Apr 1, 2018 | Book Reviews
by Nina Josefowitz and David Myran
The first and most important challenge that any author who wishes to write a book about cognitive behavioral therapy (CBT) must face is the fact that the market is swamped with texts on CBT. These range from single chapters in theory textbooks to entire books devoted to the philosophical underpinnings of the theory. These also include a great number of manual-type books that are designed to provide step-by-step instructions in how to apply this theory to a clinical setting. CBT Made Simple, by Josefowitz and Myran, falls into this category. Broadly, it is a text designed to translate somewhat ambiguous theoretical concepts into practical, replicable steps that can be followed to produce a therapeutically beneficial result. Fortunately, this text presents CBT in splendid fashion and stands as a wonderful option for counselors who wish to incorporate this theory into their practices.
The text is broken down into three parts, which are further divided into individual chapters. The flow of the book makes logical sense, especially from the viewpoint of the practicing clinician, which this book is aimed toward. There is clear and intentional movement from the foundation of the theory, to basic CBT work, to more advanced interventions. The book concludes with a review of two clients that were consistently discussed throughout previous parts of the book.
The strongest element of this text is its intentional organization. Throughout the book, the authors reference the fact that CBT takes practice and that counselors who are new to CBT should not expect to be experts immediately. Knowing this, the authors provide consistent “practice” information in the core elements of the theory at the beginning of each chapter. They create a parallel process in which each chapter begins by setting an agenda, then working through it, and concluding with assigned homework. This allows the reader to become familiar with how to organize and conduct initial counseling sessions using this CBT method and then reinforces that knowledge throughout the text.
Additionally, the text encourages the reader to try the techniques on themselves or apply the principles to their own lives. This makes the book feel much more approachable. Also, the book does well in its use of concrete problems and solutions. The two recurring client cases present difficulties that most counselors will see in their clients at one time or another. The problems are addressed through the book in a way that seems doable and easy to follow. For example, when describing work with a client suffering from depression, some authors will say: “assist the client in understanding the nature of their thoughts, feelings, behaviors, and how those are related.” That’s a great goal, but difficult for some counselors to grasp. Alternatively, Josefowitz and Myran give step-by-step instructions for dealing with issues similar to this: (1) Identify the client’s thoughts; (2) Judge whether the thought is irrational; (3) Help the client to dispute the thought; and (4) Create a more effective action plan. This way is not strictly better, but is very congruent with the way this text approaches CBT.
This text will find its greatest application with professional counselors currently working in the field who are wanting to incorporate CBT into their practice and are in need of an excellent guide. Overall this book seeks to do one thing: educate practicing counselors in an effective way to practice CBT, and it does just that.
Josefowitz, N., & Myran, D. (2017). CBT made simple: A clinician’s guide to practicing cognitive behavioral therapy. Oakland, CA: New Harbinger.
Reviewed by: Wes Allen, NCC, University of Tennessee
The Professional Counselor
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Apr 1, 2018 | Book Reviews
by Ann F. Haynos, Evan M. Forman, Meghan L. Butryn, and Jason Lillis
In Ann Haynos, Evan Forman, Meghan Butryn, and Jason Lillis’ most recent publication, Mindfulness and Acceptance for Treating Eating Disorders and Weight Concerns, the authors provide a comprehensive, practical, insightful, informative, and organized resource for graduate students, practitioners, researchers, educators, and related professionals working in the field of mental health—specifically within the specialty of eating disorders. Additionally, the title of this book accurately describes its purpose, contents, and overall themes.
The current publication is divided into two parts; mindfulness interventions directed toward individuals presenting with eating disorders (Chapters 1–5) while the second part focuses more on interventions related to weight concerns (Chapters 6–9). Chapter topics include using dialectical behavior therapy and emotional acceptance to strengthen appetite awareness, improving body image, and using mindfulness-based tactics for individuals who have recently experienced bariatric surgery. The authors were also intentional in enlisting over 20 expert contributing authors who are pioneers in the field.
The book is filled with excellent case conceptualization tools and treatment applications for the various eating disorder diagnoses. Likewise, the book demonstrates how to translate theory and research into clinical practice with its mindfulness-based framework and by integrating evidence-based components into innovative techniques. Each chapter provides specific instruction, examples, and explanations for applying this approach when working with individuals presenting with body image and/or food concerns.
While eating disorders are challenging to treat, this book and ultimate resource provides hope for the entire eating disorder community. For example, the book includes strategies for helping clients understand connections between thoughts and urges, tools for separating facts from feelings, hands-on tips for reducing experiential avoidance and practicing mindfulness, and insight for viewing “self-as-context” rather than attaching to their suffering. By using this empirically supported approach, clients will be more able to stay connected with recovery and live a life consistent with their values.
While this resource does an exceptional job of incorporating acceptance and mindfulness-based approaches (ACT, DBT, MBCT) to the treatment of eating disorders and includes numerous strengths, this publication is not without potential growth areas. One area for improvement would be to consider more cultural barriers and language skills for better connecting with clients of diversity. This would also strengthen the social justice, access, and equity of service components. Additionally, it may be helpful to add a “quiz” section at the end of each chapter or section so that readers can check their comprehension. The authors may consider adding a helpful resource or quick reference section before the index, possibly listing websites, YouTube videos, sample worksheets, or in-session activities.
In summary, Mindfulness and Acceptance for Treating Eating Disorders and Weight Concerns: Evidence-Based Interventions demonstrates how theory can be translated into practice. It represents a comprehensive and valuable resource that significantly contributes to the mental health and related counseling fields, and includes research from a variety of experts in the eating disorder and mindfulness niche. Whether for graduate students or advanced professionals in the field, this book will serve as a beneficial resource that can be used across eating disorder presentations and concerns.
Haynos, A. F., Forman, E. M., Butryn, M. L., & Lillis, J. (2016). Mindfulness and acceptance for treating eating disorders and weight concerns: Evidence-based interventions. Oakland, CA: Context Press.
Reviewed by: Mary-Catherine McClain Riner, NCC, Riner Counseling, LLC
The Professional Counselor
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Mar 30, 2018 | Volume 8 - Issue 1
Trish J. Smith, Courtney M. Holmes
Intimate partner violence (IPV) is a public health concern that affects millions of people. Physical violence is one type of IPV and has myriad consequences for survivors, including traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). It is estimated that as many as 23,000,000 women in the United States who have experienced IPV live with brain injury. This article overviews the intersection of TBI and PTSD as a result of IPV. Implications for counselors treating women impacted by IPV suggest counselors incorporate an initial screening for TBI and consider TBI- and PTSD-specific trauma-informed approaches within therapy to ensure best practices. A case study demonstrating the importance of the awareness of the potential for TBI in clients who experience IPV is included.
Keywords: intimate partner violence, traumatic brain injury, post-traumatic stress disorder, PTSD, public health
In 1981, the U.S. Congress declared October as Domestic Violence Awareness Month, marking a celebratory hallmark for advocates and survivors nationwide (National Resource Center on Domestic Violence, 2012). Since this time, similar social and legislative initiatives have increased overall awareness of gender inequality, thus influencing a decline in women’s risk for intimate partner violence (IPV; Powers & Kaukinen, 2012). Recent initiatives, such as a national briefing focused on brain injury and domestic violence hosted by the Congressional Brain Injury Task Force, continue to call increased attention to the various intersections and implications of this national public health epidemic (Brain Injury Association of America, 2017). Unfortunately, despite various social advocacy movements, IPV remains an underrepresented problem in the United States (Chapman & Monk, 2015). As a result, IPV and related mental and physical health consequences continue to exist at alarmingly high rates (Chapman & Monk, 2015).
IPV refers to any act of physical or sexual violence, stalking, or psychological aggression by a current or previous intimate partner. An intimate partner is an individual with whom someone has close relations with, in which relations are characterized by the identity as a couple and emotional connectedness (Breiding, Basile, Smith, Black, & Mahendra, 2015). An intimate partner may include but is not limited to a spouse, boyfriend, girlfriend, or ongoing sexual partner (Breiding et al., 2015). Physical violence is the intentional use of force that can result in death, disability, injury, or harm and can include the threat of using violence (Breiding et al., 2015). Sexual, emotional, and verbal abuse are often perpetrated in conjunction with physical violence in relationships (Krebs, Breiding, Browne, & Warner, 2011).
Heterosexual and same-sex couples experience IPV at similar rates (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015). Researchers estimate that more than one in every three women and at least one in four men have experienced IPV (Sugg, 2015). These rates likely underestimate the true prevalence of IPV, given that populations with traditionally high incidences of abuse (e.g., poor, hospitalized, homeless, and incarcerated women) may not be included in survey samples (Scordato, 2013; Tramayne, 2012). Additionally, fear and shame often serve as a deterrent to reporting abuse (Scordato, 2013). Although both men and women are victims of IPV, women are abused at a disproportionate rate (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015) and have a greater risk than men of acquiring injury as a result of physical violence (Scordato, 2013; Sillito, 2012). Data have shown that 2–12% of injuries among women brought into U.S. emergency departments are related to IPV (Goldin, Haag, & Trott, 2016), 35% of all homicides against women are IPV-related (Krebs et al., 2011), and approximately 22% of women have experienced physical IPV, averaging 7.1 incidences of violence across their lifespan (Sherrill, Bell, & Wyngarden, 2016). IPV is a pervasive relational problem that creates a myriad of complex mental and physical health issues for female survivors (Sugg, 2015). One health issue commonly experienced by female survivors of IPV is post-traumatic stress disorder (PTSD; Black et al., 2011).
