online publication of undergraduate studies Department of Applied Psychology Fall 2013
EDITORS Kelsey Block David Freedman Vera Stiefler Johnson FACULTY MENTOR Dr. Elise Cappella STAFF WRITERS Sophie Barnes Emily Gallagher Donna Poon Tyler Sabourin Yimkwan Tsang CONTRIBUTORS Sarah Collin Magdalena Lewandowska Jillian Shainman EXECUTIVE DIRECTOR Samantha Pratt LAYOUT DIRECTOR Amelia Chu PUBLIC RELATIONS MANAGER Emil Hafeez SPECIAL THANKS NYU Steinhart Department of Applied Psychology Dr. Gigliana Melzi FOUNDERS Vanessa Victoria Volpe Jackson J. Taylor Sibyl Holland
Applied Psychology OPUS was initiated in 2010 by a group of undergraduate students in NYU Steinhardtâ€™s Department of Applied Psychology. The ideas and opinions contained in this publication solely reflect those of the authors and not New York University. All work is licensed under the Creative Commons Attribution Noncommercial No Derivative Works License. To view a copy of this license, visit http://creativecommons.org
Cover Photo by Emil Hafeez
nyu applied psychology
online publication of undergraduate studies Volume V | Fall 2013
Contents LETTER FROM THE EDITORS David Freedman Kelsey Block Vera Stiefler Johnson | 4 STAFF ARTICLES Peer Relationships, Protective Factors, and Social Skill Development in Low-Income Children Sophie Barnes | 08 The Effects of Teacher-Student Relationships: Social and Academic Outcomes of Low-Income Middle and High School Students Emily Gallagher | 12 Parental Influence on Asian Americansâ€™ Educational and Vocational Outcomes Donna Poon | 16 Socio-Emotional and Psychological Outcomes: Music Therapy for Individuals with Autism Spectrum Disorders Tyler Sabourin | 20 Chinese Taoist Cognitive Psychotherapy: A Culturally Appropriate Form of Therapy Yimkwan Tsang | 25 SUBMISSIONS The Schizophrenia-Cocaine Link: Breaking the Cycle Sarah Collins | 34 Social Relations and Pediatric Cancer: The Struggles of Adolescent Cancer Patients Magdalena Lewandowska | 39 Counseling During a Disease Epidemic Jillian Shainman | 44 STAFF & CONTRIBUTOR BIOS | 48
Letter from the Editors | 4
Letter from the Editors New York University’s Applied Psychology Online Publication of Undergraduate Studies, also known as OPUS, is a semiannual publication showcasing the work of undergraduate students in the Applied Psychology program. OPUS was developed by undergraduate students in 2009, and remains a student-driven endeavor: students write, edit, and handle the administrative duties of OPUS. In keeping with the student-driven nature of OPUS, the articles in this semester’s issue truly reflect the diversity of interests of the Applied Psychology students. The topics of these articles range from Tyler Sabourin’s discussion of the suitability of music therapy for treating autism spectrum disorders, to Sophie Barnes’s exploration of the educational challenges low-income students face. Despite the range of topics, a thorough understanding of context and a focus on treatment are common themes throughout this edition. When writing about psychology in real world settings, it is important to consider the context in which it is occurring in order to fully understand the subject. In her paper, Yimkwan Tsang explores the challenges and considerations of adapting western treatment modalities to Chinese culture. Yimkwan outlines the unique cultural and philosophical context of mainland China that these modalities are being adapted to. This exploration deepens our understanding of the Asian-American immigrant context explored by Donna Poon. Together, these papers provide us with a dual perspective of how these cultures interact. However, context comprises much more than just culture; it is also influenced by socio-economic status. We see this as Sophie Barnes and Emily Gallagher look at peer relationships and teacher-student relationships, respectively, and education. Additionally, we see this as Sarah Collins explores the link between cocaine and schizophrenia and the need for more accessible treatment in low-income communities, and as Magdalena Lewandowska explores the role of social support in aiding adolescent cancer survivors. Yimkwan’s paper’s focus on treatment types highlights the importance of utilizing the appropriate form of treatment for a specific population. Jillian Shainman’s paper explores how HIV/AIDS patients can benefit from a dual public-health and mental-health perspective, considering how mental and physical well-being interact. Whereas Jillian’s paper focuses on how patient needs require a particular set of considerations, Tyler Sabourin focuses on how music therapy is uniquely suited for assisting people with autism spectrum disorders in emotional identification. As editors, we see a strong connection between the works selected for the Fall 2013 issue and the Applied Psychology program; linking theory, research, and practice. We would like to congratulate our staff writers and contributors in creating this edition of OPUS, as well as our administrative staff without whom this would not have been possible. We would also like to thank our faculty mentor, Dr. Elise Cappella, who has guided us through the process of creating this semester’s journal.
Vera Stiefler Johnson
8 | Staff Articles
Peer Relationships, Protective Factors, and Social Skill Development in Low-Income Children Sophie Barnes
ow-income families often face economic insecurity, housing instability, and difficulty seeking and maintaining employment. These obstacles can lead to psychological stress, a lack of opportunity for socio-economic status mobility, and minimal time for family interactions (Brooks-Gunn & Duncan, 1997; Raver, 2002). Although parents want to afford their children with rich, supportive learning environments and opportunities for social interaction, this can be less realistic for low-income families to achieve as compared to families with a higher socio-economic status (Brooks-Gunn & Duncan, 1997; Heymann & Earle, 2000). Social skills are an important component of academic achievement, however low-income children may struggle to succeed academically as they often enter school with fewer social skills, unprepared for the social interactions that facilitate learning and are crucial to acquire in the early years of schooling (Duncan, Jean Yeung, Brooks-Gunn, & Smith, 1998; McClelland, Morrison, & Holmes, 2000). Classroom relationships, especially those experienced between peers, can help children develop the social skills necessary for school adjustment and long-term academic success (Bulotsky-Shearer, Bell, Romero, & Carter, 2011; Sebanc, 2003; Stuhlman & Pianta, 2009). Engaging in peer relationships can help economically disadvantaged students improve their social skills, increase school engagement, and help them create a positive outlook about school, the relationships formed, and the learning process (Milteer, Ginsburg, & Mulligan, 2011; Stuhlman & Pianta, 2009). The development of communication based social skills and social skills that focus on conflict resolution and coping mechanisms help children succeed in peer relationships, and improves the likelihood of a positive school trajectory (Benard, 2003; Stuhlman & Pianta, 2009).
Home, School, Relationships: An Ecological Framework and Classroom Protective Factors Looking at the contexts of home, school, the relationships formed within these settings, and the interactions between them creates a more complete picture of childrenâ€™s development, than just looking at the contexts individually (Bronfenbrenner & Morris, 1998). Young children spend a majority of their time at home or in the classroom, making these settings their primary environments (Bronfenbrenner & Morris, 1998). Prior to formal schooling, most low-income children interact primarily with their families, thus the transition to formal schooling marks the transition to a new, structured setting for low-income children (Duncan et al., 1998). To best understand and provide a context for studentâ€™s outcomes and development, it is important to study children in their naturalistic environments and to observe them as they build relationships with their teachers and peers (Bronfenbrenner & Morris, 1998). The risk factors of low-income homes can be ameliorated by classroom protective factors (Benard, 1993). In this context, protective factors consist of components or characteristics of an environment or relationship that guard children against risk or help them face their challenges most productively and effectively (Benard, 1993; McClelland et al., 2000). Important classroom protective factors that address this risk and its potentially detrimental implications include the student-teacher relationship, peer relationships, and the creation of a classroom community (Stuhlman & Pianta, 2009). The social skills learned within these interactions help students create a strong foundation in the classroom, a positive outlook on future relationships, and can increase school engage-
Barnes: peer interaction and social skill development | 9 ment (Stuhlman & Pianta, 2009). Emotionally supportive relationships aid in emotional adjustment and create protective factors that defend children against psychological stressors (Hamre & Pianta, 2005). Children interact with their peers and teachers on a regular basis, making those relationships important to understand (Bronfenbrenner & Morris, 1998; Stuhlman & Pianta, 2009). Emotionally supportive teachers can make children feel that there is an adult who cares about them, listens to them, and provides encouragement. A trusting, warm relationship with an adult is an important part of the development of a studentâ€™s self-perception and therefore the classroom community (Hamre & Pianta, 2005; Spira & Fischel, 2005). If a student and a teacher have a positive relationship, the student will likely feel confident and demonstrate pro-social classroom behaviors, engaging in peer play and comfortably exploring the classroom (Spira & Fischel, 2005; Stuhlman & Pianta, 2009). The relationship can also adversely affect students and their development. A negative or tense relationship between a student and a teacher can lead to an expression of antisocial behaviors that inhibits positive peer interactions (Spira & Fischel, 2005). Teachers can help students regulate their behavior and advance academically (Hamre & Pianta, 2005). In fact, children who have better relationships with their teachers tend to do better in school and feel more engaged overall (Woolley & Grogan-Kaylor, 2006). Peer relationships also serve as protective factors that shape a childâ€™s school experience (Benard, 1993; Woolley & Grogan-Kaylor, 2006). Partaking in a classroom community or classroom group encourages participation, idea sharing, and gives children a sense of belonging (Benard, 1993). Participation in a classroom community helps children understand the way a group functions, internalize social norms, and develop more comprehensive social skills (Benard, 1993). Peer relationships form within these communities and these relationships, and the presence of peer play can help children develop communication and problem solving skills that will have long term benefits for children (Bulotsky-Shearer et al., 2012; Hamre & Pianta, 2005). Children who are engaged in mutual friendships are more likely to think positively about school
and the learning process. If students do not participate in warm, mutual interactions and relationships at home, it is crucial that they receive this support while in the classroom (Stuhlman & Pianta, 2009). School engagement is an important protective factor that develops through these classroom relationships (Alexander et al., 1997; Benard, 1993). Low-income students are more likely to drop out of school than higher income students (Duncan et al., 1998), however students who feel engaged in school and the learning process are less likely to drop out than those who do not (Alexander et al., 1997). If the process of school engagement begins in the first year of formal schooling, students can create strong, positive associations with school that will likely lead to lower rates of high school dropout (Alexander et al., 1997). Indeed, positive or negative introductions to formal schooling can shape the way a child views the process and the relationships within it (Stuhlman & Pianta, 2009). As previously discussed, classroom relationships are instrumental components of the learning process and each play a vital role in the formation of school engagement and positive school perceptions (Alexander et al., 1997; Hamre & Pianta, 2005). In the student-teacher relationship, if a student feels connected to a teacher and perceives their relationship to be emotionally supportive, they are likely to feel more engaged than a student who does not perceive their relationship with their teacher to be emotionally supportive (Stuhlman & Pianta, 2009). In addition, if a teacher holds high expectations for a student, that student will likely perceive that the teacher believes in them, increasing their school engagement and desire to succeed (Alexander et al., 1997). Group membership also affects school engagement, as children who feel that they belong to a group at school feel more engaged (Woolley & Grogan-Kaylor, 2006). These relationships are not only formed through the use of social skills, they are the primary mechanisms of social skill development (Bulotsky-Shearer et al., 2012).
Peer Relationships and Skill Development The development of positive peer relationships is
10 | Staff Articles especially important for low-income children whose parents must focus on meeting their children’s basic needs and often do not have the time or resources to dedicate to skill development and educational interactions (Duncan et al., 1998; Milteer et al., 2012). Therefore, children must master these skills and experience these relationships in the classroom (Hamre & Pianta, 2005). The social skills gained by peer interactions can fall into two categories: social skills that focus on basic communication and social skills that deal with stress management, coping and more complex social interactions. Each of these skill sets creates protective factors and is crucial for long-term positive outcomes (Bulotsky-Shearer et al., 2012; Milteer et al., 2012). Although parents and educators may perceive friendship as fluid and trivial for young children, friendships are significant and can influence the trajectory of a student’s school career (Bulotsky-Shearer et al., 2012; Sebanc, 2003). Peer relationships are comprised of positive or negative features. Positive features of friendships include trust, communication, and a willingness to help, while negative features include characteristics such as disloyalty and rejection (Sebanc, 2003). These features create conflict-ridden relationships that can negatively influence a child’s trajectory (Sebanc, 2003). Children’s perceptions of early friendships and peer interactions often influence the way they perceive peer relationships throughout school (Bulotsky-Shearer et al., 2012; Sebanc, 2003). If students engage in friendships with positive features and feel accepted by their peers, they will likely continue to engage in prosocial behaviors and think positively about friendships (Sebanc, 2003; Spira & Fischel, 2005). Conversely, if students’ friendships are characterized by negative features or if they face peer rejection, antisocial behavior is likely to begin or continue and can lead to negative perceptions of friendships and peer interactions. Furthermore, peer rejection or acceptance often remains stable and influences the skill development, academic achievement, and self-image of a child (Sebanc, 2003; Spira & Fischel, 2005). Although this paper focuses on friendships with positive features and therefore positive outcomes, it is important to remember that negative peer relationships can be detrimental to students’
outcomes. Children’s positive peer relationships aid in the development of communication based social skills, which can enhance academic achievement (Raver, 2002; Sebanc, 2003). In order to engage in complex peer play, children need to communicate verbally. The necessity of creating coherent, effective, and clear phrases in order to communicate with their peers forces children to develop language skills. These communication skills also benefit students academically as language development in the early years of schooling can predict students’ later reading abilities (Alexander et al., 1997; Hamre & Pianta, 2005). Therefore, low-income children who do not learn communication skills at home must engage in peer play in the classroom in order to face similar chances for academic success as their higher income counterparts (Raver, 2002). Peer play provides another forum for academic, social, and behavioral learning in the classroom (Bulotsky-Shearer et al., 2012; Milteer et al., 2012). If children are shy, encouraging peer play in the classroom can give children who may not otherwise seek out this contact experiences with peer relationships at a young age, thus preparing them for a long term positive outlook on peer relationships (Milteer et al., 2012). In addition to communication based social skills, peer play can also aid in the development of another set of social skills that will improve the likelihood for school success. These skills include conflict resolution, problem solving, and stress management skills (McClelland et al., 2000; Milteer et al., 2012). Once students engage in these more complex interactions, problems may arise and conflict can occur. Through dealing with this conflict, students can develop problem solving and conflict resolution skills (Bulotsky-Shearer et al., 2012). Students can develop these necessary skills in the safe classroom space but will likely develop a strong skill set that will be beneficial outside of the classroom environment. Development of these more advanced skills will likely only occur after social skill development and improvement, and often can only develop naturally through peer play (Bulotsky-Shearer et al., 2012). Development of these relationships and skills can be crucial
Barnes: peer interaction and social skill development | 11 for a child’s success or failure. If children can develop these skills at a young age, it can create firm foundations for processing stress, solving problems, dealing with conflict, and communicating that can help them regulate their emotions, engage in peer relationships, cope with difficult situations, and succeed academically (Sebanc, 2003). Peer play can help children process stress as it allows them to express themselves and to deal with issues that may be too difficult to outwardly discuss (Milteer et al., 2012; Sebanc, 2003). Since low-income children may experience higher stress environments than higher-income children, learning how to deal with the possible stress, and developing strategies and skills to do so is crucial (Brooks-Gunn & Duncan, 1997; Duncan et al., 1998). Children who can develop this secondary set of skills will face greater chances for school success as they will be more able to navigate through hardships and stressors in their lives and cope with situations they encounter. If children can start to process and work through complex, stressful emotions, it may lower their behavioral disturbances as the classroom can represent a place of expression rather than repression. Since low-income children may not receive the necessary social skill development in the home, it is important that these skills are acquired in the classroom, specifically through peer relationships (BrooksGunn & Duncan, 1997; Milteer et al., 2012). Peer relationships and peer play serve as a protective factor and facilitate the essential social skill development (Benard, 1993; McClelland, 2000). Indeed, communication based social skills and social skills that help children deal with conflict and cope with stressful situations are crucial components of a strong foundation for low-income children. Development of these skills through peer relationships and peer play can shape children’s perceptions of school and the relationships formed within it, thus increasing adjustment, academic achievement, and school engagement (McClelland et al., 2000). If children can develop the social skills needed to interact with peers through peer play at a young age, they will likely experience increased feelings of belonging and more developed language skills, allowing them to communicate clearly and effectively
and leading to a greater likelihood for a positive school trajectory (Benard, 1993; Bulotsky-Shearer, 2012; McClelland et al., 2000; Milteer et al., 2012).
