THE RELATIONAL EXPERIENCES OF TRANSITION-AGE YOUTH LIVING WITH MENTAL

418 Pages·2017·1.68 MB·English

CLOSED OFF AND OPENING UP:
THE RELATIONAL EXPERIENCES OF TRANSITION-AGE YOUTH
LIVING WITH MENTAL HEALTH DIFFICULTIES
By
BETH FRANCES SAPIRO

A dissertation submitted to the
School of Graduate Studies
Rutgers, The State University of New Jersey
In partial fulfillment of the requirements
For the degree of
Doctor of Philosophy
Graduate Program in Social Work
Written under the direction of
Cassandra Simmel, Ph.D., MSW
and approved by
____________________________________
____________________________________
____________________________________
____________________________________

New Brunswick, New Jersey
May 2018
© 2018
Beth Frances Sapiro
All rights reserved
ABSTRACT OF THE DISSERTATION

CLOSED OFF AND OPENING UP:
THE RELATIONAL EXPERIENCES OF TRANSITION-AGE YOUTH
LIVING WITH MENTAL HEALTH DIFFICULTIES

By BETH FRANCES SAPIRO

Dissertation Director:
Cassandra Simmel

The transition to adulthood is a critical developmental period. For marginalized
youth, it is a stage of life when inequalities may either be magnified or reduced. Positive
interpersonal relationships are an essential component of health and well-being; yet
young people living with mental health difficulties may experience multiple barriers to
the formation and maintenance of healthy interpersonal relationships, including shame,
stigma, symptom management, and structural oppression. This qualitative study explored
the relational experiences of transition-age youth living with mental health difficulties.
Within the larger context of the Cornerstone study, an intervention providing peer
support and boundary-spanning case management to youth living with mental illness, this
study explored how these young people experience three distinct aspects of relationships
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with others: trust, mutuality, and disconnection. Brief qualitative interviews focusing on
relationships were conducted with 47 transition-age youth, ages 16-20, who were
receiving services for a mood disorder, anxiety disorder, or thought disorder. In-depth
interviews were conducted with 13 young women, ages 17-20, living with a mood
disorder or an anxiety disorder, as well as the five service providers (social workers and
peer mentors) employed in Cornerstone. This study was grounded in the theoretical
framework of relational-cultural theory, emphasizing the role of relationships in young
adult growth and development. It utilized multiple methods of data collection (brief
interviews, limited group observations, and in-depth interviews with both youth and
providers) as well as data analysis (thematic analysis and the Listening Guide).
Data analysis of the interviews with transition-age youth revealed that family
continued to play a prominent role in the lives of young people living with mental health
difficulties. For some, family was a source of support; for others, family relationships
were characterized by lack of understanding or ongoing conflict. Thematic analysis
indicated that these young people expressed both a desire for a trusted connection with a
helping professional, as well as guardedness and wariness in these relationships.
Experiences of mutuality in helping relationships were particularly valued by these youth.
Relationships with peers were similarly valued by participants, and offered camaraderie,
emotional support, practical assistance, and company for creative pursuits. Participants
varied in the extent to which they felt comfortable being authentic and vulnerable with
peers. Thematic analysis also found evidence of both growth-promoting relationships as
well as the use of strategies of disconnection in peer relationships. The Listening Guide
analysis of a single case revealed the use of multiple strategies employed to navigate a
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landscape of unsatisfying relationships, including minimizing feelings, asserting feelings,
seeking connection, and lashing out.
Findings from this study make a number of contributions to the literature on the
relational experiences of transition-age youth living with mental illness. They provide
evidence of the central relational paradox in young people’s relationships with helping
professionals, and reveal discrepancies in how some youth and some providers perceive
the meaning of similarities and differences in a helping relationship.
Findings show that shared lived experience is meaningful in peer relationships as
well as in helping relationships, and that supportive peer relationships make a significant
contribution to recovery for transition-age youth. In this study, young women who
described their peer relationships as mutually supportive were also likely to describe
them as growth-promoting. Findings also reveal evidence of relational resilience among
some participants with histories of maltreatment. The variations identified in approaches
to peer relationships both support and build on existing research. Echoing the literature
on stigma, some youth chose to limit their self-disclosure and relate to others using
strategies of disconnection. However, others chose instead to embrace their vulnerability
and represent themselves authentically with trusted peers.
Findings from this study suggest that social workers who work with transition-age
youth would do well to emphasize relationships in treatment, be attuned to the impact of
cultural messages and stereotypes, and address both similarities and differences between
young people and themselves. Findings also suggest the importance of affirming youth
agency in helping relationships and empowering young people to recognize the impact of
structural oppression on the transition to adulthood.
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ACKNOWLEDGEMENTS
Throughout my doctoral education, the concept of independent scholarship has
always seemed to me to be somewhat of a misnomer. My success in reaching this point is
a testament to the support and encouragement of many people.
I am grateful to the members of my committee for their guidance and support
throughout this process. My advisor and chair, Dr. Cassandra Simmel, invested countless
hours in reviewing drafts, consulting on methodological decisions, and offering wise
counsel while always respecting my right to make my own decisions. She is a model
mentor and I have been truly lucky to work with her for the past six years. Dr. Beth
Angell offered patient, thoughtful advice throughout this study, from conception through
to data collection and analysis. Dr. Jerry Floersch brought a unique combination of
clinical insight, levity, and theoretical sophistication to the study’s design and execution.
Dr. Michelle Munson was kind enough to allow a doctoral student from another
university to join her research project and collect data for this dissertation. She also
offered valuable perspectives on qualitative data collection, relational-cultural theory, and
clinical social work research. I am exceedingly grateful to have been supported by such a