PTSD and IPV
A Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnosis of PTSD is based on the client’s exposure to a dangerous or life-threatening stressor and consists of the following symptomology: intrusion of thoughts or re-experiencing of the event, including flashbacks; avoidance of experiences or thoughts related to the stressor; negative alterations in cognition and mood; and changes in reactivity, including hypervigilance or hyperarousal. According to Bourne, Mackay, and Holmes (2013), flashbacks are the hallmark symptom of PTSD and involve a process in which the individual dissociates and feels as though they are re-experiencing the traumatic event through involuntary, vivid, and emotional memories. Although PTSD symptoms may occur immediately after a traumatic event, symptoms may have a delayed onset in which the full range of symptoms can manifest even 6 months after the event, showing only partial symptom criteria in the preceding months (Utzon-Frank et al., 2014).
Experiencing IPV increases risk for developing PTSD (National Center on Domestic Violence, Trauma, and Mental Health, 2014). In a national sample of 9,000 women, 62% who experienced some form of IPV reported at least one PTSD symptom (Black et al., 2011). Women who experience IPV are almost three times as likely to meet criteria for PTSD when compared with those who have not had such experiences (Fedovskiy, Higgins, & Paranjape, 2008). Although PTSD is a common manifestation of IPV, another condition, traumatic brain injury (TBI), also is prevalent in survivors (Sherrill et al., 2016). The symptomology of TBI mirrors that of PTSD, rendering the clinical tasks of appropriate diagnosis and treatment planning especially difficult (McFadgion, 2013).
TBI and IPV
TBI is defined as a change in brain function caused by an external force (e.g., strike to the head or strangulation; Murray, Lundgren, Olson, & Hunnicutt, 2016). Symptoms include headaches, dizziness, fatigue, difficulty concentrating, irritability, and perceptual difficulties with noise and light (Zollman, 2016). Other symptoms can include problems with attention, memory, processing speed, decision making, and mood (Jeter et al., 2013). Professionals can use computerized tomography (CT) scans to find contusions, hematomas, diffuse axonal injury, and secondary brain injuries, which aid in the medical diagnosis of TBI (Currie et al., 2016). Although CT is widely used in assisting with the identification of TBI, a final diagnosis is most often made in a clinical interview with the patient, treating physician, and if feasible, those who observed the violent incident or responded to it (Zollman, 2016). Violence that causes TBI may or may not leave internal or external physical evidence of trauma (e.g., bruising, scarring); thus it is crucial that assessment and screening attempts take place beyond neuroimaging technology and are included as a part of a comprehensive evaluation (Joshi, Thomas, & Sorenson, 2012).
Researchers indicate that over 60% of women, with estimates as high as 96%, who experience IPV sustain injury to the face or head areas, including attempted strangulation (McFadgion, 2013; Sherrill et al., 2016; St. Ivany & Schminkey, 2016). Acquired TBI through IPV can complicate the therapeutic treatment of women (Murray et al., 2016). Brain injury shares similar symptomology with PTSD, increasing likelihood for misdiagnosis, complications with care, and long-term brain damage (McFadgion, 2013). Additionally, TBI and PTSD are often comorbid diagnoses, and those who survive physical trauma and incur a TBI suffer negative mental health impacts such as depression, anxiety, and suicidal ideation (Smith, Mills, & Taliaferro, 2001).
PTSD and TBI have an extensive impact on brain functioning (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Individuals with PTSD experience daily cognitive failures in memory, perception, and motor function (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Other researchers have shown that PTSD negatively impacts brain functioning on multiple levels, including stimuli recognition, and overall cognitive functioning (Saar-Ashkenazy et al., 2016). Similarly, individuals with TBI may experience physical, sensory, cognitive, and social difficulties as a result of their brain injury (Brain Injury Association of Virginia , 2010). Given the overlapping symptoms of PTSD and TBI, and the overall impact on functioning, it is critical for counselors to consider these factors when diagnosing and treating women who have experienced IPV.
In sum, IPV is a widespread public health issue with a multitude of negative consequences related to human functioning. Incidences of TBI in women who have experienced IPV cannot be overlooked. A framework for mental health counselors that includes awareness of the overlapping symptoms between two likely outcomes of IPV and their manifestation is crucial for successful case conceptualization and treatment.
Counseling Implications
PTSD and TBI have extensive impact on human functioning, and it is critical that counselors examine appropriate responses and considerations for therapeutic treatment of female survivors of physical violence resulting from IPV. Clinical considerations should be incorporated into initial screening, therapeutic approaches, and communication with clients.
Screening and Assessment
McLeod, Hays, and Chang (2010) suggested that counselors universally screen clients for a current or past history of IPV. Based on the literature, survivors of IPV face various challenges when seeking services and either reporting or disclosing abuse, including: self-blame for the abuse; fear of the perpetrator; internalized shame; lack of acknowledgement of the level of danger; perception that community services are not helpful; lack of housing, child care, and transportation; access to money; and lack of educational opportunities (Fúgate, Landis, Riordan, Naureckas, & Engel, 2005; Lutenbacher, Cohen, & Mitzel, 2003; McLeod et al., 2010; Scordato, 2013). Minority populations experience additional challenges, including fear of prejudice and systemic oppression (Scordato, 2013). Thus, counselors carry the responsibility to broach screening with all clients. With an intentional screening for IPV, counselors are able to further identify TBI as a result of physical violence in IPV to ascertain medical and related concerns. Given the statistical probability that a woman who experienced physical IPV sustained past injury to the head or neck, initial screening is critical (Murray et al., 2016). The Pennsylvania Coalition Against Domestic Violence (PCADV; 2011) provides a guide based on a classic TBI screening called HELPS. The guide asks questions in the context of IPV, including if the person has ever been: (a) hit on the head, mouth, or other places on the face; (b) pushed so hard the head strikes a hard or firm surface; (c) shaken violently; (d) injured to the head or neck, including strangulation, choking, or suffocating that restricted breathing; and (e) nearly drowned, electrocuted, or intentionally given something allergic. These questions serve as a guide in detecting if the survivor has acquired TBI; however, they should not be used in place of a medical assessment (PCADV, 2011).
The Brain Injury Association of America (2015) describes symptoms of TBI as including: headaches, dizziness, lack of awareness of surroundings, vomiting, lightheadedness, poor attention and concentration, fatigue, and ringing in the ears. Impairments involving functions related to memory, decision making, and processing speed may be indicators of brain injury (Jeter et al., 2013). Recognizing TBI allows for the appropriate response in treatment, including identifying necessary medical consultations and referrals.
Therapeutic Approaches to IPV
After the brain is injured, a recovery process involving three stages is prompted, including: cell repair, functional cell plasticity, and neuroplasticity (Villamar, Santos Portilla, Fregni, & Zafonte, 2012). Zasler, Katz, Zafonte, and Arciniegas (2007) described neuroplasticity as the process in which spared healthy brain regions compensate for the loss of functioning in damaged regions. Kimberley, Samargia, Moore, Shakya, and Lang (2010) suggested that repetition of activities is required to induce neuroplasticity, or recovery of the brain.
Researchers have shown that certain techniques in talk therapy can aid in the recovery of the brain, serving to benefit both the treatment of PTSD as well as the alleviation of symptoms in TBI (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011). For example, Chard et al. (2011) compared two therapies: (a) cognitive processing therapy (CPT), a form of cognitive behavioral therapy effective in treating PTSD; and (b) an alternate version of CPT, CPT-cognitive only (CPT-C), which omits the writing and reading of one’s trauma narrative and instead emphasizes cognitive challenging and rehearsal. Both approaches were applied to a sample of 42 male veterans who met criteria for PTSD, had history of TBI, and were compared across four groups based on severity and treatment approach (Chard et al., 2011). In addition to speech therapy two to three times a week and a psychoeducation group 23 hours a week, CPT-C individual sessions and group sessions were each held twice a week as a part of a residential treatment program (Chard et al., 2011). Chard et al. identified a significant main effect across PTSD and depression measures for both groups, indicating CPT-C as a plausible treatment for clients with TBI.
