Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2007 The Effects of Caregiver Stress Upon Ethics at-Risk Behavior Among Florida Licensed Marriage and Family Therapists Jack Eric Gentry Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected] THE FLORIDA STATE UNIVERSITY COLLEGE OF HUMAN SCIENCES THE EFFECTS OF CAREGIVER STRESS UPON ETHICS AT-RISK BEHAVIOR AMONG FLORIDA LICENSED MARRIAGE AND FAMILY THERAPISTS BY J. ERIC GENTRY A Dissertation submitted to the Department of Family & Child Sciences In partial fulfillment of the Requirements for a degree of Doctor of Philosophy Degree Awarded: Fall Semester, 2007 The members of the Committee approve the dissertation of J. Eric Gentry defended on June 10, 2005. ____________________________________ Charles R. Figley Professor Directing Dissertation ____________________________________ Leo Sandon Outside Committee Member ____________________________________ Ronald L. Mullis Committee Member ___________________________________ Christine A. Readdick Committee Member Approved: __________________________________ Robert E. Lee, Director Marriage and Family Therapy Program __________________________________ Billie Collier, Dean College of Human Sciences The Office of Graduate Studies has verified and approved the above-named committee members ii This dissertation is dedicated to Charles R. Figley, Ph.D. iii ACKNOWLEDGMENTS This dissertation involved the assistance of many wonderful friends, instructors, and colleagues. I am grateful to the following for all your contributions: Jennifer Bass, Lee Norton, Karen Mumford, Karen DeMeester, Louis Savary, Marjie Scofield, Gale Gardener, Augie G., Mike Dubi, Jennifer Baggerly, Anna Baranowsky, D. Franklin Schultz, Carrie Elk, Kevin Lutz, Dane Clare, Sally Karioth, Leo Sandon, Coco Readick, Ron Mullis, Mary Hicks, and Mom. This dissertation was completed by standing on the shoulders of giants. My mentors in order of their appearance in my life: Charlie Yeargan, Louis Tinnin, Charles Figley, and Michael Rank. All my work is suffused with your wisdom, your kindness, and your faith in me. Finally, I would like to gratefully acknowledge the love, compassion, and miracles delivered me daily by H.P. and N.A. Without you I would not be here. iv TABLE OF CONTENTS LIST OF TABLES vii ABSTRACT viii 1. INTRODUCTION Introduction…………………………………………………………… 1 A Personal Bias …………………………………………………..… 6 Definitions …………………………………………………………… 8 Epidemiology ……………………………………………………….. 10 Theoretical Foundation……………………………………………… 13 The Study ………………………………………………………….... 14 Research Questions………………………………………………… 15 2. REVIEW OF THE LITERATURE Introduction…………………………………………………………… 18 The AAMFT Code of Ethics History…………………………………………………………… 18 The Code………………………………………………………... 26 Critical Review Method for Selecting Literature……………………………….. 30 Ethical Practice Literature 31 Summary of the Ethical Practice Literature….…….………... 44 Burnout, Caregiver Stress and Compassion Fatigue …………. 47 Burnout………………………………………………………….. 47 v Caregiver Stress………………………………………………... 54 Compassion Fatigue…………………………………………… 58 Rejected Measurement Instruments……………………………… 64 Conclusions ………………………………………………………... 68 3. METHODOLOGY Sample ……………………………………………………………... 73 Procedure ………………………………………………………….. 74 Instruments ………………………………………………………… 76 Independent Variables………………………………………… 80 Statistical Analyses ……………………………………………….. 89 Hypothesis Testing……………………………………………. 90 Exploratory Analyses………………………………………….. 93 4. RESULTS Introduction………………………………………………………….. 97 Sample……………………………………………………………….. 98 Data Review…………………………………………………………. 98 Demographic Data………………………………………………….. 99 Hypothesis Testing…………………………………………………. 103 Exploratory Research………………………………………………. 104 5. DISCUSSION Introduction………………………………………………………….. 119 Hypothesis Testing…………………………………………………. 121 Exploratory Research………………………………………………. 124 Study Limitations……………………………………………………. 131 Implications for Future Research and Theory Development…… 134 Implications for Training and Practice……………………………. 141 vi Summary…………………………………………………………….. 144 APPENDICES A. Human Subjects Approval…………………………………….. 146 B. Sample Survey Packet…………………………………………. 147 C. Scatter Plots of Residuals……………………………………... 156 REFERENCES 157 BIOGRAPHICAL SKETCH 171 vii LIST OF TABLES Table 1: Descriptive Statistics……………………………………………. 99 Table 2: Demographic Data………………………………………………. 99 Table 3: Scoring Criterion for the EARTMFT…………………………… 105 Table 4: EARTMFT Responses…………………………………………... 106 Table 5: SWLS Scoring Interpretation…………………………………… 113 Table 6: Partial Correlations between Demographic Variables and 114 Ethics At-Risk…………………………………………………….. Table 7: Pearson Product-Moment Correlations Among Dependent 115 Variables…………………………………………………………. Table 8: Regression Summary…………………………………………… 116 Table 9: ANOVA for Total Model and Compassion Fatigue…………… 116 Table 10: Coefficients……………………………………………………… 117 Table 11: Summary of Findings………………………………………….. 