References Alexander, K., Entwisle, D., & Horsey, C. (1997). From first grade forward: Early foundations of high school dropout. Sociology of Education, 70(2), 87-107. Benard, B. (1993). Fostering resiliency in kids. Educational Leadership, 51(3), 44-48. Bronfenbrenner, U., & Morris, P.A. (1998). The ecology of developmental processes. In W. Damon (Series Ed.) & R.M. Lerner (Vol. Ed.). Handbook of child psychology: Vol. 1. Theoretical models of human development (5th ed., pp. 993 – 1028). New York: Wiley Brooks-Gunn, J., & Duncan, G.J. (1997). The effects of poverty on children. In R.E. Behrman (Ed.), Children and Poverty, The Future of Children, 7, 55-71. Bulotsky-Shearer, R. J., Bell, E. R., Romero, S. L., & Carter, T. M. (2012). Preschool interactive peer play mediates problem behavior and learning for low-income children. Journal of Applied Developmental Psychology, 33, 53-65. Duncan, G. J., & Brooks-Gunn, J. (2000). Poverty, welfare reform, and child development. Child Developent, 71(1), 188-196. Duncan, G.J., Yeung, W.J., Brooks-Gunn, J., & Smith, J.R. (1998). How much does childhood poverty affect the life chances of children? American Sociological Review, 63, 406-423. Hamre, B. K., & Pianta, R. C. (2005). Can instructional and emotional support in the first‐grade classroom make a difference for children at risk of school failure?. Child development, 76(5), 949-967. Heymann, J., & Earle, A. (2000). Low-income parents: How do working conditions affect their opportunity to help school-age children at risk? American Educational Research Journal, 37(4), 833-848. McClelland, M. M., Morrison, F. J., & Holmes, D. L. (2000). Children at risk for early academic problems: The role of learning-related social skills. Early Childhood Research Quarterly, 15(3), 307329. Milteer, R. M., Ginsburg, K. R., & Mulligan, D. A. (2012). The importance of play in promoting healthy child development and maintaining strong parent-child bond: Focus on children in poverty. Pediatrics, 129(1), 204-213. Raver, C.C. (2002). Emotions matter: Making the case for the role of young children’s emotional development for early school readiness. SRCD Social Policy Report, 16, 1-20. Sebanc, A. M. (2003). The friendship features of preschool children: Links with prosocial behavior and aggression. Social Development, 12(2), 249-268. Spira & Fischel, E., & Fischel, J. (2005). The impact of preschool inattention, hyperactivity, and impulsivity on social academic development: A review. Journal of Child Psychology and Psychiatry, 46(7), 755-773. Stuhlman, M., & Pianta, R. (2009). Profiles of educational quality in first grade. The Elementary School Journal, 109(4), 323-342. Woolley, M. E., & Grogan-Kaylor, A. (2006). Protective family factors in the context of neighborhood: Promoting positive school outcomes. Family Relations, 55(1), 93-104.
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The Effects of Teacher-Student Relationships: Social and Academic Outcomes of Low-Income Middle and High School Students
eachers play an important role in the trajectory of students throughout the formal schooling experience (Baker, Grant, & Morlock, 2008). Although most research regarding teacher-student relationships investigate the elementary years of schooling, teachers have the unique opportunity to support students’ academic and social development at all levels of schooling (Baker et al., 2008; Bronfenbrenner, 1979; Bronfenbrenner & Morris, 1998; McCormick, Cappella, O’Connor, & McClowry, in press). Aligned with attachment theory (Ainsworth, 1982; Bowlby, 1969), positive teacher-student relationships enable students to feel safe and secure in their learning environments and provide scaffolding for important social and academic skills (Baker et al., 2008; O’Connor, Dearing, & Collins, 2011; Silver, Measelle, Armstron, & Essex, 2005). Teachers who support students in the learning environment can positively impact their social and academic outcomes, which is important for the long-term trajectory of school and eventually employment (Baker et al., 2008; O’Connor et al., 2011; Silver et al., 2005). When teachers form positive bonds with students, classrooms become supportive spaces in which students can engage in academically and socially productive ways (Hamre & Pianta, 2001). Positive teacher-student relationships are classified as having the presence of closeness, warmth, and positivity (Hamre & Pianta, 2001). Students who have positive relationships with their teachers use them as a secure base from which they can explore the classroom and school setting both academically and socially, to take on academic challenges and work on social-emotional development (Hamre & Pianta, 2001). This includes, relationships with peers, and developing self-esteem and self-concept (Hamre & Pianta, 2001). Through this secure relationship, students learn about socially appropriate behaviors as well as academic expecta-
tions and how to achieve these expectations (Hamre & Pianta, 2001). Students in low-income schools can especially benefit from positive relationships with teachers (Murray & Malmgren, 2005). Students in high-poverty urban schools may benefit from positive teacher-student relationships even more than students in high-income schools, because of the risks associated with poverty (Murray & Malmgren, 2005). Risk outcomes associated with poverty include high rates of high school dropout, lower rates of college applications, low self-efficacy, and low self-confidence (Murray & Malmgren, 2005). There are several factors that can protect against the negative outcomes often associated with low-income schooling, one of which is a positive and supportive relationship with an adult, most often a teacher (Murray & Malmgren, 2005). Low-income students who have strong teacher-student relationships have higher academic achievement and have more positive social-emotional adjustment than their peers who do not have a positive relationship with a teacher (Murray & Malmgren, 2005). There is substantial research on the importance of teacher-student relationships in the early elementary years (Pianta, 1992; Hamre & Pianta 2001). However, little is known about the effects of teacher-student relationships on high school students. Studies show that early teacher-student relationships affect early academic and social outcomes as well as future academic outcomes (Pianta 1992; Hamre & Pianta 2001), but few researchers have looked at the effects of teacher-student relationships in later years of schooling. Researchers who have investigated teacher-student relationships for older students have found that positive teacher-student relationships are associated with positive academic and social outcomes for high school students (Alexander, Entwisle, & Horset,
Gallagher: Teacher-Student Relationships | 13 1997; Cataldi & KewallRamani, 2009).
Academic Outcomes Although many studies focus on the importance of early teacher-student relationships, some studies have found that teacher-student relationships are important in transition years; the years when students transition from elementary to middle school or middle to high school (Alexander et al., 1997; Cataldi & KewallRamani, 2009; Midgley, Feldlaufer, & Eccles, 1989). Studies of math competence in students transitioning from elementary to middle school have found that students who move from having positive relationships with teachers at the end of elementary school to less positive relationships with teachers in middle school significantly decreased in math skills (Midgley et al., 1989). For students who are considered at high risk for dropping out of high school, math achievement is significantly impacted by the perception of having a caring teacher (Midgley et al., 1989). Furthermore, students who went from low teacher closeness to high teacher closeness significantly increased in math skills over the transition year, from elementary to middle school (Midgley et al., 1989). These studies show that relationships with teachers in the later years of schooling can still significantly impact the academic achievement trajectories of students (Midgley et al., 1989). Another example of the importance of teacher-student relationships in high school students stems from intervention studies aimed at improving academic outcomes for low-income students (Murray & Malmgren, 2005). In one intervention study that aimed to increase positive relationships between low-income high school students and their teachers, results showed that students who participated in the intervention significantly improved their GPA over the course of five months (Murray & Malmgren, 2005). Such research shows that positive teacher-student relationships can improve academic skills in students as early as middle school and as late as high school (Midgley et al., 1989; Murray & Malmgren, 2005). In addition to positive teacher-student relationships, students’ motivation to learn is another factor that
influences social and academic outcomes. A possible reason for the association between academic improvement and positive teacher-student relationships is students’ motivation and desire to learn (Wentzel, 1998). Motivation may play a key role in the relationship between teacher-student relationships and academic outcomes (Bandura, 1997; Fan & Willams, 2010; Pajares & Graham, 1996; Ryan, Stiller, & Lynch, 1994; Wentzel, 2003; Zimmerman, Bandura, & Martinez-Pons, 1992). Motivational theorists suggest that students’ perception of their relationship with their teacher is essential in motivating students to perform well (Bandura, 1997; Fan & Willams, 2010; Pajares & Graham, 1996; Ryan, Stiller, & Lynch, 1994; Wentzel, 2003; Zimmerman, Bandura, & Martinez-Pons, 1992). Students who perceive their relationship with their teacher as positive, warm and close are motivated to be more engaged in school and to improve their academic achievement (Hughes, Cavell, & Jackson, 1999). Students’ motivation to learn is impacted positively by having a caring and supportive relationship with a teacher (Wentzel, 1998). Motivation is closely linked to student’s perceptions of teacher expectations. Studies of middle and high school students have shown that students shape their own educational expectations from their perceptions of their teachers’ expectations (Muller, Katz, & Dance, 1999). Students who perceive that their teachers have high expectations of their academic achievement are more motivated to try to meet those expectations and perform better academically than their peers who perceive low expectations from their teachers (Muller et al., 1999). Due to the influence of expectations on motivation, expectations can be an important factor on a students’ academic achievement. Furthermore, teacher-student relationships have an impact on the academic self-esteem of students (Ryan et al., 1994). High-poverty students often have low academic self-esteem and low confidence in their academic and vocational futures (Wentzel, 2003). Thus, positive relationships with teachers are important in supporting higher levels of self-esteem, higher academic self-efficacy, and more confidence in future employment outcomes (Ryan et al., 1994; Wentzel,
14 | Staff Articles 2003). Self-confidence and future aspirations have a significant impact on students’ interest in school, their academic self-efficacy and in turn, their academic achievement (Wentzel, 2003). In addition to academic achievement, positive teacher-student relationships provide important social outcomes for students.
Social Outcomes Although there is more research regarding the academic effects of positive teacher-student relationships for older students, there are notable social outcomes as well. Teachers are an important source of social capital for students (Muller, 2001). Social capital in a classroom setting is defined as caring teacher-student relationships where students feel that they are both cared for and expected to succeed (Muller, 2001). Social capital from positive teacher-student relationships can manifest itself in many different ways. For high school students, positive teacher-student relationships can reduce rates of dropping out by nearly half, help explore options for college, and provide support for further academic or vocational aspirations (Dika & Singh, 2002). Common reasons for dropping out include low levels of family support, low academic achievement, poor relationships with peers and adults, and low interest in academics (Henry, Knigh, & Thornberry, 2012). Positive teacher-student relationships can impact students social and academic outcomes, and thus reduce drop-out rates (Dika & Singh, 2002; Wentzel, 2003). Low-income students often have neither the support they need to complete high school nor access to the information they need to pursue education beyond high school (Dika &Singh, 2002). It is important for low-income students who experience academic difficulties and negative social outcomes to gain social capital from their teachers, because research shows they can benefit from the guidance and support (Croninger & Lee, 2001). Further, teacher-student relationships can impact peer relationships in schools. Teacher-student relationships can have a significant effect on the peer acceptance of students. Teachers’ interactions with students can affect classmates’ perceptions of individual students, in turn affecting
which students classmates choose to interact with and accept (Hughes et al., 1999). Conflicting interactions between teachers and students may convey a lack of acceptance, causing other students to also reject the student involved in the conflict with the teacher (Hughes et al., 1999). Peer rejection significantly impacts self-esteem of students leading to several negative social outcomes (Hughes et al., 1999). As mentioned earlier, students with high self-esteem are more likely to be self-efficacious and set higher goals (Ryan et al., 1994; Wentzel, 2003). Self-esteem also affects students socially (Orth, Robins, & Widaman, 2012). Students with high self-esteem are more likely to have positive relationships with peers as well as with adults (Orth et al., 2012). Self-esteem also affects students’ mental health outcomes including reducing anxiety and symptoms of depression (Orth et al., 2012). Self-esteem is especially important during adolescence and helps students develop a positive sense of self (Orth et al., 2012). A positive sense of self in adolescence leads to future outcomes including relationship satisfaction, job satisfaction, occupational status, emotional regulation, and physical health (Orth et al., 2012). The support of positive teacher-student relationships for self-esteem and related social outcomes affects students during schooling as well as in their future educational and occupational outcomes (Orth et al., 2012).
Conclusion and Limitations
Although there is extensive research on the positive effects of teacher-student relationships on elementary school students, there is little research on middle and high school students. Middle and high school is when students begin to think about their academic futures, which are informed by academic achievement and social capital in elementary years (Alexander et al., 1997; Cataldi & KewallRamani, 2009; Dika & Singh, 2002; Muller, 2001). Early high school is usually when students dedicate themselves to graduating or decide to drop out (Henry et al., 2012). Currently, high school dropout rates are high, and improving teacher-student relationships for students at this stage may decrease dropout rates
Gallagher: Teacher-Student Relationships | 15 (Henry et al., 2012). Similarly, high school is when students decide if they plan to attend college or stop their education (Alexander et al., 1997; Cataldi et al., 2009; Henry et al., 2012). Therefore, it is important to develop positive teacher-student relationships during this time. Empirical evidence does show that teacherstudent relationships are very important for high school students (Alexander et al., 1997; Cataldi et al., 2009; Dika &Singh, 2002; Hughes et al., 1999; Midgley et al., 1989; Ryan et al., 1994; Wentzel, 2003). Studies that have investigated older students’ relationships with teachers have found that students improve both academically and socially from positive teacher-student relationships (Alexander et al., 1997; Cataldi et al., 2009; Dika &Singh, 2002; Hughes et al., 1999; Midgley et al., 1989; Ryan et al., 1994; Wentzel, 2003). However, much of this research is dated. Due to the ever-changing nature of the American educational system and the increasingly diverse student body, more current studies are needed to look at the effects of teacher-student relationships for this changing population. It is important to learn more about teacher-student relationships for lowincome students to decrease high school dropout, and improve students’ social-emotional development. Conducting research on the relationship between high school students and teachers may be essential in improving the outcomes of low-income middle and high school students, and can potentially inform future interventions to help older students perform better both academically and socially.
References Ainsworth, M. D. S. (1982). Attachment: Retrospect and prospect. In C. M. Parkes & J. Stevenson-Hinde (Eds.), The place of attachment in human behavior (pp. 3–30). New York: Basic Books. Alexander, K. L., Entwisle, D. R., & Horsey, C. S. (1997). From first grade forward: Early foundations of high school dropout. Sociology of Education, , 87-107. Baker, J. Grant, s., & Morlock, L.(2008). The teacher–student relationship as a developmental context for children with internalizing or externalizing behavior problems. School Psychology Quarterly, 23(1), 3-15. Bandura, A. (1997). Self-efficacy: The exercise of control. Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. New York: Basic Books. Bronfenbrenner, U., & Morris, P. A. (1998). The ecology of developmental processes. Bronfenbrenner, U., & Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard
university press. Cataldi, E. F., Laird, J., & Kewalramani, A. (2009). High school dropout and completion rates in the United States: 2007 (NCES 2009064). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education. Croninger, R., & Lee, V. (2001). Social capital and dropping out of high school: Benefits to at-risk students of teachers’ support and guidance.The Teachers College Record, 103(4), 548-581. Dika, S. L., & Singh, K. (2002). Applications of social capital in educational literature: A critical synthesis. Review of Educational Research, 72(1), 31-60. Fan, W., & Williams, C. M. (2010). The effects of parental involvement on students’ academic self-efficacy, engagement and intrinsic motivation. Educational Psychology, 30(1), 53-74. Hamre, B. K., & Pianta, R. C. (2001). Early teacher–child relationships and the trajectory of children’s school outcomes through eighth grade. Child Development, 72(2), 625-638. Henry, K. L., Knight, K. E., & Thornberry, T. P. (2012). School disengagement as a predictor of dropout, delinquency, and problem substance use during adolescence and early adulthood. Journal of youth and adolescence, 41(2), 156-166. Hughes, J. N., Cavell, T. A., & Willson, V. (2001). Further support for the developmental significance of the quality of the teacher–student relationship. Journal of School Psychology, 39(4), 289-301. Orth, U., Robins, R. W., & Widaman, K. F. (2012). Life-span development of self-esteem and its effects on important life outcomes. Journal of personality and social psychology, 102(6), 1271. McCormick, M., O’Connor, E.E., Cappella, E. & McClowry, S. (Accepted). Teacher-child relationships and academic achievement: A multi-level propensity score model approach. Journal of School Psychology. McCormick, M., Cappella, E., O’Connor, E.E. & McClowry, S. (Under Review). Parent involvement, classroom emotional support, and student behaviors: An ecological approach. The Elementary School Journal. Midgley, C., Feldlaufer, H., & Eccles, J. S. (1989). Student/teacher relations and attitudes toward mathematics before and after the transition to junior high school. Child Development, , 981-992. Muller, C., Katz, S. R., & Dance, L. J. (1999). Investing in teaching and learning dynamics of the teacher-student relationship from each actor’s perspective. Urban Education, 34(3), 292-337. Muller, C. (2001). The role of caring in the teacher-student relationship for at-risk students. Sociological Inquiry, 71(2), 241-255. doi:10.1111/j.1475-682X.2001.tb01110.x Murray, C., & Malmgren, K. (2005). Implementing a teacher–student relationship program in a high-poverty urban school: Effects on social, emotional, and academic adjustment and lessons learned. Journal of School Psychology, 43(2), 137-152. O’Connor, E. E., Dearing, E., & Collins, B. A. (2011). Teacher-child relationship and behavior problem trajectories in elementary school. American Educational Research Journal, 48(1), 120-162. Pajares, F. (1996). Self-efficacy beliefs in academic settings. Review of Educational Research, 66(4), 543-578. Ryan, R. M., Stiller, J. D., & Lynch, J. H. (1994). Representations of relationships to teachers, parents, and friends as predictors of academic motivation and self-esteem. The Journal of Early Adolescence, 14(2), 226-249. Silver, R. B., Measelle, J. R., Armstrong, J. M., & Essex, M. J. (2005). Trajectories of classroom externalizing behavior: Contributions of child characteristics, family characteristics, and the teacher–child relationship during the school transition. Journal of School Psychology, 43(1), 39-60. Wentzel, K. R. (2002). Are effective teachers like good parents? teaching styles and student adjustment in early adolescence. Child Development, 73(1), 287-301. Wentzel, K. R. (2003). Sociometric status and adjustment in middle school: A longitudinal study. The Journal of Early Adolescence, 23(1), 5-28. Zimmerman, B. J., Bandura, A., & Martinez-Pons, M. (1992). Self-motivation for academic attainment: The role of self-efficacy beliefs and personal goal setting. American Educational Research Journal, 29(3), 663-676.