Another therapeutic approach includes CRATER therapy, which is an acronym that encompasses six targets for therapy: catastrophic reaction, regularization, alliance, triangulation, externalization, and resilience (Block & West, 2013). The first target, catastrophic reaction, is based on targeting the explosive reaction that is in response to overwhelming environmental stimuli; regularization is the therapist’s approach to establishing a regular daily routine for the client (e.g., sleep–wake cycle, meal times); alliance is the relationship between the professional and survivor; triangulate is the relationship expanded beyond the client to include a family member or friend; externalize negates self-blame; and resilience promotes the use of effective coping skills (Block & West, 2013). The individual’s family members and friends are specifically targeted in the approach to account for ecological validity and provide support. Block and West (2013) stated, “CRATER therapy targets the formation of a good working alliance, teaches the survivor to perform skills without cues from the provider and integrates both cognitive and therapy interventions” (p. 777). Overall, this theory infuses cognitive restructuring into individual psychotherapy and assists the client in developing effective coping strategies.
In addition to the implementation of specific therapeutic approaches in counseling, the counselor can incorporate management strategies to accommodate survivors’ brain injury symptoms in counseling sessions. For example, a client who takes longer to complete tasks and answer questions because of an impaired information processing speed can be accommodated by the counselor doing the following: (a) allowing extra time for responses, (b) presenting one thing at a time, and (c) not answering for them during the lapse in response time (BIAV, 2010). The PCADV (2011) also recommends speaking in a clear and literal sense as well as providing tasks in short increments. If memory is impaired, the counselor can make it a point to repeat information as necessary, encourage the use of external memory aids (e.g., journals, calendars), and give reminders and prompts to assist with recall (Block & West, 2013). In the case in which the client shows poor self-monitoring skills and lacks adherence to social rules or consistently dominates the dialogue in sessions, the counselor can provide feedback, encourage turn-taking, and gently provide redirection of behavior (BIAV, 2010). Implementing techniques that involve feedback and redirection also can decrease chances of oversharing that might re-traumatize the survivor (Clark, Classen, Fourt, & Shetty, 2014). Utilizing compensatory strategies such as these can ensure the accessibility and efficacy of counseling sessions to survivors with TBI.
Therapeutic Communication With IPV Clients
Aside from specific counseling approaches and management strategies, several considerations can be made by the counselor to ensure an informed response in communication and chosen interventions. Building a therapeutic relationship, including instilling hope for possible change, is especially useful with complex PTSD diagnoses (Marotta, 2000). Additionally, researchers suggest that receiving social support is a resiliency factor in trauma recovery (Shakespeare-Finch, Rees, & Armstrong, 2015; Zhou, Wu, Li, & Zhen, 2016). However, data suggest that women with brain injury, when compared with male counterparts, experience more negative alterations to social and play behavior, including more exclusion and rejection in social situations (Mychasiuk, Hehar, Farran, & Esser, 2014). Mychasiuk et al. (2014) indicated that group therapy or other social types of interventions related to social support building and safety planning may be contraindicated until these specific challenges can be addressed in individual counseling.
Counselors should be aware of the cyclical nature of abusive relationships that can result in multiple brain injuries over time (Murray et al., 2016). Additionally, counselors should understand complex PTSD, which is associated with prolonged exposure to severe trauma; alterations to affect and impulses, self-perception, interactions with others, and increased somatization; and medical problems (Pill, Day, & Mildred, 2017). Consideration of the potential impact that cumulative brain injuries and prolonged trauma have on health outcomes is critical for effective clinical intervention (Kwako et al., 2011), as myriad aspects of a woman’s ability to identify and understand her situation may be negatively impacted. A critical skill for women in violent relationships includes the need to account for, and effectively assess, one’s physical environment at the time of abuse. A client can take the following precautions to protect herself from future violence: (a) making herself a smaller target by curling up into a ball in a corner, (b) avoiding wearing scarves or necklaces that can be used in strangulation attempts, (c) guarding her head with her arms around each side of her head, and
(d) hiding guns or knives (PCADV, 2011). Furthermore, it is imperative that the counselor actively assist in the safety planning process given that head injury and trauma often impair cognitive processes such as a person’s ability to plan and organize (PCADV, 2011). Initiating the safety planning process as a psychoeducational component of treatment could serve to counter shame and self-blame for the survivor, ensuring that a trauma-informed approach and best practices are maintained (Clark et al., 2014).
Ethical Implications
Client cases that include current or past IPV are often fraught with numerous ethical considerations (McLaughlin, 2017). Perhaps the most pervasive ethical issue is the responsibility of mandated reporting. Counselors must be aware of the intricacies of such responsibility and understand the limits of reporting as it pertains to survivors of IPV (American Counseling Association, 2014). Clinicians should become skilled at assessing for violence in relationships so that reporting can occur if one of the following situations arise: abuse of children, older adults, or other vulnerable populations; duty to warn situations; or risk of suicide. The responsibility to report must be discussed with clients during the informed consent process and throughout treatment (American Counseling Association, 2014, B.1.d).
IPV presents additional complications for treatment providers. Researchers suggest that more than 50% of couples in therapy report at least one incident of physical aggression against their partner (O’Leary, Tintle, & Bromet, 2014). Despite this implication, counselors fail to adequately assess for violence or intervene when violence is present. Once a thorough assessment has taken place, clinicians can evaluate the most appropriate and safe course of treatment for each individual and the couple together. Treatment options include continued couples work (when appropriate), separate individual therapy, or group work that may include anger management or other behavioral-change strategies (Lawson, 2003).
Counselors working with survivors of IPV should expect to regularly determine how to “maximize benefit and minimize harm” for each client (McLaughlin, 2017, p. 45). Counselors may find themselves working with clients who want or need to stay in the relationship or those who want or need to leave the relationship. Each situation is complicated with a variety of personal factors such as level of violent threat and access to financial and other types of resources. Individual assessment in collaboration with the client to determine the best therapeutic strategy is necessary (McLaughlin, 2017).
Finally, counselors may hold overt or covert personal biases toward IPV clients and violence against women. Counselors should evaluate personal feelings toward both victims and perpetrators of IPV prior to working with them and throughout the course of treatment. McLeod et al. (2010) developed a competency checklist for counselors to assist in necessary self-reflection and self-evaluation of their level of competency when working with this population. Finally, counselors should understand the critical nature of supervision and consultation and seek it out when necessary (McLaughlin, 2017).
Case Study
The following case study is a hypothetical case based loosely on the first author’s experience as a counselor in a domestic violence shelter. The case and treatment description are meant to provide a general overview of how counselors might implement an overarching lens of screening and treatment when working with survivors of IPV.
A 48-year-old Caucasian woman sat across from her counselor, elated as she described the sense of relief she felt to finally receive counseling support during what she explained to be the worst time of her life. In disclosing several accounts of physical, sexual, and emotional abuse, she described times in which her ex-partner had blackened her eye, broken bones, and strangled her. Knowing the various causes of TBI in IPV, the counselor started a conversation about the possibility of brain injury. The client denied going to the emergency room to be assessed for injuries, a process that would have likely detected contusions or swelling of brain tissue. The absence of medical treatment was not surprising to the counselor, given the numerous barriers that often leave survivors of IPV without medical attention, including fear of further harm. Knowing this, the counselor was careful in her communication so as to not suggest blame or judgement for the client’s decisions to not seek past medical assistance. The counselor proceeded to ask questions related to whether or not the client perceived any changes to physical or cognitive functioning in comparison to life before her abusive relationship, with focus on memory, attention, and learning experiences. The client found it very difficult to answer these questions in detail, indicating that her memory was potentially impaired because of either PTSD or brain injury. A neutral, yet warm and understanding, therapeutic stance was critical for the counselor to keep the client engaged in the therapeutic process.
Following the detection of probable TBI, the counselor provided psychoeducation to promote awareness on the nature of the injury as well as referrals to various local and state resources. The counselor and client then discussed the client’s experience of PTSD symptoms and how these symptoms could mirror the symptoms of brain injury. Education is a recommended strategy when working with clients with PTSD (Marotta, 2000). The counselor knew that helping the client to differentiate between the two would help her monitor and document symptoms for the journaling homework that would eventually be assigned to her. At this time, the counselor provided the client with a handout with a t-chart comparing PTSD and TBI symptoms, knowing that a concrete, visual representation might be a helpful accommodation. For her journaling homework, the counselor instructed the client to record the following: symptom type, duration, intensity, and any contextual details. This recording would benefit the client in multiple ways, including increasing personal awareness and attention to symptoms, indicating the necessity of additional referral sources, and providing a record for discussion with future medical professionals.
At the beginning of the next several sessions, the counselor followed up on the client’s journaling homework. During these check-ins, the client reported times of forgetfulness, difficulty with attention, and problems staying organized and making decisions. One particular incident allowed the counselor and client to actively probe through differences between PTSD and TBI when the client reported a time in which she “zoned out” while running errands. They explored the event, discussing duration and contextual details. It was in this conversation that the client mentioned a glass item having fallen nearby and shattering loudly just moments before she “zoned out.” From this detail, especially noting the infrequency of her zoning out day-to-day, the counselor discussed the likelihood of it being trauma-related, connecting it to the many nights of domestic disturbances with her abuser that ended in various household items being destroyed. On the other hand, the counselor associated her increased forgetfulness, headaches, and a distorted sense of smell with possible manifestations of brain injury. The counselor recommended that the client call the state’s brain injury association to learn about medical providers who had extensive experience treating TBI.
