.3. dual: hr9Jumo I e .. :9 .. ...r..h.rn.han. : .o 4...... {.1}; 51.1121}... ‘3 5 ‘ . . 2?. «5:1.an1\ 1 1.32:3... 573)»):1 zigzez... . ‘ . (tril- 1.7.11.5. 3.13.1] é».)l:?:5\l.ai44{rl¢|lalif ialii‘ .9: il‘ta Vpirrtlv‘v {:5 31...}. . . .35.¢.J:...:l.vb) : 1.5313... . v... . by...) . fl .3: . .1:1..1V..I)11/.Iv.v , )f. {vphfl 1 us. .111... :w 15...: l...‘ :2? (Iii. .(.I:.. $1:l.;.(.§4!l ‘.4:.)th3t¢ 1 A}axklxl.x\.‘r:ru 3:! ‘1} O51). .;Il..(.ll a". 135:. 3...: .7 II. 311/1» 1 l. "HESlS (we) 31293 01706 9935 This is to certify that the thesis entitled Spiritual Development and Intimate Abuse presented by Kathy C. Belonga has been accepted towards fulfillment of the requirements for W degree in Mang— Science 727Mogflfltmd * Major professor Date—Decw 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State Unlverslty PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. 1" ,1 film DUE DATE DUE DATE DUE 1/98 alClRC/DateDuopGS-p.“ SPIRITUAL DEVELOPMENT AND INTIMATE ABUSE BY Kathy C. Belonga A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1997 ABSTRACT SPIRITUAL DEVELOPMENT AND INTIMATE ABUSE BY Kathy C. Belonga The purpose of this research was to study the spiritual development of women in abusive intimate relationships. The questions this research attempted to answer were: How does, if at all, the spiritual development of intimately abused women fit into Fowler's (1981) Stages of Faith model of spiritual development? If there is a good model fit, are there any patterns of interest to the nursing profession that can be discerned using Fowler’s (1981) model. A qualitative, directed interview design was employed with a population of seven abused women. Findings included a relatively good model fit to the population, a pattern of staged spiritual growth with content characteristics that support previous observations of this population, and evidence of depressed spiritual development due to abusive life experiences. Inferences were drawn from the conceptual model to observed and expected patterns of interest to Advanced Practice Nurses for this group of women. . Copyright by Kathy C. Belonga 1997 Acknowledgments The author wishes to acknowledge the members of this research committee: Mary Jo Arndt, RN, Ph.D., for her gentle mentoring through the qualitative research process and her demonstrated belief in this project; Sharon King, RN, Ph.D., for her guidance through the university strUcture and personal mentoring; Linda Keilman, RN, MSN, for her pioneering work in spiritual research and her editorial contributions. Without such a strong, diverse, competent team of researchers, this project would not have been possible. The author would also like to acknowledge the contributions of each and every one of the participants of this study. Their courage to come forward and tell their most intimate stories is remarkable. The author recognizes the honesty, sincerity, and compassion for others demonstrated by each of the participants and applauds their efforts toward a better understanding of the phenomena of intimate abuse and spiritual development. iv Table of Contents INTRODUCTION ........................................... I BACKGROUND ........................................... 2 UNRESOLVED ISSUES ..................................... 5 PURPOSE OF RESEARCH ................................... 6 REVIEW OF LITERATURE ................................... 7 INTIMATE ABUSE ....................................... 7 Literature Related to Intimate Abuse. .......... 7 Critical Discussion of Intimate Abuse. ......... 9 Conceptual Definition of Intimate Abuse. ...... l6 SPIRITUALITY ........................................ 19 Literature Related to Spirituality. ........... 19 Critical DiscussiOn of Spirituality Literature. .............................. 23 Conceptual Definition of Spirituality. ........ 24 CONCEPTUAL FRAMEWORK ................................. 29 RESEARCH RATIONALE ................................... 33 METHODS ............................................... 35 SELECTION OF PARTICIPANTS ............................. 35 FIELD PROCEDURES ..................................... 37 DATA COLLECTION PROCEDURE AND RECORDING ................. 38 PROCEDURES FOR PROTECTION OF HUMAN SUBJECTS .............. 38 INSTRUMENTATION ...................................... 42 SCORING AND DATA SUMMARY PROCEDURES ..................... 42 DESCRIPTION OF RESEARCH DESIGN ......................... 45 PLAN FOR DATA ANALYSIS ............................... 45 DATA ANALYSIS ......................................... 46 SAMPLE DESCRIPTION ................................... 46 CONCEPTUAL MODEL FIT ................................. 47 PATTERNS ........................................... 49 INTERPRETATION OF FINDINGS ............................ 52 CONCEPTUAL MODEL ..................................... 52 PATTERNS ........................................... 59 DISCUSSION ............................................ 63 IMPLICATIONS FOR ADVANCED NURSING PRACTICE AND PRIMARY CARE ...................................... 67 APPENDIX A: SPIRITUAL DEVELOPMENT BY ASPECTS ......... 72 APPENDIX B: FOWLER'S STAGES OF FAITH DEVELOPMENT ..... 75 APPENDIX C: INSTRUMENTS .............................. 76 DEMOGRAPHIC INFORMATION ............................... 76 USING THE LIFE TAPESTRY EXERCISE: INSTRUCTIONS FOR THE RESPONDENT .......................................... 77 THE UNFOLDING TAPESTRY OF MY LIFE ...................... 79 FAITH DEVELOPMENT INTERVIEW ........................... 8O SCORING ANALYSIS SHEET ............................... 83 APPENDIX D: UCRIHS APPROVAL .......................... 85 APPENDIX E: CONSENT FORM ............................. 86 APPENDIX F: LETTERS .................................. 87 APPENDIX G: RECRUITMENT ANNOUNCEMENTS ................ 90 REFERENCES ............................................ 