16 | Staff Articles
Parental Influence on Asian Americans’ Educational and Vocational Outcomes Donna Poon
n American culture and education, Asian Americans have been stereotyped as “the model minority” (Lee, 1994). The model minority stereotype1 presents Asian Americans as valuing hard work and education, despite studies which report that Asian Americans vary widely in their cultural values and levels of academic achievement (Suzuki, 1994; Wong, Lai, Nagasawa & Lin, 1998). Between the 1850s and the 1950s Asian American immigrants were denied the fundamental civil, marital and tenant rights enjoyed by the white majority, including joining unions, obtaining professional licenses, owning land, marrying American women, and living outside ethnic ghettos (Xie & Goyette, 2003). When the Immigration and Nationality Act of 1965 lifted discriminatory immigration quotas, Asian Americans were finally allowed to become U.S. citizens (Ludden, 2006). Over time, Asian Americans managed to achieve above-average measures of socioeconomic status despite having suffered numerous years of severe discrimination and prejudice (Cheng & Bonacich, 1984; Hurh & Kim, 1989; Xie & Goyette, 2003). The influence of first-generation Asian American parents on their U.S.-born children’s educational and vocational decisions may reflect their harsh experiences as immigrants in the United States as well as Confucian values (Xie & Goyette, 2003). Such values include filial piety, which is the act of respecting one’s elders, and interdependence, otherwise known as family centrality (Chao & Tseng, 2002). This paper seeks to explore how first-generation Asian American parents influence their U.S.-born children’s educational and vocational outcomes through the Asian American historical and cultural context.2 1 Past research indicates that the model minority stereotype generally applies to East Asians, Southeast Asians, or those with ancestry from countries that are heavily influenced by Confucian ideology such as China, Japan or Korea (Cheng; 1997).
For the purpose of this document, the term “Asian” is only generalizable to Asian Americans of East Asian descent because the topics of interest primarily revolve around the model minority stereotype, Confucianism and East Asian immigrant history in the United States. 2
Social and Historical Context of Asian Americans in the United States The historical and social context of the Asian American community in the United States affects the demands and expectations that Asian American parents have for their children (Xie & Goyette, 2003). Many Asians immigrate to the United States motivated by financial need, in pursuit of the “American dream” of greater employment and education opportunities for themselves and their children (Bates, 1997). Throughout history, the number of Asian Americans who achieve equal—and sometimes greater—socioeconomic status in comparison to the white majority in terms of education, occupation and income are high (Barringer, Gardner, & Levin, 1993). Today, immigrants who come to the United States in pursuit of economic and domestic stability project their personal aspirations onto their children by ensuring their children’s academic success to the best of their ability (Yang, 2007). In the context of U.S. society, some Asian Americans subject themselves to the self-fulfilling prophecy principle by internalizing to the model minority stereotype and adapting their behavior to what they believe is expected of them (Wilkins, 1976). In addition to societal pressure, Asian Americans also struggle to meet their parents’ high educational expectations. As a result, an insurmountable amount of pressure presented by both society and the family may pose as a psychological threat to Asian Americans who are expected to uphold high standards of educational, economic and social achievement and who fear being seen as flawed or inadequate (Singh, 2009). Current research shows that the academic interests and occupations of Asian Americans are concentrated in the science and technology fields but un-
Poon: Parental Influence on Asian Americans’ Outcomes | 17 derrepresented in the fields of humanities and social sciences (Leong & Serafica, 1995). According to the National Science Foundation (2012), in 2010, 49 percent of Asian American undergraduates in the United States reported that they intended to major in science and engineering; specifically, 18 percent had intended on majoring in biological science and engineering while 15 percent intended on majoring in agricultural science and engineering. The educational interests displayed by Asian American undergraduates are not completely reflective of their personal academic interests for due to cultural and parental influences.
Asian Cultural Influences on ParentChild Relationships Educational pressure from Asian American parents play a large role in their children’s vocational outcomes (Leong, 1985). Many parents expect their children to enter the highly demanding fields of engineering or medicine so that they will have increased chances of aquiring a well-paying job and higher socioeconomic status (Tang & Fouad, 1997). Asian American parents share common goals for their children because of their similar cultural background in Confucian ideology and values of filial piety and interdependence (Barringer et al., 1993; Chao & Tseng, 2002). Filial piety and interdependence are demonstrated through family cohesion in most Asian American households (Chao & Tseng, 2002). Because family often takes the utmost priority in Asian culture, Asian Americans view it as the central reference group for all social interactions associated with education, politics, money, and religion (Chao & Tseng, 2002; Ho, 1996). Therefore, Asian American students comply with the academic and vocational decisions made by their parents as an act of filial piety. Students take caution when making educational or vocational decisions because their actions are reflective of their parents’ abilities to cultivate and raise the child (Chen, 1996). In other words, Asian Americans feel the need to respect their family’s reputation by appeasing the demands and expectations that their parents have for them. Aligning with Confucian ideals, Asian American
children fulfill their duties of filial piety and interdependence by doing well in school and finding a steady job as compensation for their parents’ sacrifices and financial difficulties as first-generation immigrants (Fuligni & Pedersen, 2002). Sue and Okazaki (1990) introduce the concept of relative functionalism as the way Asian Americans seek occupations that give them greater opportunities to succeed because of their desire to evade blocked opportunities (Sue & Okazaki, 1990). Blocked opportunities, which arise from the model minority stereotype, are a result of racial bias toward Asian Americans that prevent them from seeking jobs that extend beyond their expected job placements. Understanding that it is more difficult for them to climb the social ladder as compared to their white counterparts, Asian Americans seek medical or business-related occupations such as that have great potential for economic success, rather than aspiring for occupations related to politics or entertainment that has comparatively more economic success barriers (Sue & Okazaki, 1990; Tang, 2002). Past research indicates that Asian Americans are less likely to exhibit cultural behaviors and characteristics for each generation that is further removed from the immigrant generation (Makabe, 1979; Phinney, Horenczyk, Liebkind, & Vedder, 2001). Acculturation, defined as the dynamic psychological process of identifying with the values, behaviors and attitudes of a non-native cultural environment, may partially explain the generational differences in culture retention of Asian Americans in the United States (Phinney, Horenczyk, Liebkind, & Vedder, 2001). Research on the study of acculturation and parent involvement indicates that being under multicultural influence affects Asian American students’ vocational decisions (Atkinson, Whiteley, & Gim, 1990; Leong & Tata, 1990). Studies show that Asian American students are more likely to comply with their parents, whereas white Americans are more likely to make career choices independently (Tang, 2002). This supports the notion that Asian society is a collectivist society that encourages group work, whereas American society is an individualistic society that fosters independence (Moy, 1992). However, depending on the acculturation level of the individual, Asian Americans
18 | Staff Articles may be less likely to be influenced by their parents’ occupational expectations (Tang, 2002). Furthermore, acculturated Asian Americans may not be as willing to compromise with their parents because of intergenerational parent-child conflicts, such as cultural, marital, economic, and lifestyle disagreements that arise from generational and cultural differences (Lee, Choe, Kim, & Ngo, 2000).
Role of the Asian Parents in Children’s Educational and Vocational Outcomes The parenting styles of Asian American parents in intergenerational families embody Confucian values (Chao, 1994). Asian American parents strongly value a good education and believe that parental effort is a crucial factor in the children’s academic achievements (Chao & Tseng, 2002). Asian American parents believe that education is a strong predictor of future success, implying that an ‘improper’ education leads to failure (Chao & Tseng, 2002). For example, in The Battle Hymn of the Tiger Mother by Amy Chua (2011), portrays all Chinese mothers as being “tiger mothers,” or authoritarian parents who force their children into endless hours of piano practice and rigorous tutoring in fear of their children’s future failure. Research shows, however, that Chinese parenting styles are both authoritative and authoritarian in nature (Buki, Strom & Strom, 2003; Chao, 1994; Cheah, Leung, Tahseen, & Schultz, 2009; Xu et al., 2005). Still, the term “tiger mother” may be grounded in some truth, for Asian American parents tend to cultivate their children’s education through strict parenting. Asian American parents believe that their children’s education requires cultivation and effort on their behalf; they also consider their children’s educational success is an indicator of their overall effort as parents (Chao & Tseng, 2002). As a result, out of respect for their parents, Asian American children aim for occupations that are indicative of high socioeconomic status and their parents’ timeless effort. Some studies show that parental involvement does not consistently correlate to academic achievement for Asian American students, despite contrary cultural beliefs (Mau, 1997). The findings show that parental
involvement may only be partially responsible for the academic success of Asian American students, while parental expectations actually play a more crucial role (Chao & Tseng, 2002). Hence, parental expectations are a great motivating factor for Asian Americans to meet their parents’ academic and vocational expectations by earning high grades and attaining a well-paying job (Chao & Tseng, 2002). It is important to note that complying with parental demands is not equivalent to actively practicing Confucian values. Rather, Confucian values are integrated into Asian culture, just as Christian beliefs of God have been integrated into the Pledge of Allegiance (1954). While not all Americans view monogamy as an active practice of Christianity, neither do all Asian Americans view filial piety as an active practice of Confucianism. However, Asian Americans who were exposed to both Asian and American cultures may find it easier to identify differences between them.
Conclusion and Future Implications The racial stereotypes and labels that Asian Americans were faced with in the past have partially shaped their experiences in American society today. Seen as the model minority, Asian Americans work to fulfill the cultural demands of their families and societal expectations of American society by being diligent workers with high academic standards (Panelo, 2010). The demand for spectacular academic and vocational achievement comes from the Confucian value of filial piety, as Asian Americans work hard to fulfill their parents’ demands and lessen the burdens their parents carry as Asian American immigrants. In addition to past discrimination against Asian Americans, the model minority stereotype makes it difficult for Asian Americans to express themselves outside of their academic and social expectations. As a result, Asian Americans pursue “socially acceptable” occupations in the fields of science and technology in order to achieve upward social mobility, or socioeconomic success. In other words, Asian Americans choose professions that may not align with their personal interests because other occupations such as being a famous celebrity or U.S. politician are incredibly difficult for Asian Amer-
Poon: Parental Influence on Asian Americans’ Outcomes | 19 icans to attain and any failed attempts would only block them from achieving socioeconomic success (Sue & Okazaki, 1990). Research on the study of heritage and cultural influence on the acculturated lives of Asian Americans in social and academic settings has been widely explored. Future research may seek to explore different levels of strictness in Asian American parents’ authoritative or authoritarian parenting styles and how it affects Asian Americans’ academic and vocational decisions. Furthermore, future research can potentially explore how strong family or collectivist values relate to the psychological well-being of Asian Americans raised in the model minority stereotype context.
References Atkinson, D., Whiteley, S., & Gim, R. H. (1990). Asian American acculturation and preferences for help providers. Journal of College Student Development, 31(2), 155-161. Bates, T. M. (1997). Race, self-employment, and upward mobility: An illusive American dream. Washington, D.C.: Woodrow Wilson Center Press. Barringer, H.R., Gardner, R.W., Levin, M.J. (1993). Asians and Pacific Islanders in the United States. New York: Russell Sage Foundation. Chao, R., & Tseng, V. (1995). Parenting of Asians. In M. H. Bornstein (Ed.), Handbook of parenting (2nd ed., Vol. 4, pp. 59-93). Mahwah, NJ: Lawrence Erlbaum Associates. Chao, R. K. (1994). Beyond parental control and authoritarian parenting style: Understanding Chinese parenting through the cultural notion of training. Child Development, 65, 1111–1119. Chen, S. J. (1996). Positive childishness: Images of childhood in Japan. In C. P. Hwang, M. E. Lamb, and I. E. Sigel (Eds.), Images of childhood (pp. 113–128). Mahwah, NJ: Lawrence Erlbaum Associates. Cheng, C. (1997). Are Asian American employees a model minority or just a minority? The Journal of Applied Behavioral Science, 33(3), 277-290. Cheng, L. & Bonacich, E. (1984). Labor Immigration under capitalism: Asian workers in the United States before World War II. Berkeley: University of California Press. Chua, A. (2011). Battle hymn of the tiger mother. New York: Penguin Press. Fuligni, A. J., & Pedersen, S. (2002). Family obligation and the transition to young adulthood. Developmental Psychology, 38(5), 856868. Higher education in science and engineering. (2012). In Science and engineering indicators 2012 (pp. 2-1-2-41). Arlington, VA: National Science Foundation. Ho, P. T. (1962). The ladder of success in Imperial China: Aspects of social mobility, 1368–1911. New York: Columbia University Press. Hurh, W.M. & Kim, K.C. (1989). The success image of Asian Americans: Its validity, practical, and theoretical implications. Ethnic and Racial Studies 12, 512–538. Lee, S. J. (1994). Behind the model minority stereotype: Voices of highand low-achieving Asian American students. Anthropology and Education Quarterly, 25, 413–429. Lee, R. M., Choe, J., Kim, G. & Ngo, V. (2000). Construction of the Asian American Family Conflicts Scale. Journal of Counseling Psychology, 47(2), 211-222. .Leong, F. T. L. (1985). Career development of Asian Americans. Journal of College Student Personnel, 26, 539-546. Leong, F. T. L., & Serafka, F. C. (1995). Career development of Asian Amer-
icans: A research area in need of a good theory. In F. T. L. Leong (Ed.), Career development and vocational behavior of racial and ethnic minorities (pp. 67-102). Hillsdale, NJ: Erlbaum. Leong, F. T. L., & Tata, S. P. (1990). Sex and acculturation differences in occupational values among Chinese-American children. Journal of Counseling Psychology, 37, 208-212 Ludden, J. (2006, May 9). 1965 Immigration law changed face of America. National Public Radio. Retrieved from http://www.npr.org/ templates/story/story.php?storyId=5391395 Makabe, T. (1979). Ethnic identity scale and social mobility: The case of Nisei in Toronto. The Canadian Review of Sociology and Anthropology, 16(2), 136-45. Mau, W. (1997). Parental influences on the high school students’ academic achievement: A comparison of Asian immigrants, Asian Americans, and White Americans. Psychology in the Schools, 34, 267–277. Moy, S. (1992). A culturally sensitive, psychoeducational model for understanding and treating Asian-American clients. Journal of Psychology and Christianity, 40, 194-199. Panelo, N. D. (2010). The model minority student: Asian American students and the relationships between acculturation to western values, family pressures, and mental health concerns. Vermont Connection, 31, 147-155. Phinney, J. S., Horenczyk, G., Liebkind, K., & Vedder, P. (2001). Ethnic identity, immigration, and well-being: An interactional perspective. Journal of Social Issues, 57(3), 493-510. Pledge of Allegiance to the Flag of the United States of America. (1954). In Encyclopedia Britannica. Retrieved from http://www.britannica.com/EBchecked/topic/464536/Pledge-of-Allegiance-to-theFlag-of-the-United-States-of-America Singh, A. A. (2009). Counseling with Asian Americans. In C. M. Ellis & J. Carlson (Eds.), Cross cultural awareness and social justice in counseling (147-168). Flourence, KY: Routledge. Sue, S. & Okazaki, S. (1990). Asian-American Educational Achievements: A phenomenon in Search of an Explanation. American Psychologist, 45(8), 913- 920. Suzuki, B. H. (1994). Higher education issues in the Asian American community. In M. J. Justiz, R. Wilson, & L. G. Björk (Eds.), Minorities in higher education (pp. 258–285). Phoenix, AZ: Oryx Press. Tang, M. (2002). A comparison of Asian American, Caucasian American, and Chinese college students: An initial report. Journal of Multicultural Counseling and Development, 30, 124–134. Tang, M., & Fouad, N. (1997). Understanding Asian Americans’ career choices: A social cognitive approach to examine the factors affecting their choices. Paper presented at the Annual Conference of American Psychological Association, Chicago. Wilkens, W. E. (1976). The concept of a self-fulfilling prophecy. Sociology of Education, 49(2), 175-183. Wong, P., Lai, C. F., Nagasawa, R., & Lin, T. (1998). Asian Americans as a model minority: Self-perceptions and perceptions by other racial groups. Sociological Perspectives, 41, 95–118. Xie, Y., & Goyette, K. (2003). Social mobility and the educational choices of Asian Americans. Social Science Research, 32(3), 467-498. Yang, K. (2007).Southeast Asian American children: Not the “model minority”. Growing Up American, 14(2), 127-133.
