Mental Health and Domestic Violence - Term Paper Example

RUNNING HEAD: STUDY EVALUATIONS Evaluation of Qualitative and CRT Studies School Evaluation of "Mental Health and Domestic Violence: 'I Call it Symptoms of Abuse'" By using the Qualitative CASP guidelines [2002] I read the article in the British Journal of Social work titled "Mental Health and Domestic Violence: 'I Call it Symptoms of Abuse'" The Humphreys and Thiara article [2003, pp. 209 - 226] saw that there are problems with the traditional medical model of social work. This model sometimes fails recognize abuse. This model tends to focus on the symptoms of the abuse and not on understanding why it happens and looking at the abuse itself. Also, by ignoring or not seeing that there is abuse occurring, the patient may feel that it is their fault. They think that because the abuse is not seen it is their fault and tells them because it is not seen that it is okay. They may not see that it has not been found. All they continue to see is that it is their fault and they are to blame. "The disproportion between, on the one hand, what is now medically and technically feasible, and, on the other, what development within society makes economically possible, makes the need for health service research more urgent than ever--especially when such research incorporates sociology, education, and economics." [Crombie & Wiley, 1996, pp. 302] In this article, the authors are saying that traditional medicine is starting to see the need of and importance of a more all broad view in these cases. In the introduction of the study, the authors state that medical model does not work in this case. I have shown why that is in the paragraph above. The statement made by the authors was not surprising. If the patient can not be helped by using the Medical Model of Treatment, children would not benefit either. Even if the children were not in treatment, if their parent was and the medical model helped them the children would have benefited. A healthier parent takes better care of her children. The voluntary programs talked about in the study worked better for the victims. These services were formed to look at abuse not at just at the mental diseases abuse causes. The patients gained more from the programs because the were set up for the purpose of dealing with abuse. They listen to the patient and don't ignore the abuse itself. The find it is there and work towards fixing that problem which is the reason for the mental disorder. These programs deal with abuse and have experience so they are better able to help victims. They know how to help not just with mental health issues but with the abusive relationship as well. These models tell the women that the abuse is not their fault and they are not to blame. The abuser is wrong, not them. If the medical model never changes to see the whole picture, it will never help victims of abuse. It can not because it does not see the abuse. If you can not see it, it will never be fixed. The voluntary model works best for victims of abuse. It looks at the entire problem. It sees the whole picture of what is happening. This helps the patient and is the method that will solve the patient's problems or at least shows the patient what she needs to do. The decision to do it has to be made by the patient. In the voluntary model the patient's fears were recognized. They were not blamed for causing the abuse and they are not blamed because they stayed in the abusive relationship. The voluntary programs gave the women choices that they could see. It showed them how they could take action now to stop the abuse. When the abuse stops they began to see that the emotional problems were caused by the abuse. The emotional problems were not present because of them. The problems existed because of the abuse. Offering emergency shelters and other services protected the children as well. As soon as a patient decided to go to a shelter both the patient and the children were immediately safer. The voluntary services empowered the women. The positive support and understanding gave them strength. These programs made them realize that things could get better. They did not feel as hopeless and saw that they could change things. They could give a better life to their children. These voluntary programs showed them was steps they had to take. It gave them something they could actually do. They let them begin to take control of their lives. Seeing each step laid out, they could see the progress they were making. This gave them more confidence and hope. After the authors had explained the two different treatment models (traditional medical and the voluntary programs) they stated the purpose of the study. The study was done to look at two things. The first was to get an understanding of all the steps a women needs to do to end an abusive relationship. The study wanted to understand what each of these steps involved, not just listing what they were but looking at how each step affects the woman and her children. The study stated that it would at such things as the legal, medical, and financial problems women go through. Also, it would look at the voluntary programs that would help the women deal with these problems. The second thing the study would do was to interview women and children who had been in abusive relationships. They would gather information from these women who have used these voluntary services and find out the specific part each agency played in resolving each area of the treatment plan. The importance of understanding this will assist health care professionals and social workers see the importance of treating the mental illness and help