Catalyst Volume 2 by Neumann University

Catalyst

N e u m a nn U n i v e r s i t y

Volume 2, Spring 2016

Journal of Student Research and Academic Scholarship

Editorial Statement Catalyst: The Neumann Journal of Student Research and Academic Scholarship is an interdisciplinary peer-reviewed student journal. The journal articles consist of academic research manuscripts authored by Neumann University undergraduate and graduate students, with the endorsement of faculty members. The mission of the Neumann Journal of Student Research and Academic Scholarship is to provide a vehicle to showcase the excellent academic research projects and scholarship of Neumann University students. Catalyst is published biennially and is available in an electronic format.

Co-Editors Stephanie Smith Budhai, Ph.D. Assistant Professor and Director of Graduate Education Division of Education and Human Services

Maureen Williams, MLIS, Information Literacy Coordinator and Reference Librarian Library Services

Editorial Review Board Barbara Hanes, Ed.D. James Houck, Ph.D. Bryce Johnson, Ph.D. Samuel Lemon, Ed. D. Elizabeth Loeper, MSN Jackie Martin, M.S.

Colleen McDonough, Ph.D. Sophia Park, Th.D. Mary Powell, Ph.D. Megan Scranton, Ed.D. Beth Toler, Th.D. Maria Traub, Ph.D.

For more information about submitting or reviewing articles for Catalyst, please visit us at www.neumann.edu/catalyst or email us at catalyst@neumann.edu

Table of Contents Arts and Sciences

“The Influence of Gangs on Juvenile Populations Walter McDonald, student author Kristen Acosta, M.S., faculty sponsor

13 “Gun Control: An Evaluation of Effectiveness”

Garrett Treer, student author Kristen Acosta, M.S., faculty sponsor

Education and Human Services

“Life within the Womb: A Process of Spiritual Transformation” Nineka Dyson, student author Sr. Suzanne Mayer, IHM, Ph.D., faculty sponsor

“Supporting the Communication Needs of Children with Hearing Impairments” Nicole Lebedz & Samantha Wilson, student authors Daniel McKee, Ed.D., faculty sponsor

“Inclusion: Is it the Right Choice for All?” Jessica Lewis, student author Daniel McKee, Ed.D., faculty sponsor

“Walk Like You Have Somewhere to Go: A Literature Review of the Academic, Social, and Cultural Needs of African American Adolescent Males in Urban Schools” Stephen D. Thorne, student author Marisa Rauscher, Ph.D., faculty sponsor

“Truth and Reconciliation in Rwanda” Mary Trotter, student author Sr. Suzanne Mayer, IHM, Ph.D., faculty sponsor

Nursing and Health Sciences

“Relationships among Smoking, Chronic Pain, Mental Health, and Opioid Use for Pain-Management in Older Adults” Marthe Adler, student author Theresa Pietsch, Ph.D., faculty

Continuing Adult and Professional Studies

115

“Music for the Body & Soul: The Benefits of Music Therapy for Pain Management” Shane Burke, student author Jilian Donnelly, Ed.D., faculty sponsor

131

“Post Traumatic Stress Disorder in the Fire Service” Devon Richio, student author Jilian Donnelly, Ed.D., faculty sponsor

Special Acknowledgements Special Acknowledgements Creating and publishing this issue of Catalyst was a collaborative undertaking and could not have been accomplished without help from the following people: Rosalie M. Mirenda, Ph.D. Lawrence DiPaolo, Ph.D. Tiffany McGregor, MLIS Carol DiAntonio Steve Bell Lisa Roberts Cadorette Nancy Tracy

Arts and Sciences

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

The Influence of Gangs on Juvenile Populations Student Author: Walter McDonald Academic Program: Arts & Sciences Faculty Sponsor: Kristen Acosta, M.S. Abstract Gang violence has been an issue of great concern to both law enforcement and the public for the past thirty years. The target demographic of today’s gangs are youth that are poor, angry, and disenfranchised who are seeking a means to escape their surroundings, and create better lives for themselves through criminal enterprises that seek to enrich the individuals involved. This paper will explore trends in gang violence, how gangs recruit membership, and the efforts of law enforcement to reduce or eliminate the presence of gangs on a national and global level. Statistical Breakdown of Gangs and Their Membership In 2011, the FBI identified 33,000 gangs with a combined membership of 1.4 million who were categorized by the following labels: “street”, “prison”, and “OMG” (outlaw motorcycle gangs) in the United States (FBI, 2011). Young people between the ages of 15-19 make up almost one- quarter of those who are affiliated with gangs at 260,000 members (Harris, 2013). These groups accounted for 48% to 90% of violent crime, depending on the jurisdiction or the location where they are based (FBI, 2011). This increase in violent crime is eight to ten times greater than the five year period between 1998-2003, when violent crime committed by gangs was at one of its lowest points, between six and ten percent (Bureau of Justice Statistics, 2005). Gangs produce revenue through a variety of activities including murder, extortion, prostitution, drug trafficking, and weapons trafficking (FBI, 2011). Over the same five year period, the Centers for Disease Control and Prevention conducted a similar study with a smaller

sample size of five cities (Los Angeles, CA, Long Beach, CA, Oakland, CA, Oklahoma City OK, and Newark, NJ). The study looked specifically at gang versus non-gang related homicides, and the statistical analysis evaluated males below the age of 24. The five cities were chosen because they had the highest level of gang related homicides by population in the United States. The Center for Disease Control (CDC) found that persons who were the victims of gang-related homicides were younger than their non-gang related homicide counterparts, with 27%-42% of these victims being between the ages of 15-19 years of age. Non-gang homicides made up only 9%-14% of victims in this age group (Centers for Disease Control and Prevention, 2012). A breakdown of the weapons used to commit the crime shows an overwhelming favoritism by gang members for firearms, which were used in 90% of all homicides in the five cities. While violent acts target adults and juveniles alike, the statistics collected from both the FBI and the CDC indicate that juveniles are the most likely targets of gang violence for the same reason that they are targeted for recruitment: their vulnerability to violence. This vulnerability stems from the need for acceptance, and the influences of neighborhood and family violence. Recruitment Methods The rise of juvenile gangs is in part due to the increased incarceration of adult gang members (FBI, 2011). Because of this, schools have become primary targets for gang recruitment. Common tactics used by gangs to attract the attention of potential recruits include parties, and other special events (FBI, 2011). The theory behind early recruitment of juveniles into the gang lifestyle is threefold: ď&#x201A;ˇ

Juveniles are considered vulnerable, and therefore are more likely to cave into peer pressure, and will join a gang to be part of the â&#x20AC;&#x153;in crowdâ&#x20AC;?, avoiding the stigma associated with being an outcast, particularly if their friends are joining.



In the judicial system, a juvenile is less likely to face harsh sentencing as compared to an adult.

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There is a willingness of younger members to commit violent crimes as part of the initiation process (FBI, 2011). Youth involvement in gangs is believed to be the result of a number of factors, a primary

one being the role of parenting in the lives of youths who participate in gang activities. Adolescents who regularly participate in gangs are often the by-product of parental units who lack the ability to effectively monitor and supervise their child’s activities. Furthermore, these youths suffer from situations where there is frequent family dysfunction, and where discipline for bad behavior is limited or nonexistent (Walker-Barnes & Mason, 2004). “Additionally, the likelihood of gang involvement in youths whose parents exert too much control over their children is also high. As parents exhibit a need to dictate and control their child’s movements, this need for control puts their children at greater risk to join gangs. Psychological, or guilt based control of an adolescent is common amongst parents whose inability to cease control over the day to day decision making in the lives of their children, drives the child away from their parental unit, and into a life of gang affiliation” (Walker-Barnes, Mason, 2004, p. 237). Law Enforcement Strategies Youth gang violence is hardly isolated to the United States. In 2013, a study was released by Project Oracle, a London-based youth violence prevention think tank. The study looked closely at youth gangs in the United Kingdom with the primary focus on groups that promote anti-gang intervention initiatives (McMahon, 2013). The London study used various forms of intervention techniques such as targeted or general and universal interventions to curtail teenage recruitment into gangs. Each type of intervention focuses on a specific set of criteria that youths

wishing to enter an intervention program must abide by in order to be accepted into a program (McMahon, 2013). Targeted interventions occur when a youth is considered to be at risk for gang membership or violent activity is at a high level. This form of intervention is more widely used in the United Kingdom because of its ability to reach out to families that are considered “hard to reach” due to circumstances such as poverty and deprivation (McMahon, 2013). General or universal intervention programs seek to create an atmosphere of openness, and their goal is to involve all youths, regardless of their propensity for gang membership or violent behavior (McMahon, 2013). The idea behind this approach is that youths who qualify for this form of intervention are not considered suitable enough to be labeled into specific categories of risk assessment. Chance UK is a London-based charity that deals with children with disciplinary or behavioral issues that would be considered precursors to future gang affiliation. This organization was one of twelve featured in Project Oracle’s research. Their target demographic is children between the ages of 5-11, this would fit under the study’s definition of a “targeted” intervention, because of the limited age demographic served by this organization. Their website states specific goals that they focus on when dealing with youths at such a young age, these goals include: ● The introduction of a safe and stable environment for the children they serve ● Address problems that children and families experience ● Promote self-esteem ● Reduce or eliminate feelings of isolation in both children and their families ● Focus children’s energy on projects that allow them to feel a sense of achievement ● Support and motivate children to acquire the life skills needed to move forth in a positive way

Another London-based project known as Conflict Resolution UnCut, works with a slightly older group than those that Chance UK works with, with the median age group being between 10-16 years old, working predominantly in schools. There are a number of risk factors that program organizers look for in students who fit the criteria for this program: 

Lack of engagement in school, which can lead to removal from school, either temporary or permanent



An unwillingness to engage positively with authority figures



Repeated anti-social behaviors exhibited in the school environment

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Displays frequent aggressive behaviors, or is in constant conflict with others



Frequent absence from school The program offers conflict resolution strategies, coping mechanisms, and support for

positive school engagement and peer and adult relationships. It works in two stages. Stage 1 is a six week program, in a group setting where the participants learn how to resolve conflict constructively using role play and other mechanisms. Stage 2 is more intense, one on one sessions that can last up to 25 weeks. The GREAT (Gang Resistance, Education, and Training) program is based in the United States and developed from a coordinated effort of federal, state, and local agencies. It provides an important tool to the law enforcement community. It seeks to stem the tide of youths who choose the life of gang involvement to steer them toward a life that is free of gang influence. Its purpose is to teach children about the dangers of gang life, and the consequences associated with involvement in gangs (Esbensen, Osgood, Taylor, Peterson, Freng, 2001). The most recent study, which was conducted in 2001, relied on the use of surveys to collect its data. These surveys were completed by students that were of middle school age in six

U.S. cities, Las Cruces, New Mexico, Lincoln, Nebraska, Omaha, Nebraska, Philadelphia, Pennsylvania, Phoenix, Arizona, and Portland, Oregon, and sampled about 3,500 students in 153 classrooms in 22 different schools. The study separated the students who were chosen for the surveys into control and treatment groups. The control group represented students not involved in the GREAT program, and the treatment group consisted of those who were. Follow-up surveys were conducted in the three years after the original survey was distributed. While the completion rate of the surveys was considered excellent for the purposes of the study, the authors did note the steady decline of respondents in each of the four years, with 86% of students responding to the survey in Year One, and only 67% by Year Four. The reasons for the decline in participation by the students varied, with the most common being either a withholding of consent from parents (10% of respondents) or failure to return the questionnaire (33% of students chosen for the survey). There were several conclusions drawn from the test subjects about the effectiveness of the program. First, the research concluded that the control and treatment groups were, for the most part, very similar, with only a few subtle differences. These differences were found in the following categories: victimization, negative beliefs about gangs, self-reported status offenses, peer delinquency, and prosocial peers (Esbensen, et al, 2001). The results of the statistics in the study showed that the retention of students, while in decline between the first and fourth years of the study, were still strong enough to warrant a positive response to the program. Conclusion Research identifies that gang recruitment and social factors have a significant influence on a juvenileâ&#x20AC;&#x2122;s decision to join a gang. FBI statistics demonstrate that violence within these gangs expose juveniles to activities in drug law violations, weapons, and homicide (FBI, 2011).

There is evidence that programs such as Project Oracle and G.R.E.A.T. can be effective measures to target youth gang involvement. However, more research is needed to investigate which factors may insulate youths from gang influence. References National Gang Threat Assessment-Emerging Trends. (2011). Retrieved from: https://www.fbi.gov/stats-services/publications/2011-national-gang-threat-assessment Finn-Aage Esbensen, Dana Peterson, Terrance J. Taylor & D. Wayne Osgood (2012). Results from a Multi-Site Evaluation of the G.R.E.A.T. Program, Justice Quarterly, 29:1, 125-151. Gang Homicides-Five U.S. Cities, 2003-2008. (2012). Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6103a2.htm. Harrell, Erika. (2005). Violence by Gang Members, 1993-2003. Retrieved from: http://www.bjs.gov/content/pub/pdf/vgm03.pdf Harris, T., Elkins, S., Butler, A., Shelton, M., Robles, B., Kwok, S., Simpson, S., et al. (2013). Youth Gang Members: Psychiatric Disorders and Substance Use. Laws, 2(4), 392â&#x20AC;&#x201C;400. McMahon, Simon. (2013). Gangs, Youth Violence, and Crime. Retrieved from: http://projectoracle.com/studies/gangs-youth-violence-and-crime/ Walker-barnes, C. J., & Mason, C. A. (2004). Delinquency and Substance Use among GangInvolved Youth: The Moderating Role of Parenting Practices. American Journal Of Community Psychology, 34(3/4), 235-250.

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Gun Control: An Evaluation of Effectiveness Student Author: Garrett Treer Academic Program: Arts & Sciences Faculty Sponsor: Kristin Acosta, M.S. Abstract Political debate regarding firearms and their control has been prolific, whereas the body of research on the topic has not. The purpose of this research is to help fill the knowledge gap and determine if more restrictive controls are effective. For the sake of this research, gun control effectiveness was evaluated by comparing the murder rates and murder rates by firearm across all fifty United States to respective ratings from the Brady Campaign to Prevent Gun Violence. The expectation was that, if more restrictive gun control is effective, states with higher ratings from the Brady Campaign would have lower rates of murder as well as murder by firearm. After accessing data published by the Federal Bureau of Investigation, the Center for Disease Control, and the Brady Campaign, the resulting analysis showed mixed results. Thus, for the purposes of this research, more restrictive gun controls are not inherently more effective. Introduction Recent tragedies, whether the sensational horror of mass school shootings or the numbing ills of routine gang violence, lend urgency to calls for gun control. This study seeks to fill the knowledge gap by looking at extant policy and evaluating its effectiveness. Other studies have considered the issue of gun control by using correlations between gun ownership and incidents of homicide, suicide, deaths, or justifiable self-defense as a means to argue for or against policy-making. Evaluating rates of incidence may indicate if a problem exists as well as its dimensions, but that a problem exists is no validation of any given policyâ&#x20AC;&#x2122;s ability to resolve it. So the question remains as to whether such policies would validate their costs with intended benefits. Answering this question is the purpose of this study. Though there exists federal firearm 13

laws which are universally applicable, each individual state retains the right to determine if and how to levy further restrictions on firearm ownership and use. This has resulted in something of a patchwork quilt of policies which in turn offers a convenient opportunity for comparison. The hypotheses are that, if gun control is effective, states with more stringent laws should demonstrate lower murder rates and, more specifically, reduced rates of murders by firearm. While other studies focus on the links between gun ownership, homicide, suicide, and selfdefense, Methodology For the purposes of this study, several comparisons were made with the specific aim of evaluating the disparate gun control policies at the state level. The primary sources for data came from the Federal Bureau of Investigation (FBI) and the Center for Disease Control (CDC). The FBI’s Uniform Crime Report (UCR) data tool and CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) are both online databases open to the public with information relevant to this study. The years targeted were the decade from 2004-2013. All rates mentioned in this report are per 100,000 and, as such, will be mentioned solely as rates. The UCR provides murder rates for each state. The murder rates provided by the UCR are used directly to address the first hypothesis, but they are also converted in order to address the second hypothesis as the UCR lacks any rates specific to murders by firearm (hereafter MbF). This conversion process uses data sourced from the UCR’s Table 20 data covering the same decade as the murder rate data (FBI Table 20, 2013). The lone exception was Florida. Though Florida had UCR murder rate data, it did not have Table 20 data. Florida’s MbF information was drawn from their own state reporting data (Florida Department of Law Enforcement, 2014). There is significant variance in the percentage of homicides by firearm in any given year for

some states. This is important as, in certain years, there may have been zero reported murders by firearm or a critically low data count. If absolutely accurate, this represents no problem. If even slightly amiss, however, the data could be inordinately skewed. Therefore the conversion process used an average of all Table 20 data by state for the decade covered. Additionally, the UCR also provided data by which to compare cities. Cities represent a much smaller data pool and thus were not included for the sake of authority. Instead, the intent was to provide yet another comparison to see the effects, if any, of gun control in disparate settings. The city data was only current to 2012, so the decade of data ranged from 2003-2012. The cities were selected only if their population exceeded 100,000. This limitation is part of the database query. It was used both to include as much data as possible while making sure not to include exceedingly small reporting areas. The intent was to create something of a peer group of cities for a fair comparison. For instance, while the state of California may have many large municipalities, the state of Montana does not. Some states lose representation, but there is still a broad representation of cities from states with varying degrees of gun control. For the sake of timeliness and convenience, the cities are assumed to have the same ratings as their respective states. While this may not be accurate as many states allow local ordinances, it proved necessary for this study and is not meant to bias findings. The WISQARS database has murder rate data and it provides MbF data directly. This serves as a basis for comparison to make sure the UCR Table 20 conversion process provides reasonable data. Just as importantly, these data represent a second, independent vantage regarding the reasonableness of the UCR data overall. Unrelated to the hypotheses of the study, WISQARS was also the source for suicide rate data mentioned in discussion. Unfortunately, the WISQARS database automatically suppresses any low counts and some of the data are thus

unusable on an individual basis. Fortunately, however, these data are still represented in aggregate. The main effect of this is that, while the UCR data and the WISQARS suicide data observations are significantly greater in number (N = 500), the WISQARS murder rate and MbF only have state averages (N = 50). All UCR and WISQARS data were used as provided except where noted otherwise (e.g. the UCR MbF conversion). This concludes the dependent variable data. Deciding how strict or lenient state gun control policies are represents an inherently subjective process. Two systems were considered for use in this study. The Legislative Strength Score (LSS) was created by the authors in a similar study to serve the same purpose (Fleegler, Lee, Monuteaux, Hemenway, & Mannix, 2013). The Brady Campaign To Prevent Gun Violence likewise evaluates firearm legislation and publishes a State Scorecard (Brady Campaign, n.d.). While the LSS as a score is more akin to a simple count of gun control legislation, where one law equals one point, the Brady score weights each legislation such that their point value may differ. The specifics of how they weight each legislation are not explained. Still, it is worth mentioning that the Brady score has very strong, r(48) = 0.92 correlation with the LSS system and that the Brady score had a greater correlation with all findings than the LSS. As a result, only the Brady score will be used for the independent variable. The Brady score, as published, is in a letter grade format similar to that from a school’s report card. Marks range from the best-awarded of ‘A-‘ to the worst of ‘F’, with ‘B’, ‘C’, ‘D’, and their plus/minus variants possible in between. These letter grades have simply been converted to a numerical score ranging from a best score of 10 to represent ‘A-‘ and scaling down to the worst score of 0 to represent an ‘F’. This conversion was necessary for statistical purposes and is demonstrated in the charts.

While efforts were made to be thorough and as fair as possible, some methodological concerns remain. It is worth noting that both the UCR and WISQARS databases have potential issues which are available on their respective online domains and are not duplicated here. Assuming that states have uniform gun control legislation ignores the countless municipal ordinances across the United States. This step, though functionally necessary for the study, may represent a significant and unknown bias in findings. The Brady Scorecard used is from 2013, though gun control legislation has changed over the course of the 2004-2013 decade. Neither the Brady score nor the LSS have an archive of scores for the period covered. This makes for a onedimensional treatment which is both necessary and unfortunate. Another concern is that strict controls may be defeated by purchasing firearms in states with more lenient controls. While the practice certainly exists, it represents illegal weapons trafficking. Noting that the practice exists, despite already being illegal, is as much of a reason to question the assumed effectiveness of gun control as it is to laud its effectiveness. No variables were controlled for in this study, unlike the study conducted by Dr. Fleegler et alia. Controlling for variables like poverty, education, and age would likely prove useful in understanding the correlations in their own right. It is worth mentioning that the emphasis of this research is for practical application and the whole of society, by definition, cannot be forced to match such controls. Policies must be effective despite heterogeneity. Lastly, different states represent different cultures, social issues, population densities, and so forth in such a manner that make comparisons rather complex. These concerns are precisely why different databases and dependent variables are used to provide as comprehensive a picture as is feasible.

Results The main findings can be expressed as the UCR and WISQARS murder rate and MbF state-level data correlated to the Brady score. Secondary findings, meant to provide greater perspective, are represented by the city-level UCR murder rate data and the WISQARS suicide data correlated with Brady score. As these data are presented in accompanying figures, the Pearsonâ&#x20AC;&#x2122;s correlation coefficient (-1 < r < 1), the significance level (0.00 < P < 1.00), and the variability explained (0.00 < R2 < 1.00) for each chart are noted. A simple linear regression was calculated with UCR data to determine murder rate to Brady score (Figure 1). A significant regression was found with p < 0.01. While the relationship was significant (or p < 0.05), the variables were very weakly correlated at r(498) = -0.12, and R2 = 0.01. The low p value is likely an artifact of the large sample. Additionally, the R2 demonstrates that almost none of the variability is explained by the relationship. While this is not murder data specific to firearms, it makes sense to see an impact given the preponderance of murders committed by firearm (FBI table 8, 2013). The next linear regression, to determine MbF from Brady score, is visually similar to the first (Figure 2). The equation was just within the confidence level of significance with p = 0.04. Even so, the correlation here is even weaker at r(498) = -0.09 and the R2 = .01. It was expected that isolating murders by firearm would

intensify the findings, though this was not the case. The WISQARS data was used to perform a simple linear regression to see the relation of state murder rate to Brady score. The result was not significant, with p = 0.28. The correlation r(48) = -0.16 is somewhat stronger than that of the UCR data, but still very weak. These findings are not surprising as the reduced number of observations made achieving significance more difficult and the expectation was for a stronger correlation from the MbF rather than murder rate to Brady score relationships.

The final primary consideration was a linear regression to find MbF from Brady score using the WISQARS data (Figure 4). Again the regression equation was not significant with p = 0.41 and the correlation was very weak r(48) = -0.12. The WISQARS data mirrors the UCR set with respect to the increased p values and decreased correlation strength of MbF compared to murder rate. This affirms the findings from the UCR data, but again this trend of weaker MbF to Brady score relationships, as compared with murder rate to Brady score relationships, is contrary to expectations.

For the sake of a different perspective, city-level data from the UCR was also used for a linear regression (Figure 5). Given that the Table 20 data only applies at the state level, no MbF data could be computed and only a murder rate from Brady score linear regression was performed. The data used was an average covering the period from 2003-2012, with N = 289. The regression equation was not significant, with p = 0.53. The correlation of murder rate to Brady score was r(287) = -0.04. Though by no means an authoritative perspective given some of the aforementioned methodological concerns, the data essentially fits with the other findings. The focus of this study is to determine the effect of gun control on murders and murders by firearm. Other studies, such as that by Fleegler et alia (2013), tend to combine murder and suicide data. Depending on the purpose of the study or of those citing it, such inclusion can be misleading as the data behave in different ways and the suicide data is much greater in volume. Of the roughly 33,000 firearm-related deaths for 2013, roughly 21,000 of them were suicides (Center for Disease Control, 2015). In order to emphasize how suicide data can alter the outlook, a linear regression using WISQARS data was performed to determine suicide rates from Brady scores (Figure 6). The regression equation was significant, with p < 0.0001). The correlation was very strong, with r(498) = -0.78. Also of note, the degree of variability explained was R2 = 0.60. This was the kind of finding that was expected for the

murder rate and especially the MbF regression equations. This is evidence of a clear-cut, negative relationship between suicide rates and gun control. The suicide date serves as a proof of concept that, if such a relationship existed for murders by firearm, they could demonstrably manifest.