92 Vi Introduction The 1970’s Feminist Movement brought intimate abuse into focus as a valid, necessary, and vitally needed topic of research. The Feminist Revolution and the women's healthcare initiative that evolved from it have also provided valuable enlightened cultural views and defined directions for action in individual treatment, program development, healthcare, and social and political policy worldwide (Dan, 1994). Studies produced by feminist researchers generated what is now the most popular school of thought regarding intimate abuse— patriarchy. Prior to the advent of the 1970’s Feminist Movement, little research existed on the subject of intimate abuse. The Feminist Movement created a Climate of increased focus and attention on issues affecting women in general and intimate abuse in particular. Currently, the literature is rich with studies from various health disciplines including nursing, medicine, public health, psychology and social work that define, describe, theorize, suggest treatment protocols, and evaluate treatment outcomes related to intimate abuse. However, little, if any, 2 decrease in the incidence of intimate abuse can be documented despite the best efforts of clinicians (Dan, 1994). This is a failure that begs re- examination of the underlying assumptions on which an understanding of intimate abuse has been based. Background There are several noticeable trends occurring in studies of intimate abuSe. Three of these trends initiated the thought process behind this study. First, the preponderance of literature, even the early model development literature, is quantitative in nature. Second, based on these studies, three divergent schools of thought related to the nature of intimate abuse have developed. Third, conclusions drawn from studies of intimate abuse have generated prevention and treatment protocols. As to the first trend, Benoliel (1984) identified four broad areas in nursing research in which qualitative approaches appear more promising than quantitative approaches: a) environmental influences on systems, b) decision—making processes, Cf people’s adaptation to critical life experiences, and d) the nature of social transactions in relation to stability and change. In relationship to the study of intimate abuse, studies have shown that all 3 four of these broad research areas are present in the study of intimate abuse: environmental influences such as wealth ( Campbell, 1985, 1992; Coleman & Straus, 1986), decision-making processes such as unilateral decision-making (Renzetti, 1992, 1994; Vivian & Langhinrichsen, 1994), adaptation influences such as presence of intimate abuse in the family of origin (Renzetti, 1992; Sorenson & Telles, 1991; Vivian & Langhinrichsen, 1994), nature of social transactions in relation to stability and change such as what social transactions within a relationship characterized by intimate abuse help maintain or destabilize that behavior (Campbell, 1985, 1992; Coleman & Strauss, 1986; Straus & Gells, I985). Curiously, little research using qualitative methods has been applied to the study of intimate abuse. The second trend, divergence of model development, has to do with basic research assumptions in study design (Dutton, 1994b). Patriarchists generally confine their study populations to traditional family structures such as married, male dominant—female submissive families (Bograd, 1988). Patriarchists define intimate abuse as coercive acts perpetrated by a man on his wife 4 (Dutton, 1994b). In so doing, the models developed by patriarchists do not explain intimate abuse within such diverse groups as homosexual populations and unmarried partners (Lie, Schilit, Bush, Montague, & Reyes, 1991; Litellier, 1994; Renzetti, 1992). Sociobiologists describe intimate abuse as behavior directly resulting from human species survival instincts of males to dominate women and thereby dominate the gene pool (Wilson, 1975). Again, this model does little to explain intimate abuse within homosexual populations (Lie, et. al., 1991; Letellier, 1994; Renzetti, 1992) nor does it contribute to knowledge about the diversity of rates of intimate abuse seen within various countries of the world (Campbell, 1985, 1992). Psychologists examine psychiatric pathology within intimate abusers (Dutton, 1994; Dutton & Hart, 1992a, 1992b; Hastings & Harmberger, 1986). While these studies partially explain some of the cases of intimate abuse, psychologists themselves admit that most intimate abusers do not exhibit psychiatric pathology (Dutton, 1994; Dutton & Hart, 1992a, 1992b; Hastings & Harmberger, 1986). 5 Lastly, the third trend of generating prevention and treatment protocols has produced ineffective protocols (Dan, 1994). Patricharchists have aimed prevention and treatment at changing cultural and family norms but the death rate due to intimate abuse continues to climb (Dan, 1994). Sociobiologists have focused prevention and treatment at teaching anger management to abusive men and women with little success (Dutton, 1994a, 1994b; Wilson, 1975). Psychiatric pathologists focus treatment and prevention at identification and treatment of the pathologic abuser, but have no protocols for the vast majority of abusers who are not pathologic (Dutton, 1994a; Dutton & Hart, 1992a, 1992b). Unresolved Issues Due in large part to the above three trends in research on intimate abuse, many unresolved issues of importance to nursing remain. For instance: What influence(s) does the environment contribute to intimately abusive couple/individual systems?; What processes of decision-making by the couple/individual contribute to development, maintenance, and/or destabilization of intimate abuse in relationships?; What influence does the 6 couple’s/individual’s adaptation to critical life experiences have in the