20 | Staff Articles
Socio-Emotional and Psychological Outcomes: Music Therapy for Individuals with Autism Spectrum Disorders
utism Spectrum Disorders (ASDs) are a collection of multisystem neurological disorders characterized by difficulty in the realms of social functioning, such as eye contact (Dawson et al., 2004; Mundy & Crowson, 1997), verbal communication (Tager-Flusberg, 1999), and emotional reciprocity (Mundy & Crowson, 1997). It is believed that these difficulties are caused by deficits in multi-modal integration as a result of short-range over-connectivity and long-range under-connectivity between different brain regions, meaning that while each area of the brain has a wealth of strong internal connections, there is a lack of connection between these areas (Belmonte et al., 2004; Courchesne et al., 2007; Minshew & Williams, 2007). Individuals with ASD also present with difficulties in physical functioning, such as repetitive (stereotyped) behaviors (Bodfish, Symons, Parker, & Lewis, 2000; Boyd, McDonough, & Bodfish, 2012), difficulty with dual-limb and multi-limb coordination (Green et al., 2009; Fournier, Hass, Niak, Lodha, & Cauraugh, 2010), postural control (Minshew, Sung, Jones, & Furman, 2004), gait (Hallett et al., 1993; Vilensky, Damasio, & Maurer, 1981), and imitation (Dewey, Cantell, & Crawford, 2007; Mostofsky et al., 2006). Since the first documented case of ASD, one of the defining features of the disorder is a lack of responsiveness, particularly in regards to emotion (Hobson, 1989, 1990, 1993; Kanner, 1943). For example, individuals with ASD have difficulty recognizing the emotions expressed by different facial features, a well as difficulty matching the emotional tone of a voice to a facial expression (Bormann-Kischkel, Vilsmeier, & Baude, 1995; Hobson, 1986a,b; Hobson et al., 1989; Loveland et al., 1994; MacDonald et al., 1989; Ozonoff, Pennington, & Rogers, 1990; Scott, 1985; Tantam, Monaghan, Nicholson, & Stirling, 1989). Despite difficulty in emotion recognition within
the context of nonverbal communication, individuals on the autism spectrum are just as able to accurately identify simple musical emotions as their typically-developed (TD) peers (Capps, Yirmiya, & Sigman, 1992; Heaton, Hermelin, & Pring, 1999), and show an equivalent enjoyment of music (Bhatara, Quintin, Fombonne, & Levitan, 2013). The establishment of standard interpretations of musical emotion is supported by a number of studies that have found that differences in tempo (Hevner, 1935; Gagnon & Peretz, 2003; Rigg, 1940) and mode (Dalla Bella, Peretz, Russeau, & Gosselin, 2001) are associated with different valences. The ability to discern these emotional distinctions are present in children as young as nine months of age (Flom, Gentile, & Pick, 2008), across cultural boundaries (Balkwill & Thompson, 1999; Balkwill, Thompson, & Matsunaga, 2004; Fritz et al., 2009), and even in individuals with brain lesions in the auditory cortex (Peretz, 1996; Peretz, Belleville, & Fontaine, 1997; Peretz & Gagnon, 1999; Peretz, Gagnon, & Bouchard, 1998). Because of this consistency, the responses provided by those with ASDs not only add to evidence of the universality of musicâ€™s ability to communicate specific emotions, but provide theoretical support for the use of music as a tool to practice emotional recognition within ASDs. Music has the potential to stimulate multiple brain regions (Srinivasan & Bhat, 2013). The practice of playing music, even individually, requires the simultaneous use of the auditory, visual, somatosensory, and motor cortices (Schlaug, AltenmĂźller, & Thaut, 2010). Brain scans of musicians show co-activation in auditory, visual, and motor areas of the brain when performing tasks that require only one of these areas, indicating multimodal integration following musical training (Bangert et al., 2006). Such promotion of long-range connectivity could work to increase the
Sabourini: Music Therapies and ASD | 21 functioning of these networks in individuals with ASD (Wan, Marchina, Norton, & Schlaug, 2012). Bruscia (1991) defines music therapy as “an interpersonal process in which the therapist uses music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help clients improve, restore or maintain health” (p. 5). has the potential to facilitate the experience and communication of emotion within a supportive social environment with the therapist(s) and group members. Because of the many facets that make up musical expression, music therapy also integrates social development with both gross and fine motor skill development, all of which work to alleviate difficulties found within ASDs while harnessing musical strengths (Darrow & Armstrong, 1999; Srinivasan & Bhat, 2013). This paper seeks to examine the efficacy of such music therapies in improving the social and psychological functioning of individuals diagnosed with ASD.
Socio-Emotional Outcomes While many with ASD suffer from difficulties in social behaviors, both individual and group music therapy interventions provide a structured, cooperative social context in which they can learn to interact more effectively, either within the context of a client-therapist relationship or with other group members (Kirschner & Tomasello, 2010; Marsh, Richardson, & Schmidt, 2009; Overy & Molnar-Szacks, 2009). This allows for the practice of social skills such as imitation, turn-taking, joint attention, shared affect, and empathy (Overy & Molnar-Szacks, 2009). Because many people with ASD can communicate their emotions more easily through music than through words, such interventions provide clients with a space for self-expression and give them a sense of being truly heard (Srinivasan & Bhat, 2013). It is in this open environment that people who struggle with sharing experiences with others are given the opportunity to express themselves without fear of rejection and to support others’ self-expression. Such therapeutic practices have shown significant results in the behaviors and lives of clients, not only within the therapy room, but within other areas
as well. For example, studies have shown that children with ASD who undergo group music therapy interventions show improved play and peer involvement (Kern & Aldridge, 2006), enhanced verbal communication (Gold, Wigram, & Elefant, 2006; Shore, 2002), increased social involvement and interaction (Wimpory, Chadwick, & Nash, 1995), engagement with others (Toolman & Coleman, 1994), and increased eye contact (Wimpory et al., 1995). Beyond improvements in interpersonal actions, music has also been shown to increase the understanding of emotions for those with autism. In a randomized study in which autistic children were taught about happiness, sadness, anger, and fear, participants in the group that utilized appropriate background music for each emotion showed the greatest gains in understanding (Katagiri, 2009). This improvement of emotional awareness further allows those with ASDs to respond appropriately in social situations. In learning to cooperate with others, the idea of social situations may begin to change from something that was once difficult and frightening to something enjoyable. Such a change would further allow these benefits to grow, for as clients become more able to successfully interact within their session, they become further able to take advantage of the benefits provided within a cooperative, music-centered relationship.
Psychological Outcomes Positive social relationships are strong emotional buffers, functioning to reduce the impacts of negative stressful events and increase emotional well-being (Burns & Machin, 2013; Dirkzwager et al., 2003; Haden, Scarpa, Jones, & Ollendick, 2007). As such, the effects of music therapy are . Not only can the therapy itself lead to increased self-esteem (Hillier, Greher, Poto, & Dougherty, 2012; Shore, 2002) and reduced stress (Khalfa, Dalla Bella, Roy, Peretz, & Lupien, 2003; Miluk-Kolasa, Obminski, Stupniki, & Golec, 1994; Trevarthen, 2002), but the relationships that it fosters further these outcomes. In interacting with others in an effectively communicative way, not only will individuals diagnosed with ASD gain self-esteem
22 | Staff Articles as a result of personal mastery, but the supportive social environment in which they gain these skills also serves to improve their overall well-being. The multiplicity of positive effects follows also in regards to emotional regulation. Simply the act of listening to music has been shown to reduce stress and improve mood regulation (Skånland, 2013; Thoma et al., 2013). Taking into account the emotional regulation fostered by improved social relationships and listening to music, music therapy interventions have been able to improve mood regulations in clients with ASDs (Trevarthen, 2002). In doing so, music therapy interventions have been effective in decreasing the frequency and intensity of self-injurious, aggressive, and stereotyped behaviors (Brownell, 2002; Carnahan et al., 2009a,b; Clauss, 1994; Devlin, Healy, Leader, & Reed, 2008; Gunter, Fox, McEvoy, & Shores, 1993; Lanovaz, Fletcher, & Rapp, 2009; Orr, Myles, & Carlson, 1998; Pasiali, 2004). After a successful music therapy intervention, clients will be provided a number of things. First of all, they will have had the opportunity to not only improve personal mastery, but will have been able to enact this mastery in successfully participating in shared music experiences, utilizing instruments in a way that adds to the quality of the music made. Secondly, in actively participating they will have developed a relationship with the therapist(s) and any group members they may have had, providing them with a supportive environment to engage and interact with one another through shared experiences. Then, when taking into account the numerous neurological and emotional benefits that simply listening to and creating music provides, a client will have been exposed to a treatment that not only teaches skills or improves self-esteem, but is layered with a number of unique and rich benefits that all serve to compound the efficacy of one another.
Conclusion With all the elements of music considered, music therapy has a distinct place in the treatment of individuals with ASDs (Srinivasan & Bhat, 2013). Because of its multimodal qualities, it has the potential to improve neurological connection between
brain regions (Belmont et al., 2004; Courchesne et al., 2007; Minshew & Williams, 2007; Schlaug, Altenmüller, & Thaut, 2010). Such improvements may lead to increased communication skills, which, combined with the social nature of music therapy interventions, allow for the continued practice of these skills (Marsh et al., 2009; Overy & Molnar-Szacks, 2009; Kirschner & Tomasello, 2010). In addition to increased interpersonal competency, music reduces stress and anxiety and improves emotional regulation, making interpersonal relationships easier to form and maintain (Skånland, 2013; Thoma et al., 2013; Trevarthen, 2002). These newly developed relationships then work to further stress reduction, working bi-directionally to improve the social, emotional, and psychological state of clients with ASDs. Despite all of this research, there are no studies that have specifically examined the effect that music has on either gross or fine motor skills in ASDs. Because it is very likely that movement difficulties compound the social problems that individuals with ASD struggle with, an improvement in physical control may also lead to improvements in social and psychological domains (Srinivasan & Bhat, 2013). Music practice has the potential to serve as a great way to improve motor skills in its ability to enhance patient motivation and allow for repetitive practice of specific motor skills in an enjoyable way (Rodriguez-Fornells et al., 2012; Schneider et al., 2007). Beyond this theoretical foundation, music-based movement therapies have been shown to improve motor skills in TD populations (Bachmann, 1991; Findlay, 1971; Hurwitz, Wolff, Bortnick, & Kokas, 1975), individuals diagnosed with dyslexia (Getchell, Mackenzie, & Marmon, 2010) and those with Parkinson’s disease (Duncan & Earhart, 2012). This indicates the potential for motor-skill improvement through music-based movement therapies to be generalized even amongst those with different disorders. Further investigation into the relation between these factors could help provide a clearer guideline for how to effectively treat ASDs within the field of music therapy.
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Tsang: CTCP: Culturally Appropriate Therapy | 25
Chinese Taoist Cognitive Psychotherapy: A Culturally Appropriate Form of Therapy
Cultural and Historical Context of Taoism in Mainland China 「道可道非常道 名可名非常名」(pinyin: dàokĕ-dào-fēi-cháng-dào míng-kĕ-míng-fēi-cháng-míng; literal meaning: The tao that can be told is not the eternal Tao; The name that can be named is not the eternal Name) are the famous opening lines of the Tao Te Ching, the classic Zhou Dynasty text by Chinese philosopher Laozi (Laozi & Mitchell, 2006; 張 子維, 2012). These lines not only introduce but also summarize the Taoist perspective of the universe and its system of values. It is important to understand the Chinese character Tao (道) because it is one of the most important terms in Taoism. Tao can be translated as the noun form of “path,” “principle,” or the verb form of “to speak” depending on one’s interpretation. The translation of the two opening lines of the Tao Te Ching varies by interpreter because of the lack of punctuation throughout the verses. However, people generally understand it as, “The ‘principle’ that can be ‘spoken’ is not the eternal ‘way’ and the ‘name’ that can be ‘named’ is not the eternal ‘name’” because it aligns with the other main concepts in Taoism (余秋 雨, 2009). Essentially, the meaning of the phrase is that the world did not come into being with pre-existing principles for humans to follow to create meaning. Humans must understand and explain the world by making their own observations and interpreting their own experiences. Because of this principle, Taoists also believe in the concepts of 「物極必反」(pinyin: wu-ji-bi-fan; literal meaning: things always reverse upon reaching an extreme) and 「無為」(pinyin: wu-wei; literal meaning: non action). According to Yip (2005), wu-wei is a combined concept of both “passive progressivity” and
“harmony with nature,” that humans accept life’s natural order without intervening (p. 5). This concept is similar to the idea of 「順流」(pinyin: shun-liu; literal meaning: going along with the flow like water) in that humans must accept that their lives change and shift depending on their environment (Slingerland, 2003; Young, Zhang, Xiao, Zhou, & Zhu, 2002). As the I Ching, a classical Chinese text from circa 800 BCE (Hacker, 1993), suggests「陰陽」(pinyin: yin-yang; literal meaning: dark bright) is the force that provides persistent adjustment within balance between opposing forces. In other words, yin and yang keep the world functioning in its natural order because of the contrary but interdependent relationship between the two concepts.
The State of Mental Health Care in Mainland China The Taoist system of values has been facilitating a solution to mental suffering since Ancient China (Cheng, Lo, & Chio, 2010). However, since Ancient Chinese philosophers never intended to study mindbody problems through empirical analysis, psychology in China has been viewed as a discipline that started in the West (Blowers, 2000). Compared to many other countries, China is far behind in terms of mental health development (Deutsch-Chinesische Akademie Fur Psychotherapie), partially because of the Great Proletariat Cultural Revolution set into motion by Mao Zedong in 1966 after his failed Great Leap Forward (Yang, 1998). The revolution has created the period of greatest political instability in the five millennia of Chinese history (Yang, 1998), bringing China to a “tempo unprecedented in history” in terms of development (Teng, 1971). The demand for clinical services increased dramatically after the multiple nat-
26 | Staff Articles ural and man-made tragedies that happened within China in the past three decades (Xu & Wu, 2011). In fact, there are only about 16,000 psychiatrists (Liu et al., 2011) for its estimated 16 million people in need of mental health care in Mainland China (Kleinberg & Thomas, 2012). Because modern empirical psychology was first developed in the West, the influence of Euro-American-based psychology has become the mainstream psychology across the world (Jing, 2000). Euro-American psychology has dominated other forms of psychology due to the massive exportation of its publications worldwide (Sexton & Hogan, 1992). The increasing number of adolescents educated outside of their own countries has also dramatically enhanced the transfer of Euro-American knowledge to regions beyond the borders of its origins (Blowers, 2010; Danziger, 2006). However, as Chinese sociologists Yang and Gao (1991) point out, Chinese culture (i.e. social structure and self) is almost the exact opposite of Western culture, and therefore, core values, standards of abnormality and treatments vary. In terms of therapy, for example, Chinese students perceive the counselor’s role more as one of an expert (61.8%) compared to a listener (31.4%), in contrast to American students’ view of counselors as listeners first (77%) and experts second (50.7%) (Mau & Jepsen, 1988). Hence, native Chinese mental health professionals are working to develop indigenous psychology in order to avoid the potential incompatibility of Euro-American psychological theories with the cultures to which these theories are exported (Jing, 2000). This paper will investigate Chinese Taoist Cognitive Psychotherapy as a culturally specific psychotherapy that may be more appropriate than Western forms of therapy within Chinese populations because of its basis in Taoist principles and Chinese language.