Discussion The stark reality is that the United States has an overall issue with violence. Gun control discourse routinely involves the efforts, legislative policies, or crime statistics of countries like England, Australia, Canada, and Japan. All of them have very low homicide rates and homicide rates by firearm when compared to the United States. The United States had a murder rate of 4.7 in 2012 (FBI table 1, 2013), with approximately 69.4% of those committed by firearm (FBI table 8, 2013). This means that even if you exclude all homicides by firearm from the United States with no displacement into other methods, the United States will still have a higher overall murder rate of 1.4 when compared to Japan at 0.4, Australia at 1.0, and Great Britain at 1.2 (Agence France-Presse, 2013). Canada slightly edges over with a murder rate of 1.56 (Loney, 2013). That the United States, even when discounting all murders perpetrated by firearm, still stands at the top in murders is astounding. Even if the passage of gun control were assumed, this shows that restricting or banning firearms will not change the social context driving current murder rates. This does not answer the question of if firearms should be further restricted.

On that front, of the five findings related to murder, just two were significant. The two significant findings also happened to be those with observations of N=500, meaning this was likely due more to sample size than anything else. Most importantly, all five findings had very weak correlations and the data were consistent despite differences in number of observations. Given this, neither hypothesis was fully supported by the data. This provides a very firm basis to suggest that there is no meaningful relationship between gun control and murders or murders by firearm. This contrasts sharply with the clear outlook provided by a similar look at suicide data. This lack of a clear, strong correlation and an ability to explain variability is critical. Social and political arguments, with the assistance of lobbying groups, have entrenched themselves in diametric opposition to each other regarding gun control. This represents a grave error in stewardship, as untold resources are being dedicated in trying to win a battle that will only yield questionable benefits at best. Meanwhile, real gains could be made by focusing on gun controls specifically designed to reduce suicide rates. Unlike the murder data, the suicide data clearly showed that gun controls were an effective mediator. This means stewardship of resources also become a matter of human dignity, as numerous lives are being lost in selfdestructive acts while politicians feud as a means to posture platform bias. Assault weapon bans and limitations on magazine capacity are not the kind of measures that will limit suicides. Likewise, their viability in achieving their stated purpose is dubious at best as these policies are already in effect in some states with no demonstrable impact on murders by firearm. This study is enough to demonstrate that we know what it is we do not know, and in not knowing we should not be wasting time advocating for policies that amount to wishful thinking. Conclusion While it is true that firearms often serve the purposes of criminal violence, they also serve

lawful, protective purposes for our police and citizenry. The simple restriction or removal of firearms does little to address the undercurrent of violence. Firearms serve as a focal point for debate, but there seems to be more at issue in need of consideration. In that regard, broader social context should be treated as an important factor in policy making. Policy solutions with credible chances for success are needed. These data imply that more thought and research are required to meet that end. Gun violence is an important social issue deserving of relevant discourse. Relevant discourse, in turn, should be informed, based on evidence, and lend itself to constructive efforts. It is hoped that this research accomplishes these objectives to form at least an initial basis for consideration. These findings indicate that gun control is not inherently effective at its stated purpose. Gun control does not clearly mediate murders by firearm and is far too weakly correlated with murders to have predictive value. Taking a gamble by doubling down on more gun control without better understanding the factors in play is to invest fully in its risks, costs, or deprivations without the good sense of ensuring any of its intended benefits. References Agence France-Presse. (2013, September 16). U.S. murder rate higher than nearly all other developed countries: FBI data. Retrieved from http://www.rawstory.com/rs/2013/09/u-smurder-rate-higher-than-nearly-all-other-developed-countries-fbi-data/ Brady Campaign to Prevent Gun Violence. (n.d.). 2013 State Scorecard. Retrieved November 10, 2014, from http://www.bradycampaign.org/2013-statescorecard?gclid=CImMwMbK8cECFQET7Aodp3kAEA Center for Disease Control. (2015, April 8). FastStats. Retrieved September 18, 2015, from http://www.cdc.gov/nchs/fastats/ Federal Bureau of Investigation. (October 2013). Table 1. Crime in the United States, 2012. 23

Retrieved November 10, 2014 from http://www.fbi.gov/about-us/cjis/ucr/crime-in-theu.s/2012/crime-in-the-u.s.-2012/tables/1tabledatadecoverviewpdf. Federal Bureau of Investigation. (October 2013). Table 8. Crime in the United States, 2012. Retrieved November 10, 2014 from http://www.fbi.gov/about-us/cjis/ucr/crime-in-theu.s/2012/crime-in-the-u.s.-2012/offenses-known-to-law-enforcement/expandedhomicide/expanded_homicide_data_table_8_murder_victims_by_weapon_20082012.xls. Federal Bureau of Investigation. (October 2013). Table 20. Uniform Crime Reports. Retrieved September, 2015 from https://www.fbi.gov/about-us/cjis/ucr/ucr-publications Fleegler, E.W., Lee, L.K., Monuteaux, M.C., Hemenway, D., & Mannix, R (2013). Firearm Legislation and Firearm-Related Fatalities in the United States. JAMA Intern Med. 2013;173(9):732-740. doi:10.1001/jamainternmed.2013.1286. Florida Department of Law Enforcement. (2014). Florida statewide murder by firearm, 1971 â&#x20AC;&#x201C; 2013. Retrieved November 10, 2014 from https://www.fdle.state.fl.us/Content/getdoc/332e1b3d-2648-4b06-8be5d322f340c95d/1971_fwd_murder_firearms.aspx Kay, R. (2013, January 22). Who knew? The leading cause of gun death Is suicide. Retrieved from http://www.forbes.com/sites/rogerkay/2013/01/22/who-knew-the-leading-cause-ofgun-death-is-suicide/ Loney, H. (2013, December 19). Canadaâ&#x20AC;&#x2122;s 2012 homicide rate at lowest level in nearly 50 years. Retrieved from http://globalnews.ca/news/1040722/canadas-2012-homicide-rate-atlowest-level-in-nearly-50-years-statscan/ Kay, R. (2013, January 22). Who knew? The leading cause of gun death Is suicide. Retrieved 24

from http://www.forbes.com/sites/rogerkay/2013/01/22/who-knew-the-leading-cause-ofgun-death-is-suicide/ Loney, H. (2013, December 19). Canadaâ&#x20AC;&#x2122;s 2012 homicide rate at lowest level in nearly 50 years. Retrieved from http://globalnews.ca/news/1040722/canadas-2012-homicide-rate-atlowest-level-in-nearly-50-years-statscan/ List of Figures Figure 1. A scatter-plot of the state murder rate over Brady Score, data taken from UCR 20042013 Figure 2.A scatter-plot of the state murder rate by firearm over Brady Score, data taken from UCR 2004-2013 Figure 3. A scatter-plot of the state murder rate over Brady Score, data taken from WISQARS 2004-2013 Figure 4.A scatter-plot of the state murder rate by firearm over Brady Score, data taken from WISQARS 2004-2013 Figure 5. A scatter-plot of the city murder rate over Brady Score, data taken from UCR 20032012 Figure 6.A scatter-plot of the state suicide rate by firearm over Brady Score, data taken from WISQARS 2004-2013

Education & Human Services

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Life within the Womb: A Process of Spiritual Transformation Student Author: Nineka Dyson Academic Program: Pastoral Clinical Mental Health Counseling Faculty Advisor: Sr. Suzanne Mayer, IHM, Ph.D.

Abstract This paper explores the personal impact of spiritual transformation in pastoral counseling, describing the journey to being the person God has called me to be as a person and a counselor. The journey is about developing true authenticity, divine connection and ultimately reaching a deeper spiritual connection with clients. The process of transformation is similar to that of a nurturing womb, cultivating the qualities within me that are useful for the work of God in ministry to clients seeking counseling. As in the womb, the development is at times turbulent but the outcome is often miraculous. Through my own work as a pastoral counselor, I find enduring a personal conversion informs my theological perspective and not only shapes, but redefines my presence with clients. This helps identify the spiritual foundations that are embedded in my growth, providing a more hospitable environment and cultivating empathy in the counseling setting. I provide a brief history of the reason I chose this profession while utilizing examples of my interaction with different clients to demonstrate the ways my core theological tenants, specifically, joy even in pain; forgiveness; prayer in the dark; and being faithful to my gifts, influence my spiritual growth, as well as, the counseling relationship.

Introduction The journey to becoming a pastoral counselor is not an abrupt decision, but a call to fulfill the work of God. I remember asking God, â&#x20AC;&#x153;What do you want me to do with my life?â&#x20AC;? out of the frustration I was experiencing with my career choices. I found fulfillment in a career that was not feasible for the family life I longed for in the near future, and disdain for the lack of concern for people in another field. The elders in my family urge younger generations to be

specific in prayer because God’s answers often surprise you. God did not answer my prayers immediately, as it was several years of working through pain and disappointment to reach a place of abundant joy, forgiveness, and understanding my spiritual purpose in life. This was the beginning of my spiritual transformation in preparation for serving God and others as a pastoral counselor. Scripture expounds on this in Ephesians 4:1 (NLT), explaining that God gives spiritual gifts to those who serve Him, to include prophets, pastors, teachers, evangelists, and apostles. These gifts are born into a person’s spirit through the transformative process similar to the many functions that take place within a thriving womb. The “spiritual midwife” and writer Joyce Rupp uses the womb as a constant metaphor for life with God. In her small book, Little Pieces of Light, Rupp (1994) says: “Darkness, a womb of silent nurturing, is where one waits patiently for the stirrings of new life to develop” (p. 72). The womb is a vessel of change in which many of life’s mysteries take place. Ironically, this dark space brings life into the light; the womb is warm and provides nutrients from the mother to the growing baby. When not properly prepared to hold new life, it can also be a hostile environment, but hospitable when nurtured to be a sustaining vessel. The womb has the capability of growing and nurturing, like the possibility of a new spiritual growth within me; however, even physically, the womb has to purge in order to develop and grow into a new spiritual self. Because of these profound and very spiritual meanings, I have chosen to use the image of the womb to present my faith journey and my theological perspectives, which have led me to and through my coursework in pastoral counseling. Joy Even in Pain Whether functional or impaired, the womb usually purges monthly through the shedding of the uterine lining as a natural process of preparing to carry a child. This shedding removes the

old un-nurturing tissue and rebuilds itself throughout the month to be open to the possibility of the conception and ongoing development of a baby. The spiritual journey is similar to this process of the womb; spiritual purging is necessary and natural, but it can take days or years to prepare a place that is favorable for growth. My journey to becoming a pastoral counselor and my personal spirituality has been a movement within the spiritual womb, involving preparation to be the person God has called me to be in this moment. The transformation of the spiritual womb is not always a comfortable process, just as starting on the path of discovering who I am spiritually can bring about what appears to be pain in the beginning. Sometimes, not for a long while does the recognition come that such pain always leads to joy. Psalms 30:5 (AMP) reminds me â&#x20AC;&#x153;[w]eeping may endure for a night, but joy comes in the morning,â&#x20AC;? and this has been my experience with spiritual growth. God is protective during the transformative process of the spiritual womb; however, the womb remains permeable to the external influences of the environment, even including such forces as family, friends, and careers. I find these external influences can make the spiritual journey a rough path to follow, as they often unintentionally and at times intentionally try to direct me along the path humans have said to be the most rewarding in material ways. On my journey, I have discovered that God is influencing me to choose the direction that will be holistically rewarding. Choosing not to seek God first in my endeavors, at times created great hurt in my life, a kind of spiritual pain within my growing womb. My experiences prior to deciding to be a pastoral counselor were rewarding, and I am grateful for the proficiencies I developed in each job; however in retrospect, the theme that I see underlying my choices of jobs was my lack of allowing God to guide my decision. Choosing not to listen to the movement of the Holy Spirit within me led to multiple feelings of hurt and lack of

fulfillment in my work. While experiencing this pain, I had the choice to become angry and stagnant in my spiritual life, but instead I chose to use the hurt to build up meaning in my life. I sought ways to find the fulfillment my soul lacked and finally understood that God can use even the pain to fulfill His goal of guiding me to pastoral counseling. Through my familiarity with being hurt and searching for meaning in my life, I am able to assist my clients in these areas as well. Forgiveness Lifeâ&#x20AC;&#x2122;s experiences of disappointment and resentment from unknowingly following a path not in Godâ&#x20AC;&#x2122;s plan caused me to carry deep anger for several years. Reflecting on this period in my life helps me to understand that it was part of the process for me to accept what God would later ask of me. In the confusing process of coming to real meaning, I held on to my disgust and anger for quite a while, until I came to the moment I prayed things would change. The need to forgive past transgressions was prominent in my thoughts and prayers when I took my first class at Neumann University, an elective that focused on forgiveness. At that time, I knew the only way for me to move forward in my call as a pastoral counselor was to go deeply inward, forgiving those that had unfairly hurt me. Looking inward led me to uncover many injustices that have occurred in my life and those that I had committed against others. Like the cleansing process necessary in the womb, part of preparing for a spiritual breakthrough requires forgiving such injustices. Impeding forgiveness creates anger for both parties, and anger supports a hostile environment antagonistic to spiritual growth. A paraphrased quote from Joretta Marshall, noted author on forgiveness describes the act as â&#x20AC;&#x153;a subversive and relational process that occurs as persons, families or communities move

away from the overwhelming power of a hurt in their lives toward reconciliation and liberation” (Mayer, 2012). When studying forgiveness I found it evident that a core principle in forgiveness is the ability to see the offending person as human. In “Moving toward Reconciliation,” Good Sider (2001) labels this point as the initiative to enter an outer circle, an entry that comes when the offended person re-humanizes the offender and begins to look at the offense from the offender’s perspective. While empathizing with the offender, the individual who has been hurt finds it necessary to be compassionate and not ask for anything in return. This type of empathy and embracing of the offender’s humanness has helped me to overcome the anger that compressed my spirit for years. I have also discovered that exploring this construct is helpful for clients presenting with clinical diagnoses. It is difficult to express the need of forgiveness in a clinical setting solely based on the medical model. The exclusively clinical approach leaves little room for helping clients with spiritual concerns, making being a pastoral counselor an asset in any practice. I have found the need to forgive surface with many clients, and one woman in particular stands out to me. Tasha (name changed for confidentiality), a client for over six months, presented with relationship problems with her fiancé. Together we unraveled the many layers of their relationship, allowing Tasha to realize that she was holding on to ill feelings toward those who had hurt her in the past. This anger had leaked into her current relationship and she acknowledged that it contributed to her reliance on illegal drugs. While we discussed the importance of forgiveness for healing, she expressed interest in exploring the process in healing both herself and her family.

Tasha had experienced seclusion from her mother, an absent father, and multiple failed relationships. Her faith tradition lay within the practices of the African-American Baptist Church; however, her experiences with church had been of her congregation’s excluding those that did not fit into the mold. For her it seems that this mold of theirs includes the illusion that everyone has to be perfect. Believing this, her background of drug use and the inability to care properly for her children drove her away from God. As she expressed her distance from God, she pled for a way to find peace and return to church. After exploring her fears, we began to work with the forgiveness process as established by Enright and his researchers (see Good-Sider, 2001). Eventually, through prayer and reading inspirational material, Tasha began to accept forgiveness from God for her past transgressions. Amazingly, once she accepted forgiveness, the ability to forgive others became easier than she imagined. Tasha now understands she is a child of God and has renewed her core beliefs as spoken by Jesus in Matthew 6:12, “…and forgive us our sins, as we have forgiven those who sin against us.” Subsequent sessions often resembled a roller coaster ride with her feelings of being unworthy acting as triggers to self and other loathing then a moving upward toward hope. The ability to facilitate growth in a client to move towards forgiveness requires me to understand the process myself and recognize areas in which my own personal forgiveness must occur. It is hypocritical for me to suggest reconciliation with one’s family for a client and refuse to enter into forgiveness with others in my own life. The key to being a pastoral counselor means having the courage to face my imperfections and use these for personal growth. Courage is the product of discovering my spiritual self and understanding forgiveness in the process of shaping my life.

Prayer in the dark As the transformation within the womb continued, I realized that my spiritual practices had become stagnant and I continued to feel incomplete. This all caused me great frustration. Rupp (2012) describes the path to an enhanced prayer life in her book The Cup of our Life as “… a journey toward becoming whole, a day-to-day movement of continually growing into the person we are meant to be” (p. 2).

The Holy Spirit began slowly filling that past void in my life

through biblical study and prayer. Rushing the process is not possible as God does everything in His time; thus I am keeping my development gradual, similar to the development of a baby in the womb. A baby does not appear overnight; likewise, becoming the person I am supposed to be will be an ongoing process. During the time I was searching for my purpose, I came to understand that prayer is essential. Sometimes, I find it difficult to pray, as though something is blocking my ability to share my thoughts or offer praise to God. During this time, I can imagine my spiritual womb nearing complete emptiness and preparing for restoration with qualities God can use to care for me as one of His children. The inability to pray can be frightening, and has caused difficult moments, even opening me to question if the move to my becoming a pastoral counselor was appropriate. In the article, The Dark Night and Depression, Carmelite writer Kevin Culligan (2004) describes such an unfulfilled feeling when a person’s ordinary method of prayer is no longer suitable for the stage of searching in spirituality. He explains discursive meditation as sensory and indicates it is the primary means of prayer at such times. I came to see that there is nothing wrong with continuing my discursive prayer life; however, it did not assist me with moving through my dark night. Now praying the Psalms is usually where I turn during these stagnant

times; these Old Testament prayers help to bridge the gap between the busyness of my life and my need to spend time with God. The Psalms help to re-ignite my dormant spiritual life; for much as within the growth of the womb, prayer needs space. As Kidner (2013) reminds us: If your ears are not hearing joy and gladness, the problem may not be around you but within you. Your heart may need to be cleansed and tuned once again to the music of God and the harmony of heaven, so that everything you hear reminds you of the Lord. I began to see myself shedding even some of the good growth as my conversion continued; after a while, even the Psalms no longer fulfilled my urge to be closer to God. I grew to know that the Dark Night offers a time of rebirth for the prayer life. Again, as Culligan (2004) states, “[o]nce the commitment to seeking God in the sensory self is sufficiently strengthened through discursive meditation, God begins to lead the person to divine union through contemplative prayer” (p.2). For me, contemplative prayer means my welcoming the presence of God and being open to God’s guidance without asking for things or having profound expectations after prayer. Thomas Keating (2002) explains, “[w]e may think of prayer as thoughts or feelings expressed in words. However, this is only one expression. Deep prayer is the laying aside of thoughts. It is the opening of mind and heart, body and feelings…” (p. 137) Turning to contemplative prayer has helped me to feel the presence of God, hear His voice and provide healing to my soul. I am able to help clients through times of darkness because of my lived experience. When children experience suffering, they often question why and how to pray during difficult times and sometimes they consider turning away from relying on God for help. While providing biblical and psycho-educational instruction, the recurrent theme I hear within the multicultural pre-teen group I co-facilitate at church is how to pray when life has not been fair. My young group members often wonder why those who do not believe in

God seem to have great lives. Leading the group through various Psalms led me to understand that God hears our frustration and that, even the great figures in the Bible, heroes such as David, experience moments in the darkness. Similarly, while serving as a chaplain intern during my clinical practicum in a hospital setting, recall burn patients struggling with finding God in the midst of their excruciating pain and darkness. After admittance to the hospital and experiencing the pain of burns and of technicians and nurses cleansing the wound, it is difficult for many dealing with such suffering to see the possibility that God can use this terrible situation to transform a life. Attending to the patients during this moment in a non-judgmental way and offering other forms of prayer, such as the prayers of presence, my praying for them, and the gift of compassion, I can help to open the door for them to share their feelings of hurt and pain not only with me, but also most importantly, with God. Being faithful to my gifts The more I search and become aware of God’s voice, the more I begin to become unsettled in doing the minimum. My response to that is to do more spiritually. When my work becomes overwhelming, the Holy Spirit further nurtures my spiritual womb. During contemplative prayer, I can hear God’s voice at a whisper, saying: “Well done; now I have something else for you.” There is a move to do more and reach more people in an attending manner. Being obedient to this message means searching for a deeper understanding of the gifts I am entrusted with by God. Rick Warren (2002) of The Purpose Driven Life provides insight into searching for personal gifts, saying, “[y]ou can’t earn your spiritual gifts or deserve them -that’s why they are called gifts! They are an expression of God’s grace to you” (p.236). The gifts

are part of the cultivation of my spiritual self. Allowing the environment around me to become uncomfortable by turning the focus from others to myself gives birth to the talents God has given me. Focusing on me had been outside of my comfort zone because I was unsure what I would discover about myself. When I read literature focused on spirituality and ministry in the church, I discovered that fear is a common theme and an integral part of many persons’ lives. Part of what I learned is that it is necessary for me to move from the negative and discover the courage available to me and my clients during tumultuous periods in life. When I am afraid, it is imperative for me to recognize my inner courage. Courage comes in the form of utilizing my spiritual gifts while being a voice in the community. I realize that many community servants lack the ability to tolerate “the other,” and some others may use the opportunity to advocate for those that are considered the other for personal gain. “The other” is anyone who appears different, whether it is because of religious beliefs, physical appearance, mental aptitude or any characteristic that marks a difference. Ryan LaMothe (2012) asserts that Nelson Mandela and Martin Luther King, Jr. possessed radical courage in that they fought for justice, while accepting the other: However, their courageous resistance was not self-righteous and not aimed at alienating whites; nor did it involve a projection of their vulnerability onto others. Even in the face of significant threat, these leaders lived a radical courage that remained open to the O/other (p. 460). While speaking out about the existing intolerance toward the O/other takes courage, doing this is necessary to accept the role God has given me. My gift is wasted if I do not voice the wrong of the narrow-mindedness inflicted by some who claim to be Christ followers. Such

loss would be, as the writer of Proverbs (30:16) calls it: “the grave, the barren womb, land, which is never satisfied with water, and fire, which never says, 'Enough!'” Some people have said that I am too vocal and my comments can come across harshly; yet, part of my gifts growing to greater depths involves the ability on my part to recognize the impact of my deliverance on others. Tactful discussion can create change, especially with the additional gifts of leadership and advocacy. Pastor Brad Kellum (2014) teaches the principle of influence through leadership as part of our faith community’s core values. Kellum (2014) explains this as Leadership Development: We encourage people to stop second-guessing themselves and begin leading as God has designed them to…We aim to teach people that leadership is influence not position. We seek to develop spiritual influencers who will use their words, actions and resources to move others toward spiritual connection with Jesus Christ (p. 27). The awakening that others and I have the ability to make a change, even a small change, has a ripple effect in the emotional sea of a community; however, recognizing the emotions is pivotal. Moments to act as a leader embodying courage often come during times when I am facing some form of distress. During family sessions with teens, the topic of religious preference can come up during the discussion of dating. Sometimes the topic can become intimidating; especially when a Christian family seeks counseling for a teen specifically due to his dating an atheist and the family is notable in the church community. This is unnerving for me because as Christians we believe in loving others despite their flaws. It is in this time that I take the risk of asking if the focus of the disgust from the parents is toward the boyfriend/girlfriend or his/her belief practice. This is necessary to help the person identify the contradiction that is born out of

this hatred. Taking the hidden emotion and placing it in front of the person can help him/her to understand that he/she too is acting in a way that is opposite of what Christ teaches. Christ used the qualities of the other to draw each person to salvation through Him. Joel Osteen (2011) in Every Day a Friday focuses on uplifting messages; however, he admits that religious people like to criticize others and encourages Christians to â&#x20AC;&#x153;[l]ook for those you can lift up instead. Help them reclaim their happiness and joyâ&#x20AC;? (p.245) Lifting others up is an important part of working with teens that are managing major mental health diagnoses, such as oppositional defiant disorder or bipolar disorder. As a counselor, I find myself speaking to parents about behavior modification within the home. These younger clients sometimes believe they receive mixed messages from their parents. They admit how confusing it is to participate actively in counseling while their home environment is causing an increase in symptoms. At times, the continuous negative feedback some of the clients receive from home causes them to look for acceptance and encouragement from people who do not have their best interests at heart. My explaining various alternatives to the current reward and punishment behaviors that parents are, even without any awareness, implementing repeatedly proves to be valuable in helping the teen identify his/her own problem behaviors. The last thing a parent usually wants to discuss with me at the end of a session is how his/her parenting style is attributing to his/her childâ&#x20AC;&#x2122;s symptoms; however, my failing to do so is an injustice to my client. In these sort of moments, I realize that the transformation God started in my spiritual womb has given birth to my new spiritual life as an empathetic, forgiving person that advocates for individuals that are searching for healing in their lives. The best advocacy I can provide for my clients is holding the counseling space like a nurturing and loving womb. Allowing them to discover their renewal during the counseling process and, like me, accept ownership of both the

strengths and weaknesses that are born through this transformative process is all part of the womb growth. References Mosak , H., & Di Pietro, R. (2006). Early recollections: Interpretive method and application. New York, NY: Routledge. Culligan, K. (2004). The dark night and depression. Presence, 10(1), 9-19. Good Sider, N. (2001). At the fork in the road: Trauma healing. Conciliation Quarterly, 20(2). Retrieved from http://www.journeytowardforgiveness.com/mapping/article1.asp Kellum, B. (2014). The playbook: God's Path to our promised land. Claymont, DE: NorthLife Community Church. Kidner, D. (2013). Psalms 51:1-9. Retrieved from Precept Austin: http://www.preceptaustin.org/psalm_511-9_commentary.htm LaMothe, R. (2012). Broken and empty: Pastoral leadership as embodying radical courage, humility, compassion and hope. Pastoral Psychology, 61, pp. 451-466. doi:10.1007/s11089-011-0417-9 Mayer, S. (2012). Forgiveness, reconciliation, and healing. Personal Collection of S. Mayer. Aston, PA: Neumann University. Osteen, J. (2011). Every day a Friday: How to be happier 7 days a week. New York, NY: Faith Words. Rupp, J. (1994). Little pieces of light: Darkness and personal growth. Mahwah, NJ: Paulist Press. Rupp, J. (2012). The Cup of Our Life. Notre Dame: IN: Ave Maria Press.

