Counseling Ohio Youth: What Their Parents Hope for in Mental Health Counseling Services in a County Identified As Appalachian

COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN

A dissertation submitted to the Kent State University College and Graduate School of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Doctor of Philosophy

Thomas Scott Newman

December 2018

A dissertation written by

Thomas Scott Newman

B.A., Malone College, 1984

M.S., Malone College, 1994

Ph.D., Kent State University, 2018

Approved by

______, Co-director, Doctoral Dissertation Committee Jane A. Cox

______, Co-director, Doctoral Dissertation Committee Jason McGlothlin

______, Member, Doctoral Dissertation Committee Steven R. Brown

Accepted by

______, Director, School of Lifespan Development and Mary Dellmann-Jenkins Educational Sciences

______, Dean, College of Education, Health and Human James C. Hannon Sciences

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NEWMAN, THOMAS SCOTT, Ph.D., December 2018 LIFESPAN DEVELOPMENT AND EDUCATIONAL SCIENCES

COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN (155 pp.)

Co-Directors of Dissertation: Jane A. Cox, Ph.D. Jason McGlothlin, Ph.D.

This study utilized Q methodology to explore the hopes of parents in an

Appalachian County in Ohio in relation to the mental health counseling treatment provided to their children. Twenty-six parents whose children received mental health counseling services in the identified county sorted 31 statements. The sorts were analyzed using and unrotated principle components analysis solution. Sorts loading on more than one factor were manually deflagged from the analysis resulting in three viewpoints being identified. Statements were also collected from parent participants during the sorting process. Analysis suggests parents in this Appalachian County have varied hopes for their children in mental health counseling services. These hopes simultaneously challenge and support some traditional beliefs about Appalachian residents highlight the continued need for mental health counseling professionals to invest effort in understanding the hopes of area parents. Implications for counselors and future research are discussed.

ACKNOWLEDGMENTS

This space is insufficient to begin thanking those responsible for supporting me throughout this process. I will do my best to highlight those who have been vital to who I was when I started and those who have helped shepherd my continued growth.

First, my family. To my angel, my all, my other self, Stephanie, a fellow traveller who reinvigorated and cajoled me through all the starts and stops. I am looking forward to celebrating our completed programs together. This is yours as much as mine and I hope to find a way to match the aid you have already delivered to me. You changed my life. I owe an unaccountable debt to my parents, Sue, a mother and an educator, and

John, a father who without almost any formal education remains the most intelligent and knowledgeable person I have met. You both suffered decades of an immature, unmotivated student. I eventually discovered what education was all about in college and have graduated several times since. I hope in some way you both are able to enjoy what your frustration and patience have earned. It still saddens me he won’t be sitting with

Mom this time, but he’s still with us. My in-laws, Don, Joyce, Laura, Andy, Jen, and other extended family that ‘always’ believed I would finish, even when I was not so sure myself. The list would not be complete without the two furry mutts who kept my feet warm these many winters of writing. I owe a vast debt of gratitude to you all.

My committee. I joked at the end of my oral defense I felt as though you had signed up for a 5k and discovered some way into the race it was a marathon and kept going. This process can make you feel moronic, lazy, crazy, and inattentive. You

minimized many of those moments for me and directed me through. Dr. Jane Cox, Dr.

Jason McGlothlin, and Dr. Steven Brown, thank you for doing much more than your jobs.

To the numerous people in the county in which this study took place, you helped make an impossible task come to fruition. There are those who consider the region’s residents backward or standoffish. I have always found the opposite. Always open and pleasant, I have not worked with a county more devoted to pursuing the cutting edge to support their residents. I am thankful you allowed me to play some part in your efforts and hope this project offers information to support those efforts. A special note of appreciation goes to the parents who took time to help us better understand what their children need, the county providers who took time out of their day to make it easier for the parents to participate, and the administrators who trusted me enough to represent them to their families in need. I hope I did you justice. To my ‘Participant Whisperer’, you know who you are, your spirit didn’t just change the direction of this study but evidenced what genuine caring creates in a world in such desperate need of more.

A small but growing group of folks were on my heart throughout this process and will continue to be. To my tenacious partner, Mary Beth, and our first additions Vanessa and Rachel, it has been incredible working in a practice where everyone is so committed to making a difference in the lives of others. It is so easy to maintain an intense level of caring when those around you are doing the same. Mary Beth and I always said we would only hire counselors better than we are and have lucked into two who were willing to clamber into our pirate ship and roll out the canons. This project represents the first step into our seriously studying how we help and how we fail, solely to do more of the

former and less of the latter. I look forward to setting the standard of what mental health counseling could be and apologize for the lumps we will take in getting there. It will be so worth it.

I have been blessed from the beginning with varied informal supports in my life.

Some transitory while others stick; some positive influences and some negative peers; some educated, others smart, and a couple who manage both. I cannot adequately communicate my appreciation for being cared for when broken, taken down a peg when overly arrogant, and challenged to be a better human than where I started. I intend to do my best to be worthy of all of your efforts and to pay it forward by encouraging others as you have encouraged me. I offer my most sincere Thank You!

TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...... iv

LIST OF FIGURES ...... x

LIST OF TABLES ...... xi

CHAPTER

I. INTRODUCTION AND LITERATURE REVIEW ...... 1 Purpose and Rationale...... 5 Definitions...... 7 Review of the Literature ...... 9 Mental Health Counseling in Rural America ...... 10 Appalachia ...... 12 Culture ...... 13 Poverty ...... 17 Mental health services ...... 18 Medical care ...... 22 Family structure in Appalachian culture ...... 24 Appalachian Ohio ...... 25 The Appalachian region ...... 26 The study’s county ...... 28 Parental Involvement in Mental Health Counseling Services for Their Children ...... 29 Children in mental health counseling ...... 30 Parental influence on children’s mental health counseling ...... 32 Addressing parental concerns in mental health counseling ...... 35 Summary ...... 37

II. METHODOLOGY ...... 38 The Present Study ...... 39 Introduction to Phase I ...... 41 Phase I: Statement collection for concourse creation ...... 41 The Q sample ...... 44 Introduction to Phase II ...... 45 Phase II: Participant selection (P set) ...... 46 Conditions of instruction to complete Q-sort ...... 49 Analysis ...... 51 Factor rotation ...... 53 Factor scores...... 53 vii

Interpretation ...... 54 Summary ...... 54

III. RESULTS ...... 56 Participants ...... 57 Statistical Data Analysis ...... 60 Correlation and Factor Analysis ...... 60 Factor Rotation ...... 61 Factor Loadings ...... 62 Factor 1: Traditional idealists...... 68 Factor 2: Private anti-participants ...... 73 Factor 3: Pragmatic family-focus ...... 76 Summary ...... 78

IV. DISCUSSION ...... 80 The Three Factors ...... 81 Factor 1: Traditional Idealists ...... 83 Factor 2: Private Anti-Participants ...... 85 Factor 3: Pragmatic Family-Focus ...... 87 Implications...... 91 Mental Health Counselors and Administrators ...... 91 Scholars in Counseling and Appalachian Studies ...... 94 Future Research ...... 95 Delimitations ...... 97 Limitations ...... 99 Summary ...... 100

APPENDICES ...... 102 APPENDIX A. INSTITUTIONAL REVIEW BOARD FOR HUMAN PARTICIPATION FORM ...... 103 APPENDIX B. REQUEST FOR AND RESPONSE TO PERMISSION TO CONDUCT STUDY AT SITE ...... 107 APPENDIX C. RECRUITMENT TOOLS, CONCOURSE INTERVIEW ...... 111 APPENDIX D. INFORMED CONSENT TO PARTICIPATE IN A GROUP INTERVIEW AND CONSENT TO AUDIO TAPE ...... 113 APPENDIX E. GROUP INTERVIEW QUESTION AND LITERATURE THEMES, CONCOURSE INTERVIEW...... 118 APPENDIX F. CONCOURSE ...... 120 APPENDIX G. Q SAMPLE ...... 123 APPENDIX H. RECRUITMENT TOOLS: Q-SORT ...... 125 APPENDIX I. INFORMED CONSENT TO PARTICIPATE IN A RESEARCH STUDY CONSENT TO PARTICIPATE IN Q-SORT ...... 128 APPENDIX J. PARTICIPANT PACKET ...... 132

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REFERENCES ...... 140

LIST OF FIGURES

Figure Page

1. The Appalachian Region as defined by The Appalachian Regional Commission ...... 8

2. Ohio’s Appalachian Counties ...... 27

3. The present study – Flow Chart ...... 40

4. Example of Fixed Quasi-normal Distribution for Q-sort ...... 50

LIST OF TABLES

Table Page

1. Topics Considered to Create Structured Format in Q Sample ...... 44

2. Parent Participant Demographics ...... 58

3. Child Treatment Demographics ...... 59

4. Parent Belief in Treatment Helpfulness ...... 59

5. Factor Matrix With Bold Font Indicating a Defining Sort, After Manual Deflagging...... 64

6. Factor Q-Sort Values for Each Statement ...... 65

7. Distinguishing Statements for Factor 1: Factor Q-Sort Value (Q-SV) ...... 70

8. Distinguishing Statements for Factor 2: Factor Q-Sort Value (Q-SV) ...... 75

9. Distinguishing Statements for Factor 3: Factor Q-Sort Value (Q-SV) ...... 77

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CHAPTER I

INTRODUCTION AND LITERATURE REVIEW

Participation in mental health counseling services can be affected by local culture

(Holcomb-McCoy & Bryan, 2010). Mental health counseling for children can also be affected by the culture of family members, particularly parents (Hawley & Weisz, 2003;

Nock & Kazdin, 2001; Raviv, Sharvit, Raviv, & Rosenblat-Stein, 2009). Different regions of the country are, at times, associated with particular cultures. Mental health counselors may well increase their effectiveness if they are aware of and account for the specific differences in each unique culture.

One example is the Appalachian Region, which has been identified as having a distinct culture affecting residents’ use of professional services, including mental health counseling (Hendryx, 2008; Owens, Murphy, Richerson, Girio, & Himawan, 2008; Tang

& Russ, 2007). Long-standing stereotypes of residents from the Appalachian region as a homogeneous and backward population have surrendered to more intensive examination, but more recent studies still report differences between Appalachian residents and those from other parts of the country. The people of Appalachia may not be all the same, but it has been suggested there are differences when compared to others in similar circumstances (e.g., socioeconomic status, rural setting) from non-Appalachian areas.

There has been limited research exploring how culture may intersect with parents’ hopes for their children’s mental health services, particularly parents from the Appalachian

Region. The purpose of this study is to improve the understanding of the hopes of parents in an Appalachian Ohio county in relation to the services offered to their children.

The Appalachian Region, as defined in The Appalachian Regional Commission’s

(2011) authorizing legislation, is a 205,000-square-mile region following the

Appalachian Mountains through all or part of 13 states. The Appalachian portions of these states are identified as more rural and poverty stricken than the rest of the country.

The region has historically been described as having a distinct culture differing from other areas of the country in terms of history (Riddel, 1974), economics, and poverty

(Behringer & Friedell, 2006). Economic concerns remain while more recent studies have identified additional differences in family structure and preferences for mental health counseling (Owens et al., 2008), education (Ali & McWhirter, 2006), health care

(Denham, Meyer, Toborg, & Mande, 2004), and interaction with professionals

(Behringer & Friedell, 2006).

There are varied explanations for common perceptions about and stereotypes of a defined Appalachian culture. Foster (1997) reported historical views of Appalachia are based on fictional or popular beliefs leaning towards a view of people from the region as isolated and backward, rather than being based on tested hypotheses. In describing a perceived absence of scientific research about the region throughout its history, Porter

(1981) suggested that the demographic similarities of people in Appalachia to mainstream America (e.g., being White, European, and Protestant) have resulted in an invisible minority. This invisibility has resulted in a shortage of both research and services in Appalachian communities. Tang and Russ (2007) reported the same sense of an invisible minority nearly 30 years after Porter’s original statement. Denham (2016) more recently suggested that following years of increased mobility in and out of the

3 region have resulted in a culture, which cannot be easily generalized to all residents who are more heterogeneous than some have reported, but can be recognized compared to other parts of the country.

People in Appalachian communities have been reported to have less contact with health professionals than residents outside of the region in areas with similar demographics (DeRigne, 2010). This difference in contact has been explained several different ways including a shortage of providers and a culture less likely to seek services when available. Appalachian counties were designated as mental health shortage areas, with 69.8% of counties, identified as Appalachian, lacking mental health services, compared to 57.7% in rural non-Appalachian counties in the same states (Hendryx,

2008). Financial concerns centered around long standing poverty and physical concerns related to isolation caused by the geographical features of the region have also been suggested as explanations for less contact with health professionals including mental health counseling.

Hendryx (2008) associated the difference in access to mental health services with low educational attainment in Appalachia. The region’s residents attempt and complete less education compared to the rest of the nation, resulting in fewer local residents becoming professionals resulting in less availability to mental health services for the region’s residents. It has also been suggested that a less educated populace may be less likely to seek out services, resulting in insufficient clientele for locally produced providers who do attempt to stay in the area. Lower levels of education may also be a

4 deterrent for outside professionals to move into the area and may cause a reduced acceptance of those professionals by the region’s residents (Hendryx, 2008).

It has been reported some cultures hold negative views of organized services and

Appalachia may present a particular division of this distrust towards helping professionals. Historically, there is an ingrained suspiciousness of outsiders and professionals by the region’s residents, directly related to outside interests’ past exploitation of the area and its inhabitants (Billings, 1974). More modern studies have also reported the region having a distinctive culture, one with a mistrust of outsiders

(Tang & Russ, 2007).

This perception of distrust of professionals has been identified in studies in the

Appalachian region. One study of the impact of Appalachian culture on the mental health counseling process sought to introduce a culturally informed, evidence-based parenting program in the region (Owens et al., 2008). Parents in the study reported barriers to participating in the program including costs in terms of time and money, as well as a need for increased social support. Parent participants also clearly reported interpersonal obstacles such as a lack of trust and perceptions of a judgmental atmosphere in the therapeutic relationship.

As evidenced in Owens et al. (2008), the Appalachian culture and the needs of parents whose children are receiving mental health counseling services must be considered if their children are to receive needed mental health counseling services.

Parents remain active participants in making decisions regarding the well being of their children. When working with children and their parents, counselors need to consider the

5 impact of the culture of the client and the parents as they relate to the process of mental health counseling (Holcomb-McCoy & Bryan, 2010). The socialization of adolescent children through their families in Appalachia is only beginning to be studied and socialization has been identified as unique in family structure, monitoring, allowance for autonomy, and responsibility (Templeton, Bush, Lash, Robinson, & Gale, 2008).

Templeton et al. (2008) reported the Appalachian family continues to evolve and change with increased interaction with and migration to more urban cultures. Programs to assist with parenting skills have shown increased success when tailored specifically to the

Appalachian culture (Marek, Brock, & Sullivan, 2006). If families and perceptions of mental health counseling vary related to the cultural background of the client and client’s family, what possible differences exist in the desires of parents from Appalachian communities compared to non-Appalachian communities? If those differences could be better understood, what changes could be made to better serve these communities through mental health counseling services?

Purpose and Rationale

The purpose of the present study is to explore what Appalachian parents hope for in mental health counseling services provided to their children. Research regarding the role of parents in decision-making and hopes for their children’s mental health counseling has been ongoing but rural areas have presented unique challenges to the mental health counseling profession (Owens et al., 2008). These challenges have led to varying research projects exploring family dynamics as they relate to the mental health counseling process but many questions remain. Studies have examined reasons for

6 parent related dropout from treatment (Kazdin, 1996; Kazdin & Wassell, 2000; Kazdin &

Whitley, 2003) and parental reluctance to seek help for their children (Raviv et al., 2009).

While the hopes of parents related to their children’s’ mental health services in

Appalachia require more attention, studies in other fields (e.g., medicine, occupational counseling, rehabilitation counseling) have found evidence of specific differences related to the use of professional services in the region. Mental health counseling studies specifically in the Appalachian region have focused on career counseling (Tang & Russ,

2007), teen socialization (Templeton et al, 2008), evidence based counseling programs

(Owens et al, 2008), the Appalachian residents as a distinct ethnic group with different beliefs related to family (Salyers & Ritchie, 2006), and the unique barriers of parents in the region related to awareness of and participation in mental health counseling for their children (Murphy, 2005). A better understanding of the perceptions of Appalachian Ohio parents may offer insight into why some of the area’s families are less likely to seek or continue mental health counseling services for their children in need. This may enable mental health counselors to better serve clients in the region. If mental health counselors better understand some of the hopes and beliefs of parents in Appalachian settings, they may be able to connect them with services which will best meet those expectations and improve the availability and retention of mental health services for rural children in need.

The literature supports a study on Appalachian parents’ perceptions of mental health counseling for their children for several reasons. First, rural areas, and Appalachia in particular, have been identified as underutilizing mental health counseling services when compared to non-rural areas (Hendryx, 2008). Second, child residents of

Appalachian areas have been reported to experience similar or increased incidence of mental health concerns and diagnoses when compared to areas with similar demographics

(e.g., socioeconomic status, population, education) of the country outside of the region

(DeLeon, Wakefield, & Hagglund, 2003). Third, parents in the region have reported different beliefs about mental health counseling (Tang & Russ, 2007) and professional services in general (Behringer & Friedell, 2006) than their counterparts in more urban settings. Fourth, parents play an important role in pursuing and continuing mental health counseling services for their dependent children (Kazdin & Wassell, 2000). Lastly, although some research has been conducted to understand specific barriers to treatment

(Kazdin, 1996; Kazdin & Wassell, 2000; Kazdin & Whitley, 2003), evidence based practices (Owens et al., 2008), and parent programs for Appalachian parents (Ruffolo,

Kuhn, & Evans, 2006), a more comprehensive understanding of the subjective perceptions of parents from the area about the hopes for mental health counseling services for their children may provide useful insight for providers. This study used Q methodology to better understand the hopes of Appalachian Ohio parents about mental health treatment for their children.

Definitions

The study of families and Appalachian populations in relation to mental health counseling has a wide variety of definitions from which to choose. Before reviewing the literature, it is therefore necessary to make explicit the definitions of some of the terms being used in this project. The following are terms and the definitions being currently applied for the purpose of this study.

Appalachia: The Appalachian region, as defined in The Appalachian Regional

Commission’s authorizing legislation (2011), is a

205,000-square-mile region that follows the spine of the Appalachian Mountains

from southern New York to northern Mississippi (see Figure 1). It includes all of

West Virginia and parts of 12 other states: Alabama, Georgia, Kentucky,

Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South

Carolina, Tennessee, and Virginia. Forty two percent of the region’s population is

rural, compared with 20% of the national population.