Importance of Language Within Culture Understanding the Chinese cultural context is essential to interpreting Chinese Taoist Cognitive Psychotherapy. Cultural context is what makes one ethnic group different from another (Bond, 2010). Culture is comprised of many dynamics, including
language for communication and tradition to express its characteristics (Bond, 2010). Culture and language are inseparable as they cannot exist and grow without each other (Brown 1994; Jiang, 2000). Although people may express the same idea differently, this does not necessarily mean that they have different ways of processing the same information (Boroditsky, 2010). Recently, cognitive scientists have begun to suggest that language can help construct human understanding of the essential but abstract ideas such as causality, space and time (Boroditsky, 2010). People build more complicated and abstract concepts, such as morality and beliefs (Boroditsky, 2010), upon the language that they are comfortable using and pass these concepts down through generations. Since language is a tool created by humanity (Piaget, 1962) to build and spread culture, it can be concluded that language is one of the most important factors that determine and define culture (Brown 1994; Jiang, 2000). Because of the complex interplay of culture and language, it is critical to understand how cultural context informs meaning in language as well. The mistranslation of “mokusatsu” during World War II, for example, is one of the most infamous mistranslations in history, serving as a reminder of the serious consequences a mistranslation can lead to. “Mokusatsu” is a Japanese word that is composed of two kanji, 默 (rōmaji: moku, literal meaning: silence) and 殺 (rōmaji: satsu, literal meaning: killing). It is an ambiguous term that means both “maintaining silence – no comment” and “treating it with contempt – not worthy to comment” (National Security Agency, 1968). The “ill-chosen translation” of the Japanese word “mokusatsu” served as a catalyst for the U.S. dropping two nuclear bombs in Japan (National Security Agency, 1968). Because an international news agency translated the word as “not worthy to comment,” the U.S. government assumed that the Japanese government was ignoring the terms of surrender, treating them with contempt (National Security Agency, 1968). The tragic linguistic error of “mokusatsu” reminds us that it is impossible to have exact translation counterparts in every other language. People sometimes use words that can only be understood accurately with appropriate contextual clues and cultural background despite
Tsang: CTCP: Culturally Appropriate Therapy | 27 seemingly paradoxical definitions (i.e. pretty and pretty ugly). People with diverse cultural backgrounds have their viewpoints influenced by their languages differently (National Security Agency, 1968). The importance of understanding cultural context can also be shown in the comparison of the word for dog in Chinese and English. Most English-speaking people will associate the word “dog” with concepts like loyalty and “man’s best friend” (Jiang, 2000, p. 329). However, Chinese language has a rather negative connotation for the word 狗 (pinyin: gou; literal meaning: dog) (Jiang, 2000), especially in use of idioms such as 狼心狗肺 (pinyin: láng-xīn-gǒu-fèi; literal meaning: brutal and cold-blooded) and 豬朋狗友 (pinyin: zhū-péng-gǒu-yǒu; literal meaning: fair-weather friend). Although the word refers to the same animal, there is an apparent distinction between the ideas that each language expresses. Studies suggest that the quality of many Western tests and assessments that are translated into other languages may be lacking (Cheung, Leong, & Ben-Porath, 2003). For example, cognitive assessment, with a heavy focus on verbal evaluation and understanding sentence structure, may have a questionable validity because of the linguistic difficulty of maintaining the meanings of all terms within the translation (Chan, Shum, & Cheung, 2003). As suggested in Jiang’s (2010) study, translated word may not always be the culturally appropriate word for the participant to stimulate an expected association. In this sense, it is fairly easy to explain the increasing demand of developing a form of psychotherapy for Chinese people that matches their language, beliefs, tradition and cultures.
The Cultural Coherence of Chinese Taoist Cognitive Psychotherapy Cognitive-Behavioral Therapy (CBT) is one the most thoroughly studied Euro-American therapies used by mental health professionals. The therapy has been used internationally because of its fundamental belief that “you are what you think you are,” which is derived from basic behavioral and cognitive principles (Dobson, 2012). It encourages members that are participating in the CBT session to develop and
maintain a positive perspective regarding their experiences by increasing coping skills such as minimizing, reappraising and restructuring distressing thoughts (Hamblen, 2010) and changing maladaptive behavior (Klein, Bernard & Singer, 1992). Previous literature suggests that Rational Emotive Behavioral Therapy (REBT), a derivation of CBT, is one of the most prominent theoretical approaches in Asian counties, including China (Hodges & Oei, 2007). Psychoanalytic and psychodynamic therapies are virtually non-existent (Cheng, 1993), whereas REBT, a comprehensive, active-directive and empirically-based psychotherapy, is fairly common. The framework of REBT matches the traditional Chinese values that seek a direct and solution-focused approach (Hodges & Oei, 2007) from a rational and authoritative expert (Chen & Devenport, 2005; Mau & Jepsen, 1988), rather than self-exploration (Cheng, 1993). In fact, Albert Ellis, the creator of this relatively new psychotherapy, advocated helping clients to change their irrational beliefs in order to alter their subsequent emotional consequences (Albert Ellis Institute). Although it is uncertain whether REBT is more effective in a particular population for a specific reason, literature emphasizes the increasing concern of the importance of language (Kung, 2004) by developing and modifying indigenous psychotherapies (Cheng, Cheung, & Chen, 1993; Zhang et al., 2002). As more and more educated Chinese mental health professionals grow aware of the differences in measurements of mental diagnosis (i.e. ICD-10, CCMD-3 and DSM-IV-TR) and social norms, there have been rising doubts as to whether Western-based treatments are suitable for Chinese people in the Chinese cultural context. Taoist beliefs have been embedded in Chinese culture for centuries. Previous literature suggests that cultural factors are a critical element of individual mental health. (Tseng, Kitanishi, Maeshiro, & Zhu, 2012) Because Chinese medical anthropologists have discovered that perception of an illness’ etiology and symptoms varies between people with different cultural beliefs (Ji, Lee, & Guo, 2010), indigenous psychotherapy might be a more beneficial form of treatment in China. Two psychiatrists, Dersen Young and Yalin Zhang, studied Taoist attitudes of mental health prin-
28 | Staff Articles ciples and developed Chinese Taoist Cognitive Psychotherapy (CTCP) as a modification of REBT in 1992. Chinese Taoist Cognitive Psychotherapy (CTCP) is an instructive treatment based on eight Taoist principles. During the course of treatment, Chinese patients ask the therapist for explanations and guidelines as opposed to engaging in behaviors such as self-exploration (Zhang et al., 2002), which may be more suitable in independent cultures like that of the United States and Western Europe. The eight core Taoist principles of CTCP are comprised of 32 Chinese characters from Tao Te Ching and used in clinical application: 1) 利而不害 (literal meaning: Benefit without harm to yourself and others); 2) 為而不爭 (literal meaning: Do your best without competition with others); 3) 少私寡慾 (literal meaning: Limit selfishness and moderate desire); 4) 知足知止 (literal meaning: Know when to stop and learn how to be satisfied); 5) 知和處下 (literal meaning: Know harmony and be humble); 6) 以柔制剛 (literal meaning: Hold softness to defeat hardness); 7) 返樸歸真 (literal meaning: Return to purity and innocence) and 8) 順其自然 (literal meaning: Follow the rule of nature) (Young et al., 2002). They applied these core principles to the ABC framework of REBT (i.e. identify the nature of the Adversity event, distinguish the irrational Beliefs from rational beliefs, and understand the Consequences of the irrational beliefs) to create its own ABCDE model: Assessment of Stress (i.e. Find actual stress factors), Belief System (i.e. Understand belief system), Conflict and coping system (i.e. Analyze conflict and coping styles), Doctrine direction (i.e. Imbue doctrine of Taoism), and Evaluate effect (Feng, Cao, Zhang, Wee, & Kua, 2011). The therapeutic model of CTCP, unlike REBT, incorporates Chinese Taoist philosophies into the treatment (Liu, & Leung, 2010). The main rationale behind the addition of Taoist philosophies is to regulate patients’ negative effect, correct maladaptive behavior, and treat psychological problems by utilizing Taoist values (Feng et al., 2011). CTCP emphasizes psychological, affective health and spiritual freedom along with Taoist concepts like detachment from excessive desires and compliance with the course of nature (Young, Tseng, & Zhou, 2005).
CTCP is a leading psychotherapy that has become widely acceptable and studied in China since 1995 (Mao, & Zhao, 2011). Literature suggests that, because of Taoism’s heavy emphasis on natural order without human interference, Taoist values are particularly helpful to patients with an anxiety disorder, depression (李梅枝, & 姜冬久, 2011), or to patients who have immediate family members with neurotic personality disorders (李梅枝 et al., 2008). Zhu, Yang, Xiao, and Liu (2005) also reported that CTCP has significantly reduced Type A personalities and anxious-depressive behaviors in patients with coronary heart disease. However, since CTCP strongly highlights the idea of detachment, it might not be an appropriate treatment for adolescents or young adults as it might lower motivation (李梅枝 et al., 2008). For that reason, older clients with internal emotional struggles may benefit the most from this psychotherapy. Chinese people that are influenced by Chinese culture are prone to accept a more didactic form of psychotherapy because they tend to value hierarchical organization (Zhang et al., 2002) that prompts the respectfulness and compliance of authority dependence (Hsu, 1970). Therefore, they are more likely to benefit from following practitioners’ instructions and encouragements and from coping with mental health issues through Taoist values (曹鳴岐, 2004).
Future Directions Young and Zhang, two indigenous mental health professionals that are experts in the language and culture of their target population, developed CTCP partially in an attempt to address concerns that Western therapies were not suitable for the Chinese cultural context. The therapy’s directive approach of actively persuading patients to detach is an essential Taoist element that successfully tailors this psychotherapy to native Chinese people (Ji, 1994). Both practitioners and the target population benefit from this indigenous psychotherapy because most language or cultural barrier issues are minimized due to the mutual understanding of and familiarity with the language and culture. There are, however, some important issues to consider with regard to CTCP. A significant number of
Tsang: CTCP: Culturally Appropriate Therapy | 29 Chinese reports are limited to solely Chinese society because research reports generally have to be written in English for reception in the international community (Blowers, 2010; Cheung, Leong, & Ben-Porath, 2003). Future studies should take this into account in order to expand accessibility to the public. Additionally, it is uncertain whether CTCP is compatible with Chinese people that are heavily exposed to other cultures (Ward, & Lin, 2010). Chinese Americans, for example, might be experiencing a different cultural context with a complicated cultural identity and possible acculturation stress in addition to existing symptoms. Since there is a lack of literature explaining the low percentage of those seeking help from a mental health treatment provider (U.S. Department of Health and Human Services, 2001) or the high dropout rate of mental health treatment within the Chinese population in the United States (Wang & Kim, 2010), it is difficult to identify if differing cultural values or treatment incompatibility explain this underutilization. Studies have shown that in Chinese society, there is an intense stigma surrounding mental illness, and for those who require treatment, concern about shame or loss of face is common and demotivating (Kung, 2004). Previous research suggests that there is a comparably high utilization of CBT and psychodynamic psychotherapy within the Chinese population in the United States that identify as more “Americanized” (Kim, Atkinson, & Yang, 1999). However, it is uncertain whether the lower level of Chinese cultural stigma regarding mental illness or the higher level of familiarity of the English language and culture increases the likelihood of attending psychotherapy sessions for people that identify as more “Americanized”. It is therefore important to consider how strongly the patient identifies with his or her Chinese cultural heritage. Because of the development of Chinese psychology in both academic and clinical research, extra in-depth research on the effectiveness of CTCP in different populations must be done before further conclusions can be drawn.
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34 | Submissions
The Schizophrenia-Cocaine Link: Breaking the Cycle
here are many barriers that can prevent individuals in low-income communities from receiving mental health services, and as a result, a slew of mental illnesses and psychological disorders go untreated (DeCarlo, Kaltman, & Miranda, 2013). Mental illnesses can be debilitating, especially when untreated, potentially interfering with typical daily responsibilities such as maintaining a steady job or caring for children and family. As mental health assistance is less accessible in low-income communities, having an untreated mental illness can feed a vicious cycle of poverty and poor mental health (Breslau, Lane, Sampson, & Kessler, 2008; DeCarlo et al., 2013). One psychological disorder that can be particularly dangerous if left untreated is schizophrenia, especially when it exists in conjunction with cocaine abuse (Power, Dragovic, Jablensky, & Stefanis, 2012). The present paper aims to investigate how lacking mental health services in low-income populations affect individuals with a comorbidity1 of cocaine abuse and schizophrenia within populations where individuals are not likely to seek psychological help. The following will identify the relationship between cocaine and schizophrenia, in terms of cocaine-induced schizophrenia and cocaine addictions among those already diagnosed with schizophrenia, specifically with regard to the lack of mental health care in low-income populations.
Cocaine Abuse and Schizophrenia in Low-Income Communities According to the DSM-V (2013), schizophrenia is a psychological disorder that consists of “one or more of the following, each present for a significant period of time during a 1-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms, i.e., affective flattening, alogia, or avolition” (American 1
Psychiatric Association, 2013). It is a condition that can deeply affect one’s self-care, personal relationships, and awareness of reality (American Psychiatric Association, 2013). Researchers currently believe that schizophrenia is a genetic disorder; however, there has been some difficulty in explaining the heterogeneity of the disorder (American Psychiatric Association, 2013). One reason for this is that schizophrenia tends to arise as a result of a gene-environment interaction, meaning that genetic predisposition in a schizophrenic patient exists, yet often only comes to the surface as a result of environmental experiences (American Psychiatric Association, 2013). Because of the gene-environment interaction that must typically occur for an individual to become schizophrenic, the symptoms for which a patient is predisposed lay dormant in the patient’s system for many years before becoming active symptoms (Power et al., 2012). When psychotic symptoms surface early in one’s lifetime, they can become more intense and difficult to treat due to the lack of maturation of the brain, as the human brain does not fully develop until age 25 and schizophrenia tends to develop between ages 15 and 25 (Power et al., 2012). Studies have shown that two major instances that lead to early onset schizophrenia are stressful and traumatic life events and substance abuse (Paparelli et al., 2011; Picken & Tarrier, 2011). Ninety-eight percent of individuals with schizophrenia report some degree of previous exposure to trauma, such as violence, abuse, and neglect, and 47-65% of individuals with schizophrenia report prior substance abuse (Picken & Tarrier, 2011; Zhornitsky et al., 2012). Incidentally, both trauma and drug abuse are two very prevalent issues in low-income populations (Bassuk, Buckner, Perloff, & Bassuk, 1998; Davis, Ressler, Schwartz, Stephens, & Bradley, 2008). Since low-income environments are often
For the purposes of this paper, comorbidity will be defined as the simultaneous existence of two conditions in one person, regardless of a potentially causal relationship between the two
Collins: The Schizophrenia Cocaine Link | 35 stressful and trauma-ridden, and since people in these communities rarely seek psychological help, some turn to substance abuse as a way to self-medicate, which can lead to the onset of schizophrenic symptoms (Power et al., 2012). The use of cocaine in particular has strong links to the onset of schizophrenia, especially when schizophrenic individuals report using the substance within twelve months prior to the onset of psychotic symptoms (Power et al., 2012). Researchers are still struggling to establish a definitive explanation for cocaineâ€™s ability to induce schizophrenic symptoms in individuals. However, recent studies have shown that cocaine may cause a dysfunction in the prefrontal cortex of the brain, which is a neurological characteristic of schizophrenia (Chambers, Sentir, Conroy, Truitt, & Shekhar, 2012; Tseng, Chambers, & Lipska, 2009). Nearly 50% of individuals with schizophrenia experience comorbid substance abuse disorder after the initial diagnosis of psychosis, most commonly with cocaine (Atkinson, 1973; Barbee, Clark, Crapanzano, Heintz, & Kehoe, 1989; Serper, Chou, Allen, Pal, & Cancro, 1999; Zhornitsky et al., 2012). As compared to the general population, people with schizophrenia have higher rates of impulsivity, sensation-seeking, and social anhedonia (i.e., disinterest in social contact) (Serper et al., 1999; Zhornitsky et al., 2012). Social anhedonia can cause dissatisfaction with everyday social activities, which can lead to impulsive drug use in order to obtain heightened sensation (Serper et al., 1999; Zhornitsky et al., 2012). Additionally, once cocaine has entered the system of a schizophrenic individual, it increases the positive symptoms (i.e., hallucinations or paranoia) in the patient. This can lead a craving for more cocaine in order to suppress the symptoms (Brady et al., 1990; Cleghorn, Kaplan, Szechtman, Szechtman, & Brown, 1991; Satel & Edell, 1991; Seper et al., 1999; Siegel, 1984). The comorbidity of schizophrenia and substance abuse, especially cocaine abuse, is currently considered an epidemic by psychological researchers and mental health professionals alike (Jane-Llopis & Matytsina, 2006). The combination of the two disorders has led to significant difficulties in applying traditional treatment for psychotic symptoms
(Jane-Llopis & Matytsina, 2006). In fact, the use of cocaine has been shown to increase the intensity of symptoms (Jane-Llopis & Matytsina, 2006; Kelly, Daley, & Douaihy, 2012; Merikangas & Kalaydjian, 2007). As a result, it becomes necessary for a combination of different types of treatment to keep psychotic schizophrenia symptoms under control, along with reducing (or ideally eliminating) the cravings for cocaine (Kelly et al., 2012). Methods include, but are not limited to, psychotherapy, pharmacotherapy, and behavioral therapy (Baker, Hides, & Lubman, 2010; Chen, Barnett, Sempel, & Timko, 2006; Kelly et al., 2012). Despite the fact that schizophrenia is much more common amongst those with lower socioeconomic status (Holzer, Shea, Swanson, & Leaf, 1986), these psychological treatments are significantly less accessible in low-income communities.