Noting shattering glass as one of her triggers, the counselor and client discussed what she could do after perceiving this stimulus to reorient to the present. Grounding techniques such as deep breathing were discussed. To address forgetfulness, the counselor implemented compensatory strategies that included shorter responses and questions, utilization of the present time frame, and repetition of responses provided by the counselor. To encourage further assessment and treatment, the counselor followed up on the client’s contact with experienced TBI medical professionals.
Clients may be involved in both individual and group counseling simultaneously. However, group counseling may be contraindicated for women who have experienced a TBI until social and relational challenges can be addressed in individual counseling (Mychasiuk et al., 2014). Therefore, before recommending entry into a counseling group, the counselor first assessed the client’s day-to-day interactions with individuals and how her social network changed before and after sustaining TBI. This assessment allowed the counselor an opportunity to both gauge the appropriateness of group therapy and identify possible barriers to group that might be assisted with accommodation. With careful consideration and assessment, counselors can maximize the use of group therapeutic factors such as interpersonal learning, socializing techniques, and imitative behavior.
Conclusion
PV is a prevalent public health issue that impacts the development of a wide range of mental and physical health diagnoses, in which PTSD and TBI are two pervasive complications that often affect survivors of IPV. Recent initiatives, such as the national briefing hosted by the Congressional Brain Injury Task Force, are indicative of the work still needed to properly address this underrepresented national issue (Brain Injury Association of America, 2017). Counselors should understand the intersectionality of PTSD and TBI and how such experiences can complicate treatment. This article has provided several suggestions for counselors to improve their clinical practice to better accommodate survivors of IPV, including screening and assessment techniques, therapeutic approaches, and communication suggestions. Counselors should be aware of the need to adopt specific therapeutic approaches and strategies in counseling that compensate for cognitive impairments so as to avoid gaps in the delivery of services and adhere to best treatment practices. Counselors also are required to abide by ethical codes and guidelines and are urged to continually seek supervision and consultation when working with this population to ensure that the various aspects of this complicated category of violence are thoroughly considered.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Trish J. Smith is a resident in counseling and a senior client services advocate at Safe Harbor Shelter in Richmond, Virginia. Courtney M. Holmes, NCC, is an assistant professor at Virginia Commonwealth University. Correspondence can be addressed to Trish Smith, Safe Harbor Shelter, P.O. Box 17996, Richmond, VA 23226, trish@safeharborshelter.com
Mar 30, 2018 | Volume 8 - Issue 1
Danielle Pester, A. Stephen Lenz, Joshua C. Watson, Julia Dell’Aquila, Anthony Nkyi
As the counseling profession continues its globalization onto Ghanaian college campuses, there is an increased need for psychometric assessments that support programming and interventions that promote degree matriculation and general student well-being. A sample of 696 young adult Ghanaian college students completed the Inventory of New College Student Adjustment (INCA) and related measures to estimate evidence of internal structure and relationships with conceptually related constructs. Confirmatory factor analyses were completed and inspection of fit indices revealed strong evidence for internal structure, and bivariate correlations indicated statistically significant positive associations with related medium effect sizes between the INCA subscales (Supportive Network and Belief in Self) and related measures. Implications for use of the INCA to support the professional activities of Ghanaian counselors working on college campuses are provided.
Keywords: Ghanaian counselors, college student adjustment, globalization, psychometric inventory, assessment
Higher education in Ghana has experienced tremendous growth over the past two decades, increasing access to institutions of higher education and student enrollment. In 2012, there were 138 accredited higher education institutions throughout Ghana, including public and private institutions, polytechnics, and training colleges (Atuahene, 2013; National Council for Tertiary Education [NCTE], 2014). This is an exponential degree of growth when compared to the existence of only three public universities in Ghana at the close of the 1990s (Atuahene, 2013). Although access and participation in university education has grown rapidly, the proportion of enrolled students versus those eligible to be enrolled remains low. According to the United Nations Educational, Scientific and Cultural Organization (2017), the percentage of enrolled students compared to those eligible to be enrolled in higher education in Ghana for 2015 was only 16.23%, indicating inadequate pre-college academic preparation, lack of affordability, low retention rates, and inadequate supports once enrolled (Atuahene, 2012). With its higher education system facing such challenges, resources and tools that can assist Ghanaian higher education institutions meet student needs as they enter university life, adjust to the unique set of demands, and access existing supports are imperative.
Because the demand for higher education in Ghana has traditionally been greater than its supply, most of the available resources have been focused on the expansion of facilities rather than the improvement of student experiences that may promote university persistence and degree matriculation. Only in recent years has the NCTE begun to rate institutions on the quality and relevance of their academic programs. Atuahene (2012) identified several distinctive factors associated with Ghanaian student dropout, including: (a) inadequate financial support for low income students, (b) student socioeconomic and geographic background, (c) student pre-college academic preparation, (d) unfavorable institutional policies and practices, and (e) a lack of academic advising. With these barriers in mind, there is currently an opportunity in Ghanaian higher education to develop resources that can support student adjustment and academic persistence.
Researchers (e.g., Carter, Locks, & Winkle-Wagner, 2013; Gray, Vitak, Easton, & Ellison, 2013; Pascarella & Terenzini, 2005; Robbins, Oh, Le, & Button, 2009) have found first-year adjustment to an academic setting to be a crucial component in student retention. Furthermore, they have found that positive adjustment within the first year of college can significantly impact a student’s academic persistence to degree completion. Andoh-Arthur, Asante, and Osafo (2015) studied the help-seeking behaviors of Ghanaian university students and found that the first-year student population was least likely to engage in help-seeking behaviors. They attributed this to the students’ unfamiliarity with their new identity as university students. Knowing this, Ghanaian students’ first year of university experience is a crucial time for university support personnel to proactively engage students regarding college adjustment issues. The capacity to identify new university students who are struggling to adjust to college life and who also may be at a higher risk for attrition is essential for Ghanaian university personnel as they seek to improve university retention rates.
Globalization of Counseling and Its Role in University Settings
The welcome statement of NBCC International proposes an organizational intention to increase the “availability of competent, reliable services to any part of the world that indicates an interest in acquiring them . . . with the utmost care and respect for the social, cultural, political, and economic realities of the various areas where we are invited” (Clawson, 2011, para. 2). Lorelle, Byrd, and Crockett (2012) identified the globalization of counseling as an inevitability, wherein professional counseling activities are progressively transitioning from a Western-based practice to one that gives international communities the opportunity for transformation as well. Lorelle et al. suggested that as the counseling profession is introduced on a local level, opportunities emerge for adaptation to local cultures and new contexts that yield new ways of understanding culturally defined standards of care. Among the many international settings adopting the values and activities synonymous with the counseling profession, Ghana appears poised to increase the capacity and scope of counseling activities through meaningful placement of services on university campuses.
Quarshie, Annor, Tagoe, Osei-Poku, and Andoh-Arthur (2016) identified a growing population of mental health professionals within the country of Ghana. This expansion of service provider capacity has been positively correlated with growth in the Ghanaian economy and represents a commitment to developing public mental health infrastructure using existing resources and expanding capacity over time (Ghana Health Professions Regulatory Bodies Act 857, 2013). Quarshie et al.’s (2016) analyses also detected that the majority of Ghanaian mental health professionals are housed on college, polytechnic, and university campuses. Situating these providers within these settings not only provides them support for their professional preparation programs, but also provides proximal contact with students who may be experiencing mental health symptoms while attempting to adjust to new demands within university settings. This action has important consequences for both the globalization of the counseling profession and the promotion of optimal development, degree matriculation, and access to a more equitable life for Ghanaian students. However, evidence-supported interventions require evidence-supported assessments that are population-specific, and currently there is a paucity of such assessments that can be utilized by mental health professionals to understand the adjustment experiences of students at Ghanaian universities.
Rationale and Purpose of the Study
Given that one aspect of counselor identity is the use of evidence-supported assessment practices, and another is evidence-supported intervention and programming (American Counseling Association, 2014; Lorelle et al., 2012), there is a call to complete activities to support the actions of Ghanaian mental health professionals charged with promoting adjustment among local university students. The Inventory of New College Student Adjustment (INCA; Watson & Lenz, 2017) is one viable instrument for assessing college student adjustment that is free to use and has yielded promising psychometric properties among ethnically diverse samples within the United States. It has been identified as a resource to help determine the appropriate support services needed for university students, as well as a resource to assess the overall effectiveness of campus initiatives focused on student adjustment. Although the INCA could be a valuable tool to address the current needs and trends in Ghanaian higher education, the degree of validity of INCA scores for a Ghanaian university student population is currently unknown. Therefore, the purpose of this study was to evaluate the transferability of validity evidence for scores on the INCA to a sample of Ghanaian students. Specifically, we intended to identify the degree of evidence related to internal structure of the INCA scores and their relationships with conceptually related variables.