121 viii ABSTRACT A critical review exploring “at-risk” ethical practice of marriage and family therapy determined that there existed no empirical literature focusing upon the antecedent, correlative, or causal factors of unethical behaviors among LMFTs. Responding to this gap, this study was designed to test the hypothesis that a significant relationship would be found between caregiver stress and at-risk ethical practice among a sample of LMFTs of Florida. Two research questions were developed to help guide an exploratory component of this study with the hope of identifying factors contributing to the understanding of at-risk practice. Surveys containing a demographic collection tool, an instrument to measure the dependent variable (at risk ethical practice), and three instruments to measure five independent variables (caregiver stress, compassion fatigue, burnout, and satisfaction with life) were sent to a randomly selected sample of one-half (n=549) of the LMFTs in the state of Florida. After a 90-day data collection window, 82 useable surveys were returned (15%). The data were found to be significantly non-normal. Upon analyses, no significant relationship between caregiver stress and at risk practice emerged; therefore the null hypothesis was not rejected. In the exploratory portion of the study, only compassion fatigue emerged with a significant predictive relationship (R2=.140; p=.002) for at-risk practice among all the independent variables and demographic data. Nearly all respondents (86.4%) identified at least one area for which they were at-risk for practicing outside the boundaries of the AAMFT Code of Ethics. The sample for this study was remarkably healthy with positively non-normal scores for caregiver stress, compassion fatigue, burnout, and satisfaction with life. The validity of this study was challenged by a very low response rate, a non-normal and very healthy sample, and unacceptably poor psychometric performance of the Ethics At-Risk Test for Marriage and Family Therapists (Brock, 1997)—the instrument utilized to measure the dependent variable. ix Recommendations for future research resulting from the findings of this study primarily advocate studies designed to resolve the psychometric problems of measuring at-risk ethical practice. Following the resolution of the scaling problems, a program of research that recruits larger and more representative samples of cross-discipline professionals and compares this sample with professionals who have been adjudicated for ethical violations is suggested to begin to determine the antecedent, correlative, and causal factors related to professional caregivers’ practice outside the boundaries of ethical and legal constraints. x CHAPTER 1 INTRODUCTION This chapter introduces the key concepts, scope, biases, definitions, research questions, and procedures used in this study of the relationship between at-risk ethical behavior and caregiver stress. Introduction The practice of marriage and family therapy challenges practitioners’ values, assumptions, and functioning in their own marriages and families. For a therapist, bearing witness to the anger and anguish that accompany the dissolution of a marriage and/or family–so often the state in which clients present themselves–can be heartbreaking. To help clients make sense of the experiences and responses that have led to their suffering, therapists must listen to the stories of those experiences and assimilate and understand them. At the same time, therapists are challenged to help clients develop more effective and satisfying meanings and behaviors to confront their present and future. Abuse and torture; neglect and other developmental injuries; gratuitous acts of violence; along with overwhelming fear, anger, sadness, and despair are just some of the past experiences and current emotional states that torment the clients of the daily caseload of a marriage and family therapist. The conscientious practitioners cannot escape confronting the pain, despair, or trauma of their client’s lives. This confrontation can and does generate significant deleterious effects upon practitioners in the forms of emotional exhaustion, depression, physical and somatic distress, heightened anxiety, relational difficulties, despair, substance abuse, and, in extreme cases, suicide (Deutch, 1984; Farber, 1983; Freudenberger & Robbins, 1979; Pearlman & McCann, 1990; Pope & Tabachnick, 1991; Rodolfa, Kraft, & Reiley, 1988). Some of the terms associated with these negative