Warren, R. (2002). The purpose driven life: What on Earth am I here for? Grand Rapids, MI: Zondervan. Williamson, M. (1992). A return to love: Reflections on the principles of a course in miracles. New York: NY: Harper Collins.

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Supporting the Communication Needs of Children with Hearing Impairments Student Authors: Nicole Lebedz and Samantha Wilson Academic Program: Education Faculty Advisor: Daniel McKee, Ed.D. Abstract The purpose of this paper is to discuss the various ranges of hearing impairments in children and explore appropriate interventions to address their communication needs. These interventions will be examined in the school, home, and community environments. A background of the causes, characteristics, and degrees of hearing loss will be reviewed. Case studies, specific examples, and relevant applications will be evaluated in context within each environment. Consideration will also be given to appropriate accommodations for varying degrees of hearing impairments. The paper will include research-based suggestions for professionals in related fields, families affected, and all others who interacts with these children. Peer-reviewed journals, personal experience, and current research in the education field will serve as the basis for research.

The Better Hearing Institute has estimated that about 10% of the U.S. population has hearing difficulties. Of that population, at least 1.4 million are children. Compared to children who have normal hearing, those who experience some degree of hearing loss face challenges learning appropriate vocabulary, grammar, and other aspects of communication (â&#x20AC;&#x153;The Prevalence and Incidence,â&#x20AC;? 1997). There is no proof that one method of communication is best for all children with hearing loss, which makes it a challenge for professionals and caregivers to communicate effectively with children who struggle with this type of impairment. There are numerous factors that must be considered, which is why communicating effectively with those who have hearing loss is so difficult. It is imperative that professionals find an effective method 41

of communication so that children with a hearing impairment do not suffer delays in other developmental areas. This paper will describe effective communication methods, as well as the diverse characteristics of hearing loss, in an effort to support professionals and caregivers in intervening successfully with and on behalf of children who have hearing loss (Crowe, McLeod, McKinnon, Ching, Nippold, & Hayes, 2014). Hearing loss can be described as the inability to hear sounds. It is caused by damage to one or more parts of the ear in utero or after birth. However, hearing loss is not a simple disability. It is defined by type, degree, and configuration. The three main types of hearing loss are conductive, sensorineural, and mixed. Conductive hearing loss is characterized by an impairment in the outer ear canal or the middle ear. This interferes with sounds being conducted through the canal to the eardrum. Conductive hearing loss can be surgically corrected with an implanted device or addressed with a hearing aid. Sensorineural hearing loss cannot be fixed and is the most common type of permanent hearing loss (â&#x20AC;&#x153;What is Hearing Loss?,â&#x20AC;? n.d.). It occurs when the inner ear or nerve pathways are damaged. A person with sensorineural hearing loss has trouble hearing soft sounds, and speech often has a muffled tone. Mixed hearing loss is a blend of sensorineural hearing loss and conductive hearing loss. The seven degrees of hearing loss are normal, slight, mild, moderate, moderately severe, severe, and profound. Each degree is recognized by means of an audiometer and audiogram. Audiometers are machines used to assess the sounds that someone can or cannot hear. An audiogram is a chart with symbols that signify the sounds that a person is capable of hearing during an exam. The intensity of sounds is measured in decibels (dB). The decibels are divided into groups to represent each degree of hearing loss. For example, -10 to 15 decibels represents the intensity of sounds that one with a normal degree of hearing can hear (â&#x20AC;&#x153;What is Hearing 42

Loss?,” n.d.). The smaller decibels are the softer sounds. As the degree of hearing loss becomes more severe, the decibel ranges are higher because softer sounds are what people with hearing loss struggle to hear. With a more severe degree of hearing loss, people are only capable of hearing a small range of sound intensities. There are also different configurations of hearing loss which adds to the complexity of the disability. One can have bilateral or unilateral hearing loss. Bilateral hearing loss is hearing loss in both ears, while unilateral means having some degree of hearing loss in only one ear. With bilateral hearing loss, it is possible that the hearing loss can be symmetrical or asymmetrical. This means that the degree of hearing loss as well as the configuration is the same in both ears or different in each ear (“What is Hearing Loss?,” n.d.). For example, if one has bilateral hearing loss, he/she may have mild hearing loss in the left ear and severe hearing loss in the right ear. This hearing loss can develop suddenly or progressively. Sudden development of hearing loss is when the inability to hear certain sounds happens quickly versus progressive development when the hearing loss becomes apparent over a period of time. The last type of configuration for hearing loss can either be fluctuating or stable. Fluctuating hearing loss is when the tones that one can hear changes over time meaning that the degree of hearing loss may become worse or may improve. Stable hearing loss is when one can only hear the same tones at the same intensity without a change over time (“What is Hearing Loss?,” n.d.). Hearing loss is a common impairment because of the numerous causes and risk factors that can damage a person’s hearing abilities. One of the most well-known and common causes is damage to one’s ear. Abnormal bone growth, tumors, ruptured ear drums, and head traumas can also cause hearing loss. Head trauma can cause a rupture in the ear which impacts a person’s hearing. Surgery can sometimes fix one’s hearing capabilities, but it is not guaranteed (“Basic 43

Facts about Hearing Loss,” n.d.). Another frequent cause of hearing loss is ear infections which are common in small children. If ear infections are not treated right away or are recurring, they can damage the inside of the ear and cause hearing loss. Ear infections can also cause otitis media leading to a temporary, and possibly permanent, hearing loss, if not treated. If there is a buildup of ear wax in the ear, hearing loss can occur, so it is important to clean the ears regularly. Repeated exposure to loud noises, as well as listening to loud music, can progressively damage a person’s hearing. If exposed to loud noises or music, it is important to move away from the noise after a short period of time, wear protective ear plugs, or decrease the volume if it is within one’s control. Genetics are also a cause of hearing loss. About 50% of hearing loss in babies is due to genetics (“Genetics of Hearing Loss,” 2015). There are also a number of non-genetic, congenital factors contributing to hearing loss. A few examples of the non-genetic causes are prematurity, low birth weight, maternal infections, or abnormalities (Duthey, 2013). There are a few characteristics to look for that may indicate whether or not someone has difficulty hearing. Two of the most obvious behaviors are increasing the volume on the television or radio and frequently asking people to talk slower, louder, and/or clearer. A few other symptoms may be muffled speech and trouble understanding other people when they speak, especially if there is any background noise. Those having trouble hearing may avoid conversation with people, or social settings in general, because they have trouble hearing and/or understanding what is being said to them (“Hearing Loss,” 2014). Regardless of the severity of the hearing loss, it will take time for a child and the child’s family to adapt to living with the disability. The time it takes to adapt at home depends on the degree of hearing loss, the family’s knowledge of the disability, and the communication needs of 44

the child. When a child has a mild hearing loss, he/she does not typically need any amplification devices. With mild hearing loss, one may have trouble understanding speech (Moller & Jespersen, 2013). Many times people with mild hearing loss are unaware of their issues because they are so minor. Because of the mild hearing loss, there may not be any need to adapt at home or it may take only a short amount of time. It is important to talk with the child’s audiologist to discuss whether or not an amplification device, such as a hearing aid, is necessary to benefit the child. For a child with moderate hearing loss, soft sounds and fairly loud noises can become inaudible. When background noise is present, it becomes extremely difficult for a child with hearing loss to hear and understand other people when they are talking (“What Are the Different Degrees,” n.d.). Interactions with a child with a severe degree of impairment can be challenging for others as well because it takes a lot of effort by an individual to be heard by someone with severe hearing loss. The range of sounds that they can hear is very limited and they often require a high volume on electronics. With both moderate and severe hearing loss, some type of amplification device is recommended. One of the most important areas to pay attention to as a parent of a child with a hearing disability is communication. In order to communicate effectively with a child who has hearing loss, one needs to be patient and understand what their child can and cannot hear. It will take time to learn how to communicate with a child who has severe hearing loss. Some important things to remember are to face the child and to speak loudly and clearly. Many children with hearing loss learn to depend on lip reading as a back-up plan to understand what people are saying. For example, if children with hearing loss are talking to their mother, they may be reading their mother’s lips as she talks to ensure that they understand what she is saying. It is important to ensure that children are paying attention and know that they are

being spoken to. If it is possible, use visuals or gestures while speaking to children in case they are unable to understand everything being said. Another option for helping children with hearing loss is by having an alert system in the household. These systems can be set up to alert children when the phone is ringing, the doorbell has been rung, or even if there is a fire in the house. View panels in doors throughout the house may also be helpful in case children do not or cannot hear a knock on the door or hear the doorbell ring. It is common for the sound of a doorbell to be too high-pitched for a person with hearing loss to hear. For a child with severe hearing loss, they may rely on sign language as their method of communication. If that is the case, then it is important to have good lighting around the house so that when the child is communicating with others there are no difficulties seeing the signs. Good lighting can also be beneficial if a child heavily relies on lip reading while conversing with others (“Home Modifications for Hearing Loss,” n.d.). While certain sounds may be difficult for children with hearing loss to hear, it is important not to speak too loudly. Most children who have hearing loss have hearing aids. One of the most important things to know about hearing aids is that they are an amplification device; they do not fix anyone’s hearing loss. Hearing aids are able to make sounds louder for children, but they do not make speech clearer. It is important to remember not to yell at children with hearing loss as this can be both embarrassing and frustrating. The best thing to do is to speak clearly and make sure one’s voice is loud enough for the child to hear, but not so loud that the child thinks he/she is being yelled at. If parents are having trouble figuring out which volume is appropriate for talking to their children, they may want to pay attention to their child’s facial expressions or their body movements for some clue as to whether or not they understood what was said. 46

Some families may find assistive technology to be beneficial when trying to communicate with children. FM systems are common devices used with children who have hearing loss because they can be used anywhere. FM systems consist of a small microphone which is attached to a transmitter that clips onto the shirt of whomever is speaking. The student wears the hearing aids, which serve as the receiver. The hearing aid has a small wire inside of it that receives the sounds coming from the microphone (“Assistive Devices,” 2011). While at home, some children may use sound boards to communicate with their families. Sound boards consist of words, phrases, or images that the child puts together to communicate what they want or how they feel. Most sound boards can be personalized for children. Telephone conversations can be made easier by using captioned telephones. Any level of hearing loss can affect a child’s ability to succeed in school. Hearing loss can cause a delay in the development of receptive and expressive communication skills (speech and language). This language deficit may cause learning problems that result in reduced academic achievement. Communication difficulties often lead to social isolation and poor self-concept (“Hearing Assistive Technology,” n.d.). The earlier hearing loss occurs, the more serious the effects can be on the child’s development. However, if the problem is identified early and intervention begins, the overall effect can be less serious. Similar to intervention at home, there is no single treatment that will work for all children with hearing disabilities in the school environment. Research supports that a good intervention includes close monitoring, follow-up, and changes as needed along the way (“Treatment and Intervention Services,” n.d.). Working with a trained professional or team may provide the additional support needed to help a child succeed. Hearing impairments may be addressed through special education, meaning free services can be provided to students through their Individualized Education Program (IEP) 47

(“Treatment and Intervention Services,” n.d.). Given the close relationship between oral language and hearing, students with hearing loss might also have speech impairments (“Hearing Impairments,” n.d.). An IEP, which tailors students’ needs and difficulties with appropriate support, can be developed. The IEP multidisciplinary team, which can include the teacher, audiologist, speech pathologist, special education teacher, and others as appropriate, determines the best accommodations and modifications for the child (“In the Classroom,” n.d.). There are many assistive technology devices available to assist the child within the school setting. The specific device or devices used depend on the severity of the hearing loss and the task the student must complete. Options include the traditional hearing aids, cochlear implants, and the FM system previously mentioned. The FM system can be particularly beneficial for a student if the child is in a distracting environment. The FM systems require the transmitter and receiver to be on the same channel and the sound waves from the microphone can travel up to 300 feet. If there are other children who wear hearing aids and are using an FM system within 300 feet, the students may pick up mixed signals from other speakers. In order to avoid receiving these mixed signals, students in different rooms or listening to a different speaker should use different channels (“Assistive Devices,” 2011). Closed captioning on television and video programming would also support the student’s listening efforts, especially if the person talking is not visible on screen; closed captioning is useful for students without hearing loss as well. Portable sound amplifiers offer another opportunity, particularly for students with mild or moderate hearing loss. These devices can be worn on the body or handheld and help students hear what other people are saying in one-on-one conversations or small group settings. Most of these personal amplifiers come with earphones or headphones for people

without hearing aids or have a neck loop for hearing aid users to listen through their hearing aids (“Hearing Amplifiers,” n.d.). Those with severe hearing loss may use a portable sound amplifier in conjunction with other supports in order to ensure full understanding. Cellular phones are another commonly used device with options such as an extra loud ringer, bright flashes and vibrations for incoming alerts and calls, and speech-to-text. These devices can be used in higher education for social activities and communicating with peers. Most people with a hearing impairment still have some hearing ability, called “residual hearing” (“Treatment and Intervention Services,” n.d.). For a person with hearing loss, listening is often challenging without proper training. Therefore it is important to maximize the residual hearing of the student by capitalizing on the services of a speech-language pathologist. These professionals are trained to teach people how to use speech and language. Student-specific accommodations during standardized testing are available and mostly related to presentation of test material, response to test questions, setting, and timing (“Accommodations for Students,” n.d.). During class, peer note takers can assist hearing impaired students so that they can concentrate on listening and feel confident they have the correct information. With regard to learning language, there are several techniques used to compensate for the hardships hearing loss entails. American Sign Language (ASL), Manually Coded English (MCE), Conceptually Accurate Signed English (CASE), and cued speech are all different forms of visual language (“Treatment and Intervention Services,” n.d.). Participants use their hands and gestures to communicate meaning. Cued speech helps listeners differentiate between similar sounding words when lip reading is not enough. The person communicating uses eight hand shapes and four places near the mouth to differentiate among various speech sounds (“Treatment and Intervention Services,” n.d.). Finger spelling is exactly what the name suggests—the person

communicating uses hands and fingers to spell out words. This method is typically used in combination with other communication methods. Natural gestures, or body language, are commonly used, even without training or instruction. For example, if somebody was asking for a hug they might put their arms out to the side. Special attention to seating arrangements can have a significant positive impact for a student with hearing difficulties. The student needs to be seated close enough to the front so he/she can hear the teacher, but it becomes challenging if the teacher moves around the room a lot. It is important that the student and their teacher communicate often to ensure that all the material is being heard correctly and the student is not missing vital instruction. Reducing visual distractions and background noise is crucial and supports the other intervention methods being implemented. Anyone communicating with the child should pay attention to the speech reading conditions; specifically they should avoid putting their hands in front of their face, having mustaches covering the mouth, and chewing gum (â&#x20AC;&#x153;Accommodations for Students,â&#x20AC;? n.d.). Information should be presented in a simple, structured, and sequential manner. Extra time may be needed for the student to process the information and repeating or rephrasing information may be necessary. The instructor and other professionals working with the child must frequently check for understanding. Teachers should consider whether the student needs a break from listening for a period of time. Visual supports such as overheads, chalkboards, charts, vocabulary lists, and lecture outlines should be used to ease the listening burden for the child. Modifying reading and written assignments may be necessary. The student may benefit from vocabulary tutoring in advance, including early exposure to the new words and extra practice. Teachers should repeat the comments and questions of other students, especially those from the back rows, and they should acknowledge who has made the comment so students with hearing

loss can focus on the speaker. Field trip arrangements should be made early to ensure that accommodations will be in place on the given day. When a teacher is in doubt about how to assist the student, he/she should ask privately what is needed without drawing attention to the student or the disability (“Teaching Strategies,” n.d.). Additionally, for safety considerations, a flashing fire alarm may be required in the school building. Special consideration should be given to recreational and social opportunities presented to the child. The emotional challenges that come with any disability can increase in a school setting surrounded by typically developing peers. Positive peer interaction is an important social aspect. Children with hearing loss may frequently say “huh” and “what,” which can disrupt the flow of conversations. Children with hearing aids or other assistive technology will be repeatedly asked what they are and why the child has them. Having a positive circle of friends makes handling the disability easier. As a teacher, it is important to keep all the students informed about students with a hearing loss. It is very helpful when a student’s classmates know to speak loudly enough and clearly when having a conversation with a student who has hearing loss. Coping with hearing impairments in the community can be more challenging than within a school environment because others may not be aware and therefore less support is received. The Americans with Disabilities Act requires most public venues, such as movie theaters and pharmacies, to provide listening systems. According to the National Association of the Deaf (n.d.), “places of public accommodation must give persons with disabilities an equal opportunity to participate in and to benefit from their services. They must modify their policies and practices when necessary to provide equal access to services and facilities.” This may include modifications to telephones, such as amplification or a captioned phone system. Typical smoke

alarms and carbon monoxide indicators may be hard to hear, so alternate systems may be necessary (“Living with Hearing Loss,” n.d.). When communicating with a person with a hearing disability, several factors merit consideration. One should face the person directly, get their attention, and avoid noisy environments. Individuals should not shout, but rather ask how they can facilitate communication. Speaking clearly at a moderate pace is important and the speaker should not over-emphasize words because that can make a person with hearing loss feel embarrassed or the speaker could appear as rude. It is important to be respectful and help build the confidence of the person with hearing loss by holding a mutually beneficial conversation. If the speaker overemphasizes words, the person with the disability may become upset or angry and avoid the conversation. Eventually, this could lead to withdrawal from social settings and further distancing themselves from a healthy social life. Instead, it is important to rephrase sentences if the speaker is not understood and to incorporate facial expressions and gestures (“Living with Hearing Loss,” n.d.). One should be patient for the response and stay positive. This will facilitate interactions. Friends who have frequent interactions with the child with hearing loss may also consider learning sign language as another means of communication. The person with hearing loss might also want to follow some suggestions to help enhance the conversation. One suggestion is to tell other people how to best talk with them. It is helpful to pick the best spot to communicate, taking into consideration the lighting, volume of the area, and proximity to the speaker. Individuals with hearing loss should anticipate difficult situations and plan how to minimize them (“Living with Hearing Loss,” n.d.). Alternatively, listeners should not interrupt the speaker, but rather let the conversation flow to fill in the blanks and gain more meaning. 52

Joining a support group may lessen the loneliness of this disability (“Living with Hearing Loss,” n.d.). These groups give people with various degrees of hearing loss the opportunity to learn from others’ experiences. Joining an organization, such as The Hearing Loss Association of America (HLAA), can provide “assistance and resources for people with hearing loss and their families to learn how to adjust to living with hearing loss” (“Living with Hearing Loss,” n.d.). Given the prevalence of hearing loss among children, it is important to understand hearing loss and apply what we know about effective strategies and interventions to enhance their chances for success. Assistive technology, alternative communication methods, and conversation strategies all play a role in addressing developmental delays. As always, the best option is early recognition and intervention. Treat ear infections correctly and promptly, keep headphone and music levels to a minimum, and prevent injury to the ears as best as possible. All those interacting with a hearing disabled child, including family, friends, and professionals, should educate themselves and work cooperatively with the child based on his/her individual needs. References Accommodations for students with hearing loss. (n.d.). Retrieved August 14, 2015, from http://successforkidswithhearingloss.com/relationship-hl-listen-learn/accommodations Assistive devices for people with hearing, voice, speech, or language disorders. (2011, December 1). Retrieved August 10, 2015, from http://www.nidcd.nih.gov/health/hearing/pages/assistive- devices.aspx Basic facts about hearing loss. (2005). Retrieved August 9, 2015, from http://www.hearingloss.org/content/basic-facts-about-hearing-loss 53

Crowe, K. k., McLeod, S., McKinnon, D. H., Ching, T. C., Nippold, M., & Hayes, L. (2014). Speech, sign, or multilingualism for children with hearing loss: quantitative insights into caregivers' decision making. Language, Speech & Hearing Services In Schools, 45(3), 234-247. doi:10.1044/2014_LSHSS-12-0106 Duthey, B. (2013, February 20). Background Paper 6.21 Hearing Loss. Retrieved August 9, 2015, from http://www.who.int/medicines/areas/priority_medicines/BP6_21Hearing.pdf Genetics of hearing loss. (2015, February 18). Retrieved August 9, 2015, from http://www.cdc.gov/ncbddd/hearingloss/genetics.html Hearing amplifiers. (n.d.). Retrieved August 14, 2015, from http://www.harriscomm.com/equipment/personal-listening/conversation-amplifiers.html Hearing assistive technology. (n.d.). Retrieved August 14, 2015, from http://www.asha.org/public/hearing/Hearing-Assistive-Technology/ Hearing impairments. (n.d.). Retrieved August 14, 2015, from http://disability.illinois.edu/instructor-information/disability-specific-instructionalstrategies/hearing-impairments#2 Hearing loss. (2014, September 5). Retrieved August 9, 2015, from http://www.mayoclinic.org/diseases-conditions/hearing-loss/basics/symptoms/con20027684 Home modifications for hearing loss. (n.d.). Retrieved August 10, 2015, from http://www.infinitec.org/totalresource/deaf/modhearing.htm In the classroom. (n.d.). Retrieved August 14, 2015, from http://www.betterhearing.org/hearingloss-children/classroom

Living with hearing loss. (n.d.) Retrieved August 14, 2015, from http://www.hearingloss.org/content/living-hearing-loss MĂ¸ller, K., & Jespersen, C. (2013, December 9). What are some common misconceptions of mild hearing loss? Retrieved August 10, 2015, from http://www.audiologyonline.com/ask-the-experts/what-some-commonmisconceptions-mild-12268 Public accommodations. (n.d.). Retrieved August 14, 2015, from http://nad.org/issues/civilrights/ada/public-accommodations Teaching strategies for hearing impaired students. (n.d.). Retrieved August 14, 2015, from http://www.ferris.edu/htmls/colleges/university/disability/faculty-staff/classroomissues/hearing/hearing-strategy.htm The prevalence and incidence of hearing loss in children. (1997). Retrieved August 14, 2015, from http://www.asha.org/public/hearing/Prevalence-and-Incidence-of-Hearing-Loss-inChildren/ Treatment and intervention services. (n.d.) Retrieved August 14, 2015, from http://www.cdc.gov/ncbddd/hearingloss/treatment.html What are the different degrees of hearing loss? (n.d.). Retrieved August 10, 2015, from http://www.phonak.com/com/b2c/en/hearing/understanding_hearingloss/types_of_hearin g_loss.html What is hearing loss? (1997). Retrieved August 31, 2015, from http://www.asha.org/public/hearing/What-is-Hearing-Loss/

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Inclusion: Is it the Right Choice for All? Student Author: Jessica Lewis Academic Program: Education Faculty Sponsor: Daniel McKee, Ed.D.