Method
Participant Characteristics
Six hundred ninety-six Ghanaian college students (435 male [63%], 237 female [34%], 24 did not report gender [3%]), the majority of whom were young adults (M age = 22.45 years; SD = 4.37) completing undergraduate coursework at one large university in Ghana, Africa, participated in this study.
Measurement of Constructs
Inventory of New College Student Adjustment. The INCA (Watson & Lenz, 2017) was developed to assess the adjustment difficulties experienced by first-year college students and was normed using an ethnically diverse sample of 474 freshmen students in the United States. The INCA is a 14-item instrument using a 4-point Likert scale to assess participant responses from 1 (strongly disagree) to 4 (strongly agree). Scores can range from 14 to 56, with higher scores indicating higher levels of college adjustment. The 6-item Supportive Network subscale includes items such as “My friends support me as I work toward my goals” and “My family’s support makes me feel stronger.” The 8-item Belief in Self subscale includes items such as “My study habits are effective” and “I know what I will do after graduation.” Initial psychometric testing demonstrates good alpha reliability coefficients for scores on INCA subscales ranging from .77 (Belief in Self) to .83 (Supportive Network), indicating good internal consistency. Moreover, our sample reported alpha reliability coefficients of .74 for both the Belief in Self subscale and the Supportive Network subscale.
The Multidimensional Scale of Perceived Social Support. The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet & Farley, 1988) was developed to assess an individual’s perception of social support from family, friends, and significant others. Each of these sources of social support is considered a distinct subgrouping and is assessed individually. The MSPSS was normed using a subject pool of 275 undergraduate students in the United States with a nearly equal sample of male and female students (Zimet, et al., 1988). After further psychometric testing, reliability has been established for diverse samples beyond the original norming group (Stanley, Beck, & Zebb, 1998). The MSPSS is a 12-item instrument using a 7-point Likert-scale to assess participant responses from 1 (very strongly disagree) to 7 (very strongly agree). Scores can range from 12 to 84, with higher scores representing higher levels of perceived social support. For the purposes of this study, we used the Family Relationships subscale and Relationships with Friends subscale. The 4-item Family Relationships subscale includes items such as “My family really tries to help me” and “I get the emotional help and support I need from my family.” The 4-item Relationships with Friends subscale includes items such as “My friends really try to help me” and “I can count on my friends when things go wrong.” Zimet et al. (1988) reported high Cronbach’s alpha coefficients for scores on MSPSS subscales ranging from .85–.91, indicating good internal consistency. The reliability of the total scale for the initial sample was .88. Additionally, our sample reported coefficients ranging from .81 for the Family Relationships subscale and .88 for the Relationships with Friends subscale.
College Self-Efficacy Inventory. The College Self-Efficacy Inventory (CSEI; Solberg, O’Brien, Villareal, Kennel, & Davis, 1993) was developed to assess a student’s confidence in their ability to successfully complete college-related tasks. Originally developed to measure college self-efficacy in Hispanic college students, CSEI data has established reliability beyond the initial norming population to also include ethnically diverse college students (Gore Jr., Leuwerke, & Turley, 2005). The CSEI is a 20-item instrument using a 10-point scale to assess a participant’s confidence in their ability to successfully complete a task from 1 (not at all confident) to 10 (extremely confident). Scores can range from 20 to 200, with higher scores indicating higher levels of confidence in one’s ability to successfully complete college-related tasks. The 20-item scale includes items such as “Make new friends at college,” “Talk to university staff,” and “Take good class notes” (Barry & Finney, 2009). Gore et al. (2006) reported Cronbach’s alpha coefficients for scores on the CSEI subscales ranging from .62–.89. The reliability of the CSEI for the initial sample was .93 (Solberg et al., 1993). Additionally, we observed a Cronbach’s alpha coefficient of .88 for our sample.
Procedure
After ethical review board approval, students registered in classes at one large university in Ghana were asked to participate in this study. A survey administrator, who was not the course instructor, shared the opportunity to participate in this study with students and disseminated an information sheet explaining the purpose, processes, and voluntary nature of the study. After having time to review the information sheet, the students choosing to participate in the study were given a packet including a demographic questionnaire, the INCA, the MSPSS, and the CSEI. All measures except for the demographic questionnaire were counter-balanced in an effort to control for random responding, order effect, and fatigue. Participants filled out hard copy surveys in class and turned them in to the survey administrator, who supplied them to the authors. Participant answers to the survey packet were entered into an SPSS spreadsheet. After all data was documented, the original hard copy surveys were securely destroyed.
Data Analysis
Statistical power analysis. We conducted a power analysis to determine the suitability of our sample size for identifying model fit using the criteria outlined by Stevens (2009): n/p ≥ 30. Using this standard, our largest scale (Belief in Self), consisting of eight items, would necessitate a sample size of at least 240. With a sample size of 696 (i.e., 87 participants per item), we considered our sample size sufficient for making statistical inferences about model fit. We also acknowledge that this model is over-powered for hypothesis testing and may lead to type I error. Therefore, when interpreting analyses, a greater emphasis was placed on model fit indices over p-values for χ2 tests.
Preliminary data analysis. The dataset was analyzed for missing values prior to performing statistical analyses. A small percentage of missing values (684 out of 71,100; .009%) was detected, but no identifiable pattern within these absent values was present. We used the series mean imputation function in IBM SPSS, Version 23, to replace all missing values.
Evidence regarding internal structure. We analyzed model fit for the INCA subscales using the SPSS Analysis of Moment Structures Software, Version 22. We conducted our analyses of the INCA subscale factor structures based on the initial factor structure emerging from the analyses completed by Watson and Lenz (2017). Initially, we interpreted the C-minimum/degrees of freedom (CMIN/DF), p-values, root mean residual (RMR), goodness of fit index (GFI), comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA) metrics of model fit. Standards presented by Dimitrov (2012) were used to interpret these values with criteria for a strong model fit represented by CMIN/DF < 2, p > .05, RMR < .08, GFI > .90, CFI > .90, TLI > .90, and RMSEA < .10. When model fit proved inconsistent with these standards, modification indices were evaluated to determine items with potential covaried error. Covarying items provides a scenario within the factorial model wherein two items share their assumed variance. If such instances were identified, the model was computed again to re-inspect fit indices. If a factor model continued to have an inadequate fit, we inspected individual item correlation loadings and considered items for removal from the model. Items were removed if correlation coefficients were found to be less than .70.
Evidence regarding relationships with conceptually related constructs. Bivariate correlations were computed between scores on the INCA, MSPSS, and CSEI to depict degree of convergent validity between scores on the INCA subscales (Supportive Network and Belief in Self) with conceptually related constructs of perceived social support and academic self-concept, via the MSPSS and CSEI, respectively. Pearson’s correlation coefficients were interpreted as small (.10), medium (.30), or large (.50) based on the conventions reported by Swank and Mullen (2017) and evaluated at the .05 level of statistical significance.
Results
All alpha coefficients, descriptive statistics, and bivariate correlations for variables included within the analyses can be found in Table 1.
Table 1
Alpha Coefficients, Descriptive Statistics, and Bivariate Correlations for Variables Included Within Analyses.
| Scale-Construct |
α |
M |
SD |
1 |
2 |
3 |
| INCA – Belief in Self |
.74 |
23.31 |
3.32 |
44* |
|
.34* |
|
INCA – Supportive Network |
.74 |
17.44 |
2.65 |
.44* |
|
|
1. MSPSS – Family Relationships |
.88 |
20.02 |
6.49 |
|
|
|
2. MSPSS – Relationships with Friends |
.81 |
16.70 |
5.91 |
|
|
|
3. CSEI – College Self-Efficacy |
.88 |
36.77 |
14.69
|
|
|
| Note. * indicates statistical significance at .01 level |
Evidence Regarding Internal Structure
INCA – Belief in Self. The primary analysis of the Belief in Self subscale was significant for the hypothesized model, χ2(20) = 124.51, p < .01, and was suggestive of an unacceptable fit for the data: CMIN/DF = 6.22, RMR = .02, GFI = .95, CFI = .88, RMSEA = .08. After deleting item 6 and pairing the error terms for items 2 and 5 (“Past experiences help me cope with the demands of university life” and “Challenging courses make me a better student”) and 3 and 4 (“I believe I handle adversity well” and “My classmates value my opinions”), a good model fit emerged for scores on the Belief in Self subscale: χ2(12) = 28.58, p < .01. This finding was additionally supported by the fit indices: CMIN/DF = 2.38, RMR = .01, GFI = .98, CFI = .98, RMSEA = .04. Inspection of the alpha coefficient for scores for this sample (α = .74) was within the good range, indicating an acceptable degree of consistency and precision suitable for social sciences research activities.