Figure 1. The Appalachian Region as defined By The Appalachian Regional Commission

Mental health counseling: According to the American Counseling Association, mental health counseling is a professional relationship established to empower individuals, families, and groups from diverse populations in an effort to accomplish goals related to mental health, wellness, education, and career (About ACA, n.d.).

Parents and children: In the State of Ohio, parents and children are defined as a legal relationship existing between children and their natural or adoptive parents or others through which the law has conferred the rights and obligations for the child. The relationship is extended to all children and parents regardless of marital status (Ohio

Revised Code 3127.01).

Review of the Literature

This chapter includes an overview of the literature on mental health counseling in rural areas, the Appalachian region, Appalachian Ohio, mental health concerns in children, and parents’ participation in seeking and continuing mental health counseling for their children. The literature suggests meeting parents’ expectations for the treatment of their children is crucial to their children’s attendance in mental health services

(Menting, Orobio de Castro, & Matthys, 2013; Pekarik, 1992), parents from different cultures may have different expectations (Holcomb-McCoy & Bryan, 2010), and a more complete understanding of those expectations may increase the use of services and reduce premature dropout (Kazdin, 1993, 1996; Kazdin & Wassell, 2000; Kazdin & Whitley,

2003).

Mental Health Counseling in Rural America

Rural areas of the country have presented unique challenges to mental health counseling professionals for reasons ranging from economics to culture. Areas of the

United States designated as rural have often been identified as being mental health professional shortage areas (Hendryx, 2008). Varying explanations have been offered for continued shortages in services in rural areas but the majority of these explanations appear to focus on the residents and the professionals themselves. Residents in rural areas may face several barriers to seeking mental health counseling services.

Historically, the very geography of the Appalachian region made access to the region difficult, fostering a strong sense of self-reliance and community interdependence

(Behringer & Friedell, 2006). Duncan (2001) reported efforts to improve access to the region may have actually reinforced local reliance and a mistrust of outsiders, as corporations moved into the region, depleted natural and human resources, and funneled the benefits back to far away urban centers.

In addition to geographical barriers, residents of the Appalachian region may also experience other barriers to mental health counseling services. Residents may face significant pressure from family members or the community against changes resulting from mental health counseling, especially if those changes are perceived as a threat to tight family interdependence or other cultural themes. Additionally, confidentiality may be more difficult to maintain in rural settings. Small “fish-bowl” communities, where very few details of life are unknown to neighbors and the community, may present a barrier to rural residents seeking services as participation in services is more difficult to

11 keep private than for residents in more highly populated areas (Hastings & Cohn, 2013).

Mental health counselors often face ethical dilemmas in relation to confidentiality and dual relationships as rural communities are often small and tightly interwoven (Campbell

& Gordon, 2003). Long instilled values of local reliance and negative stigma attached to mental health services also present challenges to professionals practicing in these areas, due to a preference for informal supports over professional options (Hoyt, Conger, Valde,

& Weihs, 1997).

Professionals practicing in rural areas like the Appalachian region may face other challenges specific to the area. Hastings and Cohn (2013) suggested the shortage of mental health professionals in rural areas often results in professionals in Appalachia experiencing a sense of isolation, limited access to continuing education, and limited opportunity for consultation. These concerns are not limited to professional mental health counselors. For example, Sutton and Pearson (2002) suggested school counselors from more metropolitan areas described significant requirements in time and effort to overcome the culture shock of working in a rural setting, with varying success. Roots and Li (2013), in studying other helping professions, reported the reasons occupational therapists and physiotherapists seldom move into or often leave their practices in rural settings had little to do with the physical environment (e.g., geography, rural setting) when leaving to seek more urban environs. Rather, professionals often left due to a lack of professional support, limitations for growth, and difficulties understanding the cultural context of the community. Hastings and Cohn (2013), in their study of mental health

12 counselors, suggested counseling professionals may face similar challenges as physiotherapists and occupational therapists in rural settings.

Students leaving mental heath counseling training programs have been trained for more urban settings and may be surprised and ill-equipped to manage the unique problems faced in more rural settings. Curtin and Hargrove (2010) agreed different skills may be required for rural mental health counselors, highlighting a need to be more of a generalist in rural settings as referrals for specific concerns or disorders are often already fully booked or simply unavailable. Once some of these problems have been addressed

(e.g., professional support, specialized training), other perceived difficulties of rural practice may turn out to be strengths. According to Hastings and Cohn (2013), those who choose to work in rural populations are rewarded with geographical beauty and, if accepted by the community, can be relied upon as an expert.

Appalachia

Historically, the sociological and even geographical boundaries of Appalachia have multiple acceptable definitions (Riddel, 1974). The definition accepted by the

Appalachian Regional Commission (2011) is

The Appalachian region traces the spine of the Appalachian Mountains from New

York to Mississippi and includes the entire state of West Virginia and parts of

Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina,

Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia (see Figure 1). The

region has more areas designated as rural than the rest of the country. Forty-two

percent of the region’s population is rural, compared with 20 percent of the

national population.

Appalachia is consistently among the highest regions in the United States for school dropout (Ali & McWhirter, 2006), unemployment (Rogers, Mencken, &

Mencken, 1997), and correspondingly, the lowest in education and health care in the

United States. Efforts in recent decades have cut the poverty rate in the region nearly in half as industry has become more diverse, but varied success has resulted in a region of wide economic disparity (Appalachian Regional Commission, 2011). Residents of the region lag behind the rest of the nation in per capita market income by 25%, are below the poverty rate 12.7% more often, and send less than a quarter fewer of their residents successfully to college (Appalachian Regional Commission, 2011). Many have suggested the region differs from the rest of the country in more than demographics and economics, differing in its culture, which is distinct in several ways from the rest of the nation (Diddle & Denham, 2010; Lemon, Newfield, & Dobbins, 1993; Tang & Russ,

2007; Templeton et al., 2008).

Culture. Although residents of the Appalachian region may appear similar to the dominant culture in several ways, many have suggested distinct and long standing differences between the two (Ali & McWhirter, 2006; Hendryx, 2008; Tang & Russ,

2007). The Appalachian Mountains were said to shape the lives of the residents in both literal and figurative ways resulting in a distinct culture in which the physical place has been a key feature (Behringer & Friedell, 2006). The historical understanding of

Appalachian culture has been based on popular notions of isolated, backward, and

14 dysfunctional people as opposed to being rooted in scientific research (Templeton et al.,

2008). Shackelford, Weinberg, and Anderson (1977) found residents have suggested many of these stereotypes have been linked to researchers who some residents have described as experts who “pop-in, pop off, and pop out” (p. 12). Diddle and Denham

(2010) stated more modern interpretations of the region have disagreed with this singular stereotypical description and instead viewed the people of Appalachia as a diverse population. These more modern views of the regions’ residents may be more in line with the residents’ views of themselves.

In the 1960s, Weller (1965) reported varied and distinct characteristics of residents from the region, which continue to be described by more recent studies (Ali &

McWhirter, 2006; Diddle & Denham, 2010; Hendryx, 2008; Tang & Russ, 2007). Weller

(1965) described six characteristics believed to distinguish those in Appalachian areas from the dominant culture. First, he described a fierce individualism, which has become increasingly challenging to preserve as the world continues to become more interdependent. Second, traditionalism keeps residents bound to the past and past ways of doing things rather than having an orientation towards the future. Third, in a suspected defense against dissatisfaction, Weller described fatalism as a distinctive feature of

Appalachian culture. As life’s struggles are encountered, he described a tendency to simply acquiesce without much struggle or effort. As those who seek action, the fourth descriptor from Weller (1965), Appalachians may well strain against repetitive daily routines and structured or scheduled lifestyles. Fifth in Weller’s list is a psychology of fear learned through years of difficult circumstances, which he believed ran deeply

15 beneath their stoic fatalism. These fears are related to everything from natural disasters, acceptance in the family, or even the unknown. Finally, an orientation to persons rather than objects differentiates Appalachians from the dominant culture. A strong need to be connected and recognized in groups keeps established groups tightly connected. If these descriptions are accurate and have endured in the region, they may be barriers to mental health counseling in the region today. A strong sense of self-reliance, dissatisfaction with structure and schedules, and fatalistic beliefs that things are just the way they should be could keep area residents from seeking mental health services for themselves or their family members. More modern studies have continued to report similar cultural characteristics (Ali & McWhirter, 2006; Behringer & Friedell, 2006; Tang & Russ,

2007).

While the concept of the region continues to evolve, some historical notions of the area and its residents have continued to surface in research. Modern research in

Appalachia may have identified a more heterogeneous population than popular or historical descriptions have suggested, but distinguishable differences have still been identified between Appalachian residents and their neighbors. Salyers and Ritchie (2006) reported individualism, self-reliance, and pride were obvious values in Appalachian culture. Tang and Russ (2007) identified a collective over individual focus, as family well-being may often supersede individual goals. Historically, others have recognized this orientation but reported the orientation toward others is actually often viewed as serving individualistic needs (Weller, 1965). Lemon et al. (1993) described

Appalachians as having defined success by emphasizing internal qualities rather than

16 work or other external roles. He described more of a present orientation in regards to time than the strong link to the past suggested by historical studies. Lemon et al. did point out both past and present orientations appear distinctive from the future orientation of modern American culture. Ali and McWhirter (2006) suggested individualism is a central trait but strict individualism fails to take into account the collectivist ideals, which include valuing extended family or other community groups. Tang and Russ (2007) reported isolation from the mainstream culture has strengthened family and community ties as Appalachian residents rely heavily on family and community for support and survival, having been physically separated from cities and neighbors. Tang and Russ recommended mental health counseling professionals working with people in Appalachia carefully consider the interaction between the individual and the environment if they hope to address the unique challenges of the area.

While differences between the region and the rest of the country reportedly exist, research about the area has been limited. Porter (1981) suggested that the demographic similarities to mainstream American culture, such as race and religion, have resulted in an invisible minority, resulting in a lack of research and services. More recently, Tang and Russ (2007) also described Appalachian culture as an “invisible minority” (p. 34), particularly for those from more urban Appalachian areas who are quickly and negatively labeled “Appalachian” once outside the region. Tang and Russ (2007) suggested the label is often related to simple economic struggles and fails to highlight the numerous cultural distinctions and values that distinguish the region.

Poverty. Poverty has been a long-standing concern in many Appalachian communities. Appalachians have been reported to have lower incomes than the general population (Behringer & Friedell, 2006). Economic struggles have been historically associated with the region and while some conditions have improved, Appalachia continues to lag behind other areas of the country economically (Appalachian Regional

Commission, 2011). Gains have moved the region from widespread poverty to a region of great contrasts between communities. Currently two-thirds of Appalachian counties have higher unemployment, lower income, and lower Federal and private investment than the national average.

Explanations for the area’s economic struggles may be rooted in history. Billings

(1974) described two different explanations for the onset of poverty in the region. The first highlights the differences between Appalachian and traditional American cultures

(e.g., internal over external focus, adherence to historical traditions) as handicapping the region in a modern economy. The second doesn’t fault the culture but identifies it as an adaptive response to the economic realities the region has historically faced. The region has been dependent on industries, which have depleted various resources including the populace, offering only unstable and low wage jobs to those from the region. Duncan

(2001) expanded on this second possible explanation for economic concerns in the region, highlighting a history of external corporations perpetuating the culture of poverty in not only providing low wage jobs, but taking all of the profits out of the region and pulling them back to their metropolitan headquarters. He suggested the history of the practice has resulted in a protective and adaptive mistrust of outsiders. Environmental

18 and health related factors associated with these industries (e.g., cancer, lung disease) continue to plague residents of the region (Walls & Billings, 2002). A great deal of the literature focuses on economic struggles but Tang and Russ (2007) cautioned against assumptions automatically equating Appalachia with poverty. They reminded readers of the great variance in culture and needs across the region.

The Appalachian Regional Commission (2018) does report clear signs of progress in the region overall. Significant strides in reducing poverty through transitioning economic opportunities have reduced the difference in the poverty rate between residents and other Americans by nearly half in the past five decades. The commission suggests while the average has improved there remain specific counties with serious economic struggles.

Mental health services. Children’s mental health disorders have not varied much between urban and rural communities in terms of prevalence, but families in rural areas have faced barriers to receiving quality care for those disorders (DeLeon et al., 2003).

Common problems such as a lack of providers, lack of access, financial concerns, and violation of cultural norms have been identified as barriers to care. As a result, families receive no mental health services, may only have access to insufficient or substandard care, or only seek services after the problems have become severe (Owens et al., 2008).

With problems such as lack of access to mental health services, it is not surprising that the Appalachian region has been identified as an area underserved by mental health professionals. Appalachia has 268 nonmetropolitan counties. Of these counties, 69.8% have been designated as mental health shortage areas as compared to 57.7% in the

19 nonmetropolitan counties outside of Appalachia in the same states (Hendryx, 2008).

Lack of available services, combined with the Appalachian tradition of not seeking attention and trying to manage one’s own problems, represent continued challenges for mental health professionals in Appalachia (Behringer & Friedell, 2006). When mental health services are available, parents have limited knowledge of them. Murphy’s (2005) study of Appalachian parents’ awareness of service reported that while services in the region exist, parents have difficulty listing agencies they would consider when seeking mental health treatment for their children. In this particular study, 28% of parents listed no acceptable agencies with 85% listing three or less acceptable agencies. Nearly 10% of the respondents perceived there was no support available.

Some explanations of mental health professional shortages are related to financial concerns and other obstacles related to access (DeRigne, 2010). Hendryx (2008) associated these differences with lower educational attainment in Appalachia, resulting in fewer natively produced professionals or the inability of these professionals to provide services where they were raised, as residents are less likely to engage in those services when compared to residents in demographically similar (e.g., rural, socioeconomic status, education) areas. Reduced participation in mental health counseling tied to lower levels of education may also be a deterrent for outside professionals to move into the area.

Hendryx suggested lower educational attainment might also lead to reduced acceptance of outside professionals by the population.

Appalachia may present a particular stripe of distrust towards professional help unrelated to education creating another barrier to mental health care. Studies and

20 literature highlighting issues of trust in the region have spanned decades. Billings (1974) suggested there is an ingrained suspiciousness of outsiders and professionals directly related to the historical exploitation of the region and its inhabitants by outside interests.

Tang and Russ (2007) argued for a less homogeneous picture of the region but reinforced common themes of distrust towards outsiders and strong family connections. S. L. Fisher

(1993) suggested area residents share a mistrust of outside agencies and prefer self-reliance and maintaining control.

Drake (2001) reported isolation has increased dependence on family and encouraged a mistrust of outsiders, both individuals and organizations. Appalachian parents who had previously sought mental health care for their children reported more critical barriers to seeking treatment than parents who had not previously sought care

(Murphy, 2005). In Murphy’s study, parents highlighted two specific barriers both of which related specifically to the relationship between the client and the provider. They spoke of being concerned if the provider could be trusted and whether or not the provider would be “friendly” with their child. The study echoed how sociological and political history has created a lack of trust in institutions, fostering a stronger reliance on family and kinship communities for support.

Issues of trust also surfaced as a barrier to mental health counseling services in

Appalachian Ohio. Owens et al. (2008) sought to understand the impact of the

Appalachian culture on the mental health counseling process in a different Ohio county.

They studied the introduction of an evidence-based behavioral parenting program in the region. Parents’ reports of the program and barriers to participation included common

21 themes such as costs in terms of time but also included interpersonal obstacles. In addition to functional illiteracy, lack of transportation, and lack of insurance, study parents identified fears of judgment and concerns over being able to establish a trusting relationship with providers. Residents of the region also may be difficult to engage in professional services for other reasons. For example, Kimweli and Stilwell (2002) reported Appalachians have a higher subjective sense of well-being than any other similar culture which had been studied, making them less prone to view concerns as requiring assistance.

Tang and Russ (2007) highlighted several criteria to successfully engage people in an Appalachian region in career counseling. These included gaining trust prior to starting any interventions; assessing barriers and resources in the regional ecosystem through cultural knowledge and awareness; incorporating family and community resources; and considering the impact of background, opportunities and individual attributes to facilitate self-efficacy. They defined the initial criteria of building trust as being viewed as an insider rather than a representative of an outside institution.

Mental health counseling professionals may also be affected by these many barriers to services. Salyers and Ritchie (2006) suggested providers may be confused or frustrated when working with Appalachian residents. Residents may be sensitive and embarrassed by any need to seek assistance, resulting in defensiveness or an appearance of disinterest even when the need for help is obvious. To avoid further isolating

Appalachian residents, it is important to be knowledgeable about the values of this distinctive culture.

Medical care. The populations of Appalachian communities differ from other areas in their contact with mental health counseling professionals, but medical professionals as well having significantly less interaction. Studies in the Appalachian region have shown higher incidents of behaviors considered unhealthy, including alcohol and tobacco use (Denham et al., 2004) and exposure to toxins related to industry

(Behringer & Friedell, 2006) resulting in higher rates of cancer (J. L. Fisher et al., 2008), diabetes (S. L. Smith & Tessaro, 2005), and other medical diagnoses. The most common ways of earning a living in the region (e.g., mining) also contribute to health problems.

Working residents are exposed to toxic waste, unclean air and water, and more direct occupational hazards. Residents are then trapped in the predicament of facing dangerous risks or losing the ability to make a living in the area. Not all risks are related to industry.

A high prevalence of prenatal smoking was correlated to less education, low self-esteem, less intimate support (Song & Fish, 2006), and lower income and inadequate prenatal care overall in Appalachian women (Bailey, 2006). Additionally, Bailey and Cole (2009) reported rural Appalachian environmental and health conditions are likely to contribute to problematic birth outcomes. Health professionals are charged with the challenge of understanding Appalachian cultural characteristics and employing that understanding to create communication to and allow communication from residents about their well-being

(Behringer & Friedell, 2006).

Another study which explored differences in the reported needs of cancer survivors suggested survivors in more rural areas of the region report distinctively different needs than those from more urbanized areas (Katz et al., 2010). These

23 researchers identified rural survivors as not only reporting fewer needs overall but also reporting different needs (e.g., help with understanding details on billing and insurance, need for support groups) when they were reported. Meeting these needs may be difficult due to rural residents seeking information from different sources and struggling to understand the information and how it is presented.

Some cultural phenomena have been suggested as barriers to the regions’ inhabitants seeking professional medical assistance. Religion has been related to health concerns in the region (Behringer & Friedell, 2006). A belief in the will of God has been tied to a sense of fatalism, leading to the acceptance of risk and disease. Behringer and

Friedell (2006) reported Appalachians consider both their faith and medical advice when concerns arise. Diddle and Denham (2010) agreed reporting spirituality as tightly entwined with health in the Appalachian culture.

Another potential barrier to care is the pride and self-reliance of the residents

(Behringer & Friedell, 2006). To seek assistance from a professional source may suggest a stigmatizing weakness. Awareness of the culture and the traditional relationship to religion may improve communication between health providers and residents.