Abstract An increasingly common educational placement option for students with disabilities is the general education classroom. This option is known as inclusion and it is the practice of integrating students with disabilities with peers who are typically developing in the general education classroom to the maximum extent appropriate. This paper will provide a historical perspective on the inclusion of students with disabilities in the general education classroom, and will highlight the legal influences that have supported the increased utilization of this approach. Emphasis will also be placed on the analysis of case studies, through which the educational experiences of two students with disabilities who were placed in inclusive settings will be explored. Finally, the authorâ&#x20AC;&#x2122;s views on the educational and social benefits and challenges of inclusion will be shared. Introduction Inclusive classrooms are increasingly common within the educational system. Inclusive practices are based upon the professional belief that students with disabilities should be integrated into general education classrooms to the maximum extent appropriate, and should be full members of these learning communities. This paper will examine various issues related to inclusion with particular emphasis on a historical perspective, legal influences, and the benefits and challenges of this approach. Specifically, the impact of inclusion on the educational experiences of two children will be examined.

Historical Perspectives on Inclusion The view that children with disabilities should be educated with typically developing peers have not always been accepted. Historically, children with disabilities in our country may have received little or no formal education (Torreno, 2012). The prevailing view was that children with disabilities should be segregated from students without disabilities, based upon the belief that it would be beneficial to all involved. As a result, separate schools were created for the students with disabilities during the mid and late 19th century (Torreno, 2012). Although these schools claimed to be educating students with disabilities, these â&#x20AC;&#x153;schoolsâ&#x20AC;? were actually used as residential facilities and institutions to isolate pupils with disabilities from others. The societal view was that if individuals with disabilities were put in these institutions, it would no longer be necessary to deal with the issue of properly educating them. Although many people had negative feelings towards children with disabilities being educated with typically developing peers during this time period, there were others who believed students with disabilities should be treated no differently than students without disabilities. As a result of this belief, educational programs were being created for people to train on how to care for disabled students. Meanwhile, parents began to advocate for their children with disabilities and schools and programs began to be developed to attend to the specific needs of these students (Torreno, 2012). Attitudes regarding children with disabilities continued to change as the years went on. By the mid-1920s, educators began to see the positive influence that education and community involvement could have on a child with a disability. Because of this, special education began to develop and was established in large cities (Torreno, 2012). Meanwhile, while the perspectives of educators were beginning to change, many parents continued to place

their children in institutions because of the residential component. They believed it was the only place for their child to get the proper care as well as the education they needed. Legislative Influences on Inclusion The civil rights movement had an important impact on the education of children with disabilities, particularly the Brown vs. the Board of Education ruling against segregated schools. Not only did this case end segregation in public schools for children of race, but it also laid the groundwork for ending segregated programming for children with disabilities (Torreno, 2012). During the same time period, various parent groups began working on changing the belief that children with disabilities could not be taught in a general education classroom (Torreno, 2012). The Brown case and the parental movement influenced initiatives in federal and state legislation, as well as the creation of new educational and employment opportunities (Torreno, 2012). The mid-20th century was a time when many educational advances occurred for students with disabilities. For the first time, these individuals were being seen as worthy to receive a proper education alongside their peers. Despite all of these positive changes, there was still a prevalent belief that schools should remain as they were, and as a result, more than a million students with disabilities were excluded from public school and another 3.5 million did not receive the appropriate services needed to be successful (Torreno, 2012). In 1973, a landmark law was passed that served to enhance opportunities for people with disabilities. The Rehabilitation Act of 1973 guaranteed employment and educational rights to people with disabilities who attended or worked for institutions that received federal funding (Torreno, 2012). As a result of this law, individuals with disabilities received improved access to both facilities and programs. This law was later amended in 1986, and again in 1992, to keep current with changes in the educational field and work force (Torreno, 2012).

Although this law granted access to education for students with disabilities, there were still challenges within the education system, primarily because the necessary supports were not being provided. As a result, the Education for All Handicapped Children Act, also known as PL 94-142, was signed into law in November of 1975 (â&#x20AC;&#x153;The Education For All Handicapped Children Act (PL 94-142) 1975,â&#x20AC;? 2007). This law required that public schools accepting federal funding provide equal and improved learning for students with disabilities and the opportunity to learn in a general education classroom when appropriate (The Education For All Handicapped Children Act (PL 94-142) 1975, 2007). The act contained six key mandates to ensure that students with disabilities received proper care and educational supports. These mandates were 1) zero reject; 2) nondiscriminatory identification and evaluation; 3) provision of an individualized education program (IEP); 4) education in the least restrictive environment (LRE); 5) the availability of due process; and 6) parental participation (The Education For All Handicapped Children Act (PL 94-142) 1975, 2007). Zero reject was a component stating that all children, no matter what their ability, are guaranteed a free and appropriate public education (The Education For All Handicapped Children Act (PL 94-142) 1975, 2007). This component ensured that no matter how severe a studentâ&#x20AC;&#x2122;s physical or mental disability may be, he/she must receive appropriate educational services. The nondiscriminatory identification and evaluation requirement was a way to ensure that students with disabilities were not being identified or evaluated in a way that discriminated against their race or mental capabilities through the use of inappropriate tests or unqualified administrators (The Education For All Handicapped Children Act (PL 94-142) 1975, 2007). This component provided a fairer assessment model for referred students.

The IEP component was included in this act to ensure that the individual needs of a disabled student were being met. This mandate required each student with a disability to have a program designed specifically for him/her that focused on both strengths and weaknesses, and identified goals to be met and steps to meet those goals. The least restrictive environment mandate means that children with disabilities are taught with students without disabilities to the maximum extent appropriate. The goal is to promote educational, social, and behavioral growth through the integration of children with disabilities in the typical classroom, as long as the educational process is not compromised. The due process mandate means that students with disabilities and their families are offered legal protection in resolving disputes with schools (The Education For All Handicapped Children Act (PL 94-142) 1975, 2007). Detailed procedures have been developed to address disagreements, particularly about where and how a child is educated, and these procedures have been specifically applied to student placement either in special settings or the studentâ&#x20AC;&#x2122;s home school district. The parental participation mandate requires that parents have an opportunity to participate in the decision-making process for their child with regard to placement, the development of the IEP, and evaluations. Because of these six mandates and the increased focus on meeting the varied needs of children with disabilities, families were able to finally feel included and heard by those within the education system. Fifteen years later in 1990, the Americans with Disabilities Act was created. This law protected school-age students with disabilities beyond the education system, specifically in the areas of employment and receiving access to public and private services (Torreno, 2012).

Most recently, the Individuals with Disabilities Education Act, which was formerly known as the Education for All Handicapped Children Act, was revised and updated. This law has additional guidelines that all school districts are required to follow in order to provide a free and appropriate public education for all children in the least restrictive environment (Torreno, 2012). Analysis of Case Studies Historically, there has been a shift to making schools more inclusive with regard to the provision of services and placement options for children with disabilities. What is the value and impact of inclusion on the educational lives of individual children? Would the students truly want to be in an inclusive classroom or is it more about the preferences of parents who want their children in a particular school? The following case studies will provide two different perspectives on the topic of inclusion. The first case study is about a young woman named Ro Vargo who was diagnosed with Rett Syndrome at an early age. This disorder causes her to exhibit symptoms similar to a person with Autism Spectrum Disorder such as loss of or limited speech and avoidance of eye contact. There are also symptoms associated with Cerebral Palsy such as a delayed or absent ability to walk. Because of this diagnosis, Vargo uses a wheelchair and communicates through the use of sign language. Her parents, Rosalind and Joe Vargo, can provide several examples of the positive influence of inclusion on Vargoâ&#x20AC;&#x2122;s life with just a few minor negative instances along the way. According to Vargo, one positive outcome of attending a typical school was that her general education peers, as well as her teachers, accepted her. During fourth grade, she was voted Best Friend by her classmates and was nominated for Student of the Month by her high

school teachers (Byrnes, 2011). Vargo was well liked and people did not pity her because she had a disability. Another positive outcome was that typical students did not allow the disability to affect how they felt about Vargo or how they interacted with her. Vargo was able to build relationships that enabled her classmates to see beyond her disability and focus more on the person she was. For example, when Vargo was in fourth grade, she received a phone call from her friend, Ghadeer. Although Vargo was not able to speak, she was observed nodding, laughing, and shaking her head in agreement. When her mother observed this behavior, she became concerned that the caller, Ghadeer, may be confused and uncertain as to what was occurring. On the contrary, Ghadeer indicated that it was fine and continued on with the conversation like nothing had occurred (Byrnes, 2011). Another example of how Vargo interacted with her peers occurred during middle school. At first, Vargo felt that her classmates were not accepting her. That all changed when she meet Mauricha. Mauricha accepted her wholeheartedly, not caring what anyone else thought. When asked how they became friends, Maurichaâ&#x20AC;&#x2122;s reply was simple and showed that they were friends from the beginning (Byrnes, 2011). In both instances, neither of the girls cared about Vargo having a disability. Instead, they focused on who she was as a person with a vibrant personality and a wonderful sense of humor. Being in an inclusive setting also offered Vargo opportunities and choices that she would not have had in a special education classroom. Throughout her high school years, Vargo was able to join Key Club, a service club at her school, through which she volunteered at a fully inclusive day care, and which supported her efforts to become a role model for disabled and nondisabled students (Byrnes, 2011). Her support was particularly important for her friend, Ghadeer. During high school, Ghadeer suffered a severe stroke that caused her voice and

articulation to be impaired. She was not able to communicate orally anymore. Vargo taught Ghadeer sign language so that she would still be able to communicate with her peers and family. Not only did Vargo teach Ghadeer sign language, but also opened her eyes to her rights as a special education student as well as to many types of augmentative communication systems that she could use (Byrnes, 2011). In this instance, an inclusive setting allowed Ghadeer to meet someone like Vargo and learn vital information that would help her later on in life. Vargoâ&#x20AC;&#x2122;s engaging personality enabled her to develop and maintain friendships and connections over time. When Vargo was applying for OnCampus, an inclusive educational program at Syracuse University, the receptionist knew who she was just by her name. She remembered that they had graduated from high school together. When Ghadeer was having a graduation party, Ghadeer personally called Vargo to invite her. During Christmas time, Mauricha sent her a Christmas card. Each of these instances shows that inclusion had been beneficial for Vargo because she was able to create and maintain relationships for many years (Byrnes, 2011). Unfortunately, Vargo also encountered some negative experiences in her inclusive classrooms. For example, during middle school, Vargo was ignored, stared at, and even teased by her peers. They thought that she was weird and too different from them. In high school, some teachers did not make appropriate accommodations or modifications for Vargo and this interfered with her achievement. As a result, Vargo had trouble academically at times in school, while her typical classmates excelled. At times, incorrect assumptions were made about Vargo. On occasion, people assumed what she was thinking instead of asking her. On an application for a job for which Vargo was applying, her teaching assistant wrote down that Vargoâ&#x20AC;&#x2122;s biggest challenge was that she had Rett

Syndrome. She did not seek Vargo’s input in response to this question and this oversight was very upsetting. It provides an example that people should not just assume what a disabled person is thinking and/or feeling. No matter how disabled an individual is, he or she still has a brain that has the capability to think and formulate answers. The second case study was about a teenage boy named Eli Lewis who has Down Syndrome. For Lewis, this genetic condition hindered his cognitive and physical capabilities and for him, schoolwork was difficult. His parents wanted him to be in an environment with all types of students so he could grow and learn from them. Even though his parents meant well, Lewis felt differently and had other educational and social preferences. He wanted to be with students that were “just like him.” In fairness, Lewis had several positive experiences while being in an inclusive classroom. One positive outcome was that he was able to participate in extracurricular activities that his school offered. He was involved in his middle school chorus and worked in the school’s TV studio after taking a media class (Byrnes, 2011). Another positive outcome was that he had more interaction with the general education students. Lewis was able to interact with his classmates in the classroom and in the halls of the school. He was liked and known by his peers and teachers throughout the school. He also was able to participate in events at the school, such as his middle school science exposition. Even though Lewis’ placement in an inclusive classroom resulted in a few positive experiences, there were a number of negative outcomes for this student. Lewis never felt fully accepted by his peers. Even though they talked to him and liked him, Lewis could often be seen eating by himself or working alone in the classroom. Lewis felt different from everyone else. Because he behaved differently, Lewis never felt comfortable with his typical classmates.

Instead, he wanted to be with students who were like him and understood what he was experiencing. Based on Lewisâ&#x20AC;&#x2122; feelings on being in an inclusive classrooms, his parents agreed to send him to a special education program for students like himself when he began high school. Personal Viewpoint Based on the experiences that Vargo and Lewis had in inclusion classrooms, I feel that inclusion is appropriate for some students, but not for all. The IEP teams who decide whether or not a child should be in an inclusive classroom should look at two factors: how severe the disability is and the feelings the child has about where they will be educated. The IEP team needs to ensure that all children are benefitting when a child with a disability is included in a classroom. While it can be beneficial to have all types of students within a classroom, it is not fair if the typical students are not able to receive the instruction they deserve. With regard to the feelings of the student with a disability, it is important to determine what he or she thinks about inclusive classrooms. If the parents and the child are in favor of inclusion, they should work collaboratively with the school to obtain the appropriate supports. If the parent prefers inclusion and the child does not, then this type of placement needs to be reconsidered. It is not fair to force a child into a classroom in which they will not be comfortable, confident, and secure. This will make the child uncomfortable when he or she is at school. In Lewisâ&#x20AC;&#x2122; case, his parents favored inclusion and placed him in a class with typically developing peers, but he was not happy. As a result, he isolated himself from the other students. How was that helpful to his parents or him? A child should take part in the decision-making process since he or she is going to be the one in the classroom. Overall, inclusion may be ideal for some, but not for all. While some can be successful in an inclusive setting, others may perform better in a pull-out special education program or

resource room. Once a student has found that ideal classroom for him or herself, learning will truly have a sustained and positive impact. References Byrnes, M. (2011). Taking Sides: Clashing views in special education (5th ed.). New York, NY: McGraw Hill Company. The Education For All Handicapped Children Act (PL 94-142) 1975. (2007). Retrieved from http://college.cengage.com/education/resources/res_prof/students/spec_ed/legislation/pl_ 94-142.html Torreno, S. (2012, June 6). The history of inclusion: educating students with disabilities. Retrieved from http://www.brighthubeducation.com/special-ed-inclusionstrategies/66803-brief-legal-history-of-inclusion-in-special-education/

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

“Walk Like You Have Somewhere To Go”: A Literature Review of the Academic, Social, and Cultural Needs of African American Adolescent Males in Urban Schools Student Author: Fr. Stephen D. Thorne Academic Program: Education Faculty Sponsor: Marisa Rauscher, Ph.D. Abstract This literature review explores the topic of the academic, social, and cultural needs of African American adolescent males in urban schools. The research of this review will examine the current status of this population and the challenges they face. It will also examine best practices that have proven to be successful for these students. Some of the issues explored will be: 1. Do African American males in a middle school urban community have unique or different academic needs? 2. Do African American males have greater academic success in a single sex environment? 3. Does the gender and race of a teacher make a difference in the education of African American middle school males? 4. What is the role of parents, guardians, and mentors in collaboration with the teacher, in meeting the academic needs of African American males in a middle school urban community? 5. What can be done to address the “third/fourth grade syndrome” of many African American males in school? Finally, this research will raise key issues that will fosters a conversation for educators, parents and community members who care about the excellence of these young people. Introduction In 2014, President Barack Obama announced “My Brother’s Keeper,” a new initiative to address persistent opportunity gaps faced by boys and young men of color, in an effort to ensure that all young people can reach their full potential. He stated, “There are a lot of kids out there who need help, who are getting a lot of negative reinforcement. Is there more that we can do to give them the sense that their country cares about them and values them and is willing to invest in them?” This program, like many others, is addressing the current status of these important members of our community, as well as offering hope for boys and young men of color. The 67

following literature review will investigate the status of African American adolescent males in urban schools and the challenges they face. It will also examine how well the best practices support the academic, social and cultural successes of these young men. The Current Status of African American Adolescent Males Pedro A. Noguera, a professor at Harvard University, in a presentation titled “The Trouble With Black Boys: The Role of Environmental and Cultural Factors on the Academic Performance of African American Males” (2001). He stated the following: All of the most important quality-of-life indicators suggest that African American males are in deep trouble. They lead the nation in homicides, both as victims and perpetrators (Skolnick & Currie, 1994)…Beset with an ominous array of social and economic hardships, it is hardly surprising that the experience of Black males in education, with respect to attainment and most indicators of academic performance, also shows signs of trouble and distress. Noguera’s assessment is very concerning. He also defined other social and economic challenges that exist for African American males ranging from health issues, unemployment to crime. Research supports the relationship between these negative results and the academic needs of African American males (Cooper & Jordan, 2005). These realities are evidenced throughout the United States, especially in many urban communities, such as Chicago, Baltimore, Philadelphia and others (Kafele, 2012). Alice Goffman, Associate Professor of Sociology at University of Wisconsin – Madison, and author of On the Run: Fugitive Life in an American City, stated the following, “There are two institutions that dominates one’s [African American males’] journey - college and prison.” Her blunt assessment defines the paths of life these young people face. As a student at the

University of Pennsylvania, Goffman began to study the realities of urban life that many African American males face. Her research led to a passion that made her an advocate for change. She defines many social realities that lead to a path to criminal life that these young men face. Specifically, Goffman focuses on racial profiling (Goffman, 2013). As a woman and one who is not African American, she began to see the clear disparities of justice that are often the realities for African American males (Goffman, 2013). Chapter two of her book, Goffman defines the realties that many African American adolescent males face when dealing with law enforcement. Goffman writes: One of the first things that such a man develops is a heightened awareness of police officers - what they look like, how they move, where and when they appear…When they sense the police were near; they did what other young men in the neighborhood did: they ran and hide (23). Goffman experienced firsthand what many others live each day. A life of hiding and running from the police is a reality for many African American young men. This is especially true when school is not an engaging place and when teachers are sometimes seen as another version of the police as opposed to women and men whose goal is to educate, to draw forth academic excellence (Brown, 2012). One cannot examine the current status of African American adolescent males without acknowledging the history of racism in our nation. Swanson, Cunningham & Spencer (2005) have noted that in America, African American young men some of the most stereotypes and stigmatized. Often, they are viewed by society as people to be avoided, unless they are on a basketball court or running to an end zone, performing on a stage or clearing a dinner table. These stereotypes are even more profound as an African American young man develops

physically as an adolescent and may be larger than his teacher, who is usually white and female (Swanson, Cunningham & Spencer, 2005). Often our society cheers the athlete on television and fears the young African American man in a hoodie, who is perceived as a “thug”. These stereotypes cause us to subconsciously or overtly make assumptions about the academic needs of African American adolescent males. If a young man spends more time in the dean’s office or in “time out”, he will never be effectively taught in the classroom. Furthermore, if he is perceived by his teacher as a problem to solved, as compared to a person with an opportunity to grow, should one be surprised that he is disengaged in the academic process? One of the experts in the study of the academic, social, and cultural needs of African American adolescent males is Dr. Jawanza Kunjufu. As an educational consultant, Kunjufu has offered lectures for parents, teachers and other community members dedicated to transformation of educational systems. Since 1974, Dr. Kunjufu has served as a national consultant to public and private schools. In his many workshops, he has stated the year of third and fourth grade as a critical time in a young person’s life, especially for African American males (Kunjufu, 1985). He calls it the “Fourth Grade Failure Syndrome,” where African American boys make a poor transition between the primary and intermediate years of school. Research affirms that all children, regardless of gender or race, have challenges with school transition. However, due to various factors, African American males find this transition more difficult. Kunjufu quotes Harry Morganin his work, “How Schools Fail Black Children.” Morgan states: When blacks enter first grade the stories they create express positive feelings about themselves in the school situation, but by the second grade students’ stories express “negative imagery of the teacher and school environment.” And by fifth grade the overall feeling expressed by students is that of cynicism. In other words, upon

entering school in primary grades, black children possess enthusiasm and eager interest: however by fifth grade the liveliness and interest is gone, replaced by passivity and apathy. Primary grades presented more nurturing environments than intermediate or upper grades. In early childhood education much of the activity is childteacher centered and child-child interactive. In primary grades, blacks progress and thrive at the same rates as their counterparts until the third grade syndrome. I found after third grade, the achievement rate of blacks began a downward spiral which tended to continue in the childâ&#x20AC;&#x2122;s academic career. The classroom environment was transformed from a socially interactive style to a competitive, individualistic, and minimally socially interactive style of learning (Kunjufu, 1985). In addition to the pedagogical shift, positive relations with teachers and classmates play a greater role in their development. The middle school years are often a time when negative societal pressures and perceptions become more of a reality for African American males. Finally, it is this critical time of self-awareness that the absence of the father negatively impacts the lives of these young men, especially in their school life (Fantuzzo, LeBoeuf, Rouse, Chen, 2011). African American adolescent males, like all children, benefit from a strong relationship with family and community (Brewster, Stephenson, & Beard, 2013). Parents play a key role in the academic success of students, thus parental engagement is key. What happens in the home greatly affects a child in many ways, positively and negatively. In the African American community, the family has traditionally taken on an important role in the raising of children (Kafele, 2009). For African Americans, the extended family includes grandparents, aunts, uncles

and older siblings. Furthermore, the role of community leaders, such as mentors, coaches and pastors are important as well (Harper & Porter, 2012). For male children, the role of his father, or another adult male figure, is especially critical (Kafele, 2009). Male children have in their father an icon of selfâ&#x20AC;&#x201C;identity that goes beyond a biological similarity. Young boys watch how their father relates to women and other men as their sense of self is developed. Other activities, such as how to handle conflict, tie a neck tie and shave their face are key life lessons. Literally, they learn how to be a man from witnessing their fathersâ&#x20AC;&#x2122; actions. Boys Incorporated (Boys, Inc.) is a nonprofit agency that is dedicated to preserving the lives of young elementary school boys ages 6-12 in the Greater Memphis and Shelby County area. Boys, Inc. define their agency and programs as follows: Our programs are designed to create partnerships with local schools, other youth organizations and the juvenile court systems. Boys Inc. is a program that is in direct response to the growing number of young boys that are either falling through the cracks at school through repeated failures in the class room or who already display destructive behavior that will eventually lead them to the kind of pitfalls that can derail their lives and leave them entangled with the juvenile system. Boys Inc.â&#x20AC;&#x2122;s goal is to foster a commitment to young boys that will promote trust, strong interpersonal relationships, and reassert a sense of hope for their future. To accomplish this goal, young boys must be in a caring, comprehensive learning environment that encourages their best efforts and reinforces personal and mutual respect. One of our strategies is to get them while they are young, affectionate, and still impressionable, then nurture them from a positive support system. The focus is slightly different at each age level, but the goal remains the

same - Empower young boys to become positive young men for themselves, their families and their community . On their website, “Boys Incorporated – The Fatherless Factor” enumerate sobering statistics on the challenges boys without active fathers face in their lives. This data is a driving force for their advocacy: According to 2009 U.S. Census Bureau data, over twenty four million children live apart from their biological fathers. That is one out of every three (33%) children in America. Nearly two in three (64%) African American children live in father-absent homes. One in three (34%) Hispanic children, and one in four (25%) white children live in father-absent homes. In 1960, only 11% of children lived in father-absent homes. Children who live absent their biological fathers are, on average, at least two to three times more likely to be poor, to use drugs, to experience educational, health, emotional and behavioral problems, to be victims of child abuse, and to engage in criminal behavior than their peers who live with their married, biological (or adoptive) parents. These statistics support the key role that a father has in the life of an early adolescent male, a time when self-awareness is at a critical point of development. In a presentation, “Why Teenagers are better than Adults,” Dr. Marisa Rauscher, Associate Professor of Education at Neumann University, Aston, PA, defines the teen years as a time of transition, when adolescents are often misunderstood by adults, but exhibit great empathy and leadership (2015). Like other moments of growth in a person’s life, these years are often filled with great possibilities and challenge. Added to these moments of transition, adolescents are discovering their sexual identity. The beginning of sexual activity, along with questions about being homosexual or transgender may add to the challenges they face. This research raises

questions and add to the robust conversation about academic success and personal wellness of adolescents (Luecke, 2011). This reality of sexual identity is even more complex among African American young men, many of whom do not have positive relationships with their fathers and are trying to navigate through the crucial years of school (Swanson, Cunningham & Spencer, 2005). In light of the realities that African American adolescent males face, a renewed look at our educational models is needed. Questions such as: 1. Do African American males in a middle school urban community have unique or different academic needs? 2. Do African American males have greater academic success in a single sex environment? 3. Does the gender and race of a teacher make a difference in the education of African American middle school males? 4. What is the role of parents, guardians, and mentors in collaboration with the teacher, in meeting the academic needs of African American males in a middle school urban community? 5. What can be done to address the â&#x20AC;&#x153;third/fourth grade syndromeâ&#x20AC;? of many African American males in school? This part of the literature review affirms that African American adolescent males face many challenges. There are gaps that need to be addressed at home and in school. These challenges often lead to a life of crime and a loss of hope. However, based on the research, there is a resilience to this community (DeAngelis, 2014). There are signs that African American adolescent males are able to achieve in school and life, especially with the interventions of persons who exhibit care and foster healthy relationships. Best Practices for Academic Success for African American Adolescent Males in Urban Schools Dr. Carter Woodson, in his famous work, The Mis-Education of the Negro states: 74

