and require a holistic approach to reducing fall risks. Occupational therapists working with community- dwelling older adults should be aware of fall prevention research and recognize the need for future research demonstrating the efficacy of occupational therapy interventions addressing fall prevention in the areas of medication, behavior modification, vision, and appropriate footwear. 13 References Albert, S. M., & King, J. (2017). Effectiveness of statewide falls prevention efforts with and without group exercise. Preventive Medicine, 105, 59. doi:10.1016/j.ypmed.2017.08.010 Barney, K. F., & Perkinson, M. A. (2016). Occupational therapy with aging adults: Promoting quality of life through collaborative practice (pp. 140-141). St. Louis, MO: Elsevier. Centers for Disease Control and Prevention. (2017). Fact sheet risk factors for Falls - CDC. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf Centers for Disease Control and Prevention. (2019). Important facts about falls. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Cheal, B., & Clemson, L. (2001). Older people enhancing self-efficacy in fall-risk situations. Australian Occupational Therapy Journal, 48, 8091. http://dx.doi.org/10.1046/j.14401630.2001.00250.x Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Curl, A., Fitt, H., & Tomintz, M. (2020). Experiences of the built environment, Falls and fear of falling outdoors among older adults: An exploratory study and Future Directions. International Journal of Environmental Research and Public Health, 17(4), 1224. https://doi.org/10.3390/ijerph17041224 Elliott, S., & Leland, N. E. (2018). Occupational Therapy Fall Prevention Interventions for Community-Dwelling Older Adults: A Systematic Review. American Journal of Occupational Therapy, 72(4), 7204190040p1. doi:10.5014/ajot.2018.030494 14 Flanner House. Flanner. (2023). https://www.flannerhouse.org/leadership Howard, B. S. (2018). My Safe and Sound Plan. Howard, B., Boomershine, K., Gramman, R., Schirmer, C., & Schomber, J. (2019). Determining content validity of My safe and sound plan, a fall-risk self-assessment workbook. The American Journal of Occupational Therapy, 73(4_Supplement_1). https://doi.org/10.5014/ajot.2019.73s1-po7011 Lachman, M. E., Lipsitz, L., Lubben, J., Castaneda-Sceppa, C., & Jette, A. M. (2018). When adults dont exercise: Behavioral strategies to increase physical activity in sedentary middle-aged and older adults. Innovation in Aging, 2(1). https://doi.org/10.1093/geroni/igy007 Leland, N. E., Elliott, S. J., O'Malley, L., & Murphy, S. L. (2012). Occupational Therapy in Fall Prevention: Current Evidence and Future Directions. American Journal of Occupational Therapy, 66(2), 149-160. doi:10.5014/ajot.2012.002733 Manor, B. (2019). Preventing falls in older adults: Multiple strategies are better. Harvard Health. https://www.health.harvard.edu/blog/preventing-falls-in-older-adults-multiplestrategies-are-better-2019102218085 National Council on Aging. (2021). Evidence-Based Falls Prevention Programs. The National Council on Aging. https://www.ncoa.org/article/evidence-based-fallsprevention-programs Osho, O. A., Harbidge, C., Hogan, D. B., Manns, P. J., & Jones, C. A. (2020). Evaluation of a 15 balance and mobility program for older adults at risk of falling: A mixed methods study. Journal of Evaluation in Clinical Practice, 27(2), 307315. https://doi.org/10.1111/jep.13413 Pereira, C. L., Vogelaere, P., & Baptista, F. (2008). Role of physical activity in the prevention of Falls and their consequences in the elderly. European Review of Aging and Physical Activity, 5(1), 5158. https://doi.org/10.1007/s11556-008-0031-8 Peterson, E. W., & Clemson, L. (2008). Understanding the role of occupational therapy in fall prevention for community-dwelling older adults. OT Practice, 13(3), CE1CE8. Rivera-Torres, S., Fahey, T. D., & Rivera, M. A. (2019). Adherence to exercise programs in older adults: Informative report. Gerontology and Geriatric Medicine, 5. https://doi.org/10.1177/2333721418823604 Thompson, C. J., Holskey, T. H., Wallenrod, S., Simunovich, S., & Corn, R. (2019). Effectiveness of a fall prevention exercise program on falls risk in community-dwelling older adults. Translational Journal of the American College of Sports Medicine, 4(3), 1622. U.S. Department of Health and Human Services. (2017). Participating in activities you enjoy. National Institute on Aging. https://www.nia.nih.gov/health/participating-activities-youenjoy Valatka, R., Krizo, J., & Mallat, A. (2021). A survey-based assessment of Matter of balance participant fall-related experience. Journal of Trauma Nursing, 28(5), 304309. https://doi.org/10.1097/jtn.0000000000000602 Van Voast Moncada, L. (2011). Management of Falls in Older Persons: A Prescription for Prevention. American Family Physician, 84(11), 12671276. 16 Wheeler, E., Coogle, C., Fix, R., Owens, M., Waters, L. (2018). Physical and Occupational Therapy Practice Improvement Following Interprofessional Evidence-Based Falls Prevention Training. J Allied Health. 47(1), 9-18. World Health Organization. (2016). Discrimination and negative attitudes about ageing are bad for your health. World Health Organization. https://www.who.int/news/item/29-092016-discrimination-and-negative-attitudes-about-ageing-are-bad-for-yourhealth#:~:text=Older%20people%20who%20feel%20they%20are%20a%20burden,7.5% 20years%20less%20than%20people%20with%20positive%20attitudes. Table 1. 