Communication between professionals and residents can create trust or a lack of it; and in mental health counseling, trust is essential if residents are to seek and continue services.

Behringer and Friedell (2006) more recently identified long-standing issues as often highlighted by others regarding trusting professionals, particularly from outside of the region (Billings, 1974; Duncan, 2001; Tang & Russ, 2007). Appalachian residents may have a distrust of all health professionals and a fear of the health system as a whole.

Behringer and Friedell (2006) reported trust is difficult to earn in Appalachia but once earned it is difficult to lose. They identified culturally relevant themes regarding health education in 10 Appalachian states using five studies funded through the National

Institutes of Health (Denham et al., 2004). Themes identified in the study suggested that providers should consider use of a focus on women as holding roles responsibility for health, one-on-one approaches, and residents’ preference for realism and facts.

Authors have suggested community interventions taking culture into account are more successful in engaging more rural residents in health care (Behringer, 2006;

Denham, 2004). One recent study (Harden, 2016) sought to employ emerging web based technology in an effort to increase the availability of addiction related services in an

Appalachian area.

Recent reports prepared on health conditions in the region (Holmes, G. et al.,

2018; Marshall, J. et al., 2017) also suggested some improvements in residents’ health.

The reports suggested specific counties in the region, referred to as “bright spots” are evidencing reductions in mortality rates, mental health issues, child health problems, chronic disease, and substance use. The commission was working to identify best practices and apply them to counties showing less improvement.

Family structure in Appalachian culture. Descriptions of the concept of family in Appalachia have varied. Templeton et al.’s (2008) qualitative research about who socializes rural adolescents highlighted the centrality of family in Appalachian culture, focused on strong connections and family loyalty. In addition, the study highlighted the supportive efforts of the extended family or fictive kin network. Appalachian parents

25 who participated in the study suggested a wider community is engaged in supporting parents, monitoring children, and teaching cultural values of respect and responsibility.

Tang and Russ (2007) concurred, noting the value of family as being more important than the individual, including the Scottish kinship or derbfine network of at least four generations as integral to the concept of family. Additionally, socialization agents may include community members not genetically unrelated to the family. While some barriers may be overcome by roads and schools, less tangible barriers including issues of trust and cultural differences in family also need to be addressed. Traditional

Appalachian families have been described as paternalistic, having been built on inherited

European ideas and the harsh requirements of the frontier (Drake, 2001). As physical isolation has been increasingly overcome in the region, it is possible the traditional family has viewed the impact of outside institutions including government and business as a threat to family structure and reliance, challenging the central authority of the family in the culture.

Appalachian Ohio

Prior to describing the portions of Ohio included in the Appalachian region by the regional commission, it should be noted not all residents describe themselves as

“Appalachian,” which many consider to be offensive and related more to negative stereotypes than to geography. Some residents prefer identification by the state or county in which they reside (Katz, Wewers, Single, & Paskett, 2007). The study (Holmes et al.,

2018) which identified bright spots of health improvement, including mental health, in

Appalachian counties reported not 1 of Ohio’s 23 Appalachian counties as a bright spot.

The Appalachian region. The Appalachian region has been considered by many to encompass multiple and varied areas. Riddel (1974) described four distinct regions of

Appalachia. Modern maps continue to split the region into different sections based on geography and geology. The Appalachian Highlands, from the Catskills of New York to

Georgia, are considered a national scenic resource with heavily timbered mountain ranges and few inhabitants. The Cumberland Plateau of Northern Tennessee, Eastern Kentucky,

Southern and Western West Virginia are heavily settled but the population is scattered, with residents being spread around creeks and hollows. Southern Appalachia including the Carolinas, Virginia, Tennessee, Alabama, and Northern Georgia have experienced a declining rural population, with residents seeking increased opportunities outside of the region.

The fourth area is the Northern Allegheny Plateau, which includes much of New

York, Pennsylvania, Northern West Virginia, parts of Maryland, and Eastern Ohio. This area features more urban centers and a more industrialized economy, which has led some to question its inclusion in the greater Appalachian region. Riddel (1974) noted shifting markets and technologies have had an effect on the area’s economics and while the area may be more urban, the problems faced are similar to those of the other three sub regions.

The Appalachian region of Ohio (see Figure 2) includes 32 of the state’s total 88 counties, or 33% of the state in square miles, and accounts for 12% of Ohio’s total population (Appalachian Regional Commission, 2013a). Compared with the rest of

Ohio, these regions have been characterized by lower household incomes, less education, lower wage jobs, and increased poverty rates. L. H. Smith and Holloman (2011) studied

Figure 2. Ohio’s Appalachian Counties

health and access to health care in Ohio’s Appalachian region and found differences in health, ability to access health care, and utilization of services within the region itself.

Children from river-bordering counties had higher incidences of health concerns such as asthma and obesity. Child residents of these counties also had more difficulty accessing care, particularly the care of specialists for specific conditions. Appalachian Ohioans also face health disparities in cancer mortality compared with non-Appalachian counterparts. A recent study (Ahmed, Bates, & Romina, 2016) found evidence

Appalachian Ohioans’ sense of satisfaction with physicians can be related to the perception of some parts of the physicians’ cultural competence. This may suggest learning, understanding, and addressing the culture of residents of Appalachian Ohio residents could result in increased satisfaction of services provided to those residents.

The study’s county. The county in which this study takes place consists of roughly 500 square miles and is divided into multiple townships. Settled by Quakers,

Dutch, Germans, Welsh, Scotch, and English pioneers, different portions of the county are suitable for agriculture or for pasture and timber. The geology includes layers of coal and commercially important clays. The county also produces or has produced salt, iron, brick, cotton, wool, flour, paper, oil and natural gas. Compared to other areas in the

Appalachian region, the county has more access to multiple forms of transportation, which has traditionally supported the development of business

(http://www.countywebsite.org, January 13, 2013; name removed to maintain confidentiality).

This county in Ohio still faces economic challenges, though fairing better than some Appalachian neighboring counties. It is identified by the Appalachian Regional

Commission (2013b) as Transitional, meaning it is currently transitioning between a weak and strong economy. Transitional counties fall on an economic continuum between the worst and best 25% of the nation’s counties. The county has also been designated as containing multiple distressed areas. Distressed areas are designated as having a median family income no greater than 67% of the national average and a poverty rate at least

150% over the country’s mean poverty rate. As a whole, the county residents have a

29 three-year average unemployment percentage of over 70% out of the nation’s 3,110 least employed counties (Appalachian Regional Commission, 2013c). The county also shares challenges in education with other Appalachian counties; over 80% of county residents have completed high school, actually outpacing the national average but very few have completed a college degree, placing them below the national average. Over 15% of the county’s population lived below the poverty level in 2013.

Many mental health-counseling services are centralized at a county center.

Several programs are offered to county residents, including outpatient psychotherapy for youth and families, psychopharmacology, community support services, and intensive home based services for families (Director of Quality Improvement and Corporate

Compliance, personal communication, September 29, 2010; name not used to protect confidentiality). Family services range from parent training to individual mental health counseling with the identified client child. The most common diagnosis following admission of juveniles at the center in 2010 was Attention Deficit Hyperactivity

Disorder, followed by Adjustment Disorders, Conduct Disorder, and Anxiety Disorders.

Parental Involvement in Mental Health Counseling Services for Their Children

Parents have reportedly played an integral role in decision making regarding mental health treatment for their children (Pekarik, 1991; Pekarik & Stephenson, 1988).

Personal concerns or disagreement with providers have kept many parents from seeking or continuing mental health counseling services for their children (Hawley & Weisz,

2003; Nock & Kazdin, 2001; Raviv et al., 2009). Parents have reported many reasons for discontinuing treatment including environmental obstacles (e.g., finances, time),

30 dissatisfaction with mental health counseling approach (Pekarik, 1992), treatment which fails to account for cultural differences (Garretson, 1993; Holcomb-McCoy & Bryan,

2010; Owens et al., 2008), family circumstances, parent or child histories of antisocial behavior (Kazdin & Wassell, 2000), and low parental expectations for treatment (Nock &

Kazdin, 2001). Termination of mental health counseling services for their children prior to completion is a great obstacle to successful treatment (Nock & Kazdin, 2001).

Children in mental health counseling. Childhood and adolescence have been described as life stages of upheaval in which multiple transitions potentially result in both growth and increased stress (Kazdin, 1993; Merikangas et al., 2010). Societal changes such as increasing poverty and varied family composition have complicated the ability of families to provide supportive environments for youth during these challenging periods

(Orton, 1997). And as in the past, high-risk behaviors and mental health disorders also remain as concerns for children and adolescents. Attention Deficit Hyperactivity

Disorder (ADHD), mood disorders, anxiety disorders, eating disorders, and behavioral disorders have been associated with this age group (National Institute of Mental Health,

2013). Research supported by the NIMH suggested half of all lifetime cases of mental illness begin by age 14 (Merikangas et al., 2010).

The Centers for Disease Control and Prevention (CDC) highlighted similar concerns tracking the mental health of Americans below the age of 18 (CDC, 2013). In the Mental Health Surveillance Among Children Report, between the years of 2001 and

2005, the CDC identified anxiety disorders, mood disorders, attention deficit disorder, eating disorders, elimination disorders, and behavioral disorders as common concerns

31 with the age group. They also identified concerns with developmental disorders, incidence of suicide, and struggles in school, community, and at home at this age.

According to the report, as many as 13–20% of children in the United States experience a mental health disorder in a given year and the cost of disorders in people less than 24 years old is $247 billion annually. The CDC report also referenced studies suggesting increases in the incidence of mental health concerns among children in the United States.

Considering the prevalence of identified concerns, Kazdin and Wassell (2000) reported this population still represents a neglected area of research.

Children and adolescents have been identified as frequent participants in mental health counseling services but concerns over barriers to treatment have still been reported

(Merikangas et al., 2011). Results from a National Health and Nutrition Examination

Survey (NHANES; 1998) study on adolescents report only 55% of youth who met criteria for a mental health disorder had met with a mental health professional. This number was an improvement over reports from previous studies, but nearly half of all children in the study needing professional mental health assistance remained without it.

The NHANES study, conducted from 2001 to 2004, followed 3,042 participants between the ages of 8 and 15. The survey, which tracked six mental health disorders (Generalized

Anxiety Disorder, Panic Disorder, Eating Disorders, Depression, Attention Deficit

Hyperactivity Disorder, and Conduct disorder), recognized 13% of respondents had met the criteria of one of those six diagnoses within the last 12 months, with just over half of the 13% having contact with mental health providers (Merikangas et al., 2011). Findings from the NHANES study suggested only 36% of youth with lifetime mental disorders

32 received any mental health care, only half of the severely impaired received treatment, and those who did receive treatment had fewer than six visits in their lives up to the time of the study. Negative effects of untreated childhood mental illness have been shown to persist well beyond the scope of childhood with long-term implications for adults (Block

& Greeno, 2011).

Parental influence on children’s mental health counseling. Researchers have investigated premature termination of child and adolescent counseling services with attention given to the role of parents. Kazdin’s (Kazdin, 1993, 1996; Kazdin & Wassell,

2000; Kazdin & Whitley, 2003) multiple large studies focusing on adolescent treatment drop out identified the significant impact of parents in terms of children obtaining, maintaining, and dropping out of treatment. Positively, resolution of the identified concern was cited as the reason for some dropout, even if underlying concerns had not been addressed. Money and relationship concerns (e.g., disagreement on presenting problems or focus of treatment, no or poor perceived relationship between mental health counselor and parent or child) were also related to treatment dropout. Pekarik and

Stephenson (1988) suggested premature child dropout from services may be more common and due to very different variables than adult termination. They recommended dropout for children be studied separately from adults, including parent driven variables.

Miller et al. (2003) reported parents assigned to parent-only treatment conditions prematurely terminated treatment more than those assigned to child-only or combined conditions. Assignment to conditions, which failed to match parents’ expectations for treatment, may have predicted termination. Programs designed specifically to address

33 parental barriers to treatment such as the Incredible Years, have been shown to reduce dropout, improve outcomes, and increase reported parental satisfaction (Drugli, Fossum,

Larsson, & Morch, 2010; Lees & Ronan, 2008; Menting et al., 2013).

Parent psychopathology and perceived low quality of life have been identified as barriers to children receiving needed mental health services (Kazdin & Wassell, 2000).

Hawley and Weisz (2003) reported in the majority of youth services, parents provide access to therapy and make the decision when to stop. The same studies found that the quality of alliances between parents and the therapist was more closely related to more frequent family participation, fewer missed appointments, and improved agreement about termination between parent and therapist than therapist alliance with the identified client.

A focus on decreasing barriers and meeting needs of parents has been connected to reducing dropout from parenting programs for children’s disruptive behaviors

(Greenwood, 2008; Koerting et al., 2013), treatment for children’s eating disorders

(Hoste, Zaitsoff, Hewell, & le Grange, 2007), and treatment for a multitude of children’s

Axis I Disorders (Block & Greeno, 2011). Established alliances with both children and parents have been related to satisfaction with mental health counseling services. Bannon and McKay (2005) stated the importance of meeting parent preference for service correlated to the parents’ use of mental health counseling services for their children.

When treatment efforts meet parent expectations, it appears children attend more sessions

(Bannon & McKay, 2005). This may be more important in Appalachian regions where traditional barriers such as lower socioeconomic status combined with regional

34 differences may prove insurmountable to many families (Bannon & McKay, 2005; Block

& Greeno, 2011; Pekarik & Stephenson, 1988).

In a study of treatment dropout focused on children, results were drawn from the parents of 169 children referred for oppositional and antisocial behaviors (Kazdin &

Wassell, 2000). Parental factors (e.g., parental psychopathology, overall quality of life) were separated from child dysfunction and other variables. Parental factors alone were found to be related to a lack of therapeutic success depending on the parents’ perception of the relevancy and demands of treatment. A follow-up study related parental stress to barriers and continued treatment attendance, and found that services that added treatments to help parents better manage their stress reduced those barriers to treatment

(Kazdin & Whitley, 2003).

In studying parents of children with severe emotional disorders, Ruffolo et al.

(2006) discovered a theme of parents being upset and discouraged with mental health professionals working with their children. Parents reported a need for information in managing their children and a sense of isolation from watching their children struggle in multiple settings. Parents in the study reported feeling judged and labeled unfavorably by mental health professionals rather than having their needs met. Another study of 315 children, parents, and therapists found that child mental health treatment began without any parental agreement on the needs of treatment in 75% of the cases (Hawley & Weisz,

2003). Almost half of the cases did not even agree on a single broad presenting problem.

Failure of the therapist to collaborate and connect with parents may be related to treatment dropout.

Addressing parental concerns in mental health counseling. It may be possible to recognize and overcome barriers to mental health treatment before treatment begins.

Kazdin and Wassell (2000) found that barriers to participation in mental health counseling not only led to treatment dropout but could be identified before treatment when they might be addressed before decisions about dropout had even been considered.

A five factor model to predict attendance included 10 competing obstacles such as time and transportation restraints; 10 demands of treatment from billing to child refusal; 8 items regarding treatment relevance in expectations and outcomes; 6 related to therapeutic relationship; and discrete life events expected to disrupt treatment participation (Kazdin & Wassell, 2000). These predetermined barriers were found to be correlated to treatment dropout.

Authors of another study on premature dropout suggested parent expectations for therapy were related to barriers and drop out (Nock & Kazdin, 2001). The outcomes suggested parents with lower expectations identified higher barriers and parents with either very high or very low expectations were least likely to drop out of treatment.

Overall, parent expectations were found to be a distinctive factor in youth participation in mental health counseling.

In working with parents, mental health counselors need to consider the impact of the culture of the client child and the parent, and the process of counseling parents from culturally diverse backgrounds (Holcomb-McCoy & Bryan, 2010). Before blaming and pathologizing behaviors, mental health counselors need to understand the function of the behaviors within the context of the client family culture as these behaviors may be

36 necessary to function in difficult or dangerous cultural contexts (Garretson, 1993). In areas where clients and families have been consistently marginalized, setting the removal of maladaptive but protective behaviors as goals without first establishing alternatives may lead to treatment dissatisfaction and dropout (Ungar, 2010). Osher and Osher

(2002) suggested attempts at collaboration with families are futile when the relationship and goals of mental health counseling are based in a single cultural orientation.

Bolen, McWey, and Schlee (2008) suggested when providers do not view problems in an ecological context and make efforts to reduce parent stress and other barriers, parents’ participation, effectiveness as treatment partners, and satisfaction with services decline. If families and their perceptions of mental health counseling vary related to the cultural background, what are possible differences in the hopes of parents from an Appalachian community in relation to mental health counseling services for their children when compared to non-Appalachian communities? Murphy (2005) reported relationship and trust issues between Appalachian Ohio residents and therapists are of particular concern in attempting to provide services. Poverty and parental perceptions of mental health services may be common barriers in more geographically isolated areas.

Bennett (2008) highlighted family involvement as perhaps the most promising avenue in increasing outcome expectations and overcoming distrust towards outsiders when addressing career counseling and educational programs. An effort to install an evidence-based program in Appalachian Ohio (Owens et al., 2008) reported success after the majority of parents perceived clinicians to be responsive to parent and child needs;

37 participated in decision making; and observed improvement in their children’s academic and behavioral performance through treatment.

Summary

Children in Appalachia face increased incidence of health concerns (Behringer &

Friedell, 2006) and similar increased incidence of mental health concerns compared to other children in the United States (Hendryx, 2008). Internal culture and external barriers have resulted in fewer children from the region being connected with the services required when compared to children in similar communities outside of the Appalachian region. Parents have played an important role in children seeking or continuing services, and the ability of the mental health counseling profession to understand and meet parental expectations have been shown to contribute to parental decisions to obtain, continue, or terminate services (Kazdin & Whitley, 2003). Understanding the specific culture of an area has been related to improved relationships between parents and professionals, as well as improved contact and child outcomes (Marek et al., 2006). The present study proposes to improve the mental health counseling profession’s understanding of parents in an Appalachian Ohio community to foster those goals.

CHAPTER II

METHODOLOGY

This chapter includes a brief overview of Q method, the rationale for utilizing the method to assess Appalachian parents’ hopes for their children in mental health counseling, and the procedures and data analysis used gathering those viewpoints.

Introduced by William Stephenson (1953), Q method provides the basis for the scientific study of human subjectivity. By inverting factor analysis and comparing variability in the collected perceptions of individuals, relationships among people are examined rather than relationships among variables. Q method employs strengths from both qualitative and quantitative designs to describe life from the vantage point of the person living it

(Brown, 1996; Shinebourne, 2009). Although it does employ mathematical interpretation, that interpretation provided a structure and form to explore the subjective hopes of Appalachian Ohio parents.

Q method, with its emphasis on eliciting subjective views from individual participants and then relating those views to each other, was ideal for the present study.