“When you control a man's thinking you do not have to worry about his actions. You do not have to tell him not to stand here or go yonder. He will find his 'proper place' and will stay in it. You do not need to send him to the back door. He will go without being told. In fact, if there is no back door, he will cut one for his special benefit. His education makes it necessary” (Woodson, 1933, p.21 ). This quote from Dr. Woodson affirms what has already been examined in this literature review; namely the tremendous influence that teachers, parents and other adults have on the academic, social, and cultural needs of African American adolescent males. Although the current status of African American adolescent males may seem to be bleak and hopeless, the research also offers many signs of hope and best practices that can inspire educators, parents, and indeed the community as a whole. Sister Ellen Convey, IHM, has served as the principal of Gesu School in North Philadelphia since 1992. Gesu School defines itself as an educational community that “provides a quality, innovative education for its neighbor children to empower them to break the cycle of poverty and violence”. Specifically, Gesu School is an independent Catholic School, serving over 475 African American children pre-K to 8th grade, who live within some of the most difficult economic and family circumstances in North Philadelphia. In addressing the unique academic and social challenges of their school, Sister Ellen Convey, along with other administrators, made the decision to place the boys and girls in separate classrooms beginning in the third grade. She stated: We started the single gender classroom in the mid 1990s. We started it because even with a smaller enrollment then, we were losing the boys before eighth grade graduation. They were being put out for discipline reasons or for failures. We decided to do a "study". At that time, the African American Institute, Chicago, Dr. Jwanza Kunjufu was

commenting that many African American adolescent males become disengaged from school as early as fourth grade, let the girls run the classrooms and find their role models from negative factors of their neighborhoods. We found this to be true, so we decided to take our third, fourth and fifth grades - make them single gender homerooms with a male teacher for the boys and a woman for the girls. However, the teachers do exchange classes so the children experience both genders during the day and there is time for social interaction, such as lunch, music and assemblies. (Convey, personal communication, July 1, 2015) The gender specific classroom model that Gesu School offers, which goes from third to eighth grades, helps to develop the relationship of student and teacher. Effective teachers are a key component to the academic success of African American males in middle school. The development of the “teacher as person” is a critical component of the teaching profession (Gurian, 2011). No matter how competent a teacher may be in his or her academic field, the teacher must be able to foster healthy and mature relationships with students and parents (Lemoy, 2010). The relationship between teacher and student is critical in all academic settings (Gurian, 2011). These facts are especially true when teaching African American males. If there is a “cultural gap” between the teacher and the student, the student is more susceptible to academic failure. The ability to assess the academic needs of African American males in the middle years of school begins with a cultural understanding of the community by the teacher. This understanding may simply begin with getting to know the student and his family (Baldridge, Hill, & Davis, 2011). For all teachers of African American males a strong relationship with family and community is essential (Brewster, Stephenson, & Beard, 2013). This is true for both African American teachers and teachers of other racial backgrounds (Brown,

2012). Parents play a key role in the academic success of students, thus parental engagement is key. Data show there is a low percentage of African American teachers contributing to the field of education. This data are even lower among African American male teachers, as low as 2% (Martino & Rezai-Rashti, 2010). This is why organizations like Black Male Educator's Convening (BMEC), initiated by African American public school teachers in Philadelphia exist. Their goal is to see more Men of Color in education at all different levels in order to have a greater impact on our young people. Research affirms that most African American males will never have the experience of an African American male teacher or educational leader in their entire school experience (Bryan & Browder, 2013). Again, research discovers that the role of a teacher of the same race and gender often has a positive effect on the student (Brown, 2012). This does not mean that a teacher of a difference race and gender cannot be an effective teacher of African American males (Brown, 2012). In fact, one can compare and contrast the academic results of African American males who have experienced a classroom led by an African American male teacher. However, a clear cultural understanding of the African American culture and history by the teacher is essential for success. In order to assess the academic needs of African American males in middle school urban communities the development of partnerships and relationships is essential (Ryan & Shim, 2012). One example of adult collaboration for the good of the student can be seen at Boy’s Latin Charter School in Philadelphia. This school is an all-male, academically rigorous school in urban Philadelphia, which instructs a majority of African American students from middle school through high school. Each student is required to have a “support team” of three people (parents, siblings, pastor, coach etc.) that the school administration can rely on for support if there is a

problem, but more importantly, the support team would be able to celebrate the academic success of each young African American man (Boys Latin Philadelphia Charter High School of Philadelphia, 2014). Dr. G. Roger Jarjoura is a principal researcher in the Health and Social Development Program at American Institute for Research. He has over 16 years of experience in developing and evaluating mentoring programs. In an article entitled “Effective Strategies for Mentoring African American Boys”, he lists some effective programs for mentoring: Harlem’s Children Zone, Harlem, New York, founded by Dr. Geoffrey Canada, a nationally known and respected educator; The Mentoring Center, Oakland, California; REAL (Respect, Excellence, Attitude and Leadership), Chicago, Illinois; The African Men and Boys Harvest Foundation, Inc., Texas; Youth Advocate Programs, Chicago. Dr. Jarajoura has identified a number of Principles that are hallmarks of effective mentoring programs. Among these are: “Principle 2: Effective Mentoring is all about relationships; Principle 3: Trauma experiences and exposure to violence complicate adolescent development and must be addressed; Principle 4: Model mentoring programs for African American boys tend not to be traditional one-on-one mentoring programs.” Additionally, Principle 8, which speaks of hope, Jarjoura states: As noted earlier, African American boys are often targeted for mentoring initiatives because they are at such high risk for school failure, school exclusion, low educational attainment, gang involvement, substance abuse, and criminal justice involvement. The youth most at risk are growing up in settings where there is limited access to positive adult male role models and the stresses of poverty and exposure to violence. One challenge for these youth is that their future appears to be one in which they are more 78

likely to go to prison than they are to go to college, where they are more likely to support themselves and their families with criminal activities than with employment, and where they are more likely to die from violence than they are to live past their 21st birthday. When they look at the adult males in their communities and families, they have a hard time finding hope for their own future. Part of the powerful nature of mentoring initiatives is that, when they are done well, youth are exposed to inspiring adult role models who give the youth hope for their own futures (Jarjoura, 2013, ). The research reveals the effective role that caring adults have in the lives of African American young men. Furthermore, the research shows that unique or specially designed approaches are highly effective in helping this population achieve academic, social, and cultural success. An example of the effectiveness of mentoring can be found in Chicago’s Urban Prep. The school’s overview states: Urban Prep Academies is a nonprofit organization that operates a network of all-boys public schools including the country’s first charter high school for boys. Urban Prep’s mission is to provide a high-quality and comprehensive college-preparatory educational experience to young men that results in our graduates succeeding in college. The schools are a direct response to the urgent need to reverse abysmal graduation and college completion rates among boys in urban centers. While most of Urban Prep students come to the schools from economically disadvantaged households and behind in many subject areas, Urban Prep remains committed to preparing all of its students for college and life. Equally impressive is the fact that 100% of the Class of 2015 were accepted to college, the very same year that the city of Chicago, sadly nicknamed “Chiraq” due to the extreme rate of violence, had one of the highest murder rates of African American adolescent males in the nation

(DNAinfo Chicago, 2015). Given the facts uncovered in this literature review, Urban Prep and the work of Dr. Tim King, its founder, is indeed laudable. They live out their motto, “Changing the Narrative” very well. Conclusion Perhaps there is no prouder or more significant moment in a young person’s life than graduating from high school. With the sights and sounds of academic success, a young person walks down an aisle or across a stage with pride in the past and hope for the future. They walk like they have somewhere to go. However, this walk does not happen easily for African American young men; it takes determination, hard work, courage, and resilience, along with a community of support and love. In spite of the challenges they may face, this literature review affirms that African American adolescent males can and do achieve success in the high school, college and beyond. The great poet and teacher Dr. Maya Angelou stated, “Do the best you can until you know better. Then when you know better, do better.” This literature review has helped to discover some of what we know about African American adolescent males in urban schools. Furthermore, it has affirmed some of the positive people and programs that are having impact on the academic, social, and cultural success of these young men so they can become their best selves. References Baldridge, B., Hill., M., & Davis, J., (2011). New possibilities: Re-engaging black male youth within community-based educational spaces. Race, Ethnicity & Education, 14(1), (121136). Black Male Educator's Convening (BMEC). Retrieved from @BMECFELLOWSHIP

Boys Incorporated (2015). Retrieved from http://www.boysincorporated.org Boys Latin of Philadelphia (2015). Retrieved from http://www.boyslatin.org Brown, A. (2012). On human kinds and role models: A critical discussion about the African American male teacher. Educational Studies, 48(2), (296-315). Bryan, N. & Browder, J. (2013). Are you sure you know what you are doing?: The lived experiences of an African American male kindergarten teacher. Interdisciplinary Journal of Teaching and Learning, 3(3), (142-158). Fashola, O. (2013). Evaluation of an extended school day program for African American males in the context of single gender schooling and schoolwide reform: A case for extending the school day for African American males. Peabody Journal of Education, 88(2), (488517). Fantuzzo, J., LeBoeuf, W., Rouse, H., & Chen, C. (2011) Academic achievement of African American boys: A city â&#x20AC;&#x201C;wide, community â&#x20AC;&#x201C;based investigation of risk and resilience. Journal of School Psychology, 50(2), (559-579). Gesu School (2015). Retrieved from http://gesuschool.org Gill, D. (2014). We shall overcome by focusing on black males students, Educational Digest, 41(2), 36-39. Retrieved from www.Eddigest.com Goffman, A. (2015). On the Run. New York, NY: Picador . Gurian, M. (2011). Boys and girls learn differently. San Francisco, CA: Jossey-Bass. Harper, S. & Porter, A. (2012). Attracting black male students to research careers in education. Retrieved from http://www.gse.upenn.edu/equity Jensen, E. (2013). Educating students with poverty in mind: Practical strategies for raising achievement. Alexandria, VA: ASCD Publications.

Kafele, B. (2009). Motivating black males to achieve in school and in life. Alexandria, VA: ASCD Publications. Kafele, B. (2012). Empowering young black males. Educational Leadership, 3(2), (77-70). Kunjufu, J. (1982). Countering the conspiracy to destroy black boys. Chicago, IL, African American Images Publication. Lemoy, D. (2010). Teach like a champion. San Francisco, CA: Jossey-Bass. Luecke, J. (2011). Working with transgender children and their classmates in pre-adolescence: just be supportive. Journal of LGBT Youth, (8), (116-156). Martino, W. & Rezai-Rashti, G. (2010). Male teacher shortage: Black teachers’ perspectives. Gender and Education, 22(3), (247-262). Noguera, P. (2001). The trouble with black boys. Harvard Journal of African American Public Policy, 3(3), (51-78). Rauscher, M., (2015). Retrieved from www.neumannuniversity.edu. Ryan, A., & Shim, S. (2012). Changes in help seeking from peers during early adolescence: Associations with changes in achievement and perceptions of teachers. Journal of Educational Psychology, 104(4), (1122-1134). Swanson, D., Cunningham M., & Spencer, M., (2005). Black males’ structural conditions. achievements patterns, normative needs, and “opportunities”. Educating African American Males. Thousand Oaks, CA: Corwin Press. Urban Prep (2015). Retrieved from www. www.urbanprep.org. Wood, D., Kurtz-Costes, B., Rowley, S. & Okeke-Adeyanju, N. (2010). Mothers’ academic gender stereotypes and education-related beliefs about sons and daughters in African American families. American Psychological Association, 102(2), (521-529).

Woodson, C. (1933). The Mis-Education of the Negro. Drewryville, VA: Khalifah.

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Truth and Reconciliation in Rwanda Student Author: Mary Trotter Academic Program: Pastoral Clinical Mental Health Counseling Faculty Sponsor: Suzanne Meyer, IHM, Ph. D. Abstract Genocide is the deliberate killing of people who belong to a particular racial, political, or cultural group. In 1994, an estimated one million people were brutally murdered in Rwanda by their own neighbors. This paper explores the history of this African country that led to the ethnically motivated horrific violence and shows the stunning progress toward making peace again Rwanda has made 20 years after the genocide through the justice and reconciliation process. Through the Hebrew lens of Hineini, a framework for covenant and relationships, the faces of those healed in this process will testify to its power. It was not until the colonization by the Belgians after World War I that the Hutus and the Tutsis, who shared the same language, religion, and culture, were divided by rigid ethnic identities. The Belgians favored the minority Tutsis with privileges because they were more European in appearance and therefore superior to the Hutus. This discrimination led to tensions between groups that escalated to hostility. Just as a plan for a multi-ethnic, power-sharing government had been agreed to, the president of Rwanda was killed on April 7, 1994, and for the following 100 days Hutu extremists hunted down and slaughtered whole families of Tutsis and moderate Hutus. This paper is the story of the people of Rwanda who successfully engaged in the process of forgiveness, reconciliation, and healing. Rwandan Genocide Genocide is the deliberate killing of people who belong to a particular racial, political, or cultural group. In 1994, an estimated one million people were brutally murdered in Rwanda by their own neighbors. This paper will explore the history of this African country that led to this ethnically motivated horrific violence and show the stunning progress that Rwanda has made 20 years after the genocide through the justice and reconciliation process. Three peoples populate Rwanda: the Twas, Hutus, and Tutsis. The Twa are the aboriginal inhabitants. They are pygmies and number less than 1% of the population. The Hutu make up 84

the majority with about 85% of the population and the remaining are Tutsi. For centuries the distinctions between the groups were socio-economic and meant relatively little to the people. The Twas were hunters and gatherers. The Hutus were farmers, and the Tutsis herders. They shared the same language, religion, and culture. It was not until the colonization by the Belgians after World War I that the people were divided by rigid ethnic identities. The Belgians identified the Tutsis by their lighter skin and taller stature as more European and, therefore, superior to the Hutus. In 1935, the Belgians created a system, which required all Rwandans to carry a card that identified them by their ethnicity. This information was then used to discriminate. The Tutsis were given greater privileges, such as access to higher education and jobs with the government. Tension between the groups escalated when Rwanda gained its independence from Belgium in 1962. The Hutus were determined to take back their power as the majority in Rwanda after the Belgians left the country. The hostility between the Tutsis and the Hutus came to a head when just as a plan for a multi-ethnic, power-sharing government had been agreed to; the presidents of Rwanda and Burundi, both Hutus, were killed when their plane was hit by a missile on April 7, 1994 near the Kigali airport. For the following 100 days, Hutu extremists hunted down and slaughtered whole families of Tutsis, Twas, and moderate Hutus. Some fled to neighboring countries, while others hid under the protection of brave neighbors (National Unity and Reconciliation Commission â&#x20AC;&#x201C; Rwanda, April 22, 2014). Immaculee Ilibagiza, a Roman Catholic and Tutsi, today tells her story of survival with seven other women in a small bathroom concealed in a room behind a wardrobe in the home of a Hutu pastor. During the genocide, she lost her parents and two brothers, leaving only her and a brother who was studying in Senegal. In her book, Left to Tell (2006), she shares how her faith

sustained her through this experience and describes her coming to forgiveness and compassion toward her familyâ&#x20AC;&#x2122;s killers. There was a great need for forgiveness on many levels. It is obvious that survivors of the genocide, who must live with the pain of traumatic memories and the loss of family members, may at some time want to forgive those responsible for the massacre. Beyond the hills of Rwanda, there was a world community who for any number of reasons ignored the atrocities taking place. The United Nations did not intervene, nor did any Western powers. After three months, the genocide ended when the Tutsi-dominated army of Rwandan exiles, the Rwandan Patriotic Front (RPF) reached the capital, Kigali, and removed the governmentsupported militias from power. The RPF was led by Paul Kagame, who has dominated Rwanda ever since and has been its president since 2000 (Dixon, 2014). The journey to forgiveness, reconciliation, and healing Following the genocide in Rwanda, the justice and reconciliation process included two strategic paths: one for truth and justice and the other for unity and reconciliation (UN Department of Public Information, 2014). Truth and justice were pursued on three levels: the International Criminal Tribunal for Rwanda (ICTR), the national court system, and the Gacaca courts. The National Security Council established the ICTR in 1994 to prosecute persons bearing great responsibility for genocide and other serious violations. The national courts prosecuted those who were accused of planning the genocide or of committing serious atrocities, including rape. It is notable that in 2007, the Rwandan government abolished the death penalty. The Rwandan government reestablished the community, grassroots level Gacaca court system in 2005 to hear the trials of all genocide suspects with the exception of those involved in planning the genocide. These courts

also promoted reconciliation by serving as a community forum for perpetrators to face the families of their victims, to confess their crimes, to show their remorse, and ask for forgiveness. The court gave more lenient sentences to those who were repentant and wanted to reconcile with the community. Rwanda’s National Unity and Reconciliation Commission (NURC) was created in 1999 to reconstruct the identity of members of groups previously divided into a unified national Rwandan identity. The processes initiated by the NURC led to constitutional laws that gave all Rwandans equal rights and made the practice of discrimination and divisive genocide ideology illegal. Other efforts of the commission focused on promoting reconciliation by providing education programs (discussed elsewhere in this paper), national summits on topics related to justice, research on the causes of conflict and how to mitigate and resolve conflicts, and reports on the progress made toward unity and reconciliation. Outcomes “In scattered villages on steep green hillsides, many who killed their neighbors in Rwanda’s genocide 20 years ago now live side by side with relatives of the dead.” (Dixon, April 14, 2014).Rwanda has made great progress since the genocide in promoting forgiveness, reconciliation, and healing. A new generation of Rwandans identify themselves by nationality, rather than by ethnicity. The government under Paul Kagame aims to meet the basic needs of the population. Rwanda spends 25% of its budget on health care with good results. Life expectancy has doubled to more than 60 years of age. Infant mortality rates have declined from 230/1000 births to 55/1000 births. The economy has been growing at a rate of 8% a year. (Dixon, April 14, 2014).

President Paul Kagame has been criticized for what some call his authoritarian approach to governing. But his efforts to improve education and end poverty have been effective ways to prevent violence and promote peace in Rwanda (Dixon, 2014). This government allocates 17% of its budget to education. In addition it is extending outreach to young women, who were previously denied education. Today women are acknowledged as the vitally important other half of the population needed to contribute to the recovery and economic growth of Rwanda, only possible through their education. (Rwanda Girls Initiative, 2010). Ironically, education has been identified not only as a solution to the problems in Rwanda, but also as a factor contributing to discrimination and inequality. One of the key recommendations of the NURC was to create a history book that accurately tells the story of Rwandan history (United States Institute of Peace, 2009). A draft of such a curriculum has been created through the work of the Commission, but has yet to be used in schools in Rwanda (Deo, 2006). Compassion, mercy, and empathy Rwandaâ&#x20AC;&#x2122;s Unity and Reconciliation Commission in combination with its judicial process successfully engaged the people of Rwanda in the process of forgiveness, reconciliation, and healing by incorporating compassion, mercy, and empathy into the process. While victims and survivors may have been given priority, the perpetrators were also given a chance to be heard and benefited from facing those they hurt and the families of those they killed. For forgiveness and peaceful coexistence ever to be achieved for the people of Rwanda, it was first necessary to seek and acknowledge the truth about what happened and why it happened and who was responsible for what through communication. The stories of both the victimized and those who committed the crimes revealed pain and suffering on both sides. Listening is a gift to each other

and it opens the possibility for understanding, compassion, empathy and eventually even forgiveness (Department of Public Information, March 2014). The reports of the commission concluded that it was the political and socioeconomic issues that were responsible for the tension and conflicts that led to the genocide, rather than any fundamental differences between Hutus and Tutsis. The ethnic differences that were magnified in the past were not real differences at all. Rather it was poor governing, a culture of impunity and the social injustices of a succession of rulers that perpetuated this belief. As they listened to each other through the opportunities offered by the Commission, the Rwandans slowly have come to understand this (United States Institute of Peace, March 1, 1999). Sense of community, healing, ubuntu Bishop Desmond Tutu called ubuntu the “very essence of being human.” “I am human because I belong. I participate, I share” (Murithi, 2009). Ubuntu is the philosophical concept that frames an African worldview and incorporates a communal and collective style of relating. Ubuntu, representing a system of values, has the potential to engage a community in the process of healing and reconciliation by facilitating the recognition of each other’s humanity and need for each other for survival and peace. It is appropriate that Bishop Tutu used these principles when he was in position of leadership for the South African Truth and Reconciliation Commission. The five stages of the peacemaking process defined by Bishop Tutu when he was in a leadership role for the South African Truth and Reconciliation Commission were incorporated into the Rwandan post-genocide justice system as well as the education and community programs initiated and sustained by the NURC. The justice system created time for perpetrators to be present to their victims’ families and incentives to acknowledge guilt publically, show

remorse and repentance, ask for and give forgiveness, and make some kind of reparation for their offenses, if possible (Murithi, 2009). These opportunities to come together for forgiveness and healing, and be part of some greater whole, all create a sense of community and fulfill the steps necessary for true reconciliation. The NURC also supports annual community festivals and encourages other cultural activities to strengthen unity and social transformation. The messages of peace and social justice are integrated into community events to emphasize their importance. Participation by community members has been high (UN Department of Public Information, March 2014). It is also notable the community service events, such as “cleanup Saturdays,” also require presence, resulting in a country that is “as neat as a pin!” (Dixon, 2014). Efforts toward reconciliation as we understand it The reconciliation process in Rwanda has focused on reconstructing the Rwandan identity as well as balancing justice, truth, peace and security (UN Department of Public Education, March 2014). The NURC created a diversity of tools for gathering the population of Rwanda together to confront their deeply felt perceptions of the past, present, and future, and to promote reconciliation, healing, and human rights for all. To achieve these goals there was: a peace-building and reconciliation program with many formats for peace education (seminars, conferences, debates). Solidarity camps were conducted for newly returned emigrants to assure their safety and initiate them into the principles of peaceful coexistence, tolerance, and good governance. A leadership academy was established to promote Rwandan values and cultivate leaders who strive to build community. Grassroots leaders, political party leaders, youth, and women were trained in conflict management, trauma counseling, and early warning systems (UN Department of Public Education, March 2014).

Since 2000, there have been several national summits on topics related to justice, governance, human rights, national security, and national history. According to the ICTR reports published since 2001, hundreds of thousands of Rwandans have participated in these education programs and the summits (UN Department of Public Education, March 2014). Reconciliation literally means, “make peace again.” (Class notes). Rwanda’s Unity and Reconciliation Committee seems to have applied the formula proposed by Nelson Mandela and Bishop Tutu to create open dialogue, establish trust, and restore justice to this small country, that has suffered and lost and now appears to be experiencing peace in a way never before possible.