Barriers to Mental Health Service Access in Low-Income Communities There has been an increasing amount of research that demonstrates that individuals in low-income populations do not seek the psychological help necessary for their wellbeing (Chung et al., 2012; Thornicroft, 2012; Walker et al., 1999; Walker et al., 2003). As compared to people in other communities, people in low-income communities endure more chronic stress, including economic strain, neighborhood violence, and prevalent substance abuse(Chung et al., 2012; Thornicroft, 2012). Therefore, poor accessibility to mental health services is especially detrimental in low-income neighborhoods (Chung et al., 2012; Thornicroft, 2012). Further, research shows that chronic-stress environments increase the risk of developing psychological disorders (Lipman & Boyle, 2008; DeCarlo Santiago, Kaltman, & Miranda, 2013). There is a multitude of reasons why low-income individuals may not seek psychological assistance, including financial difficulties, lack of transportation, lack of awareness about mental health treatment, and ethnic differences regarding culture and language. Many adults in low-income populations have heavy schedules that include both a day job and a night job, leaving little free time for additional ap-
36 | Submissions pointments (Thornicroft, 2012). Since money is necessary for survival, working takes precedence over psychological care (DeCarlo Santiago, Kaltman, & Miranda, 2013; Thornicroft, 2012). Many of these families are single-parent families in which the parent is unable to afford childcare, and may not have the time to attend psychiatric sessions (Thornicroft, 2012). It is also likely that these individuals cannot afford to pay for mental health services or do not have the health insurance necessary to assist their payments (DeCarlo Santiago et al., 2013; Thornicroft, 2012). A study performed by Sentell and Shumway (2004) found that adults with insurance had double the chance of receiving mental health services compared to adults without insurance, and having a low income is a barrier toward obtaining health insurance. Furthermore, many of these neighborhoods do not have local psychological facilities, thus requiring those in need to travel elsewhere for assistance. If accessible transportation is not available, people may be less likely to seek assistance (DeCarlo Santiago et al., 2013; Thornicroft, 2012). As discussed earlier, treating schizophrenic patients with a drug addiction requires a combination of different treatment methods. This is necessary, as cocaine addiction and schizophrenia are two very different conditions that need to be addressed separately, to ensure fully effective treatment. It is typically necessary that more than one clinician is involved in the process, as addiction counselors often do not have adequate experience in treating other psychological disorders, and vice versa for general mental health clinicians (Wiechelt, Miller, Smyth, & Maguin, 2011). However, it is important that all clinicians treating an individual communicate with each other about the status of each condition as each condition is related and can affect the progress of the other (Wiechelt et al., 2011). A combination of treatments is even more difficult to attain than one treatment alone. When so many barriers toward mental health care already exist, the multiplicity of treatments necessary to effectively treat schizophrenia and cocaine abuse comorbidity creates yet another complication in the treatment process for individuals in low-income populations (Baker et al., 2010; Kelly et al., 2012).
Lack of knowledge about both mental health and mental health services in low-income communities is also an important consideration. If the peers and family members of low-income individuals have never sought psychological assistance, they may never become aware of available services (DeCarlo Santiago et al., 2013; Thornicroft, 2012). Additionally, studies have found that public schools in low-income neighborhoods rarely discuss the importance of mental health care in their health education classes, so people who grow up in these communities may simply never learn about the major potential benefits of such services, nor how to identify different disorders (Thornicroft, 2012). Many of the 46.2 million people currently living below the federal poverty line in the United States are ethnic minorities, i.e., 25.6% of Hispanic descent, 27.2% of African descent, and 11.7% of Asian descent (DeNavas-Walt, Proctor, & Smith, 2011). Minority populations face many additional issues pertaining to psychological help. People working in mental health services are predominantly English-speaking, which may not be optimal for minorities who speak different first languages (DeNavas-Walt et al., 2011). According to the US Census (2003), over 13 million Spanish-speaking individuals who live in the United States either speak minimal English or no English at all. As a result, language barriers within the mental health care system presumably prevent minority groups from obtaining appropriate services. Many minority groups may not be trusting of the people of different backgrounds who work in the mental health field (as they are often considered to be of more privileged groups), simply because they have not interacted with them before (DeNavas-Walt et al., 2011). Interviews with individuals from low-income minority groups have demonstrated that, since more privileged groups have not experienced the same hardships that they have (e.g., financial struggles, neighborhood violence, or structural discrimination), they do not understand their roots and therefore cannot be fully trusted (DeNavas-Walt et al., 2011; Thornicroft, 2012). Additionally, professionals of privileged groups may hold biased or discriminatory attitudes toward minority groups, or they may be un-
Collins: The Schizophrenia Cocaine Link | 37 informed about the cultural norms of an ethnic group, which can negatively affect treatment due to strained interactions between health professionals and those seeking aid (Roysircar, Gard, Hubbell, & Ortega, 2005). There are 31.3 million people living in the United States without citizenship, many of whom live in low-income communities (US Department of Homeland Security, 2009). Citizens are 125% more likely than non-citizens to receive mental health services (Sentell & Shumway, 2004). Non-citizens have greater difficulty obtaining private health insurance, are ineligible for Medicaid for the first 5 years of living in the United States, and are less familiar with the United States health system as they may not have lived in the country for an extended period of time (Lee & Matejkowski, 2011). Lack of trust or familiarity between mental health professionals and those seeking aid, as well as lack of citizenship, can greatly interfere with the attainment of necessary mental health services in low-income communities.
Future Directions In order to address the cycle of schizophrenia and comorbid cocaine abuse, it is crucial that mental health services become more readily available for individuals in low-income communities. Individuals with no schizophrenic symptoms, who may have had family members with untreated schizophrenia, may likely experience stressful or traumatic events in their dayto-day lives. These experiences can lead to substance abuse, which may result in the early onset of psychotic symptoms (Breslau et al., 2008; DeCarlo et al., 2013). Lack of resources and poor knowledge about mental health in these populations may cause individuals to neither seek nor receive adequate assistance (DeCarlo Santiago et al., 2013; Thornicroft, 2012). Low-income individuals whose schizophrenic symptoms did not result from trauma or substance abuse are equally unlikely to receive mental health services. Consequently, they may turn to cocaine as a form of self-medication for the disorder, which may worsen their condition (Lawrence, Rasinski, Yoon, & Curlin, 2013). If mental health providers address the barriers
low-income community members face in terms of receiving services to cope with stressful events, fewer people might resort to drug use, which could in turn keep genetic psychological issues dormant. This can be achieved by offering childcare at mental health service facilities, establishing more financial aid for treatment and transportation, and providing competent translators for those whose first language is not English. Additionally, public schools should become more active in teaching about mental health, so that people in low-income populations are well-informed about symptoms to look out for, how to seek treatment, and the resources available to them in their community. While a significant dearth in these services does exist, it is necessary to point out that there are some organizations attempting to address the barriers between mental health services and low-income community members. One of these organizations is the Multicultural Action Center of the National Alliance of Mental Illness (NAMI), which aims to â€œeliminate disparities in mental health care for diverse communities, ensure access to culturally competent services and [â€Ś] help and support people of diverse backgrounds who are affected by serious mental illnessâ€? (NAMI, 2013). However, more action should be taken in order to increase accessibility to mental health services to all low-income and minority populations across the country, and organizations such as NAMI should become more ubiquitous in our society. Schizophrenia is an extremely difficult condition to live with, both with and without cocaine addiction, and every step should be taken to improve mental health service access of these individuals.
38 | Submissions References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Atkinson, R. M. (1973). Importance of alcohol and drug abuse in psychiatric emergencies. California Medicine, 118(4), 1-4. Baker, A. L., Hides, L., & Lubman, D. I. (2010). Treatment of cannabis use among people with psychotic or depressive disorders: A systematic review. The Journal of Clinical Psychiatry, 71(3), 247–254. Barbee, J.G., Clark, P.D., Crapanzano, M.S., Heintz, G.C., & Kehoe, C.E. (1999). Alcohol and substance abuse among schizophrenia patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease, 177(7), 400-407. Bassuk, E.L., Buckner, J.C., Perloff, J.N., & Bassuk, S.S. (1998). Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. The American Journal of Psychiatry, 155(11), 1561-1564. Brady, K., Anton, R., Ballenger, J. C., Lydiard, R. B., Adinoff, B., & Selander, J. (1990). Cocaine abuse among schizophrenic patients. American Journal of Psychiatry, 147(1), 164-1167. Breslau, J., Lane, M., Sampson, N., & Kessler, R. (2008). Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research, 42(9), 708-716. Chambers, R. A., Sentir, A. M., Conroy, S. K., Truitt, W. A., & Shekhar, A. (2012). Cortical striatal integration of cocaine history and prefrontal dysfunction in animal modeling of dual diagnosis. Biological Psychiatry, 67(8), 788–792. Chen, S., Barnett, P. G., Sempel, J. M., & Timko, C. (2006). Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients’ symptom severity. Journal of Substance Abuse Treatment, 35, 95–105. Chung, J. Y., Frank, L., Subramanian, A., Galen, S., Leonhard, S., & Green, B. L. (2012). A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care. Journal of Nervous and Mental Disease, 200(5), 438-443. Cleghorn, J.M., Kaplan, R.D., Szechtman, B., Szechtman, H., & Brown, G.M. (1991). Substance abuse and schizophrenia: Effect on symptoms but not on neurocognitive function. Journal of Clinical Psychiatry, 52(1), 26-30. Davis, R.G., Ressler, K.J., Schwartz, A.C., Stephens, K.J., & Bradley, R.G. (2008). Treatment barriers for low-income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 218-222. DeCarlo Santiago, C., Kaltman, S., & Miranda, J. (2013). Poverty and mental health: How do low-income adults and children fare in psychotherapy? Journal of Clinical Psychology, 69(2), 115-126. DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2011). U.S. Census Bureau, Population Reports. Income, Poverty, and Health Insurance Coverage in the United States. Washington, DC. Holzer, C.E., Shea, B.M., Swanson, J.W., Leaf, P.J. (1986). The increased risk for specific psychiatric disorders among persons of low socioeconomic status. American Journal of Social Psychiatry, 6(4), 259-271. Jane-Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: A review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515–536. Kelly, T. M., Daley, D. C., & Douaihy, A. B. (2012). Treatment of substance abusing patients with comorbid psychiatric disorders. Addictive Behaviors, 37(1), 11-24. Lawrence, R. E., Rasinski, K. A., Yoon, J. D., & Curlin, F. A. (2013). Physicians’ beliefs about the nature of addiction: A survey of primary care physicians and psychiatrists. The American Journal of Addictions, 22(3), 255-260. Lee, S., & Matejkowski, J. (2011). Mental health service utilization among noncitizens in the United States: Findings from the National Latino and Asian American study. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 406-418. Merikangas, K. R., & Kalaydjian, A. (2007).Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Current Opinion in Psychiatry, 20(4), 353–358.
National Alliance of Mental Illness. Multicultural Action Center. (n.d.). Retrieved from http://www.nami.org/Template.cfm?Section=Multicultural_Support. Picken, A., & Tarrier, N. (2011). Trauma and comorbid posttraumatic stress disorder in individuals with schizophrenia and substance abuse. Comprehensive Psychiatry, 52(5), 490-497. Power, B. D., Dragovic, M., Jablensky, A., & Stefanis, N. C. (2012). Does accumulating exposure to illicit drugs bring forward the age at onset in schizophrenia?. Australian and New Zealand Journal of Psychiatry, 47(1), 51-58. Roysircar, G., Gard, G., Hubbell, R., & Ortega, M. (2005). Development of counseling trainees’ multicultural awareness through mentoring English as a second language students. Journal of Multicultural Counseling and Development, 33(1), 17-36. Satel, S. & Edell, W.S. (1991). Cocaine-induced paranoia and psychosis proneness. American Journal of Psychiatry, 148(12), 1708-1711. Sentell, T., & Shumway, M. (2004). Language, cultural, and systemic barriers to mental health care among racial and ethnic groups in California: Scope of the problem and implications for state policy. Retrieved from University of California, San Francisco website: http://www.cpehn.org/pdfs/FinalShumwaySentellCPACReport.pdf Siegel, R.K. (1984). Cocaine smoking disorders: Diagnosis and treatment. Psychiatric Annals, 14(10), 728-732. Serper, M. R., Chou, J. C., Allen, M. H., Pal, C., & Cancro, R. (1999). Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophrenia Bulletin, 25(2), 387. Thornicroft, G. (2012). Evidence-based mental health care and implementation science in low and middle-income countries. Epidemiology and Psychiatric Sciences, 21(3), 241-244. Tseng K. Y., Chambers R. A., & Lipska B. K. (2009). The neonatal ventral hippocampal lesion as a heuristic neurodevelopmental animal model of schizophrenia. Behav Brain Res, 204(2), 295-305. U.S. Department of Homeland Security. (2009). Interagency Security Committee use of physical security performance measures. Retrieved from http://www.dhs.gov/xlibrary/ assets/isc_physical_security_performance_measures.pdf Van Dorn, R. A., Desmarais, S. L., Young, M. S., Sellers, B. G., & Swartz, M. S. (2012). Assessing illicit drug use among adults with schizophrenia. Psychiatry Research, 200(23), 228-236. Walker E. A., Gelfand A., Katon W. J., Koss M. P., Von Korff M., Bernstein D., & Russo J. (1999) Adult health status of women with histories of childhood abuse and neglect. Am J Med, 107(4), 332-339. Walker E. A., Katon W., Russo J., Ciechanowski P., Newman E., & Wagner A. W. (2003). Health care costs associated with posttraumatic stress disorder symptoms in women. Arch Gen Psychiatry. 60(4), 369-374. Wiechelt, S. A., Miller, B. A., Smyth, N. J., & Maguin, E. (2011). Associations between post traumatic stress disorder symptoms and alcohol and other drug problems: Implications for social work practice. Practice: Social Work in Action, 23(4), 183-199. Zhornitsky, S., Rizkallah, E., Pampoulova, T., Chiasson, J. P., Lipp, O., Stip, E., & Potvin, S. (2012). Sensation-seeking, social anhedonia, and impulsivity in substance use disorder patients with and without schizophrenia and in non-abusing schizophrenia patients. Psychiatry Research, 200(2-3), 237-241.