A phenomenological method was also considered to better understand participants’ perceptions of the world through in-depth interviews. Q method was selected over a phenomenological approach in that Q method was a better fit for this particular study.

Both phenomenology and Q method may be employed to elucidate the subjective perceptions of individuals but Q method had the added benefit of providing multiple viewpoints and allowing those viewpoints to be statistically grouped and compared

(Shinebourne & Adams, 2007; Taylor, Delprato, & Knapp, 1994; Watts & Stenner,

2012). Brown (2006) described Q method as a match for studying the perceptions of marginalized people, and marginalized intrapersonal parts or perceptions of those very people, making Q method appropriate for the present study.

Q Method has been misrepresented as a transposition of R matrix correlation and factorization (Brown, 1996). Factor analysis is the technical procedure by which data are processed, but Q method is designed to study subjective viewpoints, which may include data beyond the capability of traditional R matrix factor analysis. Through Q method, subjectivity can be captured, measured, and correlated with the meaning of others. The current study had two different interactions with participants from the Appalachian Ohio county, seen as two separate phases.

The Present Study

A Q study begins by distinguishing a specific topic of study and a group of people whose subjective perspectives are of interest (Webler, Danielson, & Tuler, 2009). The present study employed Q method to illuminate subjective perceptions of parents in one

Ohio county related to their expectations of mental health counseling services for their children. The study was completed in two phases. Participants in phase I were 11 mental health counseling providers working in, and nearly all from, the identified Appalachian

Ohio county. Participants in phase II were 27 parents of children receiving mental health counseling services in the same county (See Figure 3). This study sought Institutional

Review Board (IRB) approval for two separate interactions, one in each phase (Appendix

A).

Figure 3. The present study - Flow chart

Introduction to Phase I

In phase I, following IRB approval and completion of informed consent, mental health clinicians from the identified Ohio Appalachian county were recruited for a group interview to build a collection of statements, known as a concourse, based on the following question: What do you believe the parents of your mental health counseling clients under 18 hope, or ought to hope, their children receive through your mental health counseling services? Items from the research database were also discussed with the group for inclusion or exclusion.

Phase I: Statement collection for concourse creation. An attempt was made to collect a broad range of stimuli related to Appalachian Ohio parents’ hopes for their children in mental health counseling services. In Q method, stimuli can be comprised of statements, pictures, or anything participants can sort according to their own subjective viewpoint. In the current study, stimuli were confined to statements related to children’s mental health counseling services. Scientific principles exist for the selection of statements but Brown (1995) suggested it remains more art than science. The goal is to understand how the participant reacts to the items. Watts and Stenner (2012) stated that desired data in a multiple participant Q study are the distribution of these statements on a continuum. As Stainton-Rogers (1995) described it, Q method correlates and factors participants’ choices upon a sampling of elements. It is the constructions of the participants, not the participants or “constructors” themselves, that are the focus of the approach. In the present study items to create the concourse were gathered in two stages, both during a group interview with local mental health professionals.

Stage 1. The present study identified mental health professionals from the identified Ohio Appalachian county and concepts from professional literature as the sources for gathering the stimulus statements in this study. Some Q-method studies have gathered a collection of statements from individuals similar to the expected sorting participants or from the expected sorters themselves, but other sources have also been used to construct a representative sample of statements about a topic (Van Exel & De

Graaf, 2005). Professionals were approached in this study to prevent contaminating the small population of parent participants expected to complete the sort. Several sources

(Behringer & Friedell, 2006; Denham et al., 2004; S. L. Smith & Tessaro, 2005) suggested the target population would be difficult to engage and possibly mistrustful of

“expert outsiders.” Professionals were used to limit the time and number of contacts required from the parent participants.

Statements from these interviews were consolidated by theme and amended to include additional themes identified in the literature. Once the statements were reduced to a manageable number of 31 distinct statements, the five possible modes in which the county offers services were included and both were used to construct the Q sample for the second phase of the study. It is noted information related to building a concourse is often drawn from the population who will complete the sorting process. In the current study, local mental health professionals were interviewed for multiple reasons. First, the population targeted for the sort has historically been described as private, rightfully distrusting, and difficult to engage. This study approached local counselors to avoid overtaxing possible parent participants. Additionally, as many local providers in the

43 group interview were long time residents of the identified area (Administration at the

Center, personal communication, September 29, 2010; name not used to protect confidentiality) and parents, there could be significant similarity in viewpoints. Finally, it was hoped the parents, with the ability to suggest anything the counselors may have missed, would include any additional hopes in the post-sort follow up questions.

Stage 2. The members of the group interview, following the collection of their own responses to the open-ended question, discussed statements culled from professional literature. These five concepts were chosen from the literature on the culture of the area and the services available in the county under study (e.g., format of services currently offered). Items from the literature were overarching themes of parental hopes or concerns for mental health counseling for their children. Fit and culture were items related to the people and place of the particular Appalachian Ohio County being studied

(e.g., Lemon et al., 1993; Tang & Russ, 2007; Ungar, 2010). Focus of treatment and outcome included items related to desired emotional and behavioral changes (Hawley &

Weisz, 2003; Kazdin & Wassell, 2000; Kazdin & Whitley, 2003; Pekarik, 1992). Format included items related to the wide variety of delivery available through the centralized counseling center, such as group, individual, family based (Murphy, 2005; Nock &

Kazdin, 2001; Ruffolo et al., 2006). Facilitating counselor skills included items related to relational, theoretical, and programmatic abilities of the mental health counselor (e.g.,

Owens et al., 2008; Rose-Gold, 1991; Russ, 2010). And flexibility of the study allowed for any items identified through the interview not applicable to the first four classifications. A goal was to have a set of 10 items in each category for the final Q set

44 but the total number or percentages of items identified by the interview with the mental health practitioners could alter how many items from each category would be included.

Topics discussed in the group interview taken from research and practices in the county are listed by group in Table 1.

Table 1

Topics Considered to Create Structured Format in Q Sample

Items Related to Format of Services Offered in the County 1. Individual Counseling 2. Family Counseling 3. Mixed Individual/Family Counseling 4. Community Based Counseling 5. Options For Treatment

Items Related to Facilitating Counselor Skills 6. Counselor Availability (Time/Distance) 7. Counselor Cost Financially 8. Local Area Provider 9. Counselor Religion 10. Counselor Expertise

Items Related to Fit and Culture 11. Counselor Recognition of Parent Expertise 12. Counselor Respect (Pride/Reliance) 13. Trust/Relationship Between Child and Counselor 14. Trust/Relationship Between Parent and Counselor 15. Counselor Understanding of Family & Where They Come From

Items Related to Focus of Treatment and Therapeutic Outcome 16. Therapeutic Goal Agreement 17. Child To Improve Behaviorally 18. Child To Improve Emotionally 19. Treatment Focus on Child Goals 20. Treatment Focus on Parent Goals

The Q sample. The Q sample was created by condensing the broad range of statements in the concourse into a usable and representative medium upon which participants could communicate their subjective viewpoint. Once statements were

45 gathered for the concourse in the present study, they were compared, combined, and condensed to reduce overlap and resulted in a manageable number of items for the sorting process (see Appendix G). Watts and Stenner (2012) recommended beginning with a large number of items (the concourse) that can then be condensed and refined to a conveniently sortable Q sample, complete and without redundancy. The entire population of stimuli would have been unwieldy and nearly impossible for an individual to sort. The number of acceptable items for Q samples varies as widely as 10 to 100 items (Stainton-Rogers, 1995) or 30 to 60 (Brown, Durning, & Selden, 2008). These numbers are more guideline than rule and can be adjusted with the outcome of the study in mind, resulting in a collection of items best representing all potential opinions and remaining manageable for the participants. In the current study, 69 individual statements were collected during both stages of the group interview, and 5 different modalities in which the county offers services were added for a total of 74 items. These items were reduced in consultation with the dissertation committee, based on repetition and other factors to a small but manageable number of 31. Items were then randomly numbered and placed on materials (i.e., paper slips) that were then sorted by parent participants.

Introduction to Phase II

Phase II participants were 27 parents of children receiving mental health counseling services in the county under study. These parents were recruited and upon completing their informed consent, they ranked the Q sample in a forced quasinormal distribution from most important to least important from their own viewpoint. After sorting the statements, participants were offered the opportunity to answer questions as to

46 what it was about the statements that led to their particular rankings and completed some general background information.

Phase II: Participant selection (P set). Once the Q sample was completed, parent participants were then recruited for the P set. The goal of recruitment was to ensure varied population representation. This was not accomplished through statistical means or random sampling but more theoretically. Parent participants were expected to have varied viewpoints on the stimuli being sorted. It is for this reason P sets in Q method are composed of fewer participants than is the case in R methodology. The correlated factors of the responses are of more interest than the singular responses of the participants. To include various viewpoints, efforts were made to include participants whose children are receiving mental health counseling for multiple presenting problems, and from multiple programs and formats. Parents were recruited from as many of the different programs offered through the facility under study (e.g., outpatient, community based, family) as possible.

Kampen and Tamás (2014) criticized Q methodology for the ratio of the number of participants to the number of items with which they are interacting. This is of little if any importance in Q methodology as the variability is covered by the breadth of the concourse of statements rather than the number of participants (Brown, Danielson, &

Exel, 2015). Each item’s placement or score is created from the perspective of the sorter, having been compared to each other from that singular reference point, and is therefore intertwined with all other scores from the sort. Shemmings (2006) answered critics by reminding them that the purpose of the Q method is to intensively study subjective

47 perspectives of individuals rather than generalize those perspectives to larger populations.

Instead, the sheer mathematical odds of any patterns emerging from sorting the Q sample items are so high, it suggests the method accomplishes its stated goal, identifying strong and distinct clusters of individuals sharing attitudes about specific topics. Watts and

Stenner (2012) added Q method seeks to identify the existence of subjective viewpoints existing in the general population being studied but isn’t focused on what percentage of the population may hold those views. Q method is interested in generalizing concepts rather than population statistics.

Watts and Stenner (2012) suggested the difference in method and desired outcome of Q method, when compared to R methodologies, also alters the number of participants required for a successful sort. They even suggested having more than one participant for every two items may result in difficulty. As a result, many studies have involved 12 to 20 participants.

Participants in the present study were to be solicited until between 25 and 40 parents had completed the sorting process and at the completion of data collection, 27 participants had completed the process. The number of participants fell within the ranges identified by many as sufficient in breadth (Watts & Stenner, 2012; Webler et al., 2009), while maintaining clarity for analysis (Brown, 1993).

Following IRB approval (see Appendix A) and once an appropriate Q sample had been identified in this study (see Appendix G), parents whose children are involved in mental health counseling services were invited to participate in the study. Participants were recruited through the centralized provider in the county, housing multiple mental

48 health counseling programs for adults and children, and participants were approached for recruitment in multiple ways (See Appendix H). Flyers introducing the sorting phase of the study were placed in public areas frequented by parents. Center support staff who were not involved in direct mental health counseling services offered parents the option to participate based on a script ensuring prospective participants were aware of the purpose of the study and that they were not required to participate in the study in any way. The researcher was available on site to obtain informed consent, explain the process, and answer any potential questions regarding the study. Parents had the opportunity to take the packet with them to complete at their leisure but only two packets were completed without the presence of the researcher. The researcher was also available to potential or previous participants by phone or by email while the study was being run to respond to any questions or concerns. The first few months of the study passed without a single participant. One particular support staff member was made available to recruit parent participants and was able to recruit the majority of those who consented to participate.

All parents who chose to participate reviewed a brief explanation of the study with the staff member and then signed a detailed informed consent to ensure participants understood the purpose of the study, their options for participation, and how the information was to be used (See Appendix I). Once parents had agreed to participate, they were given the option to take the materials to complete on their own or to complete the materials with the researcher. All but two parents chose to complete the packet with the researcher. Parents completing materials with the researcher first received a copy of

49 the informed consent and then a packet containing the materials needed to complete the sorting process. The participant package included detailed instructions, individual paper slips with the statements to be sorted, a guideline for the fixed distribution, a response grid to record their responses, a page to gather demographic information, and a post-sort questionnaire (See Appendix J). Once the sort was completed and all information recorded, participants sealed all materials along with the informed consent in the envelope in which the packet was provided.

Conditions of instruction to complete Q-sort. The sorting process in Q method refers to the participants literally sorting the statements provided in the Q sample as related to their own subjective level of agreement or disagreement with each statement

(Watts & Stenner, 2012; see Figure 4). The sort generally took no more than 30 minutes in most cases and most were completed while the participant’s child was in session.

Items from the Q sample were spread out for the participant to consider and the participant was asked to sort them into a fixed quasi-normal distribution with the statements most characteristic of the participant’s perception to the right and the most uncharacteristic to the left (Watts & Stenner, 2012).

The range of the distribution was based on the total number of statements. Once completed, the instructions or researcher encouraged participants to review their responses and make any changes they felt needed to be made. Once the participant was satisfied with the sort, they or the researcher recorded the placement of the items on a sheet. The fixed quasi-normal distribution allowed for parabolic significance with most

50 characteristic and most uncharacteristic items being considered significant in opposite directions. See Figure 4 for the shape of the distribution.

-4 -3 -2 -1 0 1 2 3 4

X X X X X X X X X

X X X X X X X

X X X

Figure 4. Example of Fixed Quasi-normal Distribution for Q-sort. The row of numbers is the scale for ranking the statements. Each X is a statement required for that ranking.

Once the distribution was competed, the participant was asked to complete a follow-up questionnaire (see Appendix J) related to their sort. The follow-up questionnaire consisted of open-ended questions regarding the participant’s reactions to the Q sample and possible items the participant would have included not found in the Q sample. Demographic information was collected, not as part of the sort or to screen participants but in an effort to collect information in regards to their children’s ages, type of counseling program, connection with the community, and any other information deemed important. The researcher was available to answer any questions the participant may have had in person or after the process by phone or email.

Analysis

Analysis in Q method is based on an inversion of factor analysis. Factor analysis identifies the minimum number of factors and their commonalities, which account for observed correlations. Analysis should identify orthogonal, or statistically independent, factors in descending order of importance to the observed correlations.

Brown (1980) stated theory alone cannot determine the importance of a factor.

Significance must also take into account the social and political environs to which the factor is tied. It is for this reason Q method was selected for the present study, the goal being to identify the subjective perceptions of a specific population in a specific environment within an historical social and political context.

Correlation and factor analysis are employed to illuminate viewpoints shared by participants (Brown, 1995). In R methodology, participant responses are correlated to objective traits. Q method differs in correlating intra-individual differences in the significance given to the items by the participant. Variables in R are traits; in Q they are people. Traditionally, the correlation matrix receives little attention in Q method as it is considered an intermediary step to complete the factor analysis. In Q method, factor analysis identifies how participants have classified themselves based on like-mindedness or similarity to each other’s sorts.

McKeown and Thomas (2013) stated that factor analysis is fundamental to Q method. Factor analysis is the statistical process that identifies respondents who have sorted the sample statements in similar fashion, allowing them to be grouped together.

Once participants had sorted the statements, the researcher was able to complete data

52 analysis through intercorrelations with the Q-sorts as variables (see Appendix K). This resulted in persons being correlated rather than the statements themselves. Several orthogonal factors identified unique viewpoints in the sample of participants. Brown

(1996) stated that the table of factor scores contains the most essential data in analysis, as it identifies the extent each statement characterizes each factor identified. The Q-sorts of those participants whose sort significantly loaded were combined to form a factor array or exemplar (Shinebourne, 2009). The resulting analysis highlighted points of view with each respondent loaded by her or his degree of agreement or disagreement with the viewpoint.

While similarity between a Q-sort and the composite factor array may be simple to identify, its “significance” is more complicated. McKeown and Thomas (2013) reported this significance can be based on either statistical or theoretical criteria. Most common and straightforward is the statistical basis in which significance is estimated by the sum of its squared factor loadings, making the cutoff eigenvalue for significance 1.00.

The authors argued that pure statistical consideration may identify factors that are mathematically significant but hold little meaning to the participants’ perception or may result in overlooking a factor of theoretical significance. Statistical criteria was the initial focus of this study but results were compared with additional data gathered from participants and in consultation with committee members in an effort to identify factors of possible theoretical significance.

Q-sorts completed by participants were analyzed using PQMethod 2.11

(Schmolck & Atkinson, 2002). PQMethod delivers a correlation matrix identifying the

53 relationship between the individual sorts of the participants, which was used in factor analysis.

Factor rotation. Wold, Esbensen, and Geladi (1987) identified the principal component analysis as a statistical tool to explore relationships between multiple variables. This study employed a data matrix created using a principal components method, and employed varimax rotation, to identify participants who have ranked the stimulus items in the concourse similarly. Statistical specificity for significance relied on factors related to the number of statements to be sorted and the outcome of the individual distributions.

Factor scores. Participants representing various factors were identified by their individual Q-sorts having loaded on specific factors, the interest being in the difference between viewpoints based on the same topic. It was not the participants’ specific responses but how those responses were similar to some other participants’ responses and different from others.

PQMethod 2.35 was employed to compare participants’ similarities and differences in sorting. The study used computed eigenvalues over 1.00 to classify the statistical significance of identified factors. Six factors with significant eigenvalues were initially identified as statistically significant. A three-factor solution (three of the initial six statistically significant factors) was selected for this study because it accounted for all but one of the participants loading onto at least one factor, whereas multiple participants were unaccounted for using two, four, five, or six factor solutions.

Interpretation

Once factor scores and factor loadings were obtained, interpretation was accomplished by comparing similarities and differences between the factor arrays. The goal was to allow the statements and the significance attached to them to guide interpretation as opposed to imposing preexisting beliefs on the factors.

An often overlooked step in Q method is a follow-up interview with participants, allowing investigators further insight into the individuals’ logic applied to the items, improving understanding. In lieu of an interview, all participants in the study were given a post-sort questionnaire. The researcher grouped questionnaire responses between participants whose sort results were highly correlated and included their questionnaire responses in the interpretation process to further clarify and increase understanding of their expectations for the mental health counseling services provided for their children.

The use of Q method in this study allowed the researcher to identify groups of similar and dissimilar perceptions of parents in relation to the mental health counseling of their children. Having distinguished these varied systems of beliefs may afford the service providers in the region a clearer understanding of the expectations of the varied families they serve.

Summary

Chapter 2 explained the purpose of this study and provided a rationale for why Q methodology was selected to study the perceptions of parents’ hopes in an Ohio

Appalachian county regarding the mental health treatment of their children. Two phases of this study were described. The first phase involved conducting interviews with mental

55 health counseling providers from the county under study then joining information gained from these interviews with current and historical literature on the region to create a concourse of balance and coverage. Once these statements were condensed into a manageable number (the Q sample), phase II consisted of parent participants sorting the items in relation to their personal agreement or disagreement. Factor analysis was used to analyze relationships among the subjective perceptions of parental hopes for their children’s mental health counseling and identify distinctive factors shared by parent participants.