Relationship of National Unity and Reconciliation Commission Processes and Scriptural Passage of Forgiveness Using the Process of Hineni Then I heard the voice of the Lord saying, “Whom shall I send? And who will go for us?” And I said, “Here am I. Send me!” Isaiah 6:8 (NIV) Hineni is a framework for covenant and relationships, the essence of the reconciliation efforts by the National Unity and Reconciliation Commission, established in Rwanda in 1999. Unlike other “truth and reconciliation “ commissions, the NURC does not include the truth component because the International Criminal Tribunal for Rwanda (ICTR), the national court system, and the Gacaca court system are accomplishing this aspect of rebuilding in Rwanda (UN, 2014; NURC-Rwanda, April 22, 2014). Together these various processes represent the justice and reconciliation process in Rwanda that has led to positive outcomes reported in 2014. The ICTR approached the reconciliation process first by gathering the input of community members in all 106 districts of the country, so that all Rwandans were heard and had the opportunity to contribute to the process. This first step initiated a form of covenant between

the commission and the traumatized population—a promise to “be there” for each other. It demonstrated a relationship that acknowledges the sacrifice and loss experienced by all people (the perpetrators and the victims) in Rwanda. The scripture verse, Isaiah 6:8 (NIV) is a response to God’s call to persons of covenant to be there. And to “be there” means to be fully present, responsive, and receptive. Hundreds of thousands of Rwandans answered the call of the Commission to participate in the many processes described throughout this paper that were created to promote forgiveness, reconciliation, and healing after the 1994 genocide. Two decades after the genocide, New York Times photographer Pieter Hugo captured in his beautiful “Portraits of Reconciliation” unlikely pairs of neighbors in Rwanda who have made the decision to both forgive those who have inflicted unspeakable pain and actively live with the perpetrators in peace. (The New York Times Magazine, April 4, 2014). The people who agreed to appear in the photographs did so through the efforts of a non-profit organization Association Modeste et Innocent (AMI) that works with Hutus and Tutis over a period of time with the goal of achieving a formal reconciliation between the perpetrator and the victim that culminates in a celebration with gifts of food and drink and a celebration with singing and dancing. Two pairs of neighbors from the Portraits tell their stories of reconciliation: Mudaheranwa and Mukanyandwi Mudaheranwa (Perpetrator): “I burned her house. I attacked her in order to kill her and her children, but God protected them, and they escaped. When I was released from jail, if I saw her, I would run and hide. Then AMI started to provide us with trainings. I decided to ask her for forgiveness. To have good relationships with the person to whom you did evil deeds — we thank God.”

Mukanyandwi (Victim): “I used to hate him. When he came to my house and knelt down before me and asked for forgiveness, I was moved by his sincerity. Now, if I cry for help, he comes to rescue me. When I face any issue, I call him.” Habyarimana and Mukabutera Habyarimana (Perpetrator): “When I was still in jail, President Kagame stated that the prisoners who would plead guilty and ask pardon would be released. I was among the first ones to do this. Once I was outside, it was also necessary to ask pardon to the victim. Mother Mukabutera Caesarea could not have known I was involved in the killings of her children, but I told her what happened. When she granted me pardon, all the things in my heart that had made her look at me like a wicked man faded away.” Mukabutera (Victim): “Many among us had experienced the evils of war many times, and I was asking myself what I was created for. The internal voice used to tell me, “It is not fair to avenge your beloved one.’’ It took time, but in the end we realized that we are all Rwandans. The genocide was due to bad governance that set neighbors, brothers and sisters against one another. Now you accept and you forgive. The person you have forgiven becomes a good neighbor. One feels peaceful and thinks well of the future. While many fled the country during the violence those who remained either chose to stay or had nowhere else to go. In the months and years after, many returned from hiding or refuge elsewhere because they wanted to go home. The people of Rwanda who are participating in the peace and reconciliation process may have different reasons for doing so, but what they share in common is that commitment for being in relationship with each other as neighbors and as a community. They continue to respond on a daily basis to the needs of their neighbors and their community, serving each other by simple acts of kindness and by participation in community

building activities to maintain an inviting environment that supports peace and economic growth. “Here I am” implies leaving behind, a sense of surrender and letting go of the past evil and hatred on both sides, when the offender and offended both choose to step up and face each other to make things right. It means to “be there” and to acknowledge each other as human beings. The people of Rwanda live in covenant and relationship with each other as a conscious decision resulting in unity and reconciliation unimaginable in their state of brokenness and civil war a short 20 years ago. References 1000-page new version of history due for publication. (July 22, 2009). Rwanda News Agency (RNA) Reporters. Retrieved from http://www.rnanews.com/politics/1607-1000-page-new-version-of-history-due-forpublication Deo, B. (2006). A resource book for teachers for secondary schools in Rwanda. National University of Rwanda. Butare. Retrieved from http://www.law.berkeley.edu/files/HRC/Rwanda_resource_book_for_teachers_version_1 0._rwandan_history_book.pdf Dixon, R. (April 7, 2014) Rwanda makes great progress 20 years after genocide. Los Angeles Times. Retrieved from http://www.latimes.com/world/africa/la-fg-rwandagenocide-20140407-story.html#page=1 Gwin, P. (April 7, 2014) Rwanda: The art of remembering and forgetting. National Geographic. Retrieved from http://news.nationalgeographic.com/news/2014/04/140407rwanda-genocide-today-anniversary/ Gwin, P. (April 14, 2014) Rwanda: The art of remembering and forgetting. National

Geographic. Retrieved from http://emotanafricana.com/2014/04/14/rwanda-the-art-of-remembering-and-forgettingnational-geographic/ History.com Staff, (2009). The Rwandan genocide. A & E Television Networks. Retrieved from http://www.history.com/topics/rwandan-genocide Hugo, P. & Dominus, S. (April 4, 2014). Portraits of reconciliation. The New York Times Magazine. Retrieved from www.nytimes.com/.../06/magazine/06-pieter-hugo-rwandaportraits.html Illbagiza, I. (2006). Left to tell: Discovering God amidst the Rwandan holocaust. Carlsbad, CA: Hay House. Moshman, D., (June 19, 2014). Education for Rwanda: After the genocide. Huffington Post. Retrieved from http://www.huffingtonpost.com/david-moshman/education-forrwanda-afte_b_5511630.html Murithi, T., (2009). An African perspective on peace education: Ubuntu lessons in reconciliation. International Review of Education. 55(2/3), (221-233). Retrieved from http://link.springer.com/article/10.1007%2Fs11159-009-9129-0#page-1 National Unity and Reconciliation Commission â&#x20AC;&#x201C; Rwanda. (April 22, 2014) Trial. Retrieved from http://www.trial-ch.org/en/resources/truthcommissions/africa/rwanda.html Paul Kagame. (June 27, 2014). Retrieved from Wikipedia: The Free Encyclopedia: http://en.wikipedia.org/wiki/Paul_Kagame Rwanda Girls Initiative. (2010). Retrieved from http://www.rwandagirlsinitiative.org. Rwanda â&#x20AC;&#x201C; History. (n.d.). University of Pennsylvania African Studies Center. Retrieved

June 17, 2014, from http//:www.africa.upenn.edu/NEH/rwhistory.htm. Sebahara, P., (1998). The creation of ethnic division in Rwanda. The Courier: Africa— Caribbean—Pacific—European Union. http://www.unngls.org/orf/documents/publications.en/voices.africa/number9/number8/7s ebahara.htm Sider, N.G., (2001). At the fork in the road: Trauma healing. Conciliation Quarterly, a publication of Mennonite Conciliation Services. 20(2). Retrieved from http://www.journeytowardforgiveness.com/setting-out/ The justice and reconciliation process in Rwanda. (March, 2014). The Department of Public Information. Retrieved from http://www.un.org/en/preventgenocide/rwanda/education/rwandagenocide.shtmlthe city government Wilson, D. & Williams, V., (2013). Development and framework of a specific model of positive mental health. Psychology Journal. 10(2). (80-100). Retrieved from http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=db72367c-8fc5-414f-b8860616ff33898d%40sessionmgr4001&vid=9&hid=4107

Nursing & Health Sciences

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Relationships among Smoking, Chronic Pain, Mental Health, and Opioid Use for Pain-Management in Older Adults Student Author: Marthe Adler Academic Program: Nursing Faculty Sponsor: Theresa Pietsch, Ph.D. Abstract This literature review examines observational studies to identify correlations among smoking, chronic pain, depression and/or anxiety, and opioid therapy. Its purpose is to tease out relationships between these variables in order to determine if a primary care provider needs to be wary of prescribing opioids to nicotine-addicted patients with chronic pain, simply because they are nicotine addicted. A literature search was conducted using PubMed with the search parameters used include “nicotine addiction” AND “opioid use” AND “chronic pain”. The same parameter was also used with the addition of “adult”, and the search was run again using the term “smoking” in place of “nicotine addiction”. Six studies were located that explored the relationships between smoking, chronic pain, depression/anxiety and opioid use and a seventh study looked at the timing of the development of depression in smokers. The results were unexpected in that a linear positive relationship between smoking and opioid dependence was not found, nor was a clear positive relationship found between smoking and chronic pain. A relationship between smoking and depression was found suggesting that smoking precedes the development of depression. A relationship between depression, anxiety and chronic pain was also found. This should prompt primary care providers of nicotine-addicted patients in pain to screen these patients for depression, and should provide additional support for the use of antidepressants in lieu of opioids in the treatment of chronic pain. Introduction In the United States, a large cohort of adults (the baby boomers) is aging, bringing to primary care providers a unique challenge in the coming decades. Lin, Karno, Grella, Warda, Liao, Hu and Moore (2011) state that, according to data from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions, almost 20% of the U.S. population will be over 65 by 2030. Lin et al. (2011) goes on to posit that since this cohort has had higher 98

rates of substance abuse than previous generations, the prevalence of substance abuse in older adults can be expected to double in the coming years. Substance abuse in this group of older adults will be complicated by all the common comorbidities to which the geriatric population is prone (Lin et al., 2011). Blazer and Wu (2011) report this cohort of aging adults has a significant prevalence of nicotine dependence and the percentage of adults trying to quit smoking decreases as age increases. Shi, Hooten, Roberts and Warner (2010) found that 22% of adults over 50 years reported that they had pain that interfered with â&#x20AC;&#x153;usual activities such as household chores or workâ&#x20AC;? (p. 367). This chronic pain is increasingly being treated with long-term opioid therapy, according to Hojsted, Ekholm, Kurita, Juel and Sjogren (2013), and long-term opioid therapy carries a significant risk of transitioning from use to addiction (Hojsted et al., 2013). The factors that influence the transition from use to addiction have not been well delineated, but opioid abuse has been associated with nicotine dependence and psychiatric comorbidities, in addition to chronic pain (Cicero, Surratt, Kurtz, Ellis & Inciardi, 2012). Cicero et al also found that opioid addiction increased the risk of poorer physical and mental health. Understanding the interplay between smoking, chronic pain, poor mental health and longterm opioid therapy for pain is important in order to best manage and reduce co-morbidities in the older population. If smoking, pain and opioid use are reduced, the risks for a number of other common co-morbidities of the older adult, such as heart disease, stroke, hypertension and falls might also be reduced. Reduced comorbidities will lead to increased functionality and independence of the older adult. The clinical question this integrative research review tried to answer was: Are older nicotine-dependent adults with chronic pain, who are being treated with opioids, at increased risk of developing an opioid addiction?

Methods Seven recent studies were located using the PubMed online database that explored the connections between smoking, chronic pain, and opioid use and/or abuse. Six of the seven studies also explored connections between depression and/or anxiety and smoking, pain, and opioid use. Search terms used were “smoking”, “chronic pain” and “opioid use” together, and “nicotine dependence”, “chronic pain” and “opioid use” together. Filters were activated to include only publication dates from 2009 to the present, and articles available in English. A total of thirteen articles were located; six were excluded either for not including older adults in the sample population or for not being sufficiently relevant to the clinical question. One study (Boden, Fergusson & Horwood, 2010) was retained despite having a young sample population, because of the longitudinal design that was able to infer causality. The quality of the evidence presented in the studies was evaluated using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Table that described how to evaluate the strength of cross-sectional and cohort studies. As per OCEBM, the studies presented in this integrative review are level II (cross-sectional studies with blinding, and inception cohort studies) evidence. Methodologies and Designs of the Reviewed Studies Design Exploration of the relationships among smoking, chronic pain, opioid use and mental health does not lend itself to the randomized controlled trial (RCT) design, for ethical reasons. Of the seven studies reviewed, four were observational cross-sectional studies, and three were observational longitudinal cohort studies. The three longitudinal cohort studies incorporated a temporal dimension in the data analysis. According to Song and Chung (2010), the three longitudinal cohort studies are therefore higher-level evidence than the cross-sectional studies.

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Song and Chung (2010) place the seven studies below systematic reviews, meta-analyses, and RCTs on the hierarchy of evidence, but above case reports and expert opinion. Of the three cohort studies, one by Shi, Hooten, Roberts and Warner (2010), examined modifiable risk factors for pain in older adults. The aim of the study was to use retrospective cohort data to find the presence of risk factors in the past that predicted the emergence of pain later in the cohort data collection. Another cohort study by Shi, Hooten and Warner (2010) used the same retrospective cohort data. This study looked at whether smokers who quit smoking later reported less or no pain, or more pain. The third cohort study authored by Boden, Fergusson and Horwood (2010) used retrospective cohort data from a longitudinal birth cohort to explore the link between depression and cigarette smoking at ages 18, 21 and 25. Song and Chung (2010) posit that welldesigned longitudinal cohort studies can give some idea of causality, in epidemiological situations for which randomized controlled trials (RCT) cannot be implemented. The studies by Shi, Hooten and Roberts et al. (2010) and Boden et al. (2010) were well-designed retrospective longitudinal studies. Data Analysis Univariate and multivariate regression analysis can be used to explore predictive risk between variables, and chi square analysis can look to see if binomial variables occur in conjunction with other binomial variables at a rate greater than would be expected by chance. All seven of these studies used regression analysis to explore predictive risk. Three of the seven studies also used chi square to look for correlation between binomial variables. Univariate and multivariate regression analysis is parametric statistical analysis; chi square is non-parametric analysis. The univariate and multivariate regression analyses were used to calculate odds ratios

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or adjusted odds ratios with confidence intervals, in order to look at the risks of the dependent variables occurring in the presence or absence of the independent variables. Sample Populations Four of the seven studies focused on an older adult population. Cicero et al (2012) tested the correlations between prescription opioid abuse in older adults and physical and mental health scores, pain prevalence, nicotine dependence, alcohol dependence, and psychiatric disorders. Cicero et al. (2012) used data from surveys offered to opioid-dependent patients (age 45 or older) entering treatment at nationally distributed drug treatment centers. The sample in the study by Cicero et al. (2012) was the least random; treatment center directors were allowed to select which incoming patients were offered the survey, presumably based on age since the investigators were interested in looking at correlations with opioid abuse in an older population. Shi, Hooten and Roberts et al. (2010), and Shi, Hooten and Warner (2010) used the same data set – the Health and Retirement Study (HRS), a biennial survey of “a nationally representative sample of U.S. residents over the age of 50” (Shi, Hooten & Roberts et al., 2010, p. 366) – to conduct their cohort studies. Retention rates in the HRS have been 86-90%. Blazer and Wu (2011) studied correlations between nicotine dependence, psychiatric illness and substance use, using data from the National Survey on Drug Use and Health (NSDUH) for the age groups 50-64 (baby boomers) and 65-and-over. The survey was conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and data were available for public use. Response rates for the NSDUH were 89% for the household screening portion, and 74-76% for the interviewing portion (Blazer & Wu, 2011). Three of the seven studies did not specifically examine an older population, although all except one (Boden et al., 2010) included older adults in the sample population. Hojsted et al.

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(2013) drew data from a national survey of random Danish adults, defined as sixteen years old or older. Of 25,000 adults sent the survey, 61% responded. Of the 61% who responded, data from 13,281 Danish adults (53%) were included in the results. The authors looked for other addictive behaviors that were correlated with opioid use in these Danish adults. Hooten et al. (2011) looked at the association of depression and smoking with pain severity and opioid use in an adult population entering an outpatient chronic pain treatment program. Data from all adults entering the program over the course of three years was analyzed. Boden et al. (2010) used retrospective longitudinal data from a birth cohort of 1,265 children participating in the Christchurch Health and Development Study (CHDS), using data gathered at ages eighteen, twenty-one and twentyfive to look at causal linkages between smoking and depression. Eighty percent of the original cohort was included. Song and Chung (2010) state that for a longitudinal cohort study to avoid drop-out bias, the attrition rate should be less than or equal to twenty percent. All three cohort studies had an attrition rate of less than or equal to twenty percent. Of the seven studies, Cicero et al. (2012) had a study sample that may not have been chosen at random, and therefore those results may not be representative of the population being studied. The study does not explain how the treatment center directors distributed the surveys used in the study, other than looking for older opioidaddicted patients to include in the study. This must be kept in mind while reviewing results from this study. Instruments/Measurement of Variables The instruments used to measure smoking, pain, mental health and opioid use varied across the seven studies. Six of the seven studies measured smoking by self-report of cigarette usage and estimated daily number of cigarettes smoked. Only one study, Cicero et al (2012),

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used the Fagerstrom test for nicotine dependence to assess nicotine dependence severity. The Fagerstrom test for nicotine dependence has been shown to be a valid and reliable tool for evaluating nicotine dependence (Huang & Wang, 2008). Validity and reliability of the data on smoking was addressed by Blazer and Wu (2012) who stated that a reliability study of the interview and re-interview method used in their study showed a high kappa (response consistency) of 0.92-0.93 for interview questions regarding cigarette use. In addition, Boden et al. (2010) followed up self-report of smoking with a â&#x20AC;&#x153;custom-written surveyâ&#x20AC;? (Boden et al., 2010, p.441) to look for DSM-IV criteria for nicotine dependence. Based on the survey answers, respondents were assigned an ordinal rank of nicotine-dependence severity of zero (no dependence), one (smoking but no nicotine dependence), or two (smoking with nicotine dependence). The reliability of this ranking was evaluated by additionally placing respondents in categories according to number of cigarettes smoked daily: none, less than one, 1-4 daily, 5-9 daily, 10-20 daily, or more than 21 daily (Boden et al., 2010, p.441). The presence of pain was measured by self-report in three studies, by the SF-36V2 health survey in Cicero et al. (2012), and by the pain severity subscale of the Multidimensional Pain Inventory (MPI) in Hooten et al. (2011). In Cicero et al. (2012) questions regarding the presence of moderate to severe non-withdrawal bodily pain that interfered with work and social activities (p. 4) were broken out from the SF-36V2 health survey, in order to test the relationship between opioid addiction and chronic pain. The SF-36V2 health survey also yielded an overall mental and physical health score for each respondent. In the MPI used by Hooten et al. (2011), pain is graded on a 7 point Likert scale, which makes it easy to compare the pain severity of the depressed and smoking patients in the study to the chronic pain of the average patient. In Hojsted et al. (2013), chronic pain presence was assessed by the question â&#x20AC;&#x153;do you have chronic/long-

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lasting pain lasting 6 months or more?” (p. 2678), while Shi, Hooten and Roberts et al. (2010) used three questions - “Are you often troubled by pain?”, “Do you have mild, moderate or severe pain?” and “Does pain make it difficult for you to perform household chores or work?” to assess both presence and severity of pain (p. 367). Shi, Hooten and Warner (2010) used only the first two questions listed above, from the same survey, to assess the presence and severity of pain. Two studies, Blazer and Wu (2012) and Boden et al. (2010), did not specifically address pain. Mental health was measured by self-report of a diagnosis of a mental health condition (anxiety or depression) by a health-care professional in Blazer and Wu (2012), by the SF-36V2 health survey for physical and mental health in Cicero et al. (2012), and by the Composite International Diagnostic Interview (CIDI) in Boden et al. (2010). The Center for Epidemiological Studies Depression scale (CES-D) was used to assess for depression in three studies: Hooten et al. (2011), Shi, Hooten and Roberts et al. (2010), and Shi, Hooten and Warner (2010). One study (Hojsted et al., 2013) did not examine depression or mental health. Opioid use and/or abuse was measured by self-report in Blazer and Wu (2012), who asked if prescription pain relievers, sedatives, tranquilizers or stimulants were taken that had not been prescribed for the individual, or had been taken “only for the experience or feeling they caused” (p. 4). Cicero et al. (2012) evaluated opioid and alcohol abuse and addiction using DSMIV criteria; all participants in the Cicero et al (2012) study were diagnosed with opioid addiction and admitted to a treatment center. Hojsted et al. (2013) evaluated opioid use by looking at the number of opioid prescriptions filled by respondents in a year, as listed in a national registry. In Hooten et al. (2011) opioid use was assessed by self-report and the pharmacy records of patients with chronic pain being admitted to a 3-week outpatient pain treatment center. The study by

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Boden et al. (2010) evaluated illicit drug use by self-report. Only these five of the seven studies measured opioid or other illicit drug use. Correlations and Variables Relationships between different variables were examined across the seven studies. Blazer and Wu (2012) looked at correlations between smoking and socio-demographic variables such as age, race/ethnicity, education, employment, marital status, income and location. They also examined correlations between smoking and anxiety and/or depression, and smoking and nonprescription drug use. Cicero et al. (2012) looked at correlations between the independent variable of opioid addiction (the sample population consisted of opioid addicted patients being admitted to a treatment center) and the dependent variables of physical and mental health, nicotine dependence and opioid diversion methods. The sample population was later compared to the non-addicted population to see how they fared in terms of average physical and mental health, and rates of nicotine dependence. Hojsted et al. (2013) looked for linkages between the independent variables of being a long-term opioid user with chronic pain, a short-term opioid user with chronic pain, a non-opioid user with chronic pain, and being pain free and six other addictive-behavior dependent variables: smoking, high alcohol intake, illicit drug use, obesity. long-term benzodiazepine use, and long-term benzodiazepine-like drug use. Hooten et al. (2011) used data from chronic pain patients admitted to a pain-treatment program to look at the effects of the independent variables of depression and smoking in the pain patients on the dependent variables of pain severity and opioid use. Shi, Hooten and Roberts et al. (2010) used longitudinal retrospective cohort data to treat depression, smoking, BMI and socio-demographic data as independent variables, looking at their effect on the emergence of the dependent variable of pain. This was one of two well-designed longitudinal studies that were able to give an intimation of

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causality. Boden et al. (2010) was the other well-designed longitudinal retrospective cohort study. Boden et al. (2010) looked at the effect of the independent variable of nicotine dependence on the dependent variable of the emergence of depression. Finally, Shi, Hooten and Warner (2010) used smoking or not smoking as independent variables to look at correlations with the dependent variable of pain/no pain or pain/less pain or pain/more pain, in order to gain an idea of the effects of smoking cessation on pain levels in older adults. Results of the Reviewed Studies Blazer and Wu (2012) found past year and past month smoking were associated with an increased risk of anxiety, even after adjusting for alcohol and drug use (although data were not published), and drug use was not associated with smoking after adjusting statistically for confounding variables. Cicero et al. (2012) found that older opioid addicts had significantly poorer mental and physical health than same-age non-addicted peers, and these older addicts had a higher risk of chronic pain. However, Cicero et al. (2012) found no significant correlation between opioid addiction and nicotine dependence. Hojsted et al. (2013) found that the risks of chronic pain and smoking were correlated, and that the risk of being a daily smoker increased as patients moved from the category of chronic pain with no opioids to chronic pain with short-term opioids to chronic pain with long-term opioid treatment. The risks of being a heavy smoker, however, were highest among short-term opioid users with chronic pain. Hojsted et al. (2013) also found that the risk of illicit drug use was only slightly elevated in long-term opioid users with chronic pain. Chi square analysis did show that long-term opioid use increased the likelihood of having at least two of six other addictive behaviors measured, one of which was smoking. Hooten et al. (2011) found a positive correlation between depression and pain severity, and a positive correlation between smoking and morphine equivalent dose (such that heavier

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smokers required higher doses of pain medication for pain relief), but no positive correlation between smoking and pain severity. Moreover, depression did not have a positive correlation with opioid dose. Shi, Hooten and Roberts et al. (2010) examined causality and found significant interaction between smoking and depression and pain; smokers had an increased risk of pain if they had concomitant depression, but did not have an increased risk of pain if they did not have concomitant depression. Boden et al. (2010) also looked at causality and found that smoking in a birth cohort surveyed at eighteen, twenty-one and twenty-five years of age increased the predictive risk of depression. At the same time, Shi, Hooten and Warner (2010) found no relationship between smoking cessation and the improvement or worsening of pain. Shi, Hooten and Warner (2010) also found the improvement of depression was associated with a lower risk of pain. Discussion The results of the seven studies found fairly consistent relationships between depression/anxiety and chronic pain, but not necessarily between smoking and chronic pain. The findings across the seven studies for correlations between smoking and opioid use and/or abuse were mixed. Although it was not originally expected, an association between smoking and anxiety and/or depression emerged. Cicero et al. (2012) found that older opioid-addicted patients had higher risks of both chronic pain and poorer mental health, which included depression and anxiety. In Hooten et al. (2011), linear regression analysis showed a predictive relationship between depression and pain severity such that â&#x20AC;&#x153;each 1 point increase in CES-D score was associated with a 0.28 point increase in pain severityâ&#x20AC;? (Hooten et al., 2011, p.4). While linear regression analysis also showed a predictive relationship between smoking and pain severity, after adjusting for the interaction

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between smoking and depression (smokers had higher depression scores), smoking no longer had a significant influence on pain severity (Hooten et al., 2011). Shi, Hooten and Roberts et al. (2010) found that smokers had increased risks of pain if they also had depression, but did not have increased pain risk if they did not have depression, and Shi, Hooten and Warner (2010) argued against a relationship between smoking and chronic pain by finding that smoking cessation did not improve or worsen chronic pain. These authors did find that improvement in depression symptoms was associated with a lower risk of pain (Shi, Hooten & Warner, 2010). Blazer and Wu (2012) and Cicero et al. (2012) found no relationship between smoking and opioid dependence. Hojsted et al. (2013) and Hooten et al. (2011) did find correlations between smoking and opioid dependence. However, Hojsted et al. (2013) found that while the risk of being a daily smoker was increased in patients with chronic pain on opioid therapy, the highest risk of being a heavy smoker was found in patients with chronic pain on short-term opioid therapy. This correlation was not a linear positive correlation, meaning that unknown or spurious variables may have been influencing this relationship. In addition, while Hooten et al. (2011) found that current smoking was associated with higher doses of opioids for chronic pain, the authors of the study postulated that nicotine may induce the enzymes for opioid metabolism, accounting for the increased doses of opioids. Blazer and Wu (2012) found an association between smoking and anxiety that â&#x20AC;&#x153;remained significantâ&#x20AC;Śafter adjusting for binge drinking and drug useâ&#x20AC;? (Blazer & Wu, 2012, p. 6). Finally, an interesting study from Boden et al. (2010) used retrospective data with a temporal component and found a predictive relationship between smoking in a young cohort and the emergence of depression symptoms. This points to a possible causal relationship between smoking and depression onset.