development, maintenance, and/or destabilization of intimate abuse in relationships?; What is the nature of social transaction by the couple/individual that contribute to development, maintenance, and/or destabilization of intimately abusive relationships?. Purpose of Research It is beyond the scope and intent of this thesis to examine all of these questions. The focus of this research is the individual currently involved in a relationship (within the last 6 months) characterized by intimate abuse. An attempt was made to gain insight into the influences of environment, decision-making, adaptation, and social transactions in relationship to stability and change. Specifically, the purpose of this research was to study the spiritual development of women in abusive intimate relationships. A qualitative, directed interview design developed by Mosley, Jarvis, & Fowler and revised by Boyd-DeNicola (1993) was employed. The theoretical model adopted, Fowler's Stages of Faith (1981), includes the elements of environment, decision-making, adaptation, and social transaction in relationship to stability and change. 7 Review of Literature Intimate abuse Literature Related to Intimate Abuse. In the 25 years of concentrated research into intimate abuse, three schools of thought have emerged. These include sociobiology (Daly, Wilson, & Weghorst, 1982), psychiatric pathology (Faulk, 1974), and patriarchy (Dobash &Dobash, 1979; Yllo, 1988). Sociobiologists explain intimate abuse based on the assumption that the primary motive for humans is survival of the species. To that end, individual males attempt to maximize their contribution to the gene pool by dominating females. Rage over sexual threat and threat to reducing control over females, results in violent behavior that has survival value for the human species (Wilson, 1975). Intimate abuse is therefore a symptom of the males' inability to curb this natural rage instinct to conform to society’s norms and values of non—violent intimacy. Psychiatric pathologists propose that intimate abuse is a symptom of psychiatric pathology. They theorize particular personality disorders result in intimate abusse (Dutton, 1994; Dutton & Hart, 1992a, 1992b; Hastings & Hamberger, 1988). 8 Patriarchists generally define intimate abuse as violence and/or coercive behavior committed by a man against his wife. Patriarchists reject hypotheses in which physical and/or psychological pathology may play a role or in which the wife is implicated either wholly or in part (Bograd, 1988). As a result, prior to the 1990’s, study populations consisted mainly of white, married, male- dominant/female-submissive samples. Generally excluded by design of the patriarchal argument were various cultural groups: non-violent couples; female dominant couples; lesbian, gay, and bisexual couples; and unmarried couples. Theories developed from such a small subset of the total population of couples involved in intimate abuse do not serve researchers well as they work with excluded populations even though abusive behaviors remain the same across populations (Cascardi, Langhinrichsen & Vivian, 1992; Chapman, 1989; Coleman, 1994; Drossman, Lesserman, Nachman, Li, Gluck, Toomey & Mitchel, 1990; Dutton, 1994a, 1994b; Koss & Heslet, 1992; Letellier, 1994; Miller, 1974; Renzetti, 1994). Patriarchists view intimate abuse as a direct result of patriarchal cultural norms and values that 9 encourage male dominance behavior over women. Themes stressed by this school of thought include patriarchy, power, control, social learning, intergenerational transmission of abuse, and violence cycling. Patriarchists support separation of intimates as a first step in intervention. Research conducted by this group is based on the major assumptions of the Feminist Movement: 1) intimate abuse is a direct result of a patriarchal culture; 2) women do not willingly give up power to their mates, it is taken from them through the process of continuous domination; 3) male violence against their intimates is only a part of the control tactics men learn to dominate women; and 4) research should be aimed to answer the questions, “Why do men beat their wives? and what can be done to stop this behavior?” (Bograd, 1988). Critical Discussion of Intimate Abuse. Currently, Patricharchists, Sociobiologists, and Psychiatric pathologists have researchers devoted to providing evidence that validates their claims. At this time, the preponderance of researchers ascribe to the patriarchy school of thought. Two major problems arise directly from the assumptions held by patriarchists: the first problem is one of 10 population sampling; the second deals with the narrow focus of patriarchist approach. Because the basic assumptions of patriarchy define intimate abuse as Violent and/or controlling behaviors occurring within the confines of male dominant-female submissive traditional relationships, other non-traditional intimate dyads are excluded from the studies. These include cross- cultural studies, non-violent intimates, female dominant-male submissive couples, non—married intimates, and lesbian, gay, and bisexual couples. Since approximately 1990, research efforts involving these non-traditional intimate couples has started to emerge. In reviewing the findings on these populations to date, and comparing to currently available theory surprising discrepancies come forth. For example, using a Patriarchal approach in studies of cross-cultural populations, Sorenson and Tells (1991) studied Mexican—born Hispanics (n=705) and reported that despite Hispanic cultures being more patriarchal than Americans, these couples had wife assault rates half that of a population of non- Hispanic whites (n=1149). Campbell (1985, 1992), a sociobiologist, was unable to support the concept N that male sexual jealousy, as an expression of