CHAPTER III

RESULTS

The present study utilized Q methodology to assess the views of parents in an

Ohio county identified as Appalachian and their hopes for their children attending mental health counseling in the county. This chapter includes the demographic variables of the phase 2 parent participants who sorted the statements, the statistical data analysis, and analysis of the information solicited in the Background Questionnaire (Appendix J). The overarching question of the study was: What do Appalachian Ohio parents hope for in mental health treatment provided for their children?

Data collection took place over a six-month period from June 2017 to November

2017. As described in Chapter 2, parent participants were solicited through the centralized mental health counseling provider in the Ohio county where the children of the parent participants were receiving services. These participants were recruited through the written materials described in Chapter 2 and approached by support staff who were not involved in direct care of parents or children.

Parents whose children were receiving mental health counseling services in the identified county were offered the chance to participate and 27 sorts ultimately were completed. Parent participants were offered the opportunity to take the packet containing the sorting materials with them but all chose to complete the materials at the agency when recruited. In addition to sorting the stimulus statements, parent participants completed a post-sort questionnaire containing open-ended questions about how they sorted the statements. One parent participant declined to respond to the post-sort

57 questionnaire entirely, therefore no demographic information is available for that participant. All parent participants were offered the option of reading and writing their responses to the questions or having the questions read to them and their responses transcribed by the researcher. Some participants chose to read and write their own responses and others chose to have the researcher read the questions and transcribe their responses. The sorts from each of the participants were included in analysis, as they were entirely completed by all.

Participants

The ages of the parent participants completing the sort and the post-sort questionnaire ranged from 31 to 65 with a mean age of 44.42. The mean age of these parents’ children attending mental health counseling services was 11.02 with a minimum age of 5 and a maximum of 17 years old. At least one participant stated she was a grandparent during the post-sort follow-up questionnaire. This participant reported having all responsibilities and rights raising the grandchildren. See Tables 2, 3, and 4 for demographic information.

Table 2

Parent Participant Demographics

Variable Frequency

Race (self-described) Caucasian or White 23 “Mixed” 1 Other 1 Other (Black, British) 1 Not Reported 1

Educational Level Some High 2 High School or Equivalent 8 Associates or Technical 6 Four Year Degree 4 Graduate Degree 4 Associates plus Four Year Degree 1 Not Reported 2

Relationship Status Married 11 Divorced 8 Single, Never Married 3 Separated 2 Committed, Never Married 1 Widowed 1 Not Reported 1

Employment Status Full Time 11 Part Time 6 Unemployed, Not Seeking 5 Unemployed, Seeking 2 Retired 2 Not Reported 1

Income Less than $15,000 7 $15,000 – 20, 000 7 $21,000 – 30,000 4 $31,000 – $40,000 2 $41,000 – $50,000 4 $51,000 plus 2 Not Reported 1

Table 3

Child Treatment Demographics

Variable Frequency

Length of Treatment (Child’s Current) Just Started 5 Three Months 1 Six Months 2 One Year 1 More Than One Year 19 Not Reported 1 (Note: One participant gave three separate responses, one for each child in services)

Presenting Problems (Per Parent Participant) Behavior 20 Emotions 13 School 5 Other (family) 2 Not Reported 1 (Note: Some participants gave multiple responses)

Table 4

Parent Belief in Treatment Helpfulness

Belief Services Have Been Helpful, (Scale of 0 [No Benefit] – 10 [Most Beneficial]) Mean Score 7.125 Standard Deviation 2.508 Non-Responses 2 (Note: One participant gave three separate responses, one for each child in services)

Belief Services Will Be Helpful (Scale of 0 [No Benefit] – 10 [Most Beneficial]) Mean Score 8.318 Standard Deviation 2.190 “Not Sure” 2 Non-Responses 3

Statistical Data Analysis

Q method uses factor analysis to group shared perceptions. This analysis was conducted by using the DOS-based PQMethod 2.35 (Schmolck & Atkinson, 2002). The software was developed specifically for use in Q methodological studies. The statistical operations of factor analysis are no different in Q than in other quantitative methodologies, with Q using a by-person analysis in which the Q-sorts are used as variables (Akhtar-Danesh, 2016). Participant responses were transferred from the paper response grids the participant completed to the computer program, PQMethod 2.35. The program was then used to perform by-person factor analyses of the Q-sorts. The correlation information and resulting decisions are discussed below.

Correlation and Factor Analysis

The first step in Q methodology data analysis is to conduct the by-person correlation, comparing each participant’s response to every other participant’s response.

Akhtar-Danesh (2016) suggested factor analysis is helpful in that it groups strongly related factors that have little or no relation to other factors into groups. This allows a small number of factors to be generated from a large number of variables. In the current study, the coefficients of correlation were the level of similarity in different parents’ hopes for their children receiving mental health services in the identified county. Each individual sorting of the materials represented a single participant’s subjective beliefs.

Each factor represented similar beliefs held by multiple participants. Once these hopes were grouped into common factors, they were further analyzed in PQmethod 2.35.

This study used a Principal Components Analysis (PCA) to further analyze the data offered by the correlation matrix. Although other methods of factor extraction were available, PCA was selected for its precision and commonly accepted usage in Q methodology. PCA extracts uncorrelated linear combinations of the Q-sorts to analyze all variance (Akhtar-Danesh, 2016). PCA was employed to explain the greatest variance for each factor from the complete dataset. The analysis continued until all of the variance had been explained by the extracted factors. Once PCA had been completed, Varimax rotation was employed to increase interpretability. Webler et al. (2009) stated although

Varimax rotation may not be better than other factor solutions, it is straightforward and transparent which may explain its frequent usage.

Factor Rotation

PCA results in PQMethod 2.35 are limited to eight factors. Initially, factors were identified for extraction if they had Eigenvalues of 1.00 or greater than 1.00. The current study resulted in six factors with an Eigenvalue greater than 1.00. Akhtar-Danesh (2016) explained it is common practice in Q methodology to preserve any factor with two or three defining sorts following rotation. Although Akhtar-Danesh challenged some foundational tenets of Q methodology including reference to theoretical rotation, those concerns were addressed by Brown et al. (2015) and Ramlo (2016), and theoretical rotations were considered in the current study but none was found to improve upon the interpretation in the current study.

The current study was considered an exploratory, rather than a confirmatory factor analysis, being an abductory query and seeking to raise new questions or

62 possibilities about the topic, people, and place of the study, rather than confirming some predetermined idea or belief about them. In an exploratory study, varimax rotation is more commonly used. Varimax rotation is an orthogonal technique seeking to minimize the number of variables with high loadings for each factor in an effort to maximize the variance explained by each factor, simplifying interpretation (Tabachnick & Fidell,

2001).

Varimax rotation was completed for all six factors with Eigenvalues of 1.00 or greater. Additional information was sought by also completing varimax rotation for three, four, and five potential factors. A rotation of three factors resulted in factors with low correlation and at least two participants loading on each factor. The three-factor analysis also resulted in the maximum number of participants having loaded on a factor with only one participant not doing so. All other rotations resulted in multiple participants failing to load on any specific factor. Of the three factors identified by factor analysis, Factor 1 contained 10 participants (from an initial 21 prior to deflagging) and accounted for 39% of the variance, Factor 2 contained 2 participants and accounted for

8% of the variance, and Factor 3 contained 3 participants and accounted for 15% of the variance.

Factor Loadings

In Q methodology, a factor loading describes the level of similarity each participant’s sorting has to each factor. Factor loadings are considered to be significant

(p < 0.01) if they are greater than ±2.58 (McKeown & Thomas, 2013). The factor loadings were the product of the three-factor varimax rotation.

Review of the factor sorts revealed several sorts that were highly correlated on

Factors 1 and 3. To further clarify interpretation, those sorts were manually deflagged to emphasize the difference between those sorts loading on a single factor. Deflagging refers to the process of manually removing participant sorts from analysis. In this study, sorts were removed due to their high correlation on more than a single factor. Once deflagged, defining sorts were selected related to how strongly each individual sorting of statements was related to similar viewpoints (factors) and dissimilar to others. The factor

Matrix with higher numbers representing more correlation to specific factors can be found in Table 5. Higher correlation identified participants whose individual viewpoints were strongly related to each other.

Normalized factor scores for all three factors were also identified by PQMethod

2.35. Webler et al. (2009) described normalized factor scores as an idealized sorting of the statements for each factor, highlighting those statements most like and those most unlike the participants’ hopes. The statements for each factor are included in Table 6.

Table 5

Factor Matrix With Bold Font Indicating a Defining Sort, After Manual Deflagging

Loadings QSORT Factor 1 Factor 2 Factor 3

1 0.6441 0.2486 0.4785 2 0.7845 -0.1671 -0.0560 3 0.7158 0.0447 0.0486 4 0.1769 -0.1325 0.7221 5 0.7169 0.1097 0.3424 6 0.5819 0.1584 -0.0911 7 0.5441 -0.2166 0.5584 8 0.6904 -0.3489 0.2304 9 0.6639 -0.1751 0.5414 10 0.7037 -0.2904 0.3549 11 0.6859 0.0315 0.2153 12 0.7199 -0.0392 0.4275 13 -0.0528 0.2020 0.6054 14 0.7050 0.1115 0.3646 15 0.7827 -0.0904 0.3120 16 0.7527 0.0868 0.2341 17 0.8411 0.1682 0.0182 18 0.5695 -0.3196 0.3940 19 0.6705 -0.2923 0.3057 20 0.6680 0.1680 0.4681 21 0.2045 0.0538 0.7667 22 0.7587 -0.0375 0.2681 23 0.5409 0.3054 0.3903 24 0.6577 0.1590 0.3665 25 -0.0715 0.7544 0.0225 26 0.6296 -0.2007 0.4621 27 0.2169 0.8346 0.0829

%expl.Var. 39% 8% 15%

Table 6

Factor Q-Sort Values for Each Statement

Factor Arrays No. Statement Statement No. 1 2 3

Will help me parent in a way that’s going to work 1 1 -2 0

Is an expert in the field 2 2 0 0

Will help us deal with other agencies 3 1 4 1 (court, school, DJFS)

Will know things, but knows they don’t know everything 4 1 3 -1

Will understand how I feel (angry/frustrated) 5 2 1 -3 without judgment

Is from the area, knows about who we are and what 6 -1 1 -2 we believe

Will understand my family wellbeing is as important 7 4 2 3 as each individual’s well being

Knows how it is to live in area cares about and cares 8 0 2 -2 about the people here

Is not some young kid but old enough 9 -1 -3 0

Will work on helping my child feel better about themselves 10 3 -1 2

Will tell me what I’m doing right 11 0 0 2

Will quickly provide answers 12 0 0 0

Is genuine and real 13 4 1 4

Will work with me, not direct me 14 0 -1 1

Will come to our home and meet with all of us 15 -2 -4 0

Will see any problems with my child the same way I do 16 -2 1 2

Is of the same religion as my family 17 -3 -2 -3

Will help control my child’s behavior 18 0 0 -2

(table continues)

Table 6 (continued)

Factor Q-Sort Values for Each Statement

Factor Arrays No. Statement Statement No. 1 2 3

Is of the same race as my family 19 -4 0 -1

Will work on relationships within the family 20 0 -4 3

Is the gender (male or female) I want my child to see 21 -2 -1 -1

Will understand some things are just the way they are, 22 -1 1 -3 they don’t need to or can’t change

Is a caring person 23 3 0 -1

Will respect me, and my family, and my world 24 3 2 1

Is younger, so that they can connect with my child 25 -3 -1 -4

Will have the same political beliefs as I do 26 -3 -2 -4

Is a parent themselves 27 -1 0 0

Will meet with my child one on one 28 0 3 3

Will meet with the whole or parts of the family 29 1 -3 1

Will meet with child at school, I don’t need 30 -4 4 4 to be involved

Will meet with me and give ideas for parenting 31 1 -3 0

Variance = 4.839 St.Dev. = 2.200

PQ Method identified Consensus Statements, those that did not distinguish between or differ much between any pair of factors. In the current study, some of the statements sorted as important hopes for parents across the sample were understanding

(factor scores of 4, 2, and 3 for statement #7 “Will understanding my family wellbeing is as important as each individuals well being”), a counselor who is genuine and real (factor

67 scores of 4, 1, and 4 for statement #13 “Genuine and real”), and respect (factor scores of

3, 2, and 1 for statement #24 “Will respect me, and my family, and my world”). Several of the statements sorted towards the negative were counselor demographic statements suggested in the group interview with county mental health professionals such as the religion (factor scores of -3, -2, and -3 for statement #17 “Is of the same religion as my family”), gender (factor scores of -2, -1, and -1 for statement #21 “Is the gender (male or female) I want my child to see”), age (factor scores of -3, -1, and -4 for statement #25 “Is younger, so that they can connect with my child” and factor scores of -1, -3, and 0 for statement #9 “Is not some young kid but old enough”), race (factor scores of -4, 0, and -1 for statement #19 “Is of the same race as my family”), and political beliefs (factor scores of -3, -2, and -4 for statement #26 “Will have the same political beliefs as I do”) of the counselor. One Factor 1 parent addressed thoughts about the demographic items, stating,

All the negative ones (-1’s) and negative twos were hard . . . they all seemed the

same and don’t matter. Just help, I don’t care about age, religion, politics, as long

as it’s not shoved down their throat in session.

Another, in reference to similar political beliefs, asked, “Why would that be an issue if you are working with kids?” Another parent stated, “Race doesn’t matter to me at all,” and added, “I’m an atheist and my kid believes in God. I let him choose. I want him to be educated in all of it.” Counselors providing quick answers (factor scores of 0, 0, and 0 for statement “Will quickly provide answers”) or counselors being parents themselves

(factor scores of -1, 0, and 0 for statement “Is a parent themselves”) were sorted towards the center by all three factors.

PQ Method also provided distinguishing statements for each factor.

Distinguishing statements are a list of the statements ranked significantly differently between a given factor and all other factors (Coogan & Harrington, 2011). These statements help to define the factors by highlighting possibly subtle differences between two or more factors. These distinguishing statements were employed to help describe the differences between the hopes of the parents in all three factors. Distinguishing statements for each factor with a high positive ranking (i.e., +4 and +3) indicated statements that were perceived as being most important to parent participants, whereas distinguishing statements with the lowest negative rankings (i.e., -4 and -3) indicated statements that were sorted as being least important to parent participant hopes. The range of distinguishing statements that were closer to neutral (i.e., +2, +1, 0, -1, -2) were statements about which individuals falling into each factor equated neither positively nor negatively compared to other statements.

Each factor was given a title and short statement to reflect as much of that particular point of view as possible in few words. Certainly, the titles are not intended to include all facets of that particular viewpoint but do attempt to express the core of each groups’ hopes for their children in mental health counseling.

Factor 1: Traditional idealists. Ten parent participants (2, 3, 6, 8, 11, 15, 16,

17, 19, and 22) remained on Factor 1, following manual deflagging. Hopes of Factor 1 parents might be summarized as: I hope my child receives individual outpatient counseling, focused on the child’s behaviors and feelings, from a knowledgeable professional who cares and is respectful and genuine Factor 1 was the most prominent

69 factor in the study, accounting for 39% of the variance in the sample. Statements distinguishing Factor 1 (see Table 7) from other factors included the importance of a caring and expert counselor.

Factor 1 parents expressed hoped for help with children and parenting from a counselor who would allow parents to express their feelings without judgment. Factor 1 parents sorted working on relationships within the family neutrally but statements made in the post-sort follow up suggested a desire for help for family relationships as long as the focus of treatment remains on the child and helping with behavior. Factor 1 participants placed one-on-one sessions (statement #28) toward the center of the distribution (factor score of 0) but the one-on-one option was the highest sorted of the treatment modalities offered in the materials. Meeting in the home and meet with all of us” (Statement #15) or at the school without any parent involvement (statement #30) were both negatively sorted. When sorting, participants’ hopes related to counselor demographics appear to be of little concern to those in Factor 1.

Factor 1 parent participants reported a hope for real and genuine counselors who have expertise but know their limitations, varied options for method of services delivery from individual to multiple family members, and have understanding or lack of judgment.

Factor 1 parents did not sort family-focused treatment significantly as a hope, but did express a desire for more information or an idea as to what was happening in services and how they could be active allies in the process outside of session. Factor 1 participants did identify behavioral concerns but in their post-sort statements, many highlighted a hope for their child to “feel” better about themselves more than other issues and higher than

Table 7

Distinguishing Statements for Factor 1: Factor Q-Sort Value (Q-SV)

No. Statement Factors 1 2 3 Q-SV Q-SV Q-SV

23 Is a caring person 3* 0 -1

5 Will understand how I feel (angry/ 2 1 -3 frustrated without judgment)

31 Will meet with me and give me 2* -3 0 ideas for parenting

2 Is an expert in the field 2 0 0

4 Will know things, but knows 1 3 -1 they don’t know everything

20 Will work on relationships 0* -4 3 within the family

28 Will meet with my child one on one 0* 3 3

8 Knows how it is to live here in 0 2 -2 the area and cares about the people here

22 Will understand some things are -1* 1 -3 just the way they are, they don’t need to or can’t be changed

16 Will see any problems with my -2* 1 2 child the same way I do

15 Will come to our home and -2 -4 0 meet with all of us

30 Will meet with my child at school, -4* 4 4 I don’t need to be involved

19 Is of the same race as my family -4* 0 -1

(p < .05; Asterisk (*) Indicates Significance at p < .01)

71 participants loading on other factors. All participants were offered the opportunity to respond to open-ended questions after they sorted the statements (see Appendix J).

Participants were given the option of reading the questions and writing their own answers or being asked the questions by the researcher who then transcribed their responses.

Factor 1 participants’ responses to the post-sort survey related to counselor genuineness and caring included:

Parent 2: “There is a chance to build a better relationship and get more help if a counselor is real.”

Parent 3: “I want my child to feel like that person [the child’s counselor] cares and is not just another client to her,” and added that the counselor being genuine and real

“is the reason my child is here in the first place.”

Parent 16: “They [the counselor] has gotta care, or they shouldn’t be in the business.”

Regarding delivery of services, Factor 1 parents reported varied ideas. A theme appeared to emerge in which Factor 1 parents desired more knowledge about, if not more involvement in the process. This hope appeared to differ from Factor 3 participants;

Factor I participants hoped the focus of the counseling process was not the family but the child. They wanted to know what was being done to help the child, how they could be helpful, and possibly what the counselor was being told about the parents and the home.

Factor 1 parents reported an interest in help with their parenting but little interest in services based on the family as a unit. It may be that Factor 1 and Factor 3 parents both hope for some assistance or direction from counseling services with Factor 1 parents

72 seeking ways to be more effective with their children and Factor 3 parents viewing the issues more systemically and hope for the family to be treated together. Factor 1 parents also expressed concerns over being judged and what might be said about them in sessions. Regarding delivery of services and parental involvement, participants noted:

Parent 18: “I want someone to help me and give me advice on how to parent the right way” and that it was “absurd to think any parent would not want to be involved” in their child’s mental health counseling.