committee of experts on mental health, system-involved youth, and qualitative methods.
In addition to my committee, I have been fortunate to receive professional
guidance and consultation on various approaches to qualitative research from a
remarkable cadre of feminist scholars, including Gina Samuels, Renee Spencer, Laina
Bay-Cheng, Niobe Way, and Carol Gilligan. Their work has inspired my own and I am
grateful for the opportunity to have learned from them. Edward Alessi and Judie McCoyd
both mentored me in becoming a teacher of clinical social work, another form of growing
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in relationship. I am grateful as well to Allison Zippay, Amy Smiley, and Caroline
Rosenthal Gelman for their ongoing support, wisdom, and encouragement.
I am indebted to Gretchen Hoge for her assistance with data analysis on this
project. In addition to reading and making notes on 24 interview transcripts, Gretchen
was a patient and encouraging second analyst who affirmed the significance of this
research, kindly pointed out my blind spots, and helped me to make sense of a massive
amount of data. Other colleagues who also assisted with data collection in Cornerstone
include Andrea Cole, Shelly Ben-David, and Melissa Villodas. I could not have collected
data on the social networks of Cornerstone youth without their invaluable assistance and
collegial support. I am also very thankful to the Fahs-Beck Fund for Research and
Experimentation for their dissertation grant, which supported this research.
In writing about the importance of relationships, I must acknowledge my family,
who taught me the values of pursuing education, working hard, nurturing relationships,
and treating others with kindness and respect. They raised me to be a mensch, and I have
endeavored to put their values into action throughout my social work career.
This dissertation would not exist if not for the brave and insightful participants,
both youth and adults, who shared their thoughts and experiences with me. Thank you for
risking self-disclosure with me; for your willingness to correct me when I made incorrect
assumptions; and for sharing your own sometimes painful experiences with me and other
researchers so that other young people might benefit.
And finally, I am grateful to Aaron, for providing every imaginable form of
support during the long and winding road of this dissertation. Growing in relationship
with you for the past 23 years has been my life’s greatest privilege. Thank you.
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Table of Contents
Abstract .............................................................................................................................. ii
Acknowledgements ........................................................................................................... v
List of Tables .................................................................................................................... xi
Chapter One: Introduction .............................................................................................. 1
Statement of Research Problem ............................................................................................... 1
Significance and Rationale for the Study ................................................................................ 2
Significance: Mental Health Recovery Literature ................................................................... 6
Significance: The Transition to Adulthood for Vulnerable Populations ............................... 11
Research Questions .................................................................................................................. 15
Plan of the Dissertation ........................................................................................................... 15
Chapter Two: Theoretical Framework ....................................................................... 18
Introduction and Plan for the Chapter .................................................................................. 18
Theories of Relationship .......................................................................................................... 18
Erikson’s Developmental Theory .......................................................................................... 19
Attachment Theory ................................................................................................................ 23
Relational-Cultural Theory .................................................................................................... 26
Intersectionality ..................................................................................................................... 32
Chapter Summary ................................................................................................................... 33
Chapter Three: Literature Review .............................................................................. 34
Introduction and Plan for the Chapter .................................................................................. 34
Vulnerable Populations and the Transition to Adulthood ................................................... 34
Connectedness and Recovery .................................................................................................. 42
Trust in Interpersonal Relationships ..................................................................................... 48
Mutuality in Interpersonal Relationships .............................................................................. 55
Disconnection in Interpersonal Relationships ....................................................................... 58
Relational Violations ............................................................................................................. 59
Stigma .................................................................................................................................... 62
Shame .................................................................................................................................... 65
Socioeconomic Status ............................................................................................................ 67
Cultural Context .................................................................................................................... 69
Stereotypes of Gender and Sexuality .................................................................................... 73
Chapter Summary ................................................................................................................... 76
Chapter Four: Methods ............................................................................................... 78
Introduction and Plan for the Chapter .................................................................................. 78
Study Design ............................................................................................................................. 78