cultural norms, is in any way related to wife assault. In a later study, Campbell (1992), was also unable to support a linear correlation between female status verses rates of wife assault. Some researchers have chosen to work outside the confines of a particular school of thought. Coleman and Straus (1985) found no main effect of power on violence. They described their study population as: 9.4% of couples male dominant, 7.5% female dominant, 54% divided power arrangement, and 29% egalitarian. The highest prevalence rates of any violent behavior between couples occurred in female dominant couples, followed by male dominant couples. In examining “final-say” decision-making power in relationships, they found the main contributor to conflict and violence was a lack of consensus between the couple about power sharing. In surveys focusing attention on non-violent marriages, actions that might be construed as wife-beating occurred in only about 11% of marriages at any time during the marriage, occurred once in 7%, and occurred repeatedly in about 3% (Kennedy & Dutton, 1989; Straus & Gelles 1985). In other words, 90% of marriages are free of intimate violence throughout their duration. 12 Another disturbing series of studies involve female on male violence. Bland and Orn (1986) reported 73.4% of women said they were the first to use physical violence (n=616). Stets and Straus (1990) compared mutually combative couples where violence patterns were male severe/female minor to female severe/male minor. They found the female severe/male minor pattern to be three to six times more prevalent regardless of whether the couple was dating, cohabiting, or married. These studies suggest that female violence is serious and may not be in response to male violence. Studies of homosexual relationships are also yielding unexpected evidence. Lesbian relationships are significantly more violent than gay relationships with a 56% to 25% ratio (Bologna, Waterman, & Dawson, 1987). Lie, Schilit, Bush, Montague and Reyes (1991) recorded lifetime intimate abuse rates in a survey of 350 lesbians who also had prior heterosexual relationships. The participants reported a higher incidence of intimate abuse with their lesbian female partners as opposed to their heterosexual male partners. Percentages were 56.8% sexual victimization rate by a female partner verses 41.9% previous by male partners; 45% physical 13 aggression rate by female verses 32.4% by previous male intimates; 64.5% emotional victimization rate by female partners verses 55.1% by previous male partners. Renzetti (1992) found that the main contributing factors to lesbian intimate violence were dependency and jealousy. Coleman (1994) studied gay and lesbian batterers and supports Renzetti's work adding feelings of low self esteem, powerlessness, and fear of abandonment for both batterers and victims in a mirror-like relationship. Dependency, jealousy, low self esteem, powerlessness, and fear of abandonment have been found predictive of violence in heterosexual relationships (Dutton, 1994; Dutton & Painter, 1993). The second major problem with the patriarchal approach is a strong philosophical rejection of etiological factors that point towards physical and/or psychological pathologies within the abuser. Research conducted by psychiatric pathologists reveals personality disorders such as borderline, anti-social, narcissistic, and aggressive—sadistic personalities typically abuse their intimates nearly 100% of the time (Dutton, 1994; Dutton & Hart, 1992a, 1992b; Hastings & Hamberger, 1988). 14 Warnken, Rosenbaum, Fletcher, Hoge and Adelman (1994) reported on head trauma in males and its relationship to development of new physical spousal abuse. Although no relationship was found between head injury and incidence of physical violence, findings do suggest head injury to be related to increased verbal abuse, aggressive behavior and marital conflict. These same subjects also exhibited very low levels of serotonin in their cerebral spinal fluid. This study indicates a neuro— biological risk factor previously not reported. Interestingly, many of the researchers now working with sample populations outside the confines of the traditional male-female relationship are at a loss to adequately explain their findings using available theoretical frameworks (Dutton, 1994a, 1994b; Miller, 1974; Renzetti, 1994). These researchers find it difficult to define intimate abuse (Coleman, 1994; Letellier, 1994), describe the variety and variations of among and between abusers and abused (Dutton, 1994a, 1994b; Vivian & Langhinrichsen, 1994, 1994), and ignore possible etiologies of abuse (Coleman, 1994; Dutton, 1994a, 1994b; Dutton & Painter, 1993; Renzetti, 1992; Warken et. al., 1994). 15 Results of these studies, the lack of predictability of current theoretical models, and the fact that the health care community has had little effect on the incidence of intimate abuse begs re-examination of efforts to date. By expanding the search to other groups of couples, the flaws existent within the basic assumptions on which patriarchal research is based become apparent. Hanging tightly to assumptions about the nature of intimate violence that are in conflict with current findings does little to advance the primary intention, namely to reduce the incidence of intimate violence. There is something missing from current models of intimate abuse. The impact of which has been to discount the lived experience of vulnerable people by disregarding the occurrence of intimate abuse within their relationships (Dutton, 1994a, 1994b; Letellier, 1994; Renzetti, 1992). This discounting denys them access to care appropriate to their needs by providing care services for intimate abuse chiefly to traditional families and assessing only married women for relationship abuse