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Implications for Practice This integrative review suggested some interesting relationships between the variables of nicotine dependence, chronic pain, anxiety/depression and opioid drug use. The results of this review may provide guidance to the primary care provider (PCP) with older nicotine-dependent patients who have chronic pain and are seeking pain treatment, as well as raising questions for continuing research. Four studies - Blazer and Wu (2012), Cicero et al. (2012), Hooten et al. (2011), and Shi, Hooten and Roberts et al. (2010) - found a positive relationship between depression and/or anxiety and chronic pain. One study, Shi, Hooten and Warner (2010) found a negative relationship, such that lessening depression was associated with less risk of pain. This indicates that the PCP should assess for depression in patients presenting with chronic pain. There is significant evidence of a relationship between depression/anxiety and chronic pain, and there is evidence of a causal relationship between depression and chronic pain (Shi, Hooten & Roberts et al., 2010). Finally, there is evidence that improving depression can improve chronic pain (Shi, Hooten & Warner, 2010). The PCP should advise patients with nicotine dependence, depression and/or anxiety, and chronic pain that there is evidence of a correlation between anxiety and smoking (Blazer & Wu, 2012) and evidence of a possible causal relationship between smoking and depression (Boden et al., 2010). Smoking cessation may alleviate anxiety. Smoking cessation may also improve symptoms of depression, which may in turn improve chronic pain. Given the mixed findings on correlations between smoking and opioid dependence, the PCP should use caution when treating older nicotine-dependent chronic pain patients with longterm opioids, but should not necessarily feel that they are contraindicated. The original research

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question of whether older smoking adults with chronic pain are at increased risk of addiction if treated with opioids is â&#x20AC;&#x201C; not necessarily. Opioid therapy remains a treatment option if an older adult with chronic pain is also a smoker. However, the PCP should keep in mind that prescribing opioids to older adults with chronic pain may increase the older adultsâ&#x20AC;&#x2122; risk of falls, lower respiratory disease, constipation and others. This literature review suggests alternate paths to increased functionality may include assessing for and treating depression in order to alleviate some chronic pain. The PCP should also keep in mind that nicotine-dependent patients may require higher doses of opioids for pain relief due to metabolic interactions. Conclusions The serendipitous finding of relationships between smoking and depression, and relationships between depression and chronic pain that were uncovered by this integrative review are intriguing. It would be interesting to explore the question of whether successful depression therapy leads to higher smoking cessation rates, or whether smoking cessation leads to higher success rates for depression therapy. In the future, it would also be interesting to look at the effect of depression treatment and/or smoking cessation on chronic pain and the need for pain medication. As the population with the co-morbidities of depression, nicotine dependence and chronic pain grows, evidence addressing these questions could further guide the PCP in the treatment approach to these patients. References Blazer, D., & Wu, L. (2012). Patterns of tobacco use and tobacco-related psychiatric morbidity and substance use among middle-aged and older adults in the United States. Aging Mental Health, 16(3), 296-304. doi:10.1080/13607863.2011.615739

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Boden, J., Fergusson, D., & Horwood, L.J. (2010). Cigarette smoking and depression: Tests of causal linkages using a longitudinal birth cohort. British Journal of Psychiatry, 196, 440446. doi:10.1192/bjp.bp.109.065912 Cicero, T., Surratt, H., Kurtz, S., Ellis, B., & Inciardi, J. (2012). Patterns of prescription opioid abuse and co-morbidity in an aging treatment population. Journal of Substance Abuse Treatment, 42(1), 87-94. doi:10.1016/j.jsat.2011.07.003 Hojsted, J., Ekholm, O., Kurita, G.P., Juel, K., & Sjogren, P. (2013). Addictive behaviors related to opioid use for chronic pain: A population-based study. Pain, 154, 2677-2683. doi:10.1016/j.pain.2013.07.046 Hooten, W.M., Shi, Y., Gazelka, H., & Warner, D. (2011). The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain, 152(1), 223229. doi:10.1016/j.pain.2010.10.045 Huang, C., Lin, H., & Wang, H. (2008). Evaluating screening performances of the Fagerstrom tolerance questionnaire, the Fagerstrom test for nicotine dependence, and the heavy smoking index among Taiwanese male smokers, Journal of Clinical Nursing, 17(7): 884890. doi:10.1111/j.1365-2702.2007.02054.x Lin, J., Karno, M., Grella, C., Warda, U., Liao, D., Hu, P., & Moore, A. (2011). Alcohol, tobacco, and non-medical drug use disorders in U.S. adults aged 65 and older: Data from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions, American Journal of Geriatric Psychiatry, 19(3):292-299. doi: 10.1097/JGP.0b013e3181e898b4 OCEBM Levels of Evidence Working Group, â&#x20AC;&#x153;The Oxford 2011 levels of evidenceâ&#x20AC;?, Oxford

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Centre for Evidence-Based Medicine. Retrieved from http://www.cebm.net/index.aspx?o=5653 Shi, Y., Hooten, W.M., Roberts, R., & Warner, D. (2010). Modifiable risk factors for incidence of pain in older adults, Pain, 151, 366-371. doi:10.1016/j.pain.2010.07.021 Shi, Y., Hooten, W.M., & Warner, D. (2010). Effects of smoking cessation on pain in older adults. Nicotine & Tobacco Research, 13(10), 919-925. doi:10.1093/ntr/ntr097 Song, J., & Chung, K. (2010). Observational studies: Cohort and case-control studies. Plastic and Reconstructive Surgery, 126(6), 2234-2242. doi:10.1097/PRS.0b013e3181f44abc

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Continuing Adult & Professional Studies

Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Music for the Body & Soul: The Benefits of Music Therapy for Pain Management Student Author: Shane Burke Academic Program: Continuing Adult and Professional Studies Faculty Sponsor: Jilian Donnelly, Ed.D. Introduction “If I should die, God forbid, let this be my epitaph: The Only Proof He Needed for the Existence of God was Music.”- Kurt Vonnegut This timeless quote by the late novelist and notorious humanist Kurt Vonnegut sums up the overwhelming power that music has over the individual. It is the universal language, bringing together people who on the surface may not have anything in common with one another, and yet once that first wave of ecstasy from an opening guitar riff or the pounding of the kick drum spread throughout a crowd like electricity, there is absolutely no denying music’s Godliness. Native Americans, with drums made from animal hide, would pound and pound the drums in a 4/4 rhythm mimicking the heartbeat, the pulse of human beings. There is also biblical reference to the power of music in which Saul, by punishment, was tormented by an evil spirit from God and was encouraged to set out looking for David, who was renowned for his exceptional ability to play the lyre (a harp-like instrument). Saul found David and “whenever the harmful spirit from God was upon Saul, David took his lyre and played it with his hand: so Saul was refreshed and was well, and the evil spirit departed from him” (Samuel 1 16:23). This is the ability of

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music to soothe the soul, change the brain, and bring the individual who is partaking in the musical journey to peace. There is a connection and a bond between all things. The way one thinks and perceives a situation directly determines how they will physically react or feel, which can be illustrated in the phenomenon of a “gut feeling”. This connection between the nervous system and the digestive system through the enteric nervous system (ENS) has been dubbed the “second brain” because of its similarities in size, neurotransmitters, and molecular signals with that of the brain itself (Mayer 453). It is also common knowledge that a disorder such as major depression can negatively influence the individual’s physical state, in that when the individual is depressed, their motivation to get the right amount of exercise or eat healthy is almost non-existent. Therefore, when the individual is not nourished properly or not treating their body correctly, it is not just the mind and spirit that is suffering but all three aspects of the individual: mind, body, and spirit. The healing of these three pieces of the human being is what is at the heart of the alternative form of treatment referred to as music therapy. Another universal trait of mankind, besides the effect of music, is the phenomenon of pain. According to the International Association for the Study of Pain, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. For most individuals, the sensation of pain is perceived solely as a physical phenomenon and the idea that it could be an emotional experience or that the process of pain begins in the brain, is almost never acknowledged or understood. So then, pain can be seen as both a sensory process that is experienced within the body, as well as a subjective occurrence that is ultimately influenced by the psychological make-up of one’s brain (Bicknell 1). Add stress and anxiety to the mix, and the experience of pain increases exponentially.

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The alleviation of this stress and anxiety while, or before, an individual experiences the phenomenon of pain is the main function of music therapy. Music therapy is defined as “an established health profession that uses music and the therapeutic relationship to address physical, psychological, cognitive and/or social functioning for patients of all ages and disabilities” (American Music Therapy Association). Research has shown the benefits of this particular form of treatment for the issue of pain management, which is one of the more prevalent health issues in today’s world; chronic pain from either an accident or a disease such as fibromyalgia; and finally, the reduction of the need for opioid pain medication which, over time, can become more of a burden than actual help. This alternative form of therapy is unique and, more importantly, effective in that it targets each aspects of the human being that is suffering from pain: mind, body, and spirit. Literature Review Before delving into the numerous studies and examples of music therapies healing properties, it is first paramount to understand what exactly a music therapist does and what occurs within this therapeutic setting. According to the American Music Therapy Association, what these therapists actually do is provide an opportunity, through the use of both instrumental and vocal activities, for a reduction in stress and anxiety, a reduction of the need for pain medication, and a positive change in the patient’s outlook and emotional state. In a study in which three licensed music therapists were interviewed about their experiences in the field, the author (Kwan 51) discovered six common themes that emerged: trust, presence, caring, physical empathy, empowerment, and emotional expression. It is this initial trust that seems to be the icebreaker in whether or not the patient feel comfortable enough to share their story and create music with a total stranger. One of the interviewee’s of this article discussed how

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“there is this trust that develops where they (the patients) just relax when they see us because we’re not bringing in a needle… So when we walk in, it’s just like ahhh! (deep inhalation), something friendly, something familiar” (Kwan 52). For patients in the hospital setting who are either recovering from or about to undergo some type of medical procedure, the days can be long, tedious, and stressful. In a study in which the use of bedside music therapy is provided, the authors discovered first-hand how stressful and draining the recovery from a specific medical procedure can be on the individual’s body, mind, and spirit. Richards, Johnson, Sparks, and Emerson discusses how the hospital setting and atmosphere can actually aid in the patients anxiety levels, and what music therapy provides for such patients is a break in the monotony, a distraction from a painful procedure or recovery, and a refuge in the music (9). The environment of the hospital, for medical professionals and patients alike, has an atmosphere of tenseness and urgency. The cold temperatures, strange and constant noises, and bright lights coupled with the patient’s pain, anxiety, and discomfort all make for a challenging experience (Kemper & Danhauer 282). Despite these stressors, music therapy has been shown to help alleviate the pre/post operative states of anxiety, stress, and pain. In the studies that use preferred music for pain and anxiety, what the researchers discovered was that it was not the actual content of the music itself that aided in relief, but rather the individual’s relationship with the music (Knox, Beveridge, Mitchell, and MacDonald 1673). That being said, studies have also shown that certain genres of music have been more effective than others in the relieving of pre/post operative anxiety and pain. Kemper and Danhauer discuss how despite the various types of preferred music that each individual uses, there are certain genres of music that seem to elicit a consistent physiological effect (283). For example, when the participants listened to grunge rock, there was a significant increase in sadness, fatigue,

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hostility, and a decrease in compassion. However, when “new age” music was provided there seemed to be an across the board increase in relaxation and compassion, while all the negative aspects that came about from the grunge music, significantly decreased (Kemper & Danhauer 284). This relaxation response is what music therapists strive to unearth in patients who are struggling with pain and anxiety from their specific ailment. An important factor in the individual’s ability to experience relaxation and peace is the reduction of anxiety. Since the areas of the brain that control emotions and the perception of pain are so closely related, it is essential to target the emotional areas of the brain, which in turn affect the centers of the brain which perceive pain. In the various studies that discussed the effect music therapy has on one’s anxiety and stress levels, there is an almost universal conclusion that music drastically reduces anxiety, helping the patient to experience less pain and to recover quicker. In an article entitled “Music Therapy for Patients Receiving Spine Surgery” which studied the benefits of music therapy for individuals who were undergoing spinal surgery, it was noticed that anxiety associated with varying factors such as elevated body temperature, the need to urinate, thirst, and elevated blood pressure, was drastically reduced for patients who listened to music prior to their respective surgeries (Lin, Lin, Huang, Hsu, Lin 961). In another study, participants who were recovering from cardiac surgery were given a choice from four ambient music CD’s, one of which was made up entirely of bird songs. They were instructed to chart their pain while listening to their respective CD for 20 minutes twice a day. The results were an increase in relaxation, as well as a decrease in their anxiety levels, showing music’s ability and potential to heal in the short term, which in fact helps to prevent long-term pain (Cutshall, Anderson, Prinsen, Wentworth, Olney, Messner, Brekke, Li, Sundt, Kelly, and Bauer 19).

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Apart from the obvious effect music therapy has on the individual’s anxiety and stress levels either before a major medical situation or in the recovering stages afterwards, the benefits that occur within the body of the patient is of enormous benefit. It is almost a certainty that with the process of surgery and the recovery thereafter, the experience of anxiety and stress is commonplace, as is the experience of pain. However, the perception of pain can be actively distracted by the bombardment of the other sensory input to the brain, such as music. This in turn, distracts the thoughts of pain, provides a sense of relaxation, and closes the proverbial “gate” on the pain (Vaajoki, Kankkunen, Pietilä, and Vehviläinen-Julkunen 412). This is referred to as the Gate Control Theory of pain. In a study from Vaajoki et al. over one hundred patients who underwent abdominal surgery were utilizing music therapy for 25 months afterwards. The result of this study showed that on the first and second post-operative day, the patient’s systolic blood pressure and respiratory rate had been reduced significantly (Vaajoki et al. 417). This is of extreme importance to those who have undergone abdominal surgery, as the surgery has an effect on the patient’s ability to breathe comfortably post-operation. In the intensive care unit of hospitals, there has been a steady increase in the use of music therapy to help alleviate the post-operative pain and help restore the patient’s overall health. One study analyzed 40 patients who had recently undergone cardiac bypass grafting and aortic valve replacement, in which their levels of oxytocin and PaO2 (partial pressure of oxygen in the blood) greatly increased (Trappe 29). Alongside with cardiac issues and procedures, chemotherapy has been one of the most common causes for hospital stays and challenging recoveries. One, if not the most, prevalent side effects of chemotherapy is the severe nausea and vomiting that is coupled with the process of treatment for those diagnosed with cancer. For the children in the Stephen D. Hassenfeld

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Childrenâ&#x20AC;&#x2122;s Center for Cancer and Blood Disorders in New York, daily activities include chemotherapy, radiation, and surgery, resulting in a life-style that is on the opposite spectrum of children without their diagnosis. The reason music therapy is so beneficial to these children is because it provides music and art in a social setting, allowing them to act and behave like normal children their age without the feeling of isolation that comes with their treatment (Nesbitt & Tabatt-Haussmann 58). Another reason why music therapy is playing a larger role in oncology units around the world is because of the fact that most patients undergoing chemotherapy who are given antiemetic (anti-vomiting) treatment still experience nausea and vomiting. This can also be attributed to a phenomenon referred to as anticipatory nausea and vomiting which normally appear a day or so before the individual is set to under go chemotherapy because of a learned response to the treatment (Karagozoglu, Tekyasar, and Yilmaz 40). Music therapy helps release endorphins in the body, which in turn help to strengthen the spirit of the patient, giving them a reason to continue their chemotherapy treatment and thus, increasing their life expectancy (Karagozoglu et al. 40). For these patients, whose age groups range from children to adults, the key is to find solace and peace within the walls of their hospital rooms or waiting areas. There is no question that comfort and peace during a medical emergency is a very difficult state to achieve, and even the strongest of individuals find themselves utterly powerless over their ailment and pain. This is especially true of the elderly community and those who are under palliative and hospice care. It is at this juncture that music therapy can be used as an adjuvant to this medication, which not only assists with the physical relief from pain, but the mental and spiritual fatigue as well. Listening to music and the act of singing has been shown to significantly reduce the symptoms of anxiety and dementia in older adults, and in one study, the positive effects lasted

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for up to two months after the last session (Eells 13). Eells references a study in which 66 participants suffering from osteoarthritis, one of the most common ailments among the older adult community, listened daily to pre-recorded classical music while charting their pain levels before and after. The results showed that pain had been significantly decreased in these individuals after listening to the music. Another example of the benefits of music therapy for older adults is the feeling of community and purpose that comes about from creatively expressing oneself. In an article that discusses clinical implications for music interventions, the example of community music is introduced as a means for older adults to participate in music based activities without therapy being the backbone of it. For example, if an older adult takes part in a community choir whose primary motive is to give the individual a chance to sing, the by-product of the individual feeling empowerment or social support can be seen as stepping stone in the progression of self-esteem and self-confidence (MacDonald 2). For those who are under the end-of-life care, the use of music therapy is of paramount importance to the individualâ&#x20AC;&#x2122;s need for relationships with those who love and care for them most. According to an article from Clements-Cortes which details music therapyâ&#x20AC;&#x2122;s role in end-of-life care, there are essentially three levels of care: supportive, which is geared towards providing comfort, support or pleasure for the patient, while helping to alleviate the physical, psychological, and cognitive symptoms that are usual to end-of-life situations (131); communicative/expressive, which allows for the patient to unearth and express feelings that might have been dormant (135); and finally the transformative stage, which facilitates insight and growth while asking the patient to review his/her life and forgive themselves (140). Cancer diagnoses, terminal illnesses, and the sudden onset of chronic pain that occur with old age can have an enormous impact on an individualâ&#x20AC;&#x2122;s perception of life. When these critical events occur,

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there is one area of the human being that has the potential to be affected more crucially than others. That is of the spiritual aspect of an individual through the use of music therapy. As stated before, the sensation of pain is an interconnected process that affects the body, mind, and spirit. Perhaps the most important effect music has on an individual is its ability to bring about spiritual changes in the individuals life. This is especially true of those who are experiencing chronic pain or find themselves in hospice or palliative care. In an article entitled “The Healing and Spiritual Properties of Music Therapy at a Cancer Care Center” which details the spiritual properties of music therapy at a cancer care center, participants use music as a means to express the transition of one feeling to another. For example, the group’s musical sound may mimic chaos in one instant, and then transition to cohesion in the next instant (McClean, Bunt, and Daykin 404). The results of these groups were split into four common themes of spirituality and music therapy: transcendence, in which participants found the experience “powerful,” “uplifting,” and “energizing,”; connectedness, with reported descriptions of “co-operation,” “harmony,” and “deep communication”; meaning-making, which contributed to search for meaning and feelings of insight and healing; and finally, faith and hope, manifested in the participants willingness to look forward to the future, no matter how poor the diagnoses (McClean 406). Just as music can be of benefit to older adults and those who are in the final stages of their lives, music therapy can also be utilized for infants who are born premature or require an extended stay in the hospital setting, and thus do not receive the proper social interactions that aid in their development. In such situations, the infant is, above all things, cared for in a strictly medical environment, which gives the infant the strongest chance for surviving. Therefore, the infant does not receive the emotional and loving support it desperately needs and is often

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suffering from pain and discomfort (Malloch, Shoemark, Črnčec, Newnham, Paul, Prior, Coward, and Burnham 387). Through the use of pre-recorded soothing music, the infant’s heart rate stabilizes, the stress response is significantly reduced, blood oxygen saturation increases, and ultimately their hospital stays are shortened (Malloch et al. 388). Another study shows how music therapy can successfully reduce a premature infant’s energy expenditure, resulting in an increase in the infant’s sleep quality and quantity (Haslbeck 208). Another interesting facet of Haslbeck’s study shows that not only did the premature infants benefit from music therapy, but their mother’s did as well. The study showed an increase in the mother’s well being, the coping behavior of the parents, and a positive influence on the mother-child interaction patterns (211). This speaks volumes of music’s ability to consciously and subconsciously provide peace and calm to all spectrums of life, whether it be newborn infants or the mothers who gave birth to them. Experiential Learning Jan Stouffer, a licensed music therapist at Penn State Hershey Medical Center in Pennsylvania, is a testament to music therapy’s inclusive capability as she deals with infants from the NICU all the way to the adult patients of the hospital. What Jan emphasized was the music therapist goal of invoking a relaxation response in the patient, a change from the consistent and overbearing pain associated with their hospital stay. She found that the most effective way to elicit this response was through what is referred to as active music therapy, or focused distraction. During this process, the patient is actively involved in the creation of music rather than passively listening to music. These two elements are different in their execution, however they both aim to achieve the same goal: healing. In some instances, if the patient is unable or instructed not to move, he/she will participate in the passive element of simply

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listening to the music and trying to associate positive memories or feelings to the music from the therapist. As stated earlier, music therapists attempt to lessen the anxiety that the individual experiences pre-procedure, and Jan attempts through music to try and quell these anticipatory stressors and symptoms. This process is most effective when the patient can actively engage in the music making, singing, and association of positive memories to whatever music is being played. After the active distraction, Jan coaches them through muscle relaxation techniques and deep breathing exercises that aim to lessen the patientâ&#x20AC;&#x2122;s anxiety levels before surgery. In the post-operative recovery stage of the patient, the most common form of treatment is administered through the use of pain medication such as morphine, opiates, and including over the counter Tylenol. As useful as some of these opioid medications may be in short-term recovery, they come with various negative side effects such as addiction, liver damage, and constipation. According to Jan, constipation is seen as a widespread issue with these medications because of the fact that the patients who are using these medications are lying in hospital beds all day, and the pain becomes more and more unbearable. One of the unique and positive side effects of music therapy is that there are no negative side effects. The only negative aspect of this form of treatment is that for some individuals who suffer from chronic pain, the effect is not immediate and drastic enough in the lessening of their pain. This in turn leaves the patient feeling frustrated and unwilling to continue the music therapy. However, those who stay committed to the process and utilize all the tools that music therapy has to offer, find themselves benefiting from it. Most of these sessions take place in the one-on-one therapeutic setting, usually at bedside, rather than musical group setting that seems to prevalent in the studies on music therapy. These bedside sessions usually consist of the patient along with their families, creating a safe, comfortable, and familiar environment for the patient.