Procedure .................................................................................................................................. 81
Brief Qualitative Interview .................................................................................................... 82
Group Observations ............................................................................................................... 82
In-Depth Interviews ............................................................................................................... 83
Sampling and Recruitment of Participants ........................................................................... 85
Sample: Cornerstone Participants .......................................................................................... 86
Sample: In-Depth Interview Participants .............................................................................. 89
Study Site .................................................................................................................................. 93
Data Collection ......................................................................................................................... 94
Brief Qualitative Interview .................................................................................................... 94
Group Observations ............................................................................................................... 96
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In-Depth Interviews ............................................................................................................... 97
Data Analysis ............................................................................................................................ 99
Thematic Analysis ................................................................................................................. 99
The Listening Guide: A Case Study .................................................................................... 104
Strategies for Rigor ................................................................................................................ 109
Ethical Issues .......................................................................................................................... 117
Protection of Human Subjects ............................................................................................. 117
Ethical Issues: Data Collection and Analysis ...................................................................... 118
Chapter Summary ................................................................................................................. 124
Chapter Five: Findings from Brief Qualitative Interview .s..................................... 125
Introduction and Plan for the Chapter ................................................................................ 125
Brief Qualitative Interviews: Patterns in Social Network Maps ....................................... 125
Brief Qualitative Interviews: Themes .................................................................................. 129
Family .................................................................................................................................. 129
Friends ................................................................................................................................. 133
Professionals ........................................................................................................................ 137
Providing Support ................................................................................................................ 137
Chapter Summary ................................................................................................................. 138
Chapter Six: Relationships with Family ................................................................... 140
Introduction and Plan for the Chapter ................................................................................ 140
Beneficial Aspects of Family Relationships ......................................................................... 140
Family Support .................................................................................................................... 140
Challenges in Family Relationships ..................................................................................... 144
Lack of Understanding ........................................................................................................ 144
Difficult Family Relationships ............................................................................................ 152
Chapter Summary ................................................................................................................. 162
Chapter Seven: Relationships with Helping Professional s...................................... 163
Introduction and Plan for the Chapter ................................................................................ 163
Trust in Helping Relationships ............................................................................................. 163
Factors Facilitating Trust ..................................................................................................... 164
Factors Impeding Trust ....................................................................................................... 178
Trust As A Process .............................................................................................................. 187
The Central Relational Paradox in Helping Relationships .................................................. 201
Mutuality in Helping Relationships ..................................................................................... 210
Experiences of Mutuality .................................................................................................... 211
Professional Authenticity and Self-Disclosure .................................................................... 214
Disconnections in Helping Relationships ............................................................................. 220
Cherished Relationships ...................................................................................................... 221
Disconnections in Helping Relationships ............................................................................ 222
Repair .................................................................................................................................. 225
Chapter Summary ................................................................................................................. 227
Chapter Eight: Relationships with Peers .................................................................. 229
Introduction and Plan for the Chapter ................................................................................ 229
Facilitating Trust: Valued Friendship Traits ...................................................................... 230