INCA – Supportive Network. The primary analysis of the Supportive Network subscale was significant for the hypothesized model, χ2(9) = 102.28, p < .01, and was suggestive of an unacceptable fit for the data: CMIN/DF = 11.37, RMR = .03, GFI = .95, CFI = .80, RMSEA = .12. After pairing error terms for items 1 and 3 (“My friends support me as I work toward my goals” and “My friends help me to grow in important ways”) and items 4 and 6 (“My family’s support makes me feel stronger” and “I can be real with at least a few of my friends”), a good model fit emerged for scores on the Supportive Network subscale: χ2(7) = 14.03, p = .08. This finding was additionally supported by the fit indices: CMIN/DF = 3.41, RMR = .01, GFI = .98, CFI = .96, RMSEA = .05. Inspection of the alpha coefficient for scores for this sample (α = .74) was within the marginal range, indicating an acceptable degree of consistency and precision suitable for social sciences research activities.
Evaluation of Conceptually Related Measures
Family Relationships. The primary analysis of the Family Relationships subscale of the MSPSS was significant for the hypothesized model, χ2(2) = 45.47, p < .01, and was suggestive of an unacceptable fit for the data: CMIN/DF = 22.73, RMR = .10, GFI = .96, CFI = .97, RMSEA = .17. After pairing the error terms for items 3 and 4 (“I can talk about my problems with my family” and “My family is willing to help me make decisions”) a good model fit emerged for scores on the Family Relationships subscale: χ2(1) = 9.21, p <.01. This finding was additionally supported by the fit indices: CMIN/DF = 9.21, RMR = .04, GFI = .99, CFI = .99, RMSEA = .10. Inspection of the alpha coefficient for scores for this sample (α = .88) was within the good range, indicating an acceptable degree of consistency and precision suitable for social sciences research activities.
Relationships with Friends. The primary analysis of the Relationships with Friends subscale of the MSPSS was significant for the hypothesized model, χ2(2) = 49.52, p < .01, and was suggestive of an unacceptable fit for the data: CMIN/DF = 24.76, RMR = .15, GFI = .96, CFI = .95, RMSEA = .18. After pairing the error terms for items 1 and 2 (“My friends really try to help me” and “I can count on my friends when things go wrong”), a good model fit emerged for scores on the Relationships with Friends subscale: χ2(1) = 1.43, p = .23. This finding was additionally supported by the fit indices: CMIN/DF = 1.43, RMR = .02, GFI = .99, CFI = 1, RMSEA = .02. Inspection of the alpha coefficient for score for this sample (α = .81) was within the good range, indicating an acceptable degree of consistency and precision suitable for social sciences research activities.
College Self-Efficacy. The primary analysis of the College Self-Efficacy subscale of the CSEI was significant for the hypothesized model, χ2(9) = 66.70, p < .01, and was suggestive of an unacceptable fit for the data: CMIN/DF = 7.41, RMR = .34, GFI = .97, CFI = .98, RMSEA = .09. After pairing the error terms for items 1 and 2 (“Manage time effectively” and “Research a term paper”) and 3 and 5 (“Do well on your exams” and “Understand your textbooks”), a good model fit emerged for scores on the College Self-Efficacy subscale: χ2(7) = 22.45, p <.01. This finding was additionally supported by the fit indices: CMIN/DF = 3.20, RMR = .10, GFI = .98, CFI = .99, RMSEA = .05. Inspection of the alpha coefficient for scores for this sample (α = .88) was within the good range, indicating an acceptable degree of consistency and precision suitable for social sciences research activities.
Evidence Regarding Relationships With Conceptually Related Constructs
Bivariate correlation analysis of scores on the INCA Belief in Self subscale and CSEI resulted in a statistically significant positive relationship (r = .34, p < .01) indicative of a medium effect size. The correlation analysis of scores on the INCA Supportive Network subscale and MSPSS Family Relationships and Relationships with Friends subscales also resulted in statistically significant positive relationships (r = .448, p < .01, r = .448, p < .01, respectively) indicative of medium effect sizes. The strong positive relationships between scores on the two INCA subscales and conceptually related constructs are suggestive of support for convergent validity wherein the scores on the INCA tended to increase while scores on related measures increased too. Taken together, students who reported a greater belief in self also tended to report a greater sense of college self-efficacy. Similarly, participants who reported a greater belief in self during the first year of transition to college life also tended to report higher scores, indicating strong relationships with friends and family.
Discussion
The purpose of this study was to evaluate the validity evidence for the INCA using a Ghanaian college student population, with the hope that the instrument could be used by mental health professionals working in Ghanaian universities. Given the robust nature of our findings, we are heartened by the potential for the INCA and other emerging assessments to contribute to evidence-supported practices for optimal development and adjustment among students at Ghanaian universities. In light of our findings, several considerations warrant discussion.
Foremost, the INCA has potential uses that could address some of the most prominent issues facing higher education in Ghana today, particularly low matriculation rates. As the NCTE begins to rate institutions on the quality and relevance of their academic programs, the INCA can be used by university personnel to assess student adjustment so that necessary changes to student affairs programming can be made to improve the adjustment experiences of Ghanaian college students. Specifically, the INCA can be used by university personnel to gain a better understanding of the adjustment experiences of their first-year college students. This understanding can have important implications for program development at Ghanaian higher education institutions. As university personnel better understand the adjustment experiences of their first-year students, they can create programs that are more specialized to meet the needs of the Ghanaian student population, improve retention rates, and increase matriculation. Such activities have auspicious implications for not only promoting optimal development proximally, but encouraging access to a more equitable life, one characterized by fewer disparities than individuals within the emerging Ghanaian economy who do not have similar educational preparation and training.
Additionally, scores on the INCA can support early identification of first-year students who are struggling to adjust to university life. Because first-year students are least likely to engage in help-seeking behaviors (Andoh-Arthur et al., 2015), university personnel can develop proactive strategies to support struggling students and provide psychoeducation about the benefits of help-seeking behaviors. Such activities may include designing early detection protocols within orientation activities or integrating screening and referral within initial coursework activities.
In the cases of both program development and early identification, scores on the INCA have potential for evaluating outcomes in a manner that is culturally valid to a reasonable degree. Thus, the quantification of intervention outcomes by student affairs programmers and mental health professionals can provide an impetus for further understanding their students’ needs and the best strategies for meeting them. This is an important consideration in an era wherein Ghanaian mental health professionals are leveraging existing resources while extending their scope of influence within an emerging sociopolitical climate, which has expanded professional counseling activities through legislative action (Ghana Health Professions Regulatory Bodies Act 857, 2013). It is reasonable to conjecture that through the use of the INCA and other emerging assessments, the utilization and extension of personnel resources can not only be data-driven, but data-justified as well.
Finally, as the globalization of the counseling profession continues to be cultivated worldwide, it is important that counselors in international settings have valid psychometric tools that are population specific. Validation activities, such as the INCA project reported here, provide psychometrically robust assessments that Ghanaian mental health professionals can add to their growing corpus of resources. Although the use of assessment-based programming and outcome measurement do not define the whole of a counselor’s professional identity, it is a critical feature (American Counseling Association, 2014; Lorelle et al., 2012). Therefore, as the INCA and other assessments continue to be validated with Ghanaian student populations, the professionalization of Ghanaian mental health professionals grows lockstep.
Limitations and Recommendations for Future Research
Some important limitations and related recommendations for future research are indicated. First, although we sampled almost 700 Ghanaian students, the scope of our participant sample was limited to one campus. Therefore, we regard our findings as preliminary and most relevant to the student body from which they were affiliated. While it is reasonable that a substantial degree of validity generalization may be present, future studies completed at other Ghanaian universities are needed to estimate the transferability of INCA scores across regions. Second, internal consistency of INCA scores (α) were within the acceptable range (.70–.80), yet they did not reach a level that would warrant use for high stakes decision-making, such as program eligibility or dismissal. Further research evaluating content-oriented evidence (Lambie, Blount, & Mullen, 2017), cognitive processing, and response processes (Peterson, Peterson, & Powell, 2017) of INCA items and scores is needed to identify variables that may influence the reliability of items. It is possible that because INCA factors were developed from a Western theory of student adjustment, that consistency may be affected and indicative that some modification of item wording may be warranted (Lenz, Soler, Dell’Aquila, & Uribe, 2017). Thus, further evaluation related to cross-cultural adaptation and representation of constructs consisting within Ghanaian culture is warranted. Finally, this study only reported two sources of validity evidence. Although evidence across all sources of validity would not necessarily imply that INCA is inherently useful (Lenz & Wester, 2017), future research that elucidates INCA features associated with construct irrelevance and underrepresentation would further promote responsible testing and evaluation practice (Spurgeon, 2017).
Conclusion
In conclusion, this study evaluated the transferability of validity evidence for scores on the INCA to a sample of Ghanaian college students. The findings suggest the INCA is a valid psychometric assessment that has the potential to contribute to evidence-supported practices for optimal development and adjustment among students at Ghanaian universities. Specifically, the INCA can be used by Ghanaian university personnel to assess student adjustment, make any necessary changes to student affairs programming to improve the adjustment experiences of their college students, identify first-year students who are struggling to adjust to university life, and develop proactive strategies to support struggling students. Although initial results are promising, continued research is needed to validate the INCA at various universities across Ghana to continue to determine its degree of generalizability.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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Danielle Pester is a doctoral student at Texas A&M University-Corpus Christi. A. Stephen Lenz is an associate professor at Texas A&M University-Corpus Christi. Joshua C. Watson, NCC, is a professor at Texas A&M University-Corpus Christi. Julia Dell’Aquila is a doctoral student at Texas A&M University-Corpus Christi. Anthony Nkyi is a lecturer at the University of Cape Coast. Correspondence can be addressed to Danielle Pester, 6300 Ocean Drive, Corpus Christi, TX 78412, danielle.pester@tamucc.edu.