Lewandoski: Social Relations of Adolescent Cancer Survivors | 39
Social Relations and Pediatric Cancer: The Struggles of Adolescent Cancer Patients
ver 8,000 children are diagnosed with cancer in the United States in any given year (Aldridge & Roesch, 2007; Hockenberry-Eaton, Kemp & Dilorio, 1994). Of this population, the survival rate for adolescents between the ages of 15-21 exceeds 80% (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994; Jones, 2008; Mays, Black, Heinly, Shad & Tercyak, 2011). For children and adolescents under the age of 19, cancer remains the fourth leading cause of death (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994), despite an increase in survival rates. For the purpose of this article, references to pediatric cancer patients will be limited to the adolescent age range (1216 years old) and treatment effectiveness will refer to the continuing survival of the patients. The goal of the current literature review is to examine the role social support plays in cancer treatment effectiveness in the adolescent pediatric population. Specifically, this paper explores whether social support influences treatment effectiveness of cancer in adolescent pediatric patients, and how social support may help reintegrate patients in remission into everyday life. Adolescents face a variety of stressors including hormone and body changes, and changes in peer relationships. Further stressors are associated with cancer in adolescents (e.g., the initial diagnosis, the treatment process, and life post-cancer). However, the availability of family support can increase the child’s resilience in the face of stress. Self-concept and self-esteem are increased when an adolescent comes from a stable and supportive family environment (Hockenberry-Eaton et al., 1994; Michel et al., 2010). Ensuring and maintaining an environment that optimizes growth and development during treatment has become progressively more important in recent years (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Research regarding adolescent cancer patients
and their social support networks can help health professionals develop interventions that they can use, as well as educate family members and those within the patients’ social circle. Therefore, the attention must turn to fostering stable and supportive family environments in order to ensure adequate social support for the adolescent patients.
Stressors of Adolescent Cancer Patients Stressors are operationalized as events that can make it psychologically and physically more difficult for adolescents who try to adjust to life post cancer (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Adolescent cancer patients are faced with two types of stressors: acute stressors and chronic stressors. Acute stressors are described as random events that could be frightening and painful, but did not last long, such as treatment complications, surgery, or side effects to chemotherapy (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Chronic stressors are described as day to day experiences associated with living with cancer that brought on uncertainty about the patient’s prognosis. Chronic stressors include changes in family dynamics, changes in appearance, inability to participate in school events and disruption of one’s social environment (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Another source of chronic stress can come from the hospital environment. Some children are able to face these stressors using a protective factor referred to as resilience, which is one’s ability to efficiently deal with stressors, meaning they are less affected by stressors in the long term and are able to cope with stressors in a healthy manner (Sarason et al., 1983; Wills & Bantum, 2012). Children who had a strong
40 | Submissions sense of support in their earlier years (regardless of health) were more likely to display resilience and be self-reliant in their adolescence (Sarason et al., 1983, Wills & Bantum, 2012). Children who lacked a sense of social support later had a hard time coping with stressors and were not able to achieve the quality of life they had prior to their diagnosis (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Adolescents who spend extended time in the hospital are faced with the frustration of being identified as “pediatric patients” versus “adult patients” (Dunsmore & Quine, 1996, p. 40) – often times adolescents are too old for the pediatric unit but too young to stay in an adult unit. There are only a few hospitals in the United States that have units dedicated to adolescents, and a lack of these specific units can cause discomfort and frustration in adolescent patients (Dunsmore & Quine, 1996). When placed in the pediatric unit, adolescents are surrounded by children in a setting designed to put young children at ease (e.g., colorful walls, favorite childhood TV character decals on walls, plastic play houses and slides designed for children under the age of 10). The nurses and staff are specially trained to interact with children, and older adolescents are left feeling as though the staff are treating them as children too (Dunsmore & Quine, 1996). When placed in an adult ward, adolescents risk being traumatized by the older patients, who are likely to have more advanced stages of cancer. The adolescents are left feeling frightened and depressed (Dunsmore & Quine, 1996). Both pediatric wards and adult wards can lead to the adolescent patient feeling glum and hopeless. School becomes another social environment at risk for disruption and stress. Adolescents who return to school after treatment are faced with the stress of school work, catching up and being looked at differently by their peers for having cancer, especially if there were physical changes in the patient, such as hair loss associated with chemotherapy (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). Ignorance on behalf of the patient’s teachers and peers can add additional stress for adolescents, who expressed the desire to have the people in their schools knowledgeable about cancer and why the student now
looked different upon their return to school (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). The physical changes cancer and its treatment cause (e.g., hair loss, weight change, scarring) were associated with significant stress for adolescents at a time in their lives when they are already hyperaware of their bodies with puberty, which in itself comes with its own physical changes (Williamson, Harcourt, Halliwell, Frith, & Wallace, 2010). Changes in appearance for adolescents were associated with abuse and taunting from their peers, which led to reduced self-esteem, issues with social interactions, and self-induced isolation (Williamson et al., 2010). This variety of stressors offers evidence that the return to school and normalcy is fraught with obstacles. Parents of adolescents with cancer often become overprotective of their child, which may lead them to become overbearing. This overprotectiveness works against the idea of social support and actually causes more conflict and stress within the family environment (Dunsmore & Quine, 1996). In an effort to shelter their children from the stressors of cancer, parents often withhold information from the adolescents, which leads to feelings of frustration within the patient. Adolescent patients who feel as though they have overprotective parents report feeling crowded and often wanted their own space (Decker, 2007). Research consistently shows that patients from families that openly discussed the cancer as well as treatment options had more satisfaction and felt more supported and comforted by their loved ones (Dunsmore & Quine, 1996). The main variable that acted against social support to decrease self-esteem was parental overprotectiveness (Dunsmore & Quine, 1996). Therefore, it is important to educate the adolescent patient’s social network about cancer and ways to reduce stress for the patient without adding to it. Adolescents facing these obstacles are often times helped by family, friends, and medical teams through their offered social support.
Social Support as a Construct Social support for the adolescent patient was seen as simply being physically present for the indi-
Lewandoski: Social Relations of Adolescent Cancer Survivors | 41 vidual, for example, during hospital stays and treatments, as well as the existence of a network of individuals with whom they felt was there for them and did not treat them differently because of their illness (Sarason, Levine, Basham & Sarason, 1983; Wills & Bantum, 2012; Woodgate, 2006). Social support acts as a protective factor against stress, including psychological and physical stress. Overall, social support was associated with a more positive prognosis: adolescents who reported higher levels of social support were found to have higher levels of optimism and self-esteem, better adjustment to their cancer diagnosis, and less need for medication for illnesses (Decker, 2007; Sarason et al., 1983; Wills & Bantum, 2012).
Sources of Social Support Family members. Adolescents under the age of 15 preferred to rely on their parents and did not want to partake in peer-group discussions, although there was no explanation as to why children under 15 felt this way (Dunsmore & Quine, 1996). Social support has been shown to buffer the stressors of life-threatening illnesses while increasing healthy behavior in patients and reducing harmful coping behaviors. In contrast, feeling as though there are a lack of social relationships can reduce a patient’s chances of survival (Ell et al., 1992). Adolescents identified family as the number one source of support, specifically their mothers (Decker, 2007; Dunsmore & Quine, 1996). Adolescents associated the presence of parents and family members with decreasing anxiety and helping make the patients feel connected to the outside world. Family members were less likely to make adolescents feel as though they were being treated differently because they had cancer (Decker, 2007; Dunsmore & Quine, 1996; Kliewer, Murelle, Mejia, & Torres, 2001). When controlling for age, there was a significant correlation between the level of aggressiveness of the cancer and how much adolescents depended on their families for support; the more aggressive the cancer, the more they relied on their families (Dunsmore & Quine, 1996). In turn, this support acted as a comfort and strength for patients and led to an increase in a
sense of control and self-esteem (Dunsmore & Quine, 1996). Self-esteem, which is especially important for adolescents with cancer, is the first to decline when adolescents return to school due to social factors (Williamson et al., 2010). Adolescents who had high self-esteem because of social support from their families prior to their cancer diagnoses, were more likely to maintain a high level of self-esteem throughout their treatment, and be more confident about the outcome (Hockenberry-Eaton et al., 1994). Peers. Peers were also found to help boost self-confidence and optimism in adolescent cancer patients. An adolescent’s social support network extended outside the family to include close friends, who helped the adolescent feel connected to life outside of cancer (Woodgate, 2006). Adolescent patients reported that they wanted their friends and teachers at school to know more about their cancers, which lessened the stress of returning to school after treatment (Dunsmore & Quine, 1996). When dealing with ordinary trauma, such as violence, adolescents often turn to parents for support and information (Dunsmore & Quine, 1996). In cases of cancer, adolescents over the age of 15 preferred to take part in peer-group discussions, where they found comfort in talking with other people who were able to empathize with them because of similar experiences (Dunsmore & Quine, 1996). Peer-group discussions are beneficial to adolescent patients because they allow patients to talk about their experiences with others who offered support and validation of their feelings. Peer groups gave adolescents a different perspective on surviving cancer that could not be obtained from the parents who lack firsthand knowledge of what their child is experiencing (Kliewer et al., 2001). Peer-group discussions provided comfort and validation for adolescents. Friends of adolescents were found to help alleviate the stressors caused by returning to school by engaging in “peer shielding” – their presence helped manage negative reactions (e.g., appearance changes that resulted in staring, teasing, questioning) while at the same time helping the adolescent adjust to new experiences that were accompanied with anxiety and self-consciousness (Williamson et al., 2010). Adolescents who were surrounded by friends with positive
42 | Submissions opinions experienced an increase in self-confidence (Williamson et al., 2010) and were able to maintain a sense of confidence. Some adolescents took the initiative to brainstorm ideas to help the students and teachers in their schools understand what the adolescent had gone through, for example, sending a before and after picture that detailed the physical changes the adolescent had experienced (Williamson et al., 2010). Adolescents whose parents worked in unison with the peers to improve the school environment added to the shielding effect and helped increase the self-esteem and resilience in the adolescent (Aldridge & Roesch, 2007; Hockenberry-Eaton et al., 1994). In addition to family and peer support, adolescent cancer patients also experience social support from the health care professionals involved in their treatment. Health care providers. In the absence of family and peers, adolescent cancer patients found the presence of their health care team members to be especially supportive. Adolescents valued the presence of their health care team, but only if the nurses and doctors involved in their treatment were compassionate and viewed them as more than patients (Decker, 2007). Health care professionals who showed interest in something other than their cancer diagnoses were seen as more supportive than health care professionals who were cold and detached. However, this does not mean that adolescent patients felt comfortable in confiding in their health care teams. Adolescents referred to the health care teams as sources of information, which to the adolescents was a form of support (Decker, 2007; Dunsmore & Quine, 1996). Adolescents preferred to receive their information concerning treatments directly from their physicians, as parents were seen to try to “soften the blow” by withholding information (Decker, 2007; Dunsmore & Quine, 1996, p. 52). However, for cases where parents were unable to physically be there as a support for their children, adolescents were comforted in knowing that a nurse or doctor was there for them too, which refers back to the simplest explanation of social support – just “being there” (Dunsmore & Quine, 1996; Woodgate, 2006 p. 122).
Conclusion Social support is crucial in the lives of adolescent cancer patients. Social support increases self-confidence, adds to a sense of self-control, and positively influences prognosis while helping adolescents cope with the stressors of cancer, both during and after treatment (Dunsmore & Quine, 1996; Ell et al., 1992; Hockenberry-Eaton et al., 1994; Kazak et al., 1997; Kliewer et al., 2001; Wills & O’Caroll, 2012). Thus far, there is a wealth of research concerning the benefits of peer-groups for cancer patients to talk to other cancer patients and survivors (Hockenberry-Eaton et al., 1994; Jones, 2008; Kliewer et al., 2001). Educational programs that stress the importance of social support within an adolescent cancer patients’ network need to be developed and studied in order to determine and improve their efficacy and perhaps help them achieve more funding. Future research should examine how to increase parental social support in particular, as it has been found to be most important to adolescents during this time. Once that research is established, researchers could examine the effects of social support on adolescents of specific demographics including gender, race, and socioeconomic status. This is especially important as cancer does not discriminate who is affects and, if studied, a larger and wider range of adolescents could benefit from targeted programs that improve their social support networks.
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Lewandoski: Social Relations of Adolescent Cancer Survivors | 43 10.1016/0022-3999(92)90038-4 Elwell, L., Grogan, S., & Coulson, N. (2011). Adolescents living with cancer: The role of computer-mediated social groups. Journal of Health Psychology, 16(2), 236-248. doi: 10.1177/1359105310371398 Hockenberry-Eaton, M., Kemp, V., & Dilorio, C. (1994). Cancer stressors and protective factors: Predictors of stress experienced during treatment for childhood cancer. Research in Nursing & Health, 17(5), 351-361. doi: 10.1002/nur.4770170506 Jones, B. L. (2008). Promoting healthy development among survivors of adolescent cancer. Family & Community Health, 31(1S), S61-S70. doi: 10.1097/01.FCH.0000304019.98007.ae. Kazak, A. E., Barakat, L. P., Meeske, K., Christakis, D., Meadows, A. T., Casey, R., Penati, B., & Stuber, M. L. (1997). Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. Journal of Counseling and Clinical Psychology, 65(1), 120-129. doi: 10.1037/0022006X.65.1.120 Kliewer, W., Murelle, L., Mejia, R., & Torres de G., Y. (2001). Exposure to violence against a family member and internalizing symptoms in Colombian adolescents: The protective effects of family support. Journal of Counseling and Clinical Psychology, 69(6), 971-982. doi: 110.1037/AW22-006X.69.6.971 Mays, D., Black, J. D., Mosher, R. B., Heinly, A., Shad, A. T., & Tercyak, K. P. (2011). Efficacy of the survivor health and resilience education (SHARE) program to improve bone health behaviors among adolescent survivors of childhood cancer. Annals of Behavioral Medicine, 42(1), 91-8.doi:http://dx.doi.org/10.1007/s12160011-9261-5 Michel, G., Kuehni, C. E., Rebholz, C. E., Zimmerman, K., Eiser, C., Rueegg, C. S., & von der Weid, N. X. (2010). Can health beliefs help in explaining attendance to follow-up care? The Swiss childhood cancer survivor study. Psycho-Oncology, 20(10), 1034-1043. doi: 10.1002/pon.1823 Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support: The social support questionnaire. Journal of Personality and Social Psychology, 44(1), 127-139. doi: 0022-3514/83/4401-0127S00.75 Seitz, D. C. M., Besier, T., & Goldbeck, L. (2009). Psychosocial interventions for adolescent cancer patients: A systematic review of the literature. Psycho-Oncology, 18(7), 683-690. doi: http://dx.doi. org/10.1002/pon.1473 Williamson, H., Harcourt, D., Halliwell, E., Frith, H., & Wallace, M. (2010). Adolescentsâ€™ and parentsâ€™ experiences of managing the psychosocial impact of appearance change during cancer treatment. Journal of Pediatric Oncology Nursing, 27(3), 168-175. doi: 10.1177/1043454209357923 Wills, T. A., & Bantum, E.O (2012). Social support, self-regulation, and resilience in two populations: General-population adolescents and adult cancer survivors. Journal of Social and Clinical Psychology, 31(6), 568-592. doi: 10.1521/jscp.2012.31.6.568 Woodgate, R. L. (2006). The importance of being there: Perspectives of social support by adolescents with cancer. Journal of Pediatric Oncology, 23(3), 122-134. doi: 10.1177/1043454206287396
44 | Submissions
Counseling During a Disease Epidemic Jillian Shainman
ounseling and public health are two fields that have grown significantly over the past several decades. They have gained importance and recognition by encouraging people across the world to maintain safer and healthier lifestyles for themselves and for those who are less advantaged. In recent years, counseling and public health have been merged together in research and medical practice, emphasizing that a healthy body and a healthy mind depend on one another. Counseling relies on creating a safe space in which the counselor provides the client with the comfort to explore their thoughts and actions, confront challenges, and face situations involving change in order to strengthen the mind (Cavanaugh & Levitov, 2002). Public health on the other hand relies on increasing accessibility to medicine and medical professionals and on teaching about living a healthy lifestyle in order to strengthen the body(CDC, 2013). When a person is confronted with a diagnosis that puts their health and life at risk, the best solution is often found when public health and counseling resources are combined. The HIV/AIDS epidemic in America in the 1980’s and in Africa in the present day exemplifies how patients can most benefit when they care for their minds as well as their bodies. HIV/AIDS has affected millions worldwide (UNAIDS, 2010; Valdiserri, 2011). In the United States, the first cases of AIDS that would be the start of a disease epidemic were recorded in June 1981 (CDC, 2011). Since those first cases, nearly 600,000 people have died in the United States as a result of HIV (CDC, 2011), and globally, an estimated 30 million people have died of HIV-related causes (UNAIDS, 2010) (Valdiserri, 2011). As of 2010, there were 39.5 million people living with HIV worldwide (Kumta, et al, 2010).