during health care visits (Dan, 1994; Letellier, 1994). People will continue to die and/or live with the chronic 16 disabilities associated with the legacy of intimate abuse (Cascardi, Langhinrichsen & Vivian, 1992; Chapman, 1989; Drossman, Lesserman, Nachman, Li, Gluck, Toomey & Mitchel, 1990; Koss & Heslet, 1992) until our understanding and interventions match the true nature of intimate abuse. Conceptual Definition of Intimate Abuse. What then is known abOut intimate abuse? Intimate abuse is the episodic use of physically, emotionally, and spiritually violent and/or coercive behavior within close personal and usually sexual relationships (Bland & Orn, 1986; Bologna et. al., 1987; Campbell, 1992; Cascardi et. al., 1992; Coleman & Straus, 1985; Dan, 1994; Drossman et. al., 1990; Dutton, 1994a; Kennedy & Dutton, 1989; Koss & Heslet, 1992; Leiteller, 1994; Lie et. al., 1991; Renzetti, 1992; Sorenson & Tells, 1991; Straus & Gells, 1985; Toomey, 1990; Vivian & Langhinrichsen, 1994; Yllo, 1988) In any particular intimate relationship the frequency of abusive incidences may range from never to chronically and frequently (Coleman & Straus, 1985; Dutton, 1994a; Kennedy & Dutton, 1989; Renzetti, 1992; Vivian & Langhinrichsen, 1994). The severity of the abuse can range from slight to 17 severe even to the point of chronic disability and/or death (Bland & Orn, 1986; Drossman et. al., 1990; Koss & Heslet, 1992; Lie et. al., 1991; Renzetti, 1992; Toomey & Mitchel, 1990; Vivian & Langhinrichsen, 1994; Warken, Rosenbaum, Fletcher, Hoge, & Adelman, 1994). Abusive couples may engage in unilateral abuse (one of the partners abuses, the other is victimized) with or without respect to gender, or they may mutually abuse (Renzetti, 1992; Vivian & Langhinrichsen, 1994). Risk factors for development of abuse in any relationship are personality disorder, a history of having both witnessed and been a victim of abuse in the family of origin, and a history of aggression in previous intimate adult relationships (Dutton & Hart, 1992a; Renzetti, 1992; Vivian & Langhinrichsen, 1994). Facilitating factors are substance abuse and use, and a history of intergenerational violence (Dutton & Hart, 1992a; Renzetti, 1992; Vivian & Langhinrichsen, 1994). Characteristics common to abusive couples, regardless of cultural considerations, are dependency and jealousy (Dutton & Painter, 1993; Renzetti, 1992; Vivian & Langhinrichsen, 1994). Dependency within abusive relationships can be 18 predictive of abuse development about 80% of the time (Vivian & Langhinrichsen, 1994). Individuals who present for treatment as a result of intimate abuse are characteristically described as protective of their abusers, evasive regarding the circumstances of their injuries, and narcissistic with deflated self worth (Dutton & Painter, 1993; Koss & Hart, 1992; Toomey & Mitchell, 1990). Intra-personal characteristics common to individuals involved in abusive relationships are: external locus of control, and rigidly enmeshed familial boundaries (Hastings & Harmberger; 1988, Lie et. al., 1991; Renzetti, 1992; Stets & Straus, 1990). Intimate abuse was defined individually by the participants. Participants helped to achieve this self identification by describing abusive relationships as one in which coercive behaviors and/or acts occurred between two persons who consider their relationship personally important, intimate, and usually involving sexual relations. These coercive behaviors might include physical, sexual, emotional/psychological, financial, and/or spiritual actions which resulted in the participant 19 feeling personally damaged by their participation in the relationship. Spirituality Literature Related to Spirituality. In comparison to the literature related to intimate abuse, there is a scarcity of literature related to spirituality. Some nursing theories contain concepts of spirituality (Henderson, 1966; Leninger, 1979; Neuman, 1979; Rogers, 1990; Roy, 1991; Watson, 1988). Descriptions of spirituality by nurses are prevalent but frequently conflict (Banks, Poehler, & Russell, 1984; Burkhardt, 1989, 1994; Emblen, 1992; Hasse, et. al., 1992; Hess, 1983; Paloutzian, Ellison, & Lonelines, 1982; Stoll, 1984). Several multidimensional tools related to spirituality have been developed by researchers and used by the nursing profession (Hasse, Britt, Coward, Leidy, & Penn, 1992; Moberg, 1971; Paloutzian, Ellison, & Lonelines& Paloitzian, 1982). Analysis of the concept of spirituality by nurses has been attempted (Burkhardt, 1989, 1994; Emblen, 1992; Hasse, et.al., 1992). Concept analysis literature related to spirituality will be examined in the section of this thesis relating to the conceptual definition of spiritual development. 20 Spirituality is a paradigm concept in nursing (Fawcett, 1984; Reed, 1992). Some nursing theories acknowledge the presence of spirituality or spiritual needs in humans (Henderson, 1966; Leininger, 1979; Neuman, 1989; Rogers, 1990; Roy, 1991; Watson, 1988). Roy and Andrews (1991) suggest that spiritual distress is a valid nursing diagnosis under the Self—Concept Mode. Leininger (1979), Watson (1979), Newman (1989) and Rogers (1990) all proposed an integrated spiritual dimension to their holistic models of human functioning. However, very little formal work has been done to define the phenomena (Reed, 1992). Religion and religious practices have been mentioned by nurses as integral to human well being ever since 1830 when Nightingale wrote Notes on Nursing (Nightingale, reprint 1992). Henderson (1966) suggested that assisting the patient to worship according to one's faith is one of the basic principles of nursing. Paloutzian, Ellison, and Lonelines (1982), Hess (1983), and Stoll (1984) all included religious components in their concepts of spirituality. Other specific concepts in the area