Understanding ..................................................................................................................... 230
Reliability ............................................................................................................................ 232
Shared Lived Experience ..................................................................................................... 235
Functions of Friendships ....................................................................................................... 238
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Companionship .................................................................................................................... 238
Artistic Pursuits ................................................................................................................... 240
Instrumental Support ........................................................................................................... 241
Emotional Support ............................................................................................................... 243
Reciprocity in Peer Relationships ........................................................................................ 249
Five Good Things ................................................................................................................ 254
Experiences in Friendships: A Continuum of Authenticity ............................................... 255
Supported Vulnerability and Trust in Friendships .............................................................. 256
Disconnection in Peer Relationships ................................................................................... 272
Chapter Summary ................................................................................................................. 282
Chapter Nine: The Listening Guide Analysis .......................................................... .283
Introduction and Plan for the Chapter ................................................................................ 283
Listening for the Plot: Angela’s Relational World ............................................................. 283
Sexism/Patriarchy ................................................................................................................ 294
Racism ................................................................................................................................. 294
Poverty ................................................................................................................................. 295
Mental Illness ...................................................................................................................... 296
Researcher Reaction .............................................................................................................. 297
Prior to the Interview ........................................................................................................... 298
During the Interview ............................................................................................................ 299
Intersubjective Dynamics .................................................................................................... 305
Findings: Listening Guide Analysis ..................................................................................... 306
First Strategy: Minimizing Feelings .................................................................................... 307
Second Strategy: Asserting Feelings ................................................................................... 312
Third Strategy: Seeking Connection ................................................................................... 315
Fourth Strategy: Attack ....................................................................................................... 318
Conclusion .............................................................................................................................. 324
Chapter Summary ................................................................................................................. 326
Chapter Ten: Discussion ........................................................................................... .327
Introduction and Plan for the Chapter ................................................................................ 327
Summary of Findings ............................................................................................................ 327
Trust ..................................................................................................................................... 328
Mutuality ............................................................................................................................. 329
Disconnection ...................................................................................................................... 329
Overall Themes ................................................................................................................... 330
Significance of Findings ......................................................................................................... 332
Trust ..................................................................................................................................... 332
Mutuality and Reciprocity ................................................................................................... 333
Mood and Anxiety Disorders .............................................................................................. 333
Relational Images ................................................................................................................ 334
Stigma .................................................................................................................................. 334
Shame .................................................................................................................................. 335
Trauma ................................................................................................................................. 336
Dynamics of Relationships with Helping Professionals ..................................................... 336
Dynamics of Relationships with Peers ................................................................................ 338
Dynamics of Relationship with the Researcher ................................................................... 341
Limitations .............................................................................................................................. 343
Implications for Practice ....................................................................................................... 346
Emphasize Relationships in Practice ................................................................................... 346
Build Connection and Expect Disconnection ...................................................................... 348
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