Being infected with a life-threatening disease such as HIV/AIDS causes extreme levels of stress, pain, and fear. Although scientists discovered drugs such as azidothymidine (AZT) that can keep the physical symptoms of HIV/AIDS at bay and increase the likelihood of survival, the psychological trauma may persist (Rogers, 2013). During the AIDS epidemic in the U.S., researchers made important discoveries about the ways that the mind can be used to strengthen the body. Psychologists have found success with counseling techniques such as hypnosis, narrative therapy, and open group discussions about the roles of gender and sexuality stereotypes in the spread of the disease in order to keep patients with HIV/AIDS both mentally and physically healthy (Garte-Wolf, 2011; Adler, Harmeling, Walder-Biesanz, 2013; Casale & Hanass-Hancock, 2011). However, the challenges of cost-effectiveness, stigma, and small numbers of health care workers in China, India, and Africa create barriers that prevent these vital services from reaching their general populations. During the late 1970’s-early 1980’s, a study on rates with suppressed immune systems demonstrated that immune systems can be altered with classical conditioning (Weisberg, 2008). The connection between classical conditioning and the immune system further demonstrates the connection between the brain and the body, showing that a strength in one area can lead to strength in the other (Weisberg, 2008). In addition to classical conditioning, hypnosis can also use the mind ward off stress and thus, strengthen the immune system. Hypnosis has been linked to significantly increased levels of CD4 cells, a specialized type of T-cell that recognizes and helps destroy virus infected cells (Ruzyla Smith, Barabasz,
Shainman: Counseling and Disease | 45 Barabasz, & Warner, 1995) as read in (Weisberg, 2008, p. 17). Hypnosis took the emphasis off of expensive drug treatments and instead put control back in the patient’s hands, showing them that their minds were strong enough to physically alter their ability to defend themselves against HIV/AIDS. In addition to helping to bolster the immune system, which provides long-term benefits, hypnosis can provide some immediate relief to patients by helping them manage the pain that accompanies HIV/ AIDS. Hypnosis has been shown to improve patients’ self-ratings on measures such as severity of pain, percentage their time that was spent in pain, and the amount of pain medications they had to take (Langenfeld, Cipani, & Borckhardt, 2008). Even with the developments in medicine and psychology that can effectively treat HIV/AIDS, finding positivity after diagnosis is daunting. Therefore, because dwelling on the negative aspects of life exacerbate stress levels and further weaken the immune system, having patients “reauthor” their lives to emphasize positive aspects can help provide some relief and comfort (Garte-Wolf, 2011, p. 332). This “narrative therapy,” created by Michael White, gives clients a break from the constant negative thoughts that surround a HIV/AIDS diagnosis by having them focus on more positive times in their lives (Garte-Wolf, 2011, p. 332). Narrative therapy gives power to the patient as opposed to the doctor or the disease. Instead of feeling overwhelmed by the doctor’s numbers, such as life expectancy and T-cell levels, or the disease’s ebb and flow of physical pain, the patient has the power to construct a narrative to address their physical state and how it is affecting them mentally (Garte-Wolf, 2011). Purely positive narrative therapy, however, is not always the most healthy way to cope with a disease, such as HIV/AIDS, and ignoring the negative aspects that affect patients may be detrimental to their well-being (Adler, Harmeling, & Walder-Biesanz, 2013). In a study of 54 participants over 18 years of age, researchers found that speaking openly and coherently about negative experiences can help patients make meaning of their hardships and can strengthen them mentally (Adler, Harmeling, & Walder-Bie-
sanz, 2013). Further, they found that avoiding negative experiences and topics, by speaking about them abstractly or not speaking about them at all, can reduce a person’s mental stamina when dealing with hardships, such as a disease (Adler, Harmeling, & Walder-Biesanz, 2013, p. 843). A combination of White’s positively-focused therapy and Adler, Harmeling, and Walder-Biesanz’s realistic confrontation of struggles and pain may be the best way for patients to author their disease path and strengthen their mental state (Garte-Wolf, 2011; Adler, Harmeling, & Walder-Biesanz, 2013). Narrative therapy should provide a safe space for patients to embrace the positives in their lives while gaining the strength to face the negatives. Many therapists find it most useful to implement narrative therapy in a group setting in order to foster a sense of safety and support (Garte-Wolf, 2011). Since patients often use group therapy to discuss personal topics, it takes a strong sense of trust between the therapist and the members of the group in order to have productive sessions. Once they achieve that trust, groups help foster a sense of belonging to counter loneliness (Garte-Wolf, 2011). Most people do not know what it is like to live with HIV/AIDS and to confront mortality everyday. While sympathy from others can be helpful, having a safe, open environment in which HIV/AIDS patients can speak with each other about both their darkest, scariest times as well as their sources of strength can often be the most effective support system. With narrative therapy, group members can help others who are trapped by similar oppressive situations to benefit from the narrator’s more positive outlook (Garte-Wolf, 2011). Since the 1980s HIV/AIDS epidemic in the U.S., domestic public health efforts have focused on easing the pain of people who have already been diagnosed with the disease, by using the therapies and counseling techniques described above (Weisberg, 2008; Langenfeld, Cipani, & Borckhardt, 2008; Garte-Wolf, 2011; Adler, Harmeling, & Walder-Biesanz, 2013). In addition to treating patients, many other countries with high HIV/AIDS prevalence, such as Africa and Asia, focus their efforts on developing
46 | Submissions and funding effective preventative measures as well. The southern region of Africa has some of the highest rates of risky sexual behavior—such as multiple partners and unprotected sex-- and HIV prevalence in the country (Casale & Hanass-Hancock, 2011). To prevent these from rising, researchers have found that it is important to target gender inequalities and concepts of dominant masculinity which portray males as risk-takers with uncontrollable sex drives (Casale & Hanass-Hancock, 2011). These dominant gender stereotypes may be contributing to males’ risky sexual behavior such as unprotected sex and having multiple partners. Similar to the safe, open setting described in group narrative therapy, researchers in southern Africa aim to create a setting in which young people can explore “counter-hegemonic” masculinities and talk openly about their sexuality in general (Casale & Hanass-Hancock, 2011, p. 356). Empowering both men and women through these group therapy and other similar methods is vital in order to help African youth achieve greater comfort with their own bodies and increase contraception and safer-sex practices. Projects such as The Star School and Vukuzakhe help to empower men and women to achieve their goals and to promote literacy and responsible behavior in all aspects of life (Casale & Hanass-Hancock, 2011, p. 356, 59).. Although these measures do not specifically target people who have already been infected with HIV/AIDS, they help to promote awareness early and prevent the epidemic from spreading further. Further, similar to the treatment methods common in the U.S., the two projects unite youth in an environment where they can feel safe to explore their sexuality, openly discuss their fears and preferences, and receive advice from counselors, teachers, and advisors on how to best approach uncertain sexual situations. The psychological prevention and treatment of HIV/AIDS is just as important as the medical treatment. While modern medicine has made great strides in the physical treatment of HIV/AIDS, it often leaves the patient’s mental health at risk. Hypnosis, narrative group therapy, and projects such as Star School and Vukuzakhe provide a more complete prevention and treatment: they can help patients improve their
overall wellness and outlooks on life in order to prevent contraction of the disease, as well as lessening the impact of the painful physical and mental symptoms. However, many countries with high incidences of HIV/AIDS cases face barriers such as social stigma, cost effectiveness, and quality health care that prevent counseling services from reaching potential patients. China has seen its incidence of new HIV/ AIDS cases increase from 60,000 to 70,000 just over the past year. Even with this increase of 10,000 new cases, the government is struggling to justify the cost-effectiveness of voluntary counseling and testing (VCT) for the general population, for fear of stigma and discrimination, as described by the Asia Pacific Journal of Health. A (Wang et al, 2011, p. 629). Although the general population does not access VCT services as frequently, it has proved to be both cost and life saving among the men who have sex with men (MSM) population, which suggests that VCT should be targeted at the most at-risk population in order to ensure a more effective use of funds, and therefore a higher quality of treatment (Wang et al, 2011, p. 625). A study in India has shown similar results. The National AIDS Control Organization (NACO) has found that the current AIDS epidemic in India is heterogeneous and disproportionately affects specific high-risk communities, including MSM (Kumta et al, 2010, p. 230). In order to combat the high prevalence of the disease in India, an outreach program in the metropolitan Mumbai region provides information on HIV transmission, safe sex practices, and distributes free condoms to MSM and transgendered people, in order to specifically reach out to the most at-risk population (Kumta et al, 2010, p. 228). None of these effective counseling techniques are possible without a strong health care staff. However, health care workers are often few and far between in the countries that need them most. In Malawi, vacancy rates remain around 50% for professional health workers throughout the sector (Namakhoma et al, 2010, p. 68). The health care workers that do work in high-prevalence countries are at especially high risk of contracting the disease, especially in developing countries with a high endemic rate. The Human Sciences Research Council (HSRC) found an HIV/AIDS
Shainman: Counseling and Disease | 47 prevalence rate of 15.7% amongst health workers in South Africa (Namakhoma et al, 2010, p. 68). This is partially due to the high level of exposure to HIV/ AIDS that accompanies work in the health care field, and partially due to relatively low rates of HIV/AIDS testing especially among older, divorced, and widowed health care workers (Namakhoma et al, 2010, p. 71). A diagnosis of HIV or AIDS can be extremely physically, psychologically, and socially painful—the physical weakness, the increased likelihood of mortality, and the social stigmas of being dirty or promiscuous weigh heavily on patients. However, counseling treatments provide patients with a positive outlook. Hypnosis allows them to gather internal strength to improve their physical condition, and narrative group therapy allows them to gather strength from others when they cannot muster it on their own. Further, opening the discussion to cultural stereotypes of gender and sexuality at an early age can help children have safer sex practices and lifestyles, which can help prevent them from contracting the disease in the first place. Finding skilled counselors and other health care workers, especially for developing nations, can be difficult and expensive. However, the services they provide are well worth the cost.
References Adler, J.M., Harmeling, L. H., Walder-Biesanz, I. (2013). Narrative meaning-making is associated with sudden gains in psychotherapy clients’ mental health under routine clinical conditions. Journal of Consulting and Clinical Psychology, 81(5), 839-845. Casale, M., Hanass-Hancock, J. (12 August 2011). Of drama, dreams, and desire: creative approaches to applied sex education in southern Africa. Sex Education: Sexuality, Society, and Learning, 11, 353-368. Cavanaugh, M. E., Levitov, J. E. (2002). The Counseling Experience: A Theoretical and Practical Approach. Long Grove, IL: Waveland Press. Garte-Wolf, S. I. (4 July 2011). Narrative therapy group work for chemically dependent clients with HIV/AIDS. Social Work With Groups, 34, 330-338. Kumta, S., Lurie, M., Weitzen, S., Jerajani, H., Gogate, A., Row-kavi, A., Amand, V., Makadon, H., Mayer, K. H. (1 February 2010). Bisexuality, sexual risk taking, and HIV prevalence among men who have sex with men accessing voluntary counseling and testing services in Mumbai, India. Journal of Acquired Immune Deficiency Syndrome, 53, 227-253. Langenfeld, M. C., Cipani, E., Borckhardt, J. J. (2008). Hypnosis for the control of hiv/aids-related pain [Abstract]. International Journal of Clinical and Experimental Hypnosis, 50(2), 170-188. Namakhoma, I., Bongololo, G., Bello, G., Nyirenda, L., Phoya, A., Phiri, S., Theobald, S., Obermeyer, C. M. (2010). Negotiating multiple barriers: health workers’ access to counseling, testing, and treatment in Malawi. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 22, 68-76.
Rogers, K. (2013). AZT. Retrieved from http://www.britannica.com Valdiserri, R. O. (2011). Thirty years of AIDS in America: A story of infinite hope. AIDS Education and Prevention, 23, 479-494. Wang, S., Moss, J. R., Hiller, J. E. (3 July 2011). The cost-effectiveness of HIV voluntary counseling and testing in China. Asia-Pacific Journal of Public Health, 23, 620-633. Weisberg, M. B. (July 2008). 50 years of hypnosis in medicine and clinical health psychology: A synthesis of cultural crosscurrents. American Journal of Clinial Hypnosis, 51, 13-27.
STAFF & CONTRIBUTOR BIOGRAPHIES
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Donna Poon - Senior Staff Writer email@example.com Donna is a senior in the Applied Psychology Program minoring in East Asian Studies. She is interested in Counseling Psychology and Human Development research. Donna is interested in pursuing a Master’s Degree in Mental Health Counseling and hopes to become a Licensed Mental Health Counselor. Last semester, Donna interned as an Intake Counselor at The Door, a non-profit social services agency that provides services to urban at-risk youth. Currently, she is a member of Dr. Selcuk Sirin’s research team as a research assistant for the NYCASES study. As a research assistant, Donna codes for academic and social engagement themes in transcriptions of one hour-long interviews with urban adolescent youth in New York City high schools. Her independent research project studies the relation between ethnic identity and psychological well-being as well as the role of generational status for Asian American urban high school youth. Donna is also the Senior Advisor for the NYU Chinese Student Society, an Asian interest cultural club and an active brother in Alpha Phi Omega, a coeducational National Service Fraternity.
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Tyler Sabourini - Senior Staff Writer firstname.lastname@example.org Tyler Sabourin is a Senior Staff Writer for OPUS. He is currently in his senior year in the Applied Psychology department, and is in the process of applying for Master’s programs in Music Therapy. He has maintained interest in music since a young age, and hopes to integrate his knowledge of psychology with his love of music.
Yimkwan Tsang - Senior Staff Writer email@example.com Yimkwan Tsang is a senior in the Applied Psychology program with a minor in Web Programming and Applications. She currently interns at PROspect place in Hamilton Madison House, serving mostly Chinese-American participants with mental illness in the Lower East Side. She is on Dr. Selcuk Sirin’s research team, working on the qualitative narrative summary from immigrant-origin adolescents. She is also working on the website for project A.C.E in Dr. Sumie Okazaki’s research team. Her general research interests include clinical psychology and indigenous psychology in Chinese cultures. Upon completing her bachelor’s degree, she plans to pursue a Clinical Psychology degree in Hong Kong
CONTRIBUTORS BIOGRAPHIES Sarah Collins firstname.lastname@example.org Sarah Collins is a senior in the Applied Psychology program, with a minor in American Sign Language. She has spent her undergraduate years gaining clinical experience and assisting in pediatric wellness programs, through internships at the Employment Program for Recovering Addicts, Memorial Sloan Kettering Cancer Center, and The REACH Institute. She is a member of the NYU chapter of Psi Chi, the International Honor Society for Psychology. In the future, she intends to obtain a PsyD degree, with the goal of becoming a psychologist specializing in adolescent addiction and mental health.
Magdalena Lewandowska email@example.com Magdalena Lewandowska is a senior in the Applied Psychology program at NYU. Her research interests include Bipolar disorder and child and adolescent mental health. Magdalena is currently a member of Dr. Edward Seidmanâ€™s research team refining and developing the Teacher Instructional Practices and Processes System (TIPPS), as part of The Opportunities for Equitable Access to Quality Basic Education (OPEQ) in the Democratic Republic of Congo project done by Dr. Lawrence Aber and Dr. Caralina Torrente. Upon completion of her bachelorâ€™s degree, Magdalena has plans to work, maybe travel, and begin her applications to graduate school.
Jillian Shainman firstname.lastname@example.org Jillian Shainman is a senior majoring in Applied Psychology. She enjoys working with children and adolescents, and is so happy to be interning at The Door this year as an intake counselor. Post-graduation, Jillian is planning to pursue a Masters in Social Work, and hopes to work as a school counselor in the future.
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