the woman get out of the abusive relationship. Both have to worked on to help the patient heal. Looking at just the symptoms or just the outcome is not enough. Both need to done. Understanding how stress is caused and shows itself in the patient when in an abusive relationship will help counselors know what will work best. They will be able to learn more about how abuse causes stress and how to best help the patient. This will help them to deal with the emotional issues involved and improve their lives. This means being self sufficient, leaving the abuser, gaining back their self esteem and self worth and letting them care for their children. The authors feel this can be done by understanding the steps a woman must take (the legal, medical and financial) and using the voluntary services model. The two together will be the best way to assist abuse victims and their children. However, they say that understanding the mental stresses and fears are very important and need to dealt with. They mean that once the woman is out of the abusive home the mental disorders will not suddenly go away. They still need to be treated. Through looking at the interviews listed in the paper and analyzing the patient's feelings, actions, and reactions will help counselors and medical personnel understand better what an abusive relationship is. Hearing what an abused woman feels and what she goes through is needed to really understand this. Then better treatment plans can be developed using the information learned. "Researchers who use qualitative methods seek a deeper truth" [Greenhaulgh & Taylor, 1997, n.p.] Often the questions that need answered are not those which have a definitive yes or no answer. They contain more of a 'gray area'. That is true with this paper. Each case, each woman is different. The description of methodology used to gather the data was somewhat confusing and I had to reread it twice. "Besides knowing how to read a paper, busy clinicians need help in determining what papers to read and when to read them. If you are deciding whether a paper is worth reading, you should do so on the design of the methods section and not on ... the potential impact of the results" [Greenhaulgh, 1997, pp. 196] The importance of how the methodology is determined is very important. Without a well thought out, documented plan, the study will not be taken seriously. The basis for selecting 12 different out reach programs was well defined in the introductory information on previous study findings. So specifically including Asian and minority groups was appropriate. But I then found the information confusing. I did not understand when the paper talked about the surveys handed out to 12 out reach programs and 180 surveys returned. The paper then stated that each of the programs asked to select two women that had not filled out a survey to undergo in-depth interviews. It did not explain who selected the women for interview. Was it the program managers or was there a question on the surveys asking participants to name potential women to interview This was never clearly defined. Also it never said what determined if a woman was selected for an interview. Why did they pick these women The study did not explain how many women in total were asked to participate in the interviews and how many said no. If 12 programs were used and they received 24 names for interview, why were only 20 interviewed Did the remaining four decline And if not, why and/or how were four eliminated from the interview process When I read the interviews of the abused women, I found them very informative. They seemed to support the results of previous studies the authors of this paper had used. However, it was very unclear how the interviews were conducted. I found myself asking when reading the paper on whether the authors themselves conducted the interviews or they had the programs conduct the interviews for them, Also, there was no clear or defined explanation of the interview process itself. It was not apparent if the interview was more open ended, allowing those interviewed to lead the direction of the interview. I was concerned that if the interviews were too structured, this could have lead those being interviewed to arrive at the conclusions expected by the authors. This was one area that really bothered me about the study. There was no example of the interview format made available in the paper which would have aided me in determining the method of interview. Also, if it was more an open-ended interview, I would question whether rules had been made before the interview to make sure the all areas would be discussed. Also, I wondered if more than one person conducted the interviews. Different people could affect the information received from each interview. The topic of the study as discussed in the beginning of the paper was very clear. However, it appeared that after the data had been collected, the authors did not stay with their original purpose. Instead it changed to look at the relationship of victims of abuse and how traditional medical modes of treatment were or were not helpful to them. Once they had obtained this they used the information to say what the medical mode needed to do when dealing with abuse victims. For instance, the primary issue that needed to be dealt with first was, according to the paper, the need for safety, a patient's need to feel safe. Until a woman felt safe, it was impossible to move onto dealing with any other underlying problems. The paper offered me no evidence of how the interviewers explained the purpose of the paper to the subjects of the study. I did assume in my reading that this must have been addressed