Parent 17: “My kid should control his own behavior and I want guidance to help me help my child.”

Parent 24: “I would prefer they meet one-on-one with my child.”

Parent 11 desired combined individual and family-centered options and reported,

“I’m open to whatever, as long as it’s going to work and helps us all be better.”

Participant 15: “My child doesn’t talk to us about what happens in sessions. It would like nice if we had that some . . . my kid saying this is causing me stress and we would like to address it at the house.”

Parent 1 voiced a hope to be involved but also expressed a concern as to how they would be viewed, stating, “I want to be involved, but I don’t want anyone looking down on us because we are struggling.”

Parent 19: “You need somewhere you can express your feelings but with someone who understands why.”

Parent 13: “I want someone who will work with me and not direct me, someone who’s on top of the field can make you feel like you don’t know what you’re talking about.”

Many Factor 1 parents included behaviors as a concern but in the post-sort questionnaire, many more participants loading on Factor 1 endorsed a hope of their child

“feeling” better [self-esteem/emotions] about themselves than other issues such as behaviors or school.

Parent 18: The child feeling better is “very important” to them.

Parent 15: “Self image is a big part of my child’s issues, I want her to feel better.”

Parent 16: “Overall kids seem better with self-esteem, responsibility [when in

counseling].”

Factor 2: Private anti-participants. Two parent participants (25 and 27) loaded on Factor 1, following manual deflagging. Hopes of Factor 2 parents might be summarized as; My child needs counseling, focused on their behaviors, to get the system

(justice/family services) out of our lives and I don’t want to be involved in mental health counseling services. Factor 2 participants expressed hopes for counselors who would intercede with other agencies such as the schools or courts and may only have been seeking services due to these external forces. As suggested by the distinguishing statements for Factor 2 (see Table 8) dealing with the outside agencies was the highest sorted hope for these parents.

Statements suggested Factor 2 parents sought skilled counselors but appeared wary of professionals who did not understand or accept their own limitations. Factor 2

74 parents also appeared to doubt the impact mental health counseling services could have on the family overall and the parent participants themselves. Some of the expressed and subjective hopes of parents in Factor 2 align more with long standing cultural traditions identified in the literature, including fatalism and mistrust of outside “experts.” Some demographic information (See Table 2) and other information gathered from the post-sort follow-up questions also suggested some differences between these parents and those who loaded on to Factors 1 and 3 including lower levels of completed education and financial resources.

Factor 2 participants also elaborated their viewpoint through responses given during the post-sort follow up. Their statements included:

Parent 25: “Everyone is in our lives because of my kids” and “my kids are still angry and not easy to manage.” This parent reported having been in counseling services over “four years, they don’t get better but I’ve been told they have to go [to counseling] if

I want to keep them.” Parent 25 clearly stated, “I don’t want anyone coming to my house for my kids” and suggested that at times the professionals “act like they know more than me, what am I paying them for?”

Table 8

Distinguishing Statements for Factor 2: Factor Q-Sort Value (Q-SV)

No. Statement Factors 1 2 3 Q-SV Q-SV Q-SV

3 Will help us deal with other agencies 1 4* 1 (court, school, DJFS)

4 Will know things, but knows 1 3 -1 they don’t know everything

8 Knows how it is to live here in the 0 2 -2 area and cares about the people here

6 Is from the area knows about who -1 1* -2 we are and what we believe

22 Will understand some things are just the -1 1* -3 way they are, they don’t need to or can’t change

13 Is genuine and real 4 1* 4

5 Will understand how I feel (angry/ 2 1 -3 frustrated) without judgment

25 Is younger, can connect with my child -3 -1 -4

14 Will work with me, not direct me 0 -1 1

10 Will work on helping my child feel 3 -1* 2 better about themselves

1 Will help me parent in a way that’s 1 -2* 0 going to work

31 Will meet with me give ideas for parenting 2 -3* 0

29 Will meet with the whole or parts of the family 1 -3* 1

20 Will work on relationships within the family 0 -4* 3

15 Will come to our home and meet with all of us -2 -4 0

(p < .05; Asterisk (*) Indicates Significance at p < .01)

Similarly, parent 27 stated: “Too many people think they know more than everyone else,” and “The system is a pain in the ass, and is confusing and frustrating.” “I don’t want people in our home; my family is fine, my grandkids need help because of what their parents put them through, not us.”

Factor 3: Pragmatic family-focus. Three parent participants (4, 13, and 21) loaded on Factor 3, following manual deflagging. Hopes of Factor 3 parents might be summarized as; I hope to receive validating counseling focused on the family and offering me skills to help me address my child’s behavior. Three parents loaded into

Factor 3 but the sole participant who chose not to complete any of the questions from the

Post-sort Questionnaire was one of the Factor 3 participants, resulting in even more limited demographic and follow-up information. Factor 3 parents were also somewhat correlated with those parents in Factor 1. Parents who loaded on Factor 3 reported hoping for more family-focused care to help validate what is working and what might be improved in family relationships and parenting skills (see Table 9). These parents responded in a manner suggesting they were less concerned about being judged for feelings of frustration than those in Factors 1 and 2.

Post-sort follow-up responses from Factor 3 parents included: Parent 4 reported his child had seen one counselor one-on-one at school but “we have been in various programs and will take help from anywhere.” They also stated an awareness of the local culture and people may be important: “Being from the area is not necessary, but to know could be important.”

Table 9

Distinguishing Statements for Factor 3: Factor Q-Sort Value (Q-SV)

No. Statement Factors 1 2 3 Q-SV Q-SV Q-SV

20 Will work on relationships within 0 -4 3* the family

11 Will tell me what I’m doing right 0 0 2*

15 Will come to our home and meet -2 -4 0* with all of us

31 Will meet with me and give me 2 -3 0* ideas for parenting

4 Will know things, but knows they 1 3 -1* don’t know everything

8 Knows how it is to live here in the 0 2 -2 area and cares about the people here

18 Will help control my child’s behavior 0 0 -2

5 Will understand how I feel (angry/ 2 1 -3* frustrated) without judgment

22 Will understand some things just -1 1 -3* are the way they are, they don’t need to or can’t change

26 Will have the same political beliefs as I do -3 -2 -4

(p < .05; Asterisk (*) Indicates Significance at p < .01)

Parent 21 on being genuine and real, “I don’t like phony people, they need to be able to relate to the kids. They [counselor] also need to be able to relate to me, and I can relate to my kids.” Asked by the researcher for clarification, the parent participant

78 explained it was important neither they (the parent) nor their child sensed phoniness or

“that is just going to be the end of it [counseling services].”

If Factor 1 participants were looking to the professional to create an environment and effect change, those in Factor 3 might well have been hoping for the counselor to help them, the parent, create the conditions and desired change.

Parent 21: “I don’t need them [the counselor] to do that [direct or parent my

child], that’s my job.”

Parent 4 expressed an increased desire to be involved following a belief their child had been misdiagnosed and been attending mental health counseling sessions for over a year without success. “We feel like we have to keep more of a watch to make sure things are right, that we ask questions, and that we can help [child] work on things at home.” The parent expressed a belief in eventual success as new medications and treatment had already led to improvements in the child’s behavior.

Factor 3 parents sorted in a way that suggested they are not as worried about being judged for feelings of frustration, more open to family-based services, and interested in parenting information to improve their skills. These participants did express wanting to be recognized for their efforts but were still interested in improving their abilities as parents to improve outcomes for their children. Parents in Factor 3 also appeared to be the least averse to the idea of home-based services.

Summary

Chapter 3 presented the results that were computed from the PQMethod 2.11

Software and follow-up questionnaire. Results from the analysis revealed three factors.

In some cases, there were relatively high correlations between some sorts on Factors 1 and 3 with the participant loading on more than one factor. Analysis of Factors 2 and 3 was limited by the number of participants loading on those factors and the choice by one of those few participants to not complete the post-sort follow up. A further discussion of the results is presented in Chapter 4 including discussion about the qualitative data collected from participants based on post Q-sort interview questions.

CHAPTER IV

DISCUSSION

This dissertation was designed to explore the viewpoints of parents in an

Appalachian Ohio county to understand their hopes related to their children’s mental health counseling services. Q methodology was selected to bring the subjective and personal perspectives of these parents to light where similar groups of viewpoints could be identified. A collection of statements (Q-sort) was created through interviewing 11 mental health professionals working in and from the identified county about their beliefs as to the hopes of the parents of the children receiving services in the county.

Seventy-four statements were generated, which were then reduced to 31 to eliminate redundancy and for ease of use.

Non-clinical staff in the centralized community mental health provider then recruited 27 parents. These 27 parents completed the Q-sort and all but one responded to the post-sort questions, with 20 responding to all questions. The collected data from parent participant sorts were entered into PQMethod 2.11, then between-participant factor analyses were run. These analyses suggested at least three similar and significant groups of viewpoints (factors) existed in this community of parents.

An interpretation of each factor is presented in this chapter, along with implications for research on the region and the mental health treatment in the community.

Limitations of this study and recommendations for continued research are also discussed.

The Three Factors

This study supports the implications of researchers including Hawley and Weisz

(2003); Nock and Kazdin (2001); Kazdin and Wassell (2000); Pekarik (1992); and Raviv et al. (2009) by suggesting parents have distinct hopes for the mental health counseling treatment of their children. The study also supports the concepts proposed by Garretson

(1993), Holcomb-McCoy and Bryan (2010), and Owens et al. (2008) that cultural differences can be found in specific areas and those differences are evidenced in the hopes of parents. The current study was also consistent in the use of Q methodology in illuminating the subjective internal beliefs of participants and the ability to identify similar groups based on those beliefs, as parent participants sorted the materials in a way that grouped them by similarities in their hopes for their children in mental health counseling services. There is also evidence the county in the study and potentially the

Appalachian Region at large is in flux (Solomon, 2016) and while remnants of stereotypical beliefs of residents continue to exist (Behringer & Friedell, 2006; Tang &

Russ, 2007), they are clearly not globally descriptive of this study’s participants and perhaps the county’s residents.

Table 6 in Chapter 3 presented results of the factor analysis. Three different factors or viewpoints emerged among participants relative to their sorting of statements.

These factors represent clusters of shared viewpoints about local parents’ hopes for their children in mental health counseling.

Factor scores were combined with information from the post-sort questions to describe the subjective hopes of parents grouped by the similarity of their responses.

Parent post-sort statements were collected in an effort to develop a deeper understanding of the parent reactions to the statements in the sort. Demographic information was also reviewed for interpretation once factor scores and parent statements had defined a viewpoint.

Though three distinct groups of parents were identified, several statements were labeled consensus statements, having been sorted in a similar manner by all three groups.

For example, parents in all three groups strongly hoped for understanding and respect of their children’s counselors. Participants also agreed some statements were not as important to their hopes for their child’s mental health counseling services. The professional staff in the group interview suggested several counselor demographics parents might find important including age, gender, race, religious affiliation, and political belief. Parent participants in all three groups negatively sorted these statements, and backed up the sort with comments suggesting if understanding and respect were present, the demographic information was generally viewed as inconsequential.

Each of the three emerging factors represents a cluster of shared viewpoints about the research question, meaning the sorts in each factor are comprised of individuals who completed the Q-sort in a similar manner. Distinguishing statements, which are items from the Q-sort that were statistically significant and characteristic of a factor, delineated between factors. All three factors appear to highlight consistent needs for mental health counselors to build rapport and engagement with their clients. This requires counselors to listen to and understand client personal beliefs including their relation the local culture.

Results also suggested attention to the beliefs of stakeholders, such as parents, is

83 important to maintaining the relationship necessary to successful delivery of services.

Parents in all three factors reported little concern over the demographic makeup of the counselor but unanimously expressed concern about being judged. The three factors offer some insight into different hopes parents have for the services provided to their children and may be instructive in matching families with programs or counselors.

Results may also offer county providers with some options for exploration with individual clients and parents.

Factor 1: Traditional Idealists

An attempt to summarize the hopes of Factor 1 parents participants could be, “I hope my child receives individual outpatient counseling, focused on the child, for behaviors and feelings from a professional who cares and is respectful and genuine.” The

10 parent participants who loaded onto Factor 1 accounted for 39% of the variance and found the following statements to be most important to their hopes for their child’s mental health treatment, as is denoted by rankings of +3 and +2:

# Statement Factor 1

23 Is a caring person 3

5 Will understand how I feel (angry/frustrated without judgment 2

31 Will meet with me and give me ideas for parenting 2

2 Is an expert in the field 2

The following statements were found to be least important to their hopes for their child’s mental health treatment that loaded onto Factor 1.

# Statement Factor 1

16 Will see any problems with my child the same way I do -2

15 Will come to our home and meet with all of us -2

30 Will meet with my child at school; I don’t need to be involved -4

19 Is of the same race as my family -4

Statements distinguishing Factor 1 from other Factors included the importance of a caring and expert counselor. These participants also hoped for help with children and parenting from a counselor who would allow parents to express their feelings without judgment. Together those two hopes may explain the seemingly bilateral beliefs expressed throughout the Factor 1 parents’ responses. Parents reported hopes for an expert but also appeared to express an opposing hope for a counselor who knew they didn’t know everything. They were expressing a combined hope of an expert counselor who used their knowledge and ability to help but did not look down on or judge the parent.

Working on relationships within the family did not sort as highly in the statements in Factor 1 as it did in Factor 3; however, responses to follow-up questions suggested an interest in increased involvement in the counseling process and possible assistance in parenting. There appeared to be a greater focus on helping with the child feel better about her/himself in Factor 1 participants’ hopes than in other factors which appeared to center more on removing external forces from family affairs or child behavior. Although

85 participants in Factor 3, when viewed in context similarly sorted some specific items, it may be that Factor 1 participants are looking more to the counselor to provide skills to the parent and an environment to directly address child behavior and emotions. Factor 1 participants placed one-on-one sessions toward the center of the distribution but the face- to-face option was the highest sorted of the modalities offered in the materials. Meeting in the home with a great deal of parent involvement or at the school without any parent involvement were both negatively sorted. Participants’ hopes related to counselor demographics appeared to be of little concern to those in Factor 1. The term idealist was attached to Factor 1 participants in that they identified more global hopes (e.g., self-esteem, feeling better) as opposed to the more pragmatic hopes of Factor 3 participants. These parents evidence more of the transition away from traditional stereotypical beliefs of Appalachian residents suggested by recent literature (Appalachian

Regional Commission, 2017; Solomon, 2016).

Factor 2: Private Anti-Participants

An attempt to summarize the hopes of Factor 2 parent participants could be, “My child needs counseling, focused on their behaviors, to get the system (justice/family services) out of our lives and I don’t want to be involved in mental health counseling services.” Factor 2 accounted for 8% of the variance in the sample and two participants loaded onto Factor 2. These participants were the least educated, having less than a high school education. These participants were also employed part time and both had children in mental health counseling services at least a year. The participants also reported the lowest average belief in the helpfulness of counseling to this point and the lowest average

86 belief service would be helpful in the future. This was a distinguishing issue as Factors 1 and 3 were close on current and expected benefits of counseling, and reported a more positive experience and expectation.

Factor 2 participants found the following statements most important to their hopes for their child’s mental health treatment:

# Statement Factor 2

3 Will help us deal with other agencies (court, school, DJFS) 4

4 Will know things, but knows they don’t know everything 3

8 Knows how it is to live here in the area and cares about the people here 2

The following statements were found to be least important to their hopes for their child’s mental health treatment that loaded onto Factor 2:

# Statement Factor 2

1 Will help me parent in a way that’s going to work -2

31 Will meet with me and give me ideas for parenting -3

29 Will meet with the whole or parts of the family -3

20 Will work on relationships within the family -4

15 Will come to our home and meet with all of us -4

Both Factor 2 participants hoped for counselors who would help intercede with other agencies such as the schools or courts, and may only have been seeking services due to these external forces. Statements suggested these parents wanted counselors to intercede with skill but also understand their own (counselors’) limitations. It also appeared Factor 2 parents hoped counselors would not intrude into the lives of the

87 families or the lives of the parents themselves. Participants in Factor 2 also endorsed some of the items related to traditional or historical descriptions of Appalachian culture higher than those participants who loaded on the other two factors; items related to the counselor understanding or being from the area, and a sense of fatalism were related to more traditional or historical differences suggested of Appalachian culture (Behringer &

Friedell, 2006; Billings, 1974; Duncan, 2001; Tang & Russ, 2007). This more traditional cultural view was also evidenced by Factor 2 participants’ opposition to the idea of a counselor being an outside expert. The emergence of more traditional stereotypical beliefs, such as self-reliance, a mistrust of outside professionals, and lack of engagement with health professionals, from Factor 2 parents suggests mental health counselors and administrators need to be aware of those beliefs and specific strategies for engaging these parents.

Factor 3: Pragmatic Family-Focus

An attempt to summarize the hopes of Factor 3 parent participants could be, “I hope to receive validating counseling focused on the family and offering me skills to help me address my child’s behavior.” Three parents loaded on Factor 3, accounting for 15% of the variance, and reported hoping for more family-focused care to help validate what is working and suggest what might be improved in family relationships and parenting skills.

Factor 3 parent participants were the oldest on average and were all employed full time. The sole participant who chose not to complete any of the questions from the post- sort questionnaire was one of the Factor 3 participants, resulting in even more limited

88 demographic and follow-up information. Factor 3 participants found the following statements most important to their hopes for their child’s mental health treatment:

# Statement Factor 3

20 Will work on relationships within the family 3

11 Will tell me what I’m doing right 2

The following statements were found to be least important to their hopes for their child’s mental health treatment that loaded onto Factor 3:

# Statement Factor 3

8 Knows how it is to live here in the area and cares about the people here -2

18 Will help control my child’s behavior -2

5 Will understand how I feel (angry/frustrated) without judgment -3

22 Will understand some things just are the way they are; they don’t -3 need to or can’t change

26 Will have the same political beliefs as I do -4

These parents sorted in a way that suggested they were not as worried about being judged for feelings of frustration compared to parents who loaded on Factors 1 and 2.

They also expressed a desire to be recognized for their successful efforts and abilities as a parent while working to improve them. It is possible Factor 3 parents hoped to increase their ability to care for their children and to manage their children’s behaviors as opposed to those on Factor 1 who may have been looking for more direct intervention between the counselor and the child. Parents in Factor 3 also appeared to be the least averse to the idea of home-based services but did sort a preference for one-on-one services for their child in school or the center. This raised questions about how parenting skills and family

89 focus would be addressed. The researcher observed at least two of the three Factor 3 parents attended some or all of their child’s sessions on the day of their participation; parents participated in session but also left the session to allow the child to work with counselor alone. This combination may explain the endorsement of both family-focused and face-to-face as hopes in the sort. The term pragmatic was attached to Factor 3 participants in that they sorted items related to both addressing specific needs in relationships and parenting skills as high in their hopes. The focus of concern and hope appeared to be much more on behaviors and relationship than feelings or self-esteem.