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These bedside musical sessions seem to have a significant impact on not just the patient, but the music therapist as well. Jan discusses one patient who has been in the hospital for a month recovering from a heart transplant and has had a difficult time coping with his current recovery. Before she entered the room, the patient was sobbing and full of rage. By the end of the session, he was sitting upright on the edge of his bed, strumming his guitar and teaching Jan the chords to “Wish You Were Here” by the classic English rock band Pink Floyd. The song was significant to the patient in that he was missing his close relatives as well as the lifestyle that he was so accustomed to living before this operation. As she left the room, he had remained sitting upright on the edge of the bed with a smile on his face. The joy and peace that this patient, this man felt did not come from medication, rather it came from the power of music to help heal the mind, body, and soul. Franciscan Tradition In a world where it seems as if the only way to help heal or relieve an individual’s pain is through a physical pill or form of treatment, it is uplifting to know that something as intangible and mysterious as the phenomenon of music can have a profound impact on an individual’s ability to recover. It is this ideal of using the gift of music to help aid those who are suffering from pain, that it is at the core of the Franciscan Tradition. The connection and community that occurs within a group of individuals who struggle with the daily burden of chronic pain while they participate in an active music group, is unparalleled. When two people who may not even be paying close attention to one another in a drum circle, find themselves playing exactly the same rhythm at exactly the same moment, there is an undeniable presence of something that is larger and more powerful than they are. In that moment, God is present through those individuals, through their drums or guitars, and ultimately through the music itself. One subject

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from a study in which the spiritual properties of music therapy was discussed, shared this reflection: “Music is symbolic of life and energy and all things… It represents the life force and it is something you can’t fake, you can’t fake music.” (McClean 405) It could be argued that this energy, this life force that is so often found in music therapy setting, can be seen as Godlike, in that it is indescribable and more powerful than the individuals themselves. Conclusion As the world of medicine and treatments evolve day to day, music therapy will continue to be at the forefront of alternative modes of treatment for pain management. Music therapist Jan Stouffer believes that those in her profession should continue to participate in more research, as well as collaborating with specific areas of medicine like anesthesiologists and pain management teams in an effort to create the proper protocols and guidelines. Research shows that music therapy is a low-costing, effective agent in the treatment of pain management, pre/post-operative anxiety and stress, negative side effects from certain medical procedures such as chemotherapy, and has the ability to significantly reduce the need for opioid pain medication and the risks associated with it. Works Cited "American Music Therapy Association." What Is Music Therapy. N.p., 1998. Web. 01 May 2014. Bicknell, Jeabette, Ph.D. "Music and Pain Relief." Psychology Today: Health, Help, Happiness + Find a Therapist. N.p., 1 Nov. 2011. Web. 02 May 2014.

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Clements-CortĂŠs, Amy. "The Role of Music Therapy in Facilitating Relationship Completion in End-of-Life Care." Canadian Journal Of Music Therapy 16.1 (2010): 123-147. Academic Search Complete. Web. 1 May 2014. Cutshall, Susanne M., et al. "Effect of the Combination of Music and Nature Sounds on Pain and Anxiety in Cardiac Surgical Patients: A Randomized Study." Alternative Therapies In Health & Medicine 17.4 (2011): 16-23. Academic Search Complete. Web. 15 Feb. 2014. Dunbar, R. I. M., et al. "Performance of Music Elevates Pain Threshold and Positive Affect: Implications for the Evolutionary Function of Music." Evolutionary Psychology 10.4 (2012): 688-702. Academic Search Complete. Web. 15 Feb. 2014. Eells, Karen. "The Use of Music And Singing to Help Manage Anxiety in Older Adults." Mental Health Practice 17.5 (2014): 10-17. Academic Search Complete. Web. 1 May

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Hanser, Suzanne B., and Susan E. Mandel. "Music Therapy for Pain Management." Practical Pain Management. PPM, 31 May 2012. Web. 09 Feb. 2014. Haslbeck, Friederike Barbara. "Music Therapy for Premature Infants and Their Parents: an Integrative Review." Nordic Journal Of Music Therapy 21.3 (2012): 203-226. Academic Search Complete. Web. 1 May 2014. Karagozoglu, Serife, Filiz Tekyasar, and Figen Alp Yilmaz. "Effects of Music Therapy and Guided Visual Imagery on Chemotherapy-Induced Anxiety and Nausea-Vomiting." Journal Of Clinical Nursing 22.1/2 (2013): 39-50. Academic Search Complete. Web. 1 May 2014. Kemper, Kathi J., and Suzanne C. Danhauer. "Music as Therapy." Southern Medical Journal 98.3 (2005): 282-88. Print.

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Kleiber, Charmaine, and Mary S Adamek. "Adolescents' Perceptions of Music Therapy Following Spinal Fusion Surgery." Journal Of Clinical Nursing 22.3/4 (2013): 414422. Academic Search Complete. Web. 15 Feb. 2014. Knox, Don, et al. "Acoustic Analysis and Mood Classification of Pain-Relieving Music." Journal Of The Acoustical Society Of America 130.3 (2011): 1673-1682. Academic Search Complete. Web. 1 May 2014. Kwan, Melanie. "Music Therapists' Experiences with Adults in Pain: Implications for Clinical Practice." Qualitative Inquiries In Music Therapy 5.(2010): 43-85. Academic Search Complete. Web. 15 Feb. 2014 Lucas, Linda K. "Orthopedic Outpatients' Perception of Perioperative Music Listening As Therapy." Journal Of Theory Construction & Testing 8.1 (2004): 7-12. Academic Search Complete. Web. 15 Feb. 2014. MacDonald, Raymond A. R. "Music, Health, and Well-Being: A Review." International Journal Of Qualitative Studies On Health & Well-Being 8.(2013): 1-13. Academic Search Complete. Web. 1 May 2014. Malloch, Stephen, et al. "Music Therapy with Hospitalized Infants-the Art and Science of Communicative Musicality." Infant Mental Health Journal 33.4 (2012): 386-399. Academic Search Complete. Web. 1 May 2014. McClean, Stuart, Leslie Bunt, and Norma Daykin. "The Healing and Spiritual Properties of Music Therapy at a Cancer Care Center." Journal Of Alternative & Complementary Medicine 18.4 (2012): 402-407. Academic Search Complete. Web. 1 May 2014.

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Nesbitt, Laura Letchworth, and Kim Tabatt-Haussmann. "The Role of the Creative Arts Therapies in the Treatment of Pediatric Hematology and Oncology Patients." Primary Psychiatry 15.7 (2008): 56-62. Academic Search Complete. Web. 1 May 2014. Park, Juyoung, and Anne K. Hughes. "Nonpharmacological Approaches to the Management of Chronic Pain in Community-Dwelling Older Adults: A Review Of Empirical Evidence." Journal Of The American Geriatrics Society 60.3 (2012): 555-568. Academic Search Complete. Web. 1 May 2014. Pi-Chu, Lin, et al. "Music Therapy for Patients Receiving Spine Surgery." Journal Of Clinical Nursing 20.7/8 (2011): 960-968. Academic Search Complete. Web. 1 May 2014. Richards, Terry, et al. "The Effect of Music Therapy on Patients' Perception and Manifestation of Pain, Anxiety, and Patient Satisfaction." MEDSURG Nursing 16.1 (2007): 7-14. Academic Search Complete. Web. 1 May 2014. Trappe, Hans-Joachim. "Role of Music in Intensive Care Medicine." International Journal Of Critical Illness & Injury Science 2.1 (2012): 27-31. Academic Search Complete. Web. 1 May 2014. Vaajoki, Anne, et al. "Effects of Listening to Music on Pain Intensity and Pain Distress After Surgery: an Intervention." Journal Of Clinical Nursing 21.5/6 (2012): 708-717. Academic Search Complete. Web. 15 Feb. 2014. Vaajoki, Anne, et al. "Music as a Nursing Intervention: Effects of Music Listening on Blood Pressure, Heart Rate, and Respiratory Rate in Abdominal Surgery Patients." Nursing & Health Sciences 13.4 (2011): 412-418. Academic Search Complete. Web. 15 Feb. 2014

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Neumann University Catalyst: Journal of Student Research and Academic Scholarship Vol 2, Spring 2016

Post Traumatic Stress Disorder in the Fire Service Student Author: Devon Richio Academic Program: Continuing Adult and Professional Studies Faculty Sponsor: Jilian Donnelly, Ed.D. Introduction: “Dispatch, Captain Brown, Ladder 3. I’m on the 35th floor. Relay to the Command Post that we’re trying to get up. Numerous civilians in all stairwells, numerous burn injuries coming down, but we’re still heading up.” Patrick Brown, Captain Ladder3, FDNY September 11th, 2001

“Post Traumatic Stress Disorder (PTSD) is a mental health condition that is triggered by a terrifying event, either by experience or witness. Symptoms include flashbacks, nightmares and severe anxiety, as well as uncontrolled thoughts about the event (Hall-Flavir).”PTSD can develop after an ordeal in which a person experiences physical harm or the threat of physical harm. It is most commonly associated with veterans of war. Post Traumatic Stress Disorder, a phrase coined in the 1970’s, was a term used to describe the mental state of returning Vietnam War Veterans. PTSD was used in place of terms such as shell shock, soldier’s heart, and railway spine. According to the research, PTSD affects civilians as well due to other traumatic events such as rape, assault, torture, kidnappings, crashes and bombings.

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This research paper will focus on one specific group of people that are subject to the horrors of humanity and Mother Nature; our Nationâ&#x20AC;&#x2122;s firefighters. It will also look at PTSD coping measures, as well as treatment options, available to members of our fire departments. PTSD is among a long list of behavioral health issues facing first responders, and it is an evergrowing problem in all ranks of the fire service. These men and women are expected to respond at a momentâ&#x20AC;&#x2122;s notice to events that are beyond the control of the rest of the civilian populace. Firefighters routinely act with a sense of poise and courage that are beyond reproach responding day after day in rain, sleet or snow to unfathomable atrocities. Once the incident has been placed under control these individuals return to a firehouse to patiently await the next encounter with fate. Literature Review Post Traumatic Stress Disorder is just one of the many dangers that our Nationâ&#x20AC;&#x2122;s fire service professionals face on a daily, if not constant, basis. In the United States, between approximately 7% and 37% of firefighters meet the clinical criteria to be diagnosed with PTSD (del Ben 38). In the City of Philadelphia, with a firefighting force of over 2100 (Philadelphia Fire Department), there are at least 800 potential members that could be diagnosed with PTSD but are not. This can be attributed to a lack of awareness about PTSD symptoms and treatments as it applies to its effects on members of the fire service. Awareness of the disorder can be a first step to helping those in need. Firefighters are at a high risk given their constant exposure to situations that may develop into PTSD (Haslam 277). Post Traumatic Stress Disorder is characterized by intrusive memories, reoccurring nightmares, avoidance of the event or similar situations, and changes in emotional reactions. These emotional reactions include irritability, an overwhelming sense of guilt, self-

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destructive behavior, trouble concentrating or trouble sleeping (Hall-Flavir). Research shows that firefighters are at higher risk because of many factors. Some of these factors are starting emergency service work at a young age, being unmarried, holding a supervisory rank, and proximity to death following a traumatic event (Tull). Some experience ‘survivor’s guilt’, which happens after an incident in which the individual lives while others died. Starting work as a firefighter at a younger age lengthens the exposure to traumatic events that the individual witnesses. In some cases, young firefighters can begin a career at the age of 18 and retire many years later at the age of 68. Being unmarried can leave a firefighter to feel a sense of loneness with no confidant at home. Holding a supervisory rank is especially stressful due to the fact that the officer is responsible not only for himself but the lives and wellbeing of others. Other factors that can predispose firefighters to PTSD include a history of family violence, drug misuse, traumatic experiences in foster care, as well as prior military service (C. S. Fullerton 1370). Career factors play a crucial part in the effects of stress on firefighters. Research has shown that incidents involving children have been the most stressful and lead to the most intrusive effects. Others issues that contribute to stress include incidents involving the elderly, Line of Duty Deaths, incidents involving severe trauma, burnout and shiftwork. PTSD efforts are more commonly focused on firefighter stress following large-scale incidents such as the terrorist attacks of September 11th rather than incidents that first responders respond to more frequently such as motor vehicle accidents and structure fires (Haslam 278). Carlier, Lamberts and Gersons suggested that some stresses were not brought on by individual incidents, but fire department organizations themselves, in the form of shift work, managerial and organizational problems (264). They suggested a ‘rest period’ after traumatic incidents in which the company would not respond to emergencies, however, many firefighters compared the subsequent response to getting

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back on a bicycle after falling off. This shows the resiliency of firefighters, who put their mind and bodies at risk on a daily basis to positively affect the lives of others. The American Psychiatric Association established the criteria for diagnosing Post Traumatic Stress Disorder as exposure to a traumatic event, with persistent re-experiencing and avoidance of similar situations, along with emotional numbing and increased arousal. All symptoms must be present for a duration of longer than one month, cause significant impairment to the individual and not be attributed to a substance or co-occurring medical condition. Assessment of individuals suspected of meeting the diagnosis criteria is usually achieved with a Trauma Screening Questionnaire (TSQ). The TSQ is a series of ten yes or no self-administered questions with a score over 5 indicating likelihood for PTSD (Griffin). Also used is the PTSD Symptom Scale, which uses 17 questions to identify the severity of PTSD. This assessment is interview driven as apposed to the self-administered TSQ. PTSD can be managed immensely through identification and prevention. Critical Incident Stress Debriefing (CISD) has been shown as a preventative measure against PTSD, but recent research has determined that it may have no effect on the first responderâ&#x20AC;&#x2122;s mental health (Carlier et al. 143). Another prevention method is the process of early detection. While researching US Army soldiers prior to a combat deployment, researched Mirjam Van Zuiden developed a test for blood biomarkers that identified precursors to PTSD. Van Zuiden found that soldiers with higher glucocorticoid receptor (GR) levels were at a higher risk of developing PTSD six months after a combat deployment. While the elevated levels of GR were not determined to be the cause of PTSD, they were identified as an indicator that an individual was exposed to some type of trauma in the past (Zuiden 1132).

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Psychological debriefings are another prevention method. Conducted through interviews with individuals following a traumatic event, it allows the individual to express feelings related to the incident with a counselor. Studies have recently shown that psychological debriefings can be unhelpful and potentially harmful, because they force the individual to relive the traumatic experience that may have triggered the PTSD initially (Rose, Bisson and Churchill). Intervention and types of medication have also been found to be useful prevention methods. Medications block stress receptors and lower the effects of adrenaline on the human mind. If prevention does not work, the effects of PTSD are managed by several different methods such as cognitive behavioral therapy, eye movement desensitization and reprocessing and interpersonal psychotherapy. Cognitive Behavioral Therapy is the coping method most widely used by the Veteranâ&#x20AC;&#x2122;s Administration to treat veterans suffering from the disorder (Hassjia and Grey 166). Cognitive behavior therapy works by having the individual re-experience an incident and identify thoughts that make them uncomfortable and replace them with more pleasant thoughts. Eye movement desensitization and reprocessing is another coping method in which the individual focuses on the movement of their eyes during times of stress or re-experiencing. By focusing on the eyes movements, the individual can then begin to control the movement, thereby reducing the effects of the stress (Shapiro 199). Firefighters are resilient and have been found to have a plethora of built-in, effective coping methods. It is reasonable to assume that this is because of frequent exposure to traumatic situations. One of the most prevalent coping measures is social support (Heinrichs 274) in the form of conversations with coworkers who have experiences similar traumas. Informal conversations among firefighters are quite possibly the most frequented and simplest coping

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methods that fire service professionalsâ&#x20AC;&#x2122; use. Often referred to as â&#x20AC;&#x2DC;kitchen table talk,â&#x20AC;&#x2122; these very informal debriefing sessions are found to be extremely beneficial and comforting to young firefighters after experiencing a traumatic event (Walls). These conversations have been shown to help the behavioral and mental health of the affected. Carlier et al. also noted that firefighters found it beneficial when a senior member of the company reached out a short time after an incident and asked how the firefighter was feeling. This finding speaks volumes to the brotherhood shared by all firefighters. Humor, by reducing stress and increasing social support, has also been identified as coping measure (Fullerton 371). Official debriefings, such as Critical Incident Stress Debriefing (CISD), are aimed at reducing the psychological damage of traumatic events (Bolwig 169), however, Hytten found that there was no difference in the effects of official debriefing as opposed to casual social support (Hytten 50). The United States National Center for PTSD also recommends moderate exercise as a coping method, a way to build self-esteem and regain a sense of control while distracting from the disturbing effects of PTSD (National Center for PTSD). It is estimated that in the United States, 6.8% of Americans meet criteria to diagnose with Post Traumatic Stress Disorder. Most of these cases come from rape, combat, childhood neglect or abuse (Kessler 12). Studies on PTSD rates in the military have concluded that between 11% and 20% of military servicemen returning from operations in the Global War on Terror, either in Iraq or Afghanistan, have been diagnosed with PTSD (National Center for PTSD). A separate study found that there were differences in the rates at which service members were being diagnosed, mostly relating to their wartime experiences and duties. The study found that service members deployed to combat were roughly 7% more likely to become diagnosed than their counterpoints in non-combat zones. Another finding was that being wounded or injured in

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combat increased the diagnosis rate 27%, and a 22% increase if the service member thought that they had killed someone as result of combat (Resul, Sabia and Erdal ). As mentioned earlier, between 7% and 37% of firefighters in the United States meet the criteria for PTSD diagnosis, which puts them at almost double the diagnosis rate of US service personnel. Compared to US military personnel, firefighters do not receive the same attention as it pertains to PTSD research. Franciscan Tradition Firefighters are constantly caring for others, whether at an emergency, or back at the station talking with their fellow members. The bible calls this kind of genuine, un-conditional love “agape”. The care and compassion they show for complete and total strangers is remarkable, to say the least. John 15:13 says, “Greater love hath no man than this, that a man lay down his life for his friends,” which could possibly be the best description of the average firefighter. These brave men and women, at a moment’s notice, put their selves and their wellbeing on hold to better the lives of people they have never met, and quite possibly will never see again. Firefighting is not done for fame or fortune; there are no riches to be made as a civil servant. It’s done because of a sense of duty and compassion. Experiential Learning An interview was conducted with a combat veteran of the United States Marine Corps and a Philadelphia Firefighter assigned to a busy North Philadelphia ladder company. Because of his experiences, he has a wealth of knowledge as it pertains to PTSD and its management. In conversations, the participant noted the similarities and differences between PTSD in the fire service and in the military. He noted that while firefighters do in fact experience traumatic events, it is not at the same frequency as the average Marine on a combat deployment. During his time as a firefighter, the participant also believes that the department does not do enough for its

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members when it comes to PTSD treatment. He attributes this to the so called â&#x20AC;&#x153;Alpha Maleâ&#x20AC;? culture that exists in the American fire service. There may be reluctance in asking for help or admitting a problem because it can be perceived as weakness by fellow members. Conclusion As psychological advances and treatment options become more advanced and available, there needs to be constant remembrance that not only our military is in need for PTSD management. Research has proven that firefighters are at the same, if not at greater, risk of becoming diagnosed with PTSD. Yet all too often, programs for addressing PTSD and other behavioral issues are not provided to the firefighter by his/her department. It is important for the member to seek help when experiencing high levels of stress. If left untreated, this stress can worsen and can lead to attempted or successful suicide attempts. A number of states across the country have introduced presumptive legislation that would add PTSD to the list of occupational diseases in first responders. Presumptive PTSD laws could help raise awareness about the disease. Often, the stigma associated with PTSD prevents many firefighters from admitting something is wrong. Unfortunately, in many departments, even where the stigma is reduced, there are few, if any, programs in place to assist the members of the department. Every fire department needs a unit to deliver behavioral health services. No matter how large or small the department, the behavioral health unit should include 24/7 access to services, behavioral health education and continued education for firefighters, their families and retired members. Peer counselors should be made available to identify and confidentially meet with members who may need assistance, as well. To ignore these facts is a great disservice to brave men and women that simply need a helping hand.

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Works Cited Bolwig, T G. "Debriefing after psychological trauma." Acta Psychiatrica Scandinavica 98 (1998): 169. Print. Carlier, I V, R D Lamberts and B R Gersons. "Trauma at work: Posttraumatic stress disorder as occupational hazard." Journal Occupational Health Safety*/Australia and New Zealand (1994): 264. Print. Carlier, Ingrid V. "Disaster-related post-traumatic stress in police officers: A field study of the impact of debriefing." Stress Medicine (1998): 143. Print. del Ben, Kevin S. "Prevalence Of Posttraumatic Stress Disorder Symptoms In Firefighters." Work & Stress 20.1 (2006): 37-48. Print. Fullerton, Carol S. "Acute Stress Disorder, Posttraumatic Stress Disorder, and Depression in Disaster or Rescue Workers." American Journal of Psychiatry (2004): 1370-1376. Print. Fullerton, Charles. "Psychological responses of rescue workers: Fire fighters and trauma." American Journal of Orthopsychiatry (1992): 371. Print. Griffin, Michael G. "The validation of a self-report measure of posttraumatic stress disorder : the Posttraumatic Diagnostic Scale." Psychological Assessment (2004): 445. Print. Hall-Flavir, Daniel. Post-traumatic stress disorder (PTSD). 15 April 2014. Web. 2 September 2014 <http://www.mayoclinic.org/diseases-conditions/post-traumatic-stressdisorder/basics/definition/con-20022540>. Haslam, Cheryl. "A preliminary investigation of post-traumatic stress symptoms among firefighters." Work & Stress 17.3 (2003): 277. Print. Hassjia, Christina J and Matt J Grey. "Behavioral Interventions for Trauma and Posttraumatic

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Stress Disorder." International Journal of Behavioral Consultation and Therapy (2007): 166. Print. Heinrichs, Markus. "Predicting Posttraumatic Stress Symptoms From Pretraumatic Risk Factors: A 2-Year Prospective Follow-Up Study in Firefighters." American Journal of Psychiatry 162.12 (2005): 274. Print. Hytten, K. "Fire fighters: A study of stress and coping." Acta Psychiatrica Scandinavica (1989): 50. Print. Kessler, Ronald C. "Posttraumatic Stress Disorder in the National Comorbidity Survey." Archives of General Psychaitry (1995). Print. National Center for PTSD. Department of Veteran's Affairs. Web. 2 September 2014. <http://www.ptsd.va.gov/public/treatment/cope/index.asp>. Philadelphia Fire Department. Philadelphia Fire Department. 14 August 2014. Web. 2 September 2014. <http://www.phila.gov/fire/about/about_commissioner.html>. Resul, Cesur , Joseph Sabia and Tekin Erdal . "The Psychological Cost of War: Military Combat and Mental Health." 2011. Print Rose, Susanna C., Jonathan Bisson, Rachel Churchill, and Simon Wessely. "Psychological debriefing for preventing post traumatic stress disorder (PTSD)â&#x20AC;? Cochrane Database of Systematic Reviews (2002). Web. 2 September 2014. Shapiro, Francine. "Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories." Journal of Traumatic Stress (1989): 199. Print. Tull, Matthew. About Health. 29 January 2013. Web. 3 September 2014 <http://ptsd.about.com/od/prevalence/a/Firefighters.htm>. Walls, Steven. Interview. Devon Richio. 21 09 2014.

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Zuiden, Mirjam Van. "Deployment-related severe fatigue with depressive symptoms is associated with increased glucocorticoid binding to peripheral blood mono-nuclear cells." Brain Behav Immun (2009): 1132. Print.

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