to the women being interviewed. Because the interviews were conducted with abuse victims, I would think that they would be afraid of revealing information about the abuser. They would fear talking about the events surrounding the abuse and the identity of the abuser as well. Throughout the paper, the abuser's name was replaced by an initial only to protect their privacy. The women were named only by first name which also is appropriate and a standard approach for such a topic. I could not help wondering how these issues were explained to the subjects and wonder what was said. Could that have changed some of the responses In looking at the beginning of the findings sections, there was a brief discussion on what appeared to be some statistical analysis of the subjects' responses to the question: Why did you leave The paper did not explain how the numbers were reached and what the question was that was asked. That was the only attempt at numerically defining the information from the interviews that I noted in the paper. Although a majority of the answers according to the study fell into specific categories, the answers that did not say what the authors wanted them to were mostly ignored. It would have been interesting to see what the other 34% felt were their reasons for leaving. Bloor and Taraborelli in a British Journal of Medicine article stated that often qualitative research is discounted by more traditional medical as non-exacting. However, rather than minimize the data collected and the findings they felt that "the only notable weakness is that some of the short papers do not give enough detail of the methods used" [1995]. Instead of discounting qualitative studies the medical community should pay more attention to good qualitative studies. Often they answer questions that standard medical research models can not. In several instances conflicting data was dealt with properly. For example, when the study talked about the perceived usefulness of medication, there were responses which both favored and disfavored it. Both sides when discussed reflected that those who favored medication tended to feel it was useful when used as part of treatment plan and not as a singular solution. "Continuous analysis is almost inevitable in qualitative research: because the researcher is "in the field" collecting the data, it is impossible not to start thinking about what is being heard and seen." [Pope, Ziebland & May, 2000, pp. 114 - 116] This is one area where I really have concern, the personal opinion or focus on the researcher gathering the data. How would a qualitative study differ if done by another researcher Objectivity and non bias is the key. Now, I question whether this instance was discussed and explained further because it tended to support the authors' viewpoints. When I was done reading the study I was left wondering exactly what the purpose of the interviews was. I don't altogether disagree when the authors did state that this in an important area which needs to be focused. I tended to disbelief the survey not because of what the women said but because I did not believe the authors. They left out too much information. I had too many questions and very few answers. Upon reading this paper I began to question whether it was actually a study or research paper. In my opinion, although an area that truly is important and needs to be understood to assist victims of violence, this paper neither brought us closer to arriving at a solution nor offering any new direction for research that was not already proposed in the literature they had used to support the need for their study. References Bloor, E. M. & Avebury, P. T., (1995), Qualitative Studies in Health and Medicine. British Medical Journal, 310:1079, n.p. Available from: [26 November 2005] Crombie, I. K. & Wiley, D., (1996), Research in Health Care. British Medical Journal, 312:1619, pp. 302. Available from: [26 November 2005] Greenhalgh, T. (1997), How to Read a Paper: The Basics of Evidence Based Medicine. British Medical Journal, 315:891, pp. 196. Available from: [27 November 2005] Greenhalgh, T. & Taylor, R. (1997), How to Read a Paper: Papers that go Beyond Numbers (Qualitative Research). British Medical Journal, 7110:315, n.p. Available from: [28 November 2005] Humphreys, C. & Thiara, R. (2003). Mental Health and Domestic Violence: 'I Call it Symptoms of Abuse'. British Journal of Social Work, 33, pp. 209 - 226. Pope, C., Ziebland, S. & Mays, N., Qualitative (2000) Research in Health Care: Analysing Qualitative Data. British Medical Journal, 320, 114 - 166. Available from: [26 November 2005] Qualitative CASP (Critical Appraisal Skills Programme) Worksheet. (2002). Milton Keynes Primary Care Trust Evaluation of "Effectiveness of out-of-home day care for disadvantaged families: randomised controlled trial" Through use of the CASP RCT Appraisal Sheet [2002], I reviewed the article entitled "Effectiveness of out-of-home day care for disadvantaged families: randomised controlled trial" from the British Medical Journal [2003, n.p.] to determine the effectiveness of the study and gain a better understanding of the necessary components needed to evaluate an RCT study. By looking at the screening questions I saw that the study topic was quite focused. The paper explained in detail the purpose of the test, the specific criteria for acceptance into a trial group and also discussed other possible outcomes I also saw through the authors' introductory information, a need for trial data on measuring the effectiveness and outcome data on quality day care availability for low income families. Use of a random test was appropriate in this trial to