of spirituality have been examined. In 1989, the Fifth 21 National Conference on Nursing Diagnosis describes spirituality as the dimension of a person that integrates and transcends the biological and psycho- social nature (North American Nursing Diagnosis Association, 1989). This conference also established Spiritual Distress as a diagnostic category. Moberg (1971), a theologian, was the first to develop a multidimensional tool to assess Spiritual Well-Being. This 82 item questionnaire includes the factors of social attitudes, self-perceptions, theological orientation, serving others, opinion, experiences, preferences and affiliation. Paloutzian, Ellison, & Lonelines, (1982) also developed a model and measurement tool for Spiritual Well—Being. The model contains a theoretical framework of a two dimensional axes, the Spiritual Well-Being Scale and the Religious Well—Being Scale. Other nurses have devised short spiritual needs assessment surveys using open—ended interviews (Hess, 1983; Stoll, 1984). These spiritual needs assessments traditionally rely heavily on assessment of religious practices and interference with these practices by the rigors and routines of the hospital environment (Carson, 1986; Dennis, 1991; Hess, 1983; Reed, 1991; Soeken & Carson, 1986; Stoll, 1984). 22 Efforts by nurse researchers attempting to begin a definition of spirituality have yielded many descriptions, but as yet, no conceptual definition of spirituality. In 1984, Banks, Poehler, and Russell suggested that the characteristics of the spiritual dimension are a unifying force, meaning and purpose in life, relating to God, a common bond between individuals, and individual beliefs and perceptions that guide behavior. Utilizing literature review techniques, Emblen (1992) reviewed nursing literature published from 1963 to 1989 and attempted to distinguish the concept of religion from that of spirituality. Emblen concluded that the definition of spirituality should include the words “personal, life, principle, animator, being, God (god), quality, relationship, and transcendent” (Emblen, 1992., p. 46). Whereas the definition of religion should contain the words “system, beliefs, organized, person, worship, and practices” (Emblen, 1992, p. 46). Emblen further emphasizes that spirituality is a larger concept than religion and may in fact embody parts of religion. Emblen did not present a definition of the concept of spirituality. 23 James Fowler (1981), a theologian, proposed a holistic model of spiritual development known as the Stages of Faith Development. Throughout an individual’s life span, Fowler proposes six stages of spiritual development, the first four usually coincide with the transitions occurring at childhood, school age, adolescence, and young adulthood. Each stage of spiritual development is associated with distinct changes in each of seven defined domains of spirituality. The stages are hierarchical, invariantly sequential, and appear to be universal regardless of religion, culture, or family tradition (Carroll, 1993; Fowler, 1981; Grossman, 1991; Hoffman, 1993; Morgan, 1993). Critical Discussion of Spirituality Literature. The Moberg (1971) Spiritual Well—Being tool is comprehensive, but lengthy quantitative tool and specific to Christianity. The model and measurement tool for Spiritual Well-Being developed by Paloutzian, Ellison, and Lonelines (1982) can be used cross-culturally, but, the concepts of value integration and spiritual meaning-making are not included in this tool. Both the Hess and Stoll tools, like the Spiritual Well-Being Model (Paloutzian, Ellison, & Lonelines, 1982) concentrate 24 on the specific content of the individual’s spirituality and ignore the structure. Fowler’s Stages of Faith (1981), in contrast to other concepts of spirituality, is more inclusive. He examines not only the content ( values, power, Chosen religious rites and symbols) but includes the structure (phases of development, domains) and therefore the meaning—making inherent in spirituality. Furthermore, Fowler has developed a research methodology and tool to test the conceptual framework (Moberg, et. al., 1993). A systematic process of encoding responses and assigning stage rating was developed and tested on nearly 400 subjects during the development of the framework and continues to be tested and improved as research progresses. Results of over 95 additional subjects have been published since the model was completed (Carroll, 1993; Chychula, 1995; Grossman, 1991; Hoffman, 1993; Morgan, 1993). Conceptual Definition of Spirituality. Nursing has yet to propose a conceptual definition of spirituality. Burkhardt (1989) attempted a concept analysis of spirituality that resulted in teasing out the structural dimensions of 25 self, other, world, transcendence, and development over time as well as the content components of value, power, symbol, and life meaning. Nagi— Jacobson & Burkhardt (1989) used this analysis informally for clinical assessment of spirituality. In 1994, Burkhardt used a qualitative, naturalisitc inquiry, grounded theory approach in examining the spirituality of women. Based on her findings, Burkhardt describes the spirituality of women as: “the unifying force that shapes and gives meaning to the pattern of one’s self-becoming."(Burkhardt, 1994, p. 14). The most recent attempt at concept analysis of spirituality was performed by Haase, Britt, Coward, Leidy, and Penn (1992). These researchers developed a new technique of simultaneous concept analysis based on concept analysis techniques first proposed by Wilson and described by Walker and Avant (Haase, et. al., 1992). They attempted to distinguish between the concepts of spiritual perspective, hope, acceptance, and self-transcendence within nursing literature. The authors propose that spirituality is “a basic or inherent quality of all humans” (Haase, et. al., 1992, p. 146) that is an antecedent to one’s spiritual perspective. 