Historical research identifies the Appalachian Region as a culturally unique area created by geographical, economic, and social barriers limiting interaction with other areas of the country. Some of the identifying differences previously suggested in the research include a mistrust of outsiders, dependence on informal networks over professionals, paternalistic family structure, and deficits educationally and economically

(Behringer & Friedell, 2006; Billings, 1974; Duncan, 2001; Tang & Russ, 2007). Tang and Russ (2007) highlighted several criteria to successfully engage people in an

Appalachian region in career counseling. Similarly, this study sought to bring to light the subjective beliefs of parents in an Appalachian Ohio community to possibly improve successful engagement of parents of children receiving mental health counseling services.

Two of the three grouped viewpoints did not report finding “expertise” or being an outside professional a concern as long as that professional was caring and helpful.

Parent participants in those two groups also evidenced a belief that services had proven helpful and hopes that services would be helpful in the future.

Factors 1 and 3 may suggest that reduced geographic barriers, and the weakening of the cultural and social barriers between area residents and outsiders, is diminishing both positive and negative aspects of a unique culture. In many ways, these two factor groups highlight breaks from the more traditional descriptions of residents in the

Appalachian Region. They were bringing their children for professional services, were not resigned to a fatalistic sense of the way things are, expressed trust in their child’s counselor, acknowledged services had made a difference, and described hope for the future given those services. Therefore, the current study does appear to suggest that the county is undergoing consistent change as a culture. It is impossible for the researcher to suggest the changes are related to positive growth or an unfortunate loss of a unique culture, but the study does suggest the county may reflect more mainstream cultural values than the more unique descriptions historically applied to the area. It is possible, as with most change, there are and will be positive and negative effects of continued change in the county and region.

The remaining factor (Factor 2) cautions against believing those distinctive aspects created through years of abuse and negative characterization at the hands of outsiders do not still exist, and do not need to be assessed and addressed to improve the ability of mental health counseling services to engage parents and their children. This

Factor was the most limited in number of participants loading onto a factor, which may suggest a decrease in county residents holding these stereotypical beliefs but Q methodology does not endeavor to generalize numbers of participants to percentages of the population at large (McKeown & Thomas, 1988). Very limited demographics hint

91 that those most limited in education and finances may be more inclined to maintain a larger portion of those beliefs related to mistrust of outsiders or professionals, and fatalism. Participant responses also suggest this group (Factor 2) is the least likely to seek out services on their own, least likely to perceive any value in those services, and have the lowest sense of hope that services will make a difference in the future.

The importance of Factors 2 and 3 could be questioned related to the number of participants loading on those factors. The importance given to their emergence in the current study is linked to the limitation: it is possible residents are underrepresented in the study due to their lack of contact with professional mental health counseling services for their children and that lack of contact could be related to their subjective viewpoints.

This would make them of central import and fulfill the function of the methodology as designated by Brown (2006) as a marginalized methodology for studying the marginalized.

Implications

The current study has potential benefits to two different groups: (a) mental health counselors and administrators, and (b) scholars in counseling and Appalachian studies.

The following sections broach some of those implications.

Mental Health Counselors and Administrators

Not only do parents bring their children to counseling for different reasons, the current study suggests parents from Appalachian communities have the potential to hold some unique beliefs and hopes. Knowledge of and information about different perceptions may help administrators and mental health counselors prepare for working

92 with children while also meeting some of the needs of the parents. Improvements in fulfilling the hopes parents have about services could increase retention of children in counseling and possibly even parent participation. Administrators may consider offering training or other information to educate local providers in efforts to build treatment engagement. It may be helpful to offer some education or materials for county parents targeted to the hopes of the three groups identified in the study. Materials could highlight various options for delivery of services and attempt to address some of the barriers identified by each factor group. A special effort might be directed towards county residents with greater limitations in finances and education, who may be less likely to engage in services. Local administrators could also develop some brief assessment questions to be employed at first contact or intake to better understand the hopes of parents and assist in pairing children with services providing the best fit with those hopes.

It is possible the reported differences between parent, child, and provider problem identification and focus of treatment could be addressed to some degree through a better understanding of the hopes of parent participants. Understanding goals from as many perspectives as possible could allow providers to better plan for and achieve those goals and improve retention in mental health counseling services. This accomplishment could result in improved outcomes in less time and improve child functioning and/or relationships with family or others.

The fact that local mental health counseling providers endorsed items in the group interview that were dismissed by all three factors suggests mental health counselors are never going to be fully informed about the population with which they work. Mental

93 health counselors need to continually learn about the people with whom they work, as well as their clients’ community. This study serves as a reminder that mental health professionals are imperfect but if they are interested in serving their clientele, they can continue to improve their understanding of their population. Increased understanding should lead to improved and continued engagement. It was noted during the group interview in Phase I the identification of many of the demographic factors of the counselors identified as important for parents were attached to specific episodes in which the providers were told thusly (e.g., you’re too young; too old; female; won’t understand me due to difference in race; etc.). It may be the providers generalized these individual

“rejections” to the greater populations.

Parents from the current study do appear to have varied but identifiable hopes for their children in counseling. The study suggests serving the parents needs may be as important as meeting those of the child. This study is similar to findings by Hawley and

Weisz, (2003), Pekarik and Stevenson, (1988), and Kazdin (2003, 2000, 1996) suggesting understanding parental hopes is integral to rapport. The current study also suggests understanding the cultural makeup of the clients’ community may not always be integral to building a therapeutic relationship, though at times it may be. This is similar to findings made by Bannon and McCoy (2005), Garretson, (1993), Holcomb-McCoy and Bryan (2010), and Ungar, (2010). Counselors need to have awareness of the area and its culture and to invest sufficient and ongoing time and effort in each client and stakeholder’s personal subjective connection to that culture

Recruitment problems and successes suggest engaging participants in

Appalachian communities can be difficult. Months passed without a single parent consenting to participate. Once another office staff person (secretary) was engaged in recruitment, the response rate improved. The staff member took time with all clients, remembered who they were, and evidenced personal interest in their well-being. The change in recruitment suggests administration can improve engagement and connection with clients and their families by ensuring all points of contact know how to effectively connect to the local culture and the population.

Limited demographic information suggested parent participants loaded into

Factors 1 and 3 have more formal education and are in a more advantageous position financially than those of Factor 2. This may suggest increased education is related to a reduction in stereotypical Appalachian beliefs and a reduction in barriers to seeking out mental health services for children in need. County administrators and stakeholders may take some solace their efforts to improve the health of their constituents appears to have some effect.

Scholars in Counseling and Appalachian Studies

Recent studies of the Appalachian region (Bennett, 2008; Protivnak, Pusateri,

Paylo, & Choi, 2017; Solomon, 2016) suggested there remains a deficit of research on the region, particularly in relation to mental health counseling and bridging gaps between providers, participants, and key stakeholders such as parents. These studies also suggested as the region continues to increasingly interact with communities outside of the region, the people and culture may well be in constant flux, necessitating ongoing efforts

95 to understand and address needs in the region. For example, residents had been isolated for years by geographical and then sociological factors but these recent studies suggest increased mobility and interaction with varying outsiders are influencing the culture.

Concerns over being stripped of a unique culture can be balanced with hopes for increased opportunity and options for wellbeing from medicine to mental health counseling.

The current study suggests although the specific county is changing, some of the long established cultural beliefs can be found in the hopes of parents whose children are receiving mental health counseling services. This study was not designed to compare the degree to which these beliefs are held in other cultural areas, nor was it designed to establish living in the region as the cause of those beliefs. The study does suggest those beliefs are held by some parents in the county in which the study took place. Some of these beliefs included a degree of mistrust in outsiders or professionals, fear of judgment, or loss of control that could be related to decades of exploitation of the region and residents, and some acceptance of fatalism.

Future Research

There are several areas of interest raised by the current study that could be the focus of future studies. Studies for mental health administration and providers could benefit from a study highlighting what changes parents had perceived as a result of helpful counseling for their children and how it relates to their increased hope for future services may identify early goals important for building rapport and sustaining engagement. The lack of perceived success and lack of hope for the future in participants

96 from Factor 2 might identify some areas needing more focus or effort to engage those who report little choice in bringing their children to counseling for efforts to improve engagement in the community. If more traditional stereotypical beliefs are recognized as a part of family hopes and beliefs, specific goals or plans could be implemented by providers to address those hopes, with some success achieved early in the process.

Hopefully, this could translate into increased hope that continued services will lead to meeting longer-term goals. Replication of the current methodology in adjacent

Appalachian counties or other areas could support commonly held viewpoints or could add new viewpoints to be considered in planning and delivering treatment to children in these regions. Replication of this study in one of Ohio’s other Appalachian counties or

Appalachian counties from other states could reinforce the identified factors or identify new groups. Replicating this study in the same county with the inclusion of follow up interviews, particularly for Factor 2 and 3 participants should offer increased insight into their hopes for their children in counseling. Approaching parents who have not or would not engage mental health counseling services for their children could provide valuable information to community providers in addressing the needs of children and families who could benefit from services. It is possible county parents who have not sought counseling services nor would ever consider seeking them may maintain hopes and beliefs for their children related to more traditional stereotypes of the residents (e.g., mistrust of professionals or outsiders). Of course it is just as possible those parents may maintain less traditional stereotypes than the parent participants of this study and have not engaged services for a multitude of other reasons.

The current study suggests to researchers in the Appalachian region, the county of study is undergoing cultural changes related to possible overall changes in the region.

Decreasing barriers to the areas outside of the region and dedicated efforts to improve conditions long considered problematic will have ongoing effects on area residents, both positive and negative. The Appalachian Region has historically suffered from a lack of interest and research. As large and diverse as the region is, and as rapid change continues to take place, possible targets of research abound.

Delimitations

Decisions in design made to address a population the research base suggested to be highly private and difficult to engage likely limited interpretations of subjective viewpoints. This was particularly true of Factors 2 and 3.

Results and implications of the current study are limited in generalizability. Q methodology does not intend to prove what percentage of the population holds a viewpoint or whether those viewpoints are applicable to other populations, it intends to show that the viewpoint exists in the population at the time of the study. The Ohio county in which this study took place is a very small section of a vast region. The entire region is diverse in geography, history, and culture. The results of this study may inform the understanding of parent residents but could not hope to generalize these viewpoints throughout the entire region.

Implications and the subjective viewpoints identified in the study should also not be viewed as exhaustive or complete. It would also be problematic to accept results as more than information related to the beliefs of a group of people at a specific time.

Participants live in a society in constant change and may have experienced incidents in counseling services or life, altering their perceptions and beliefs related to the needs of their children. Continual tracking of changing perceptions provides the field with the best information to assess and meet the needs of their clients and key stakeholders.

The study was completed by parents using mental health counseling services for their children, and the viewpoints of those who do not or would not engage mental health services for their children may be vastly different and represent entirely different facets of the population in the county. It is possible a better understanding of the viewpoints of parents who do not seek mental health services for their children could prove even more vital to providers in trying to serve their communities.

Prior to the study, concerns were expressed over appropriateness of materials for a target population with historical deficits in education. Statements for the concourse were crafted simply and participants appeared to complete the process with very little evident struggle. Several participants expressed relief upon completion of the process, that it had been easier than expected and some even described it as “fun” and “thought- provoking.” There is wisdom in knowing the potential limitation of your population but in hindsight there is a possibility this study may have overcorrected and aimed more towards those limitations than was necessary. If the researcher were to repeat this study in hindsight, follow-up interviews competed after factor analyses of the sorts would be strongly considered. To do so would require collection and maintenance of personal information for some period, which would still be a consideration in regards to maintaining privacy. The researcher’s concern that multiple contacts might affect

99 participation may have limited the data for analyses and, given the ongoing changes in the region, may have been given too much weight in considering requests for follow-up interviews.

Several choices were made in the present study in efforts to balance the accuracy and breadth of the information with necessary privacy and the expected reticence of the population, particularly limiting amount of exposure required to participate. The choices were both supported and challenged during the study. Initial months of recruitment proved completely unsuccessful, without a single parent consenting to participate.

Recruitment improved dramatically when a specific staff member who knew everyone’s name on sight, and also knew generally about their lives (e.g., family and pets) began recruiting. Parents who began to participate and reported interest in the study, generally participated fully. It is unclear if a request for additional engagements with the researcher to clarify their hopes for their children would have altered participation.

Limitations

Limited participants sorting on two of the three factors likely limited the understanding of those viewpoints. Additionally, non-completion of post-sort questions by one of those few participants most likely limited what was collected for interpretation from follow-up interviews. In hindsight, it may well have been favorable to request follow-up interviews, even if there were a number of refusals for additional contacts.

Any participants consenting to additional contacts may have presented some additional data for interpretation, particularly on factors with limited participants and completion of post-sort information.

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Another limitation of the current study is related to the demographic profile of the participants. Of those who chose to participate, the vast majority identified themselves as

“White.” One parent described himself as “mixed,” one as “other,” one as “other”—

Black British, and one did not provide any demographic information. It is possible the lack of racial diversity limited the information available in the analyses. Information from Town Charts (2018) suggests the racial makeup of the county is 95% White or

Caucasian, 2.3% Black or African American, and 0% other according to 2017 census data, and participant demographics may be representative of the county residents. A second demographic statistic of note was the level of education reported by parent participants. The parent participants in the current study reported levels of education higher than expected for Appalachian residents. A study for the Appalachian Regional

Commission (Holmes, et al, 2018) reports Ohio Appalachians still lag behind Ohio residents from non-Appalachian counties in education. This suggests the possibility parent participants may differ from other area residents.

Summary

This study was designed to explore the viewpoints of parents in an Appalachian

Ohio county to understand their subjective hopes related to their children’s mental health counseling services. Q methodology was selected to bring the subjective and personal perspectives of these parents to light where similar groups of viewpoints could be identified. Twenty-seven participants completed Q-sorts during the study and most completed follow-up questions related to their sorting rationale. Q-sort data were entered and analyzed using PQMethod 2.11. Analysis revealed at least three distinct groups of

101 parental hopes based on the similarities between the responses of the participants. This chapter discussed distinguishing statements for each factor. Limitations of this study and implications for future research were also discussed.

APPENDICES

APPENDIX A

INSTITUTIONAL REVIEW BOARD FOR

HUMAN PARTICIPATION FORM

Appendix A

Institutional Review Board for Human Participation Form

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APPENDIX B

REQUEST FOR AND RESPONSE TO

PERMISSION TO CONDUCT STUDY AT SITE

Appendix B

Request for and Response to

Permission to Conduct Study at Site

Study Title: COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN

Dear Clinical Director,

I am conducting a study to explore the hopes parents have for what their children receive from mental health counseling services. Please note that this study has received approval from the Institutional Review Board of Kent State University for the proposed study.

I am sending you a list of what will be required to complete the study. I am hoping you will review the requirements, find them acceptable, and give me permission to conduct the project.

The study will take place in two phases, each with different participants and elements:

Phase 1:

In phase 1, I would like to conduct a group interview with 5 to 10 people who provide services to clients under the age of 18 years in your county. The interview will consist of questions about what providers perceive are the parents’ (of minor clients) hopes for their children in mental health counseling services. Responses from the interview will be used to create a series of statements, which will be used in the phase 2.

I am seeking permission for the following to complete phase 1 of the proposed project:

 Contact information and the opportunity to recruit 5 to 10 direct service providers for a 60 minute group interview. The decision to participate or not participate would be held confidential from center administration or other staff to protect mental health clinicians from any sense of coercion. I would like to recruit participants directly, via email, and with a possible reminder email if necessary Preferably, interviewees would represent as many different treatment modalities as possible from the center (e.g., individual, group, family, community, etc.).  For the convenience of interviewees, I would like to identify a space which could be used to conduct the interview which would both be close to their regular activities and protect their confidentiality.

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 The group interview would be audio recorded (with written permission from each interviewee) for the sole purpose of later transcribing the responses.  I would gladly provide a meal for those consenting to the interview at my own expense.  If for any reason (e.g., scheduling conflict, act of God, insufficient information from the interview) the initial interview is insufficient I would also like permission to recruit and conduct a second group interview under the same conditions, if necessary.

Phase 2:

In phase 2, parents of children receiving services will be asked to sort the items created from the group interview and a review of literature. The sorting process should allow the responses of parents who share similar hopes for their children’s services to be grouped to better understand the varied hopes of local parents.

I am seeking permission for the following to complete phase 2 of the proposed project:

 I would like to recruit parents to complete the sorting process until 25 - 40 parents have completed the sort.  I would like to offer parents two ways to complete the sort. o Parents would be able to complete the sort somewhere at the center. The place would have to be private and quiet. There would need to be a chair and a table large enough for parents to spread out the sort materials.  I would also like to provide a sealed participant packet with sort materials and instructions, which could be taken and completed at the parent’s convenience, then sealed and returned to me.  Materials in both sorting conditions would include my contact information for any questions but sorting completed at the center may engender on-the-spot questions, which would also need to be included in the staff recruitment training.

Thank you for your consideration in regards to the project. I hope you find the requirements acceptable and look forward to learning more about your clients’ parents. If there are any questions or concerns regarding the project, please let me know.

Sincerely,

Tom Newman

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APPENDIX C

RECRUITMENT TOOLS, CONCOURSE INTERVIEW

Appendix C

Recruitment Tools, Concourse Interview

Meeting Announcement and Follow-up Email:

Study Title: COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN

Greetings,

We are conducting a research study in an effort to better understand what area parents hope for in the mental health counseling services provided to their children. It is my hope that this understanding will help pair families with services that will meet those desires. Please note that this is my dissertation research, which is part of the requirements for a PhD at Kent State University. This study has been approved by the Institutional Review Board of Kent State University and by Marcy Patton and Virginia Cluse in your agency.

The first step in the study is to gather a small group (6-8) of service providers from varied programs in your agency to participate in a group interview to gather information as to what parents’ hopes might be. The interview will be scheduled at the participants’ convenience and is expected to last from 60-90 minutes and will last no longer than 90 minutes.

The information gathered from the group interview will be used by area parents to rank their own personal beliefs. Your participation in the group interview is completely voluntary and there is no benefit or risk in choosing to participate or not participate. Administration and staff from your agency will not be provided information as to attendance or information from the group interview by the researchers.

I am asking you to participate in the interview if you feel you have an understanding of local parents and what they hope for in the treatment of their children. If you choose to participate a meal will be provided by the researcher during the interview.