eliminate bias. "Evidence based medicine has been a topic of considerable controversy in medical and health care circles over its short lifetime, because of the claims made by its exponents about the criteria used to assess the evidence for or against the effectiveness of medical interventions." [Ashcroft, 2003, 131] I did consider where this was the best methodology. I wondered if other things such as social problems by the group could affect the results. However, after review, I felt RTC would not limit the findings of this study. By using a random control test and having both a test and a control group seeing the outcome of both groups will show if there is variation. As earlier stated, although the study appeared when I first read it to be somewhat limited in scope, given the opportunity for the research and the absence of any such testing done previously it was an important and valuable first step in examining the relationship between quality out of home day care and employment of low income mothers. "Without major design innovations, it is more likely that the information generated by this research will have limited practical use, especially if the RCT model is unable to control for the effect of social complexity and the interaction between social complexity and dynamic systemic change" [Wolff, 2000, 97] When I read this section of the study I was somewhat concerned whether an RTC was an appropriate trial method here. The article was dealt with complex social issues. However, after reading this study further, I realized that any possible complex issue had been accounted for and RTC was the best methodology to use. As stated earlier the main fault I found with the trial was the small number of participants eligible to participate due to the limited spaces at the day care facility. That apart, the randomisation process was appropriate and well thought out. The criteria for acceptance into the study were based on application by the family for placement of the child in the newly opening day care centre. This eliminated any question on bias as the applications were already received without any knowledge of the research to be conducted. When the applications were received each family was given a number to identify them. This eliminated bias. The assignment to available slots was done by computer based on the number given to each family. Confounders were determined before the study. Some of these were: single parent families, size of family and whether subsidized or paying full cost. After identifiers were in place, a computer generated a random list of order of placement in the available slots. Additionally, it was noted that although initially there were 70 slots available for study participants, when actual placement was done the number was reduced to 64. This was done by the day care itself and was not because of the study. Once the computer generated order was completed the list was given to the day care administrators for rematching to names and notification was sent to families that spaces were available. The control group was selected from those not selected for the available slots. Participation in the trial was voluntary. Parents were not aware of the study until after children were selected for the day care. Participation or non participation was not a factor in allocating of available slots. It was further noted that as additional spaces became available within the day care additional participants would be added if they wished to participate. The research was well laid and there was good documentation. Both the control group and the study group baseline data were examined and any differences noted were minimal. This was done prior to beginning of the actual test. The participants of the study were not blind to the study. There was actually a two areas being looked at in this study: frequency of childhood illness and ear infections and maternal employment. The first, results were documented by health care records and medical testing at set times during the test period. Bias was not a factor here for participants. However, results of testing did hold the potential for bias. To eliminate potential for bias by medical workers, medical personnel conducting the hearing test did not know which group each child belonged to. Further, examiners of test results were given the audiograms with no identifiers about the subject of each test. This eliminated all potential for bias. The one area where a slight possibility for bias was present was with the parents telling their child's doctor that they were participating in such a study. This was looked at by the researchers and it researchers felt this would not create bias.. This also discounted the 'placebo effect'. [Liebert, 2001, 216] All mothers in the studywere aware of the study and it was impossible to conduct the study without their agreement. Also it was impossible for a family not to know which group they belonged in. Obviously the research group was allotted slots in the day care and the control group was monitored but were not given slots. The control group mothers were aware of their participation and the purpose was to analyze whether the placement of children in quality day care would impact mother's employment. Throughout the eighteen months of the study, the researchers did recognize that some of the participants moved from control to trial group and some from control to trila group. This was not a part of the study but because of the family circumstances. At each point in the trial where results were gathered it was shown if children had moved from one group to another. One area that may have been useful when analyzing