26 Spiritual perspective between individuals is the phenomena that varies, not spirituality. Enablers of this variance in spiritual perspective include love, understanding, wisdom, and crucial life events. Haase, Britt, Coward, Leidy, and Penn (1992) further state that significant relationships with others play pivotal roles in development of love, understanding, and wisdom while critical life events provide the catalyst for development of a particular spiritual perspective. Haase, Britt, Coward, Leidy, and Penn (1992) describe spiritual perspective as having several critical attributes: 1) connectedness (i.e., with others, nature, the universe or God), and unification and integration of the person (i.e., physical, psycho-social, and spiritual dimensions), 2) belief (i.e., in something greater than the self, an intangible domain, and faith that positively affirms life), and 3) creative energy in constant, dynamic, evolutionary flux. In a research field other than nursing, Fowler (1981) proposed a definition of faith development which is analogous with nursing’s descriptions of spirituality. Fowler (1981) defines faith (spiritual) development as a sequence of 27 transformative and transcendent developmental stages by which an individual organizes the self, others, and the world in response to questions of value, power, and stories that contribute to the supreme meaning of their life. In his discussion of this definition, Fowler (1981) identifies the domains of spiritual development in this model as: 1) form of logic as defined by Piaget, 2) social perspective taking as defined by Selman, 3) form of moral judgment as defined by Kohlberg and modified by Gilliam, 4) bounds of social awareness, 5) locus of authority, 6) form of world coherence, and 7) symbolic function. Appendix A lists the content of the conceptual framework by Stage and domain. In Burkhardt’s (1989) concept analysis of spirituality, she delineates similar dimensions and components as Fowler’s definition (i.e.: self, other, world, value, power, symbol, life meaning, growth and development, and transcendence). Paloutzian, Ellison, and Lonelines (1983) recognize that the outcomes of spiritual development (Spiritual Well—being and Religious Well-being) change over time in response to life events and nursing interventions. Watson (1988) writes that the basic striving of persons is achievement of 28 increasing spiritual development. Watson describes spiritual development as a “greater sense of self awareness, a higher degree of consciousness, an inner strength, and a power that can expand human capacities and allow a person to transcend his or her usual self” (Watson, 1988, p. 49). Nurse researchers Haase, Britt, Coward, Leidy, and Penn (1992) proposed a concept of spiritual perspective that is consistent with Fowler’s model. Fowler’s model contains the same process model as Haase, Britt, Coward, Leidy, and Penn: antecedants of spiritual development (spirituality itself), enablers (life experiences, understanding, wisdom, love), critical attributes (connectedness with self, other, world, God (god)), and outcomes (purpose and meaning, values to guide conduct, self— transcendence). The above descriptions of spiritual development are far from being definitions that can be compared and contrasted with Fowler’s definition of faith development. Still, it is clear that Fowler’s definition contains the same content and much of the structure as nursing’s descriptions of spiritual development. In the absence of precise definitions of spiritual development in the nursing literature, 29 and since there is logical congruence of Fowler’s definition of faith development to the descriptions of spiritual development available in nursing literature, for the purposes of this research Fowler’s definition of faith development will be adopted as the conceptual definition of spiritual development. Conceptual framework Fowler's conceptual framework entitled Stages of Faith (1981) describes at what developmental level an individual is in their process of spiritual development. Fowler (1981) defines faith (spiritual) development as a sequence of transformative and transcendent developmental stages by which an individual organizes the self, others, and the world in response to questions of value, power, and stories that contribute to the supreme meaning of their life. Presumably, according to Fowler (1981), actions taken by any individual must be congruent with their current stage of spiritual development. Each stage of development contains all of the seven defined domains. The exact behavioral content of each of the seven domains defines the stage at which the individual functions. Life crisis, developmental or contextual, that cannot be resolved using the 30 current stage of development precipitate transition toward the next stage. Arrest of spiritual development can and does occur in response to life crisis (Fowler, 1981). Achievement of at least Stage II or above appears to be necessary for adult function, however, adults functioning at Stage III or below may be an at risk population (Chychula, 1995). Looking at a graphic representation of the framework (Appendix B), one sees an eccentric helical spiral with seven distinct overlapping loops beginning and ending on the left with the middle of the spiral pulled toward the right. A dotted curved line pierces the center of each spiral loop. The dotted curved line has no beginning or ending. This is an attempt by Fowler to illustrate several principles. First the process of faith development is dynamically connected (helical spiral) with each successive stage (loop) linked to and adding to the next. The first and smallest loop represents infancy and