Mar 30, 2018 | Volume 8 - Issue 1
Maribeth F. Jorgensen, William E. Schweinle
The 68-item Research Identity Scale (RIS) was informed through qualitative exploration of research identity development in master’s-level counseling students and practitioners. Classical psychometric analyses revealed the items had strong validity and reliability and a single factor. A one-parameter Rasch analysis and item review was used to reduce the RIS to 21 items. The RIS offers counselor education programs the opportunity to promote and quantitatively assess research-related learning in counseling students.
Keywords: Research Identity Scale, research identity, research identity development, counselor education, counseling students
With increased accountability and training standards, professionals as well as professional training programs have to provide outcomes data (Gladding & Newsome, 2010). Traditionally, programs have assessed student learning through outcomes measures such as grade point averages, comprehensive exam scores, and state or national licensure exam scores. Because of the goals of various learning processes, it may be important to consider how to measure learning in different ways (e.g., change in behavior, attitude, identity) and specific to the various dimensions of professional counselor identity (e.g., researcher, advocate, supervisor, consultant). Previous research has focused on understanding how measures of research self-efficacy (Phillips & Russell, 1994) and research interest (Kahn & Scott, 1997) allow for an objective assessment of research-related learning in psychology and social work programs. The present research adds to previous literature by offering information about the development and applications of the Research Identity Scale (RIS), which may provide counseling programs with another approach to measure student learning.
Student Learning Outcomes
When deciding how to measure the outcomes of student learning, it is important that programs start with defining the student learning they want to take place (Warden & Benshoff, 2012). Student learning outcomes focus on intellectual and emotional growth in students as a result of what takes place during their training program (Hernon & Dugan, 2004). Student learning outcomes are often guided by the accreditation standards of a particular professional field. Within the field of counselor education, the Council for Accreditation of Counseling & Related Educational Programs (CACREP) is the accrediting agency. CACREP promotes quality training by defining learning standards and requiring programs to provide evidence of their effectiveness in meeting those standards. In relation to research, the 2016 CACREP standards require research to be a part of professional counselor identity development at both the entry level (e.g., master’s level) and doctoral level. The CACREP research standards emphasize the need for counselors-in-training to learn the following:
The importance of research in advancing the counseling profession, including how to critique research to inform counseling practice; identification of evidence-based counseling practices; needs assessments; development of outcome measures for counseling programs; evaluation of counseling interventions and programs; qualitative quantitative, and mixed research methods; designs in research and program evaluation; statistical methods used in conducting research and program evaluation; analysis and use of data in counseling; ethically and culturally relevant strategies for conducting, interpreting, and reporting results of research and/or program evaluation. (CACREP, 2016, p .14)
These CACREP standards not only suggest that counselor development needs to include curriculum that focuses on and integrates research, but also identify a possible need to have measurement tools that specifically assess research-related learning (growth).
Research Learning Outcomes Measures
The Self-Efficacy in Research Measure (SERM) was designed by Phillips and Russell (1994) to measure research self-efficacy, which is similar to the construct of research identity. The SERM is a 33-item scale with four subscales: practical research skills, quantitative and computer skills, research design skills, and writing skills. This scale is internally consistent (α = .96) and scores highly correlate with other components such as research training environment and research productivity. The SERM has been adapted for assessment in psychology (Kahn & Scott, 1997) and social work programs (Holden, Barker, Meenaghan, & Rosenberg, 1999).
Similarly, the Research Self-Efficacy Scale (RSES) developed by Holden and colleagues (1999) uses aspects of the SERM (Phillips & Russell, 1994), but includes only nine items to measure changes in research self-efficacy as an outcome of research curriculum in a social work program. The scale has excellent internal consistency (α = .94) and differences between pre- and post-tests were shown to be statistically significant. Investigators have noticed the value of this scale and have applied it to measure the effectiveness of research courses in social work training programs (Unrau & Beck, 2004; Unrau & Grinnell, 2005).
Unrau and Beck (2004) reported that social work students gained confidence in research when they received courses on research methodology. Students gained most from activities outside their research courses, such as participating in research with faculty members. Following up, Unrau and Grinnell (2005) administered the scale prior to the start of the semester and at the end of the semester to measure change in social work students’ confidence in doing research tasks. Overall, social work students varied greatly in their confidence before taking research courses and made gains throughout the semester. Unrau and Grinnell stressed their results demonstrate the need for the use of pre- and post-tests to better gauge the way curriculum impacts how students experience research.
Previous literature supports the use of scales such as the SERM and RSES to measure the effectiveness of research-related curricula (Holden et al., 1999; Kahn & Scott, 1997; Unrau & Beck, 2004; Unrau & Grinnell, 2005). These findings also suggest the need to continue exploring the research dimension of professional identity. It seems particularly important to measure concepts such as research self-efficacy, research interest, and research productivity, all of which are a part of research identity (Jorgensen & Duncan, 2015a, 2015b).
Research Identity as a Learning Outcome
The concept of research identity (RI) has received minimal attention (Jorgensen & Duncan, 2015a, 2015b; Reisetter et al., 2004). Reisetter and colleagues (2004) described RI as a mental and emotional connection with research. Jorgensen and Duncan (2015a) described RI as the magnitude and quality of relationship with research; the allocation of research within a broader professional identity; and a developmental process that occurs in stages. Scholars have focused on qualitatively exploring the construct of RI, which may give guidance around how to facilitate and examine RI at the program level (Jorgensen & Duncan, 2015a, 2015b; Reisetter et al., 2004). Also, the 2016 CACREP standards include language (e.g., knowledge of evidence-based practices, analysis and use of data in counseling) that favors curriculum that would promote RI. Although previous researchers have given the field prior knowledge of RI (Jorgensen & Duncan, 2015a, 2015b; Reisetter et al., 2004), there has been no focus on further exploring RI in a quantitative way and in the context of being a possible measure of student learning. The first author developed the RIS with the aim of assessing RI through a quantitative lens and augmenting traditional learning outcomes measures such as grades, grade point averages, and standardized test scores. There were three purposes for the current study: (a) to develop the RIS; (b) to examine the psychometric properties of the RIS from a classical testing approach; and (c) to refine the items through future analysis based on the item response theory (Nunnally & Bernstein, 1994). Two research questions guided this study: (a) What are the psychometric properties of the RIS from a classical testing approach? and (b) What items remain after the application of an item response analysis?
Method
Participants
The participants consisted of a convenience sample of 170 undergraduate college students at a Pacific Northwest university. Sampling undergraduate students is a common practice when initially testing scale psychometric properties and employing item response analysis (Embretson & Reise, 2000; Heppner, Wampold, Owen, Thompson, & Wang, 2016). The mean age of the sample was 23.1 years (SD = 6.16) with 49 males (29%), 118 females (69%), and 3 (2%) who did not report gender. The racial identity composition of the participants was mostly homogenous: 112 identified as White (not Hispanic); one identified as American Indian or Alaska Native; 10 identified as Asian; three identified as Black or African American; eight identified as multiracial; 21 identified as Hispanic; three identified as “other”; and seven preferred not to answer.
Instruments
There were three instruments used in this study: a demographic questionnaire, the RSES, and the RIS.
Demographics questionnaire. Participants were asked to complete a demographic sheet that included five questions about age, gender, major, race, and current level of education; these identifiers did not pose risk to confidentiality of the participants. All information was stored on the Qualtrics database, which was password protected and only accessible by the primary investigator.
The RSES. The RSES was developed by Holden et al. (1999) to measure effectiveness of research education in social work training programs. The RSES has nine items that assess respondents’ level of confidence with various research activities. The items are answered on a 0–100 scale with 0 indicating cannot do at all, 50 indicating moderately certain I can do, and 100 indicating certainly can do. The internal consistency of the scale is .94 at both pre- and post-measures. Holden and colleagues reported using an effect size estimate to assess construct validity but did not report these estimates, so there should be caution when assuming this form of validity.
RIS. The initial phase of this research involved the first author developing the 68 items on the RIS (contact first author for access) based on data from her qualitative work about research identity (Jorgensen & Duncan, 2015a). The themes from her qualitative research informed the development of items on the scale (Jorgensen & Duncan, 2015a). Rowan and Wulff (2007) have suggested that using qualitative methods to inform scale development is appropriate, sufficient, and promotes high quality instrument construction.