17 Session 1 (Week 5) Introduction and Exercise Overview of the program, sharing fall experiences, learning different fall risks, and introducing exercises, benefits and barriers of exercise, and safe mobility, changing their mind -Identification of intrinsic/extrinsic fall risk factors. - Participants shared personal experiences and feelings related to falling -Educational concepts -Small group discussion - Instruction on strength and balance exercises - Exercise log Session 2 (Week 6) Home Safety Going over different home safety techniques and adaptive equipment. Identify hazards in the home, go over the home safety checklist, and problem-solving solutions. - Educational concepts -Small group discussions at each table -Activity - Home safety checklist and exercise log Session 3 (Week 7) Health Management Talk about certain medications that increase fall risks. Identify the importance of heart health, Vitamin D and Calcium to protect from fall injury. -Shared results of their Home Hazard Checklists - Educational Concepts -Small group discussion - Activity - Exercise Log Session 4 (Week 8) Vision and Footwear/ Footcare Discuss the influence of vision on risk of falling and strategies on how to get around the community and reduce the risk of falling. Learn about the features of safe footwear and identify hazards. - Educational Concepts - Small Group discussion - Activity - Exercise Log Figure 1. Pre and Post Test 18 Figure 2. Pre and Post Test Figure 3. Pre and Post Test Figure 4. Pre and Post Test 19 Figure 5. Pre and Post Test 20 Wee k 1 DCE Stage (orientation, screening/evaluatio n, implementation, discontinuation, dissemination) Orientation Weekly Goal 1) Complete orientation by the end of the week Objectives Meet with site mentor, other site personnel, and the site participants to introduce myself and educate them on why I am here/what I will be doing for the 14 week Document supervision plan and update MOU with site mentor Screening/Evaluati on 2)Complete Needs Assessment by the end of the week Tasks Set up meetings with key personnel Create a talking point document for when I meet with various people Finalize MOU Ensure that all paperwork for orientation is complete Understand site environment/wh ere to work/dress code/ etc Determine who to meet with and Finalize what questions for questions to Needs ask and set Assessment up meeting Complete SWOT analysis Date comple te 1/13 21 2 Screening/Evaluat 1)Complete search ion of literature for program evaluation measures by midweek Establish Outcome assessment Review outcome assessments with site mentor & faculty mentor 1/20 Finalize Introduction 3 Screening/Evaluat ion 1) Complete outcome assessments Administer survey to participants Finalize Background 1/27 Review Complete Fall evidence for Risk best Theory/ assessments with Framework participants Update Background 4 Screening/ Evaluation 1) Finish outcome assessments Administer survey to participants. Complete Fall Risk with Participants Finalize Theory/ Framework Section 2/3 Write Project Design Update Theory/Framew ork Assess outcomes/ feedback from surveys 5 Implementation 1) Complete first workshop session Complete educational concepts Complete first session on introduction 2/10 22 Create small group discussions. to fall risks, exercise, and changing ones mind. Create handouts on walker safety, Creating a getting up after a schedule fall, and cane safety Create exercise logs Create activity Create attendance sheet 6 Implementation 2) Complete second workshop session Complete educational concepts Create small group discussions. Print out exercise logs Create handouts/resourc es. Complete second session on home safety 2/17 Provide a home safety checklist. Administer a mini quiz Create activity 7 Implementation 3) Complete third workshop session Complete educational concepts Create small group discussions. Print out exercise logs Complete third session on Vitamin D, calcium, and medication 2/24 23 Create handouts/resourc es on vitamin D, calcium, and medication management. Create activity 8 Implementation 4) Complete fourth workshop session Complete educational concepts Create small group discussions. Complete fourth session on vision/ footwear 3/3 Finalize Project Implementati on section 3/10 Print out exercise logs Create handouts/resourc es on vision/ footwear Create activity 9 Outcomes/ Discontinuation 1) Outcome assessments Administer post survey Research different resources for Flanner House Assess outcomes Write Project Outcomes and finish Project Implementation 10 Discontinuation 1) Outcomes/ Disseminati on Revisit Dissemination Plan Finalize Outcomes Section 3/17 24 11 Discontinuation 1) Discontinuat Continue to Work on ion finalize Scholarly Scholarly Report Report Work on Dissemination Plan 12 13 Discontinuation Dissemination Work on Disseminatio n Plan 1) Discontinuat Continue to Work on ion finalize Scholarly Scholarly Report Report 1) Disseminati on Work on Dissemination Plan Work on Disseminatio n Plan Dissemination Presentation Finalize summary, conclusion, and abstract sections Resource Packets 3/24 3/31 4/7 Present Disseminatio n Plan to Debra White and Gerald Ardis 14 Dissemination 1) Disseminati on Evaluation Finalize Scholarly Report Finalize Disseminatio n Plan Complete Final Evaluation with Debra White 4/14  ...