only postulated by the framework, not defined. Stages overlap and spiritual issues that reoccur (overlap on loops) at each stage are revisited at differing levels of complexity (upward movement, separation of loops) Viewed as a whole, there is developmental growth and movement outward toward individuation (right skew of spiral) during the first four stages (childhood M through adulthood) and a doubling back movement with continued growth and development toward participation and oneness (upper left skew of spiral) during Stages 5 and 6 though at far different levels of complexity than at earlier times. Each successive stage represents a widening of vision, personal depth, and valuing (increasing size of loop). The dotted line tracks this progress, growth and movement. y Fowler’s Stages of Faith may shed new light on the subject of intimate abuse. The characteristic attributes of individuals involved in abusive relationships have a common theme. They can be assessed by examining an individual’s system of principles and values, relationship with self-other- world, and personal meaning-making (Fowler, 1981; Mosley et. al., 1993). According to Fowler (1981), an individual brings order to and derives meaning from life through the spiritual dimension. Behaviors exhibited by the individual must be in accordance with the individual’s spiritual development. For instance, the abused must have within their spiritual dimension characteristics which harmonize with each of their behaviors. The abused must be able to use their logic pattern, perspective, moral 32 reasoning, social awareness, locus of authority, world coherence, and symbolism to gain order, purpose and meaning to the abusive acts in which they participate. Examining the common characteristic attributes of the abused in relation to Fowler’s Stages of Faith, empirical evidence exists such that the pattern of behaviors seen in this population could be described by one of the Faith Stages described by Fowler, namely Stage II—Mythic—Literal Faith (Fowler, 1981). At this stage, logic is concrete operational, perspective is simple perspective taking, morality is based on instrumental hedonism, stereotypic shared characteristics form the bounds of social awareness, authority is encompassed in authority roles with increased importance on relatedness, world coherence is narrative and dramatic without systematic structure or content, and symbolism is one dimensional and literal (Fowler, 1981). Research has shown that the abused draw no inferences between the severity of abuse and the act for which they are being punished (concrete operational logic) (Vivian & Langhinrichsen, 1994), they are egocentric with low self esteem (perspective taking) (Drossman et. al., 1990), they 33 believe they deserve their abuse (reciprocal form of moral judgment)(Renzetti, 1992; Yllo, 1988), they seek to maintain rigidly enmeshed familial boundaries (familial bound of social awareness)(Drossman et. al., 1990; Dutton & Painter, 1993), authority is imbued in highly attached and dependent relationships (locus of authority)(Dutton & Painter, 1993), they believe the world to be unpredictable (lack of systematic form of world coherence)(Coleman, 1994), and often believe that the abusive behavior is a show of passionate love (one dimensional, literal symbolism) (Renzetti, 1992; Yllo, 1988). Research Rationale The purpose of this research was to study the spiritual development of women in abusive intimate relationships. The intent was to gain a better understanding of both the phenomena of spiritual development and intimate abuse from an individual’s point of View. A qualitative, directed interview design developed by Mosley, Jarvis, & Fowler and revised by Boyd-DeNicola (1993) was employed. It should be noted that this developmental framework is still in the process of refinement and revision by Fowler and others at this point in time. None the 34 less, it will be employed as an assessment tool and conceptual framework for this study. The need for further study into intimate abuse is clear. Few changes in the incidence, prevalence, or outcome of abusive relationships have occurred despite 25 years of intensive study. Current models of intimate abuse have not generated effective prevention and treatment protocols. The need for further research into human spirituality is also clear. Very little research is available to improve understanding about the spiritual domain of human response. Perhaps by taking a fresh look at intimate abuse through the lens of spirituality, new patterns may emerge to aid understanding of both phenomena. The questions this research attempted to answer were: how does, if at all, the spiritual development of intimately abused women fit into Fowler’s (1981) model of spiritual development? If there is a good model fit, are there any patterns in environmental influences, decision-making processes, adaptation to critical life experiences, and/or the nature of social transactions in relation to stability and change that can be discerned using 35 Fowler’s (1981)\conceptual framework which may shed light on abusive intimate relationships? Methods Selection of Participants A convenience sample of the first seven volunteers was recruited from a pool of persons inquiring about participation in this project who met the following eligibility criteria: female; aged 25-55; currently involved in a relationship that the individual characterizes as intimate and in which a pattern of physically, emotionally, and/or spiritually violent and/or coercive behavior has occurred within the past six months; could articulate their thoughts verbally in English; had a self defined secure and confidential mailing address (or other secure means of sending and receiving confidential messages); and demonstrated a willingness to participate in the