If you are interested in participating in the group interview, please contact Tom Newman at [email protected] or 330-858-0443. If you have any questions or concerns regarding the study you may contact Tom Newman at the above contact information or the study’s advisors Dr. Jane Cox at 330-672-0698 and Dr. Jason McGlothlin at 330-672- 0716.

Thank you for your consideration and I hope to hear from you soon,

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APPENDIX D

INFORMED CONSENT TO PARTICIPATE IN A GROUP INTERVIEW AND

CONSENT TO AUDIO TAPE

Appendix D

Informed Consent to Participate in a Group Interview and Consent to Audio Tape

Study Title: COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN

Principal Investigator: Dr. Jane Cox Co-Investigators: Dr. Jason McGlothlin; Tom Newman

You are being invited to participate in a research study. This consent form will provide you with information on the research project, what you will need to do, and the associated risks and benefits of the research. Your participation is voluntary. Please read this form carefully. It is important that you ask questions and fully understand the research in order to make an informed decision. You will receive a copy of this document to take with you.

Purpose: This study has been designed to better understand the hopes of parents when it comes to mental health counseling services their children receive. We want to examine the hopes parents have about mental health counseling for their children. We think these views may help understand how parents perceive mental health counseling and potential barriers to mental health counseling. We would like you to take part in this project because we believe you will be able to provide a unique view about what parents in the area hope for in the mental health counseling of their children. This portion of the study involves a group interview to gather as much varied information as possible as to what local parents hope for in the mental health counseling services provided to their children. We believe your work in the area gives you insight into what these hopes might be.

Procedures The first portion of the interview will consist of open-ended responses as to your beliefs about the hopes of area parents. After responses to the opened ended question have been gathered, some themes suggested by scholarly literature about the area will be discussed as to their applicability to the area’s parents. Responses will be distilled into a smaller number of statements, which area parents will use to rank their personal responses to the statements.

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Audio and Video Recording and Photography The group interview will be audio recorded for the purpose of collecting the statements following the group interview. The recording will not be used for any other purpose and will be destroyed at the completion of the study.

Benefits This research will not benefit you directly. However, your participation in this study will help us to better understand the hopes of parents for their children’s mental health counseling and how to meet those needs in the county. Participants in the group will be provided a meal by the researcher.

Risks and Discomforts There are no anticipated risks beyond those encountered in everyday life. While there are no expectations that your responses could be held against you, several systems have been put in place to ensure no one but the researchers will have access to your responses. Administration and staff of the local mental health service providers will not be informed by the researchers who did or did not participate in the interview, nor will they be given access to information discussed in the meeting or the recording.

Privacy and Confidentiality No identifying information will be collected. Your signed consent form will be kept separate from the interview data and responses will not be linked to you. Your study- related information will be kept confidential within the limits of the law. Any identifying information will be kept in a secure location and only the researchers will have access to the data. Research participants will not be identified in any publication or presentation of research results; no identifying data or information will be used.

Voluntary Participation Taking part in this research study is entirely up to you. You may choose not to participate or you may discontinue your participation at any time without penalty or loss of benefits to which you are otherwise entitled. You will be informed of any new, relevant information that may affect your health, welfare, or willingness to continue your study participation.

Contact Information If you have any questions or concerns about this research, you may contact Tom Newman at 330-858-0443 or Dr. Jane Cox at 330-672-0698 or Dr. Jason McGlothlin at 330-672-0716. This project has been approved by the Kent State University Institutional Review Board. If you have any questions about your rights as a research participant or complaints about the research, you may call the IRB at 330.672.2704.

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Consent Statement and Signature I have read this consent form and have had the opportunity to have my questions answered to my satisfaction. I voluntarily agree to participate in this study. I understand that a copy of this consent will be provided to me for future reference.

______Participant Signature Date

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AUDIOTAPE/VIDEO CONSENT FORM

Study Title: COUNSELING OHIO YOUTH: WHAT THEIR PARENTS HOPE FOR IN MENTAL HEALTH COUNSELING SERVICES IN A COUNTY IDENTIFIED AS APPALACHIAN

Principal Investigator: Dr. Jane A. Cox Co-Investigators: Tom Newman; Dr. Jason McGlothlin

I agree to participate in an audio-taped/video taped group interview about the perceptions of the hopes of parents in the mental health counseling for their children as part of this project and for the purposes of data analysis. I agree that Tom Newman may audiotape/video tape this interview. The date, time and place of the interview will be mutually agreed upon.

______Signature Date

I have been told that I have the right to listen to the recording of the interview before it is used. I have decided that I:

____want to listen to the recording ____do not want to listen to the recording

Sign now below if you do not want to listen to the recording. If you want to listen to the recording, you will be asked to sign after listening to them.

Tom Newman may / may not (circle one) use the audio-tapes/video tapes made of me. The original tapes or copies may be used for:

____this research project _____publication _____presentation at professional meetings

______Participant Signature Date

APPENDIX E

GROUP INTERVIEW QUESTION AND LITERATURE THEMES,

CONCOURSE INTERVIEW

Appendix E

Group Interview Question and Literature Themes, Concourse Interview

Interview Question: Please offer as many responses as you can to the following question. What do you believe the parents of your mental health counseling clients hope, or ought hope, their children receive through your mental health counseling services?

Once all responses have been recorded the following items will be discussed with group participants recognizing if they have been identified and if not, group participants will be asked if they recommend the inclusion of the items in the concourse. The items have been taken from the services available in the county, research on parents of children in counseling and research on the Appalachian region.

Items Related to How Services are Offered in the County 21. Individual Counseling 22. Family Counseling 23. Mixed Individual/Family Counseling 24. Group Counseling 25. Community Based Counseling 26. Options For Treatment Items Related to Counselor and Counselor Interaction 27. Counselor Availability (Time/Distance) 28. Counselor Cost Financially 29. Local Area Provider 30. Counselor Religion 31. Counselor Expertise Items Related to Therapeutic Relationship 32. Counselor Recognition of Parent Expertise 33. Counselor Respect (Pride/Reliance) 34. Trust/Relationship Between Child and Counselor 35. Trust/Relationship Between Parent and Counselor 36. Counselor Understanding of Family & Where They Come From Items Related to Therapeutic Outcome 37. Therapeutic Goal Agreement 38. Child To Improve Behaviorally 39. Child To Improve Emotionally 40. Treatment Focus on Child Goals 41. Treatment Focus on Parent Goals

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APPENDIX F

CONCOURSE

Appendix F

Concourse

Statements collected from group interview transcript for creation of concourse

1. Fix my kid 2. Control kids behaviors 3. Please don’t them drive me crazy 4. Help them listen 5. Help me be a parent 6. Help me parent in a way that’s going to work 7. I know there’ something wrong with him or her, I just don’t know what it is…a correct diagnosis 8. Validation of a problem…I need to hear there is something wrong 9. Onsite school counseling – not able to bring kids or not involved at all (parents) 10. Get kids off probation, court costs to stop 11. Avoid another hospitalization 12. School problems 13. DJFS 14. Problems at school should be handled by school 15. Someone for them to talk to, someone they can trust 16. Relationship problem instead of kid focused problem can be a turn off 17. To get information for court, divorce, legal issues 18. To qualify for services at school, community 19. Someone that I trust 20. Someone who understands problem from my perspective. 21. Validation of their (parents) view of problems 22. Want to understand the process (counseling) 23. Help with behavior 24. Help with emotion 25. Need to understand how we were brought up, taught, how we see the world, attribute problems 26. Help with social skills 27. Help kids adjust to some situation 28. Trauma and chaos 29. AOD 30. Individual 31. Groups 32. School 33. Home based 34. Parenting groups 35. Community outreach…help meet other needs…by referral 121 122

36. Comfortable/Safe place to step into, who are you reporting to, how will you harm me? 37. Things to get better quick…answers 38. Support for dealing with issues or increases in problems on the road to improvement 39. Connection with support staff, good connection, safe place 40. Ownership, an active part of treatment, being included and heard 41. Counselor is an expert 42. Group leader is an expert 43. Counselor is a flawed expert 44. Understand how frustrated, angry, etc. I feel 45. No judgment 46. Acknowledge what I’m doing right 47. Not some young kid, old enough 48. Is a parent themselves 49. Once the kid is hooked, parents will jump on board, connection with the kid 50. Gender preference 51. Younger person they can connect with 52. Counselor can engage everyone in the system 53. Mistrust of expertise 54. Counselor has to “belong” to community, come from community, you’re one of us 55. Is able to speak my language 56. Counselor is genuine and real 57. Not intimidating, work with instead of direct 58. Needs to understand some things are just the way they are, don’t/can’t need changed 59. Needs to know struggle, have some respect for struggles of the area, poverty, getting by without an education 60. Access, help with transportation, where services are located 61. Affordable 62. Convenient times, everybody works 63. Goals have to focus on success for everyone, not just individual child (go to school/family looses another income) 64. Same religion 65. Same race 66. Respecting me and my family and my world 67. Same political beliefs 68. Caring people 69. Someone who has cared enough about the people and the area to stay

APPENDIX G

Q SAMPLE

Appendix G

Q Sample

1. Will help me parent in a way that’s going to work 2. Is an expert in the field 3. Will help us deal with other agencies (court, school, DJFS) 4. Will know things, but knows they don’t know everything 5. Will understand how I feel (angry/frustrated) without judgment 6. Is from the area, knows about who we are and what we believe 7. Will understand my family’s wellbeing is as important as each individual’s well being 8. Knows how it is to live here in the area and cares about the people here 9. Is not some young kid, but old enough 10. Will work on helping my child feel better about themselves 11. Will tell me what I’m doing right 12. Will quickly provide answers 13. Is genuine and real 14. Will work with me, not direct me 15. Will come to our home and meet with all of us 16. Will see any problems with my child the same way I do 17. Is of the same religion as my family 18. Will help control my child’s behaviors 19. Is of the same race as my family 20. Will work on relationships within the family 21. Is the gender (male or female) I want my child to see 22. Will understand some things are just the way they are, they don’t need to or can’t change 23. Is a caring person 24. Will respect me, and my family, and my world 25. Is younger, so that they can connect with my child 26. Will have the same political beliefs as I do 27. Is a parent themselves 28. Will meet with my child one on one 29. Will meet with the whole or parts of the family 30. Will meet with my child at school, I don’t need to be involved 31. Will meet with me and give me ideas for parenting

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APPENDIX H

RECRUITMENT TOOLS: Q-SORT

Appendix H

Recruitment Tools: Q-sort

Invitation

To be presented to parent with child receiving services by trained county center staff member who does not provide services or have administrative position:

I want to invite you to participate in a study designed to help us better understand what parents hope for in the mental health counseling of their children. Participation in the study is absolutely voluntary and there is no risk or benefit to choosing to participate or to not participate. The study is designed to protect your confidentiality. No information will be collected to identify you. Neither your child’s counselor nor any other staff members will know if you chose to participate. Hopefully, the study will help us better serve our families.

If you choose to participate you will be asked to sort some statements about what you find important in the mental health treatment of your children and to record your answers on a chart.

If you choose to participate I will show you to a place where you will find instructions and the materials. Or you can take a packet from the box located (somewhere in room) to complete the materials at your leisure. If you choose not to participate, thank you for your time and consideration.

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Flyer:

What Do

Parents

Hope For?

We are conducting a study to better understand what parents hope for when they bring their child to the center.

If you feel like you would want to share your hopes for your child and would like to learn more…

You Can Talk To:

Person at Center: Contact Info

Contact Tom Newman: Contact Info

APPENDIX I

INFORMED CONSENT TO PARTICIPATE IN A RESEARCH STUDY

CONSENT TO PARTICIPATE IN Q-SORT

Appendix I

Informed Consent to Participate in a Research Study

Consent to Participate in a Q-Sort

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APPENDIX J

PARTICIPANT PACKET

Appendix J

Participant Packet

INSTRUCTIONS FOR PARTICIPATION

Please read through this form and follow the instructions. If you are completing the sort at the center, you should find all of the materials in front of you. If you have taken a packet with you, try to find a half an hour block of time in a quiet area that you can sit down and complete these materials. Please try to have them completed and returned with the addressed and stamped envelope or dropped off in a box at the center by DATE. If you have any questions please feel free to contact the researcher. I can be reached at 330- 858-0443 or by email at [email protected].

Thank you for your participation.

Thomas S. Newman Doctoral Candidate Counseling and Human Development Services

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Q-SORT INSTRUCTIONS

1. You will require a space large enough to spread out all the statement cards. A desk top, floor space, or other large flat surface is ideal. 2. Read through the deck of cards, sorting the cards into three piles: a. A pile representing the statements that are most like your hopes for your children in mental health counseling b. A pile for statements which are most unlike your hopes for your children in mental health counseling c. A pile for neutral statements or statements that you are uncertain about. Note about sorting: You may find that one of the three piles you make in this step is larger than the others. This is ok. Just continue to place them in the next highest or lowest ranking depending on how they match your own hopes. 3. Use the response grid (below) as a model for arranging the marker cards. Each marker card has two numbers: one is the rating (for example, -5, +5, -4, +4, etc.). The second is how many cards you will put in that rating (for example, +5 requires 2 cards).

ILLUSTRATION OF HOW MARKER CARDS SHOULD BE ARRANGED

-4 -3 -2 -1 0 +1 +2 +3 +4 (2) (3) (3) (4) (7) (4) (3) (3) (2)

4. Starting with the first pile, select two statements that are the “most like” your hopes for your child in mental health counseling and place them under the +4 category of the response grid. Then, select three statement cards that are the next most like your hopes. Place these three statements under the +3 ranking. Continue by selecting your statements cards to place under the +2 ranking, and so forth until you have used all of the items from the first pile. 5. Next take the pile of statements that are most unlike your hopes for your child in mental health counseling and pick the two statements most unlike your hopes and place them under the -4 category of the response grid. Next, pick three for the -3 category and so on, until you have sorted all of the cards from this pile. 6. Once you have used all of the statements in your most like and most unlike your hopes piles, turn your attention to the third pile. This pile you will use to fill in the middle section between the two ends. Starting on either the positive side or the negative side, you must make distinctions between the statements to decide what will go where. 7. Once all three piles have been sorted please reexamine where you have placed all the statements and if there are any statements that need to be swapped or changed related to how much they align with your hopes, you can make adjustments. 8. After all the cards have been put in a place on the response grid please record the number on each card (in the upper right hand corner of the statement card) on the corresponding place on the response grid below.

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Most Unlike My View Most Like My View

-4 -3 -2 -1 0 +1 +2 +3 +4 (2) (3) (3) (4) (7) (4) (3) (3) (2)

9. Once you have completed the grid, please consider the questions on the Post-sort Follow-up Questionnaire Form and answer the questions to the best of your ability. 10. Once you have completed the Follow-up Questionnaire, please answer the questions on the Background Questionnaire. 11. Finally, collect your grid and both questionnaire forms and seal them in the envelope provided.

Thank you for your participation.

A Brief Review of Steps to Complete the Sort 1. Review all of the cards and arrange them in the shape of the grid according to your own personal agreement with each statement. 2. Once you are happy with the way your statements are arranged, copy the numbers from the cards into the response grid (the same shape as the cards) 3. Answer the questions from the Background Questionnaire and the Post-Sort Questionnaire. Please be as detailed as you are comfortable on the Post-Sort Questionnaire, your thoughts are important. 4. Gather all of the forms you have written information on except for your copy of the informed consent form, and seal them in the envelope they came in to protect your privacy. The second copy of the informed consent for is yours to keep.

136

Background Questionnaire

The following questions are about your background and your interaction with counseling in the past. Please answer every question to the best of your ability. If you have any questions about the form please do not hesitate to ask.

Please fill in the blanks: 7. Annual Income: a. Less than $15,000/year 1. Your Age (in years): ______b. $15,000-20,000/year c. $21,000-30,000/year 2. Ethnicity/Race: ______d. $31,000-40,000/year e. $41,000-50,000/year 3. Child’s Age(s) (in years): ______f. $51,000/year or more

Please circle the letter that best fits your 8. How long has your child been involved in answer: counseling? a. Just started 4. Highest level of education: b. Around three months a. Some High School c. Around six months b. High School/Equivalent d. Around a year c. Technical School/Associates e. More than a year Degree d. Four Year College 9. What brought your child to counseling? e. Graduate School a. Behaviors (arguing/fighting) b. Emotions (depression/anxiety) 5. Relationship Status (circle all that apply) c. School/Work (attendance/grades) a. Single never married d. Ordered (courts/other) b. Committed relationship never e. Other ______married c. Married 10. What kind of counseling is your child d. Widowed receiving? (Circle all that apply) e. Separated a. Outpatient (weekly office visits) f. Divorced b. Group b. Community (in our home) 6. Employment Status: c. Other ______a. Unemployed and not seeking work b. Unemployed and seeking work c. Part-time employment d. Full-time employment e. Retired Continued on next page.

137

Background Questionnaire Continued

11. Do you feel your child has benefited from counseling? Please circle the number that best represents your feeling with 0 being no benefit, 1 being very little benefit, and 10 being the most benefit.

0 1 2 3 4 5 6 7 8 9 10 no benefit the most benefit

Please add anything you would like to say about the benefits or lack of benefits you child has received from counseling.

12. Do you feel your child will benefit from counseling? Please circle the number that best represents your feeling with 0 being no benefit, 1 being very little benefit, and 10 being the most benefit, or you can circle “not sure”.

Not Sure 0 1 2 3 4 5 6 7 8 9 10 no benefit the most benefit

Please add anything you would like to say about the benefits or lack of benefits your child may receive from counseling.

138

Post-Sort Follow-up Questions

Once you have completed the sort, please answer the following questions about your placement of statements.

1. Describe how the two items you ranked at +5 (“Most like my hopes for my child attending mental health counseling”) are important to your view. a. Item #_____ was important because: ______

______b. Item #_____ was important because: ______

______

2. Describe why the two items that you placed at the -5 (“Most unlike my hopes for my child attending mental health counseling”) are most unimportant to your view. a. Item #_____ was most unimportant because: ______

______b. Item #_____ was most unimportant because: ______

______

3. Describe other statements that you think help define your view (either positive, negative, or neutrally ranked). a. Item #_____ helped define my view because: ______

______b. Item #_____ helped define my view because: ______

______

4. What were other specific statements that you had difficulty placing? Please indicate your dilemma. a. Item #_____ was difficult because: ______

______b. Item #_____ was difficult because: ______

______

5. Describe any other thoughts or ideas about your hopes for your child attending mental health counseling that emerged or you while sorting these statements. ______

139

______

If you are completing the sort in the center…once you have completed the sort, recorded your answers, and completed both the background questions and the post-sort questionnaire, please seal your response grid, the background questionnaire and the post- sort questionnaire in the envelope to protect your privacy.

If you have completed the sort on your own time… once you have completed the sort, recorded your answers, and completed both the background questions and the post-sort questionnaire, please seal all materials in the envelope to protect your privacy and return to the center by DATE.

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