data would have been to include data separately for all participants who were in the same group for the entire duration of the study and compare that to the data results for those who were in a particular study group at the time of the evaluation period. This may have yielded results that could have opened up other areas for consideration and study. Before the study began researchers had decided when the follow ups on the participants would be. The researchers had determined that at 6 months and again at 18 months data would be gathered for both groups. When I looked at the methodology used for gathering data there was no room for bias noted or detected, with the exception that some of the children's doctors might have been aware of the child's participation in the study based on parents revealing this to the physician. This would not impact results as the authors had stated. I did find unclear was the documenting of doctor visits. Why the children went to the doctor. Since the study was researching the relationship of out of home day care to illness in children, merely finding out how many visits each child made to the doctor was not sufficient. There are too many other reasons that children go to the doctor. Some examples are:: preventative visits for shots or physicals or return visits to perhaps monitor progress of an illness or injury previously examined for (follow-up appointments). This information would have been useful when reviewing the results of the study. The sampling as earlier stated in this study was small. Therefore findings may not be an accurate figure statistically. However, this was noted in the findings of the trial. It was further explained that although the sampling size was small, previously there has been no research in this area. The opportunity to conduct the test was there and the authors decided to conduct it even with the small size. It was an important first step. The baseline, midway and follow up results of this study were all presented in the same manner. This made it easy to compare. Mean data was used to identify demographic make up for both groups of such characteristics as age, education, employment. Mean and actual was used in the presentation of study findings in both groups. The main findings of the study were that children in day care tend to have more illness than children who do not attend day care on a regular basis and mothers who have high quality out of home day care available for their children are statistically employed more than mothers who don't have access to day care. However, the results also showed that although employment percentages increased as day care became available an increase in income did not follow. Simply stated, although more mothers are employed when they have access to day care financially there was no improvement on their gross income. "The unique advantage of random assignment is it enables you to evaluate whether the intervention itself, as opposed to other factors, causes the observed outcomes" [What Constitutes, n.d., pp. 5] If I had to sum the findings up in one word, that word would be typical. I would have expected children in contact with other children routinely to have more illness. Secondly, considering the research was conducted in a low income area and observing the age of the mothers and level of education, I would expect that although more would be able to find employment if offered child care, their employability would most likely limit their income potential because of such factors as education, training, and prior experience. The results of this study were precise enough to determine that further study is necessary. The sample was too small to make a definite causal statement, but it is a good first step in examining this. Further research with a larger sample would be helpful to document results. I say this because I envision other studies where perhaps job training is coupled with day care availability. "Observational research plays an important role in hypothesis generation, establishing questions for future randomised controlled trials and defining the clinical conditions under which they will be addressed" [Stables, 2002, pp. 101 - 102] Stables here was confirming what I myself was thinking while reading this study - the possibilities. Results of studies of this kind could eliminate the availability of day care as a causal effect of increased income. Although the day care availability is important it is merely a part of the solution not the solution itself. References Ashcroft, R. E., (2004), Current Epistemological Problems in Evidence Based Medicine, British Medical Journal, Ethics, 30, 131 - 135. Available from: [26 November 2005] Liebert, M. A., (2001), The Efficacy Paradox in Randomized Control Studies. The Journal of Alternative and Complimentary Medicine, 7:3, pp. 213 - 218. RCT Tool Critical Appraisal Skills Programme (CASP) Worksheet, (2002). Milton Keynes Primary Care Trust Stables, R. H., (2002). Observational Research in the Evidenced Based Environment: Eclipsed by the Randomised Controlled Trial. Heart, 87, 101 - 102. Available from: [26 November 2005] Toroyan, T., Roberts, I., Oakley, A., Laing, G. & Frost, C. (2003). Effectiveness of Out-of-Home Day Care for Disadvantaged Families: Randomised Controlled Trial. British Medical Journal, 327:906. What Constitutes Strong Evidence of a Program's Effectiveness. Available from: [26 November 2005] Wolf, N. (2000), Using Randomized Control Trials to Evaluate Socially Complex Services: Problems, Challenges and Recommendations. The Journal of Mental Health Policy and Economics, 3:2, pp. 97 - 109. Available from: [26 November 2005] Read More