The first step in developing the RIS items involved the first author analyzing the themes that surfaced during interviews with participants in her qualitative work. This process helped inform the items that could be used to quantitatively measure RI. For example, one theme was Internal Facilitators. Jorgensen and Duncan (2015a) reported that, “participants explained the code of internal facilitators as self-motivation, time management, research self-efficacy, innate traits and thinking styles, interest, curiosity, enjoyment in the research process, willingness to take risks, being open-minded, and future goals” (p. 24). An example of scale items that were operationalized from the theme Internal Facilitators included: 1) I am internally motivated to be involved with research on some level; 2) I am willing to take risks around research; 3) Research will help me meet future goals; and 4) I am a reflective thinker. The first author used that same process when operationalizing each of the qualitative themes into items on the RIS. There were eight themes of RI development (Jorgensen & Duncan, 2015a). Overall, the number of items per theme was proportionate to the strength of theme, as determined by how often it was coded in the qualitative data. After the scale was developed, the second author reviewed the scale items and cross-checked items with the themes and subthemes from the qualitative studies to evaluate face validity (Nunnally & Bernstein, 1994).
The items on the RIS are short with easily understandable terms in order to avoid misunderstanding and reduce perceived cost of responding (Dillman, Smyth, & Christian, 2009). According to the Flesch Reading Ease calculator, the reading level of the scale is 7th grade (Readability Test Tool, n.d.). The format of answers to each item is forced choice. According to Dillman et al. (2009), a forced-choice format “lets the respondent focus memory and cognitive processing efforts on one option at a time” (p. 130). Individuals completing the scale are asked to read each question or phrase and respond either yes or no. To score the scale, a yes would be scored as one and a no would be scored as zero. Eighteen items are reverse-scored (item numbers 11, 23, 28, 32, 39, 41, 42, 43, 45, 48, 51, 53, 54, 58, 59, 60, 61, 62), meaning that with those 18 questions an answer of no would be scored as a one and an answer of yes would be scored as a zero. Using a classical scoring method (Heppner et al., 2016), scores for the RIS are determined by adding up the number of positive responses. Higher scores indicate a stronger RI overall.
Procedure
Upon Institutional Review Board approval, the study instruments were uploaded onto the primary investigator’s Qualtrics account. At that time, information about the study was uploaded onto the university psychology department’s human subject research system (SONA Systems). Once registered on the SONA system, participants were linked to the instruments used for this study through Qualtrics. All participants were asked to read an informational page that briefly described the nature and purpose of the study, and were told that by continuing they were agreeing to participate in the study and could discontinue at any time. Participants consented by selecting “continue” and completed the questionnaire and instruments. After completion, participants were directed to a post-study information page on which they were thanked and provided contact information about the study and the opportunity to schedule a meeting to discuss research findings at the conclusion of the study. No identifying information was gathered from participants. All information was stored on the Qualtrics database.
Results
All analyses were conducted in SAS 9.4 (SAS Institute, 2012). The researchers first used classical methods (e.g., KR20 and principal factor analysis) to examine the psychometric properties of the RIS. Based on the results of the factor analysis, the researchers used results from a one-parameter Rasch analysis to reduce the number of items on the RIS.
Classical Testing
Homogeneity was explored by computing Kuder-Richardson 20 (KR20) alphas. Across all 68 items the internal consistency was strong (.92). Concurrent validity (i.e., construct validity) was examined by looking at correlations between the RIS and the RSES. The overall correlation between the RIS and the RSES was .66 (p < .001).
Item Response Analysis
Item response theory brought about a new perspective on scale development (Embretson & Reise, 2000) in that it promoted scale refinement even at the initial stages of testing. Item response theory allows for shorter tests that can actually be more reliable when items are well-composed (Embretson & Reise, 2000). The RIS initially included 68 items. Through Rasch analyses, the scale was reduced to 21 items (items numbered 3, 4, 9, 10, 12, 13, 16, 18, 19, 24, 26, 34, 39, 41, 42, 43, 44, 46, 47, 49, 61).
The final 21 items were selected for their dispersion across location on theta in order to widely capture the constructs. The polychoric correlation matrix for the 21 items was then subjected to a principal components analysis yielding an initial eigenvalue of 11.72. The next eigenvalue was 1.97, which clearly identified the crook of the elbow. Further, Cronbach’s alpha for these 21 items was .90. Taken together, these results suggest that the 21-item RIS measures a single factor.
This conclusion was further tested by fitting the items to a two-parameter Rasch model (AIC = 3183.1). Slopes were constrained to unity (1.95), and item location estimates are presented in Table 1. Bayesian a posteriori scores also were estimated and strongly correlated with classical scores (i.e., tallies of the number of positive responses [r = .95, p < .0001]).
Discussion
This scale represents a move from subjective to a more objective assessment of RI. In the future, the scale may be used with other student and non-student populations to better establish its psychometric properties, generalizability, and refinement. Although this study sampled undergraduate students, this scale may be well-suited to use with counseling graduate students and practitioners because items were developed based on a qualitative study with master’s-level counseling students and practicing counselors (Jorgensen & Duncan, 2015a).
Additionally, this scale offers another method for assessing student learning and changes that take place for both students and professionals. As indicated by Holden et al. (1999), it is important to assess learning in multiple ways. Traditional methods may have focused on measuring outcomes that reflect a performance-based, rather than a mastery-based, learning orientation. Performance-based learning has been defined as wanting to learn in order to receive external validation such as a grade (Bruning, Schraw, Norby, & Ronning, 2004). Mastery learning has been defined as wanting to learn for personal benefit and with the goal of applying information to reach a more developed personal and professional identity (Bruning et al., 2004).
Based on what is known about mastery learning (Bruning et al., 2004), students with this type of learning orientation experience identity changes that may be best captured through assessing changes in thoughts, attitudes, and beliefs. The RIS was designed to measure constructs that capture internal changes that may be reflective of a mastery learning orientation. A learner who is performance-oriented may earn an A in a research course but show a lower score on the RIS. The opposite also may be true in that a learner may earn a C in a research course but show higher scores on the RIS. Through the process of combining traditional assessment methods such as grades with the RIS, programs may get a more comprehensive understanding of the effectiveness and impact of their research-related curriculum.
Table 1.
Item location estimates.
| RIS Item |
Location Estimate |
| Item 3 |
-2.41 |
| Item 4 |
-1.80 |
| Item 10 |
-3.16 |
| Item 13 |
-.86 |
| Item 16 |
-.94 |
| Item 19 |
-3.08 |
| Item 24 |
-2.86 |
| Item 9 |
-1.10 |
| Item 12 |
.42 |
| Item 18 |
-2.24 |
| Item 26 |
-2.20 |
| Item 39 |
.20 |
| Item 42 |
-1.28 |
| Item 44 |
-.76 |
| Item 34 |
-1.27 |
| Item 41 |
-.76 |
| Item 43 |
-1.47 |
| Item 46 |
-2.03 |
| Item 47 |
-2.84 |
| Item 49 |
1.22 |
| Item 61 |
-.44 |
Limitations and Areas for Future Research
The sample size and composition were sufficient for the purposes of the initial development and classical testing and item response analysis (Heppner et al., 2016); however, these authors still suggest caution when applying the results of this study to other populations. Endorsements of the participants may not reflect answers of the population in other areas of the country or different academic levels. Future research should sample other student and professional groups. This will help to further establish the psychometric properties and item response analysis conclusions and make the RIS more appropriate for use in other fields. Additionally, future research may examine how scores on the RIS correlate with traditional measures of learning (e.g., grades in individual research courses, collapsed grades in all research courses, research portion on counselor licensure exams).
Conclusion
As counselors-in-training and professional counselors are increasingly being required to demonstrate they are using evidence-based practices and measuring the effectiveness of their services, they may benefit from assessments of their RI (American Counseling Association, 2014; Gladding & Newsome, 2010). CACREP (2016) has responded to increased accountability by enhancing their research and evaluation standards for both master’s- and doctoral-level counseling students. The American Counseling Association is further supporting discussions about RI by publishing a recent blog post titled “Research Identity Crisis” (Hennigan Paone, 2017). In the post, Hennigan Paone described a hope for master’s-level clinicians to start acknowledging and appreciating that research helps them work with clients in ways that are informed by “science rather than intuition” (para. 5). As the calling becomes stronger for counselors to become more connected to research, it seems imperative that counseling programs assess their effectiveness in bridging the gap between research and practice. The RIS provides counseling programs an option to do exactly that by evaluating the way students are learning and growing in relation to research. Further, the use of this type of outcome measure could provide for good modeling at the program level; in that, the hope would be that it would encourage counselors-in-training to develop both a curiosity and motivation to infuse research practices (e.g., needs assessments, outcome measures, data analysis) into their clinical work.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contribu tions for the developmentof this manuscript.
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Maribeth F. Jorgensen, NCC, is an assistant professor at the University of South Dakota. William E. Schweinle is an associate professor at the University of South Dakota. Correspondence can be addressed to Maribeth Jorgensen, 414 East Clark Street, Vermillion, SD 57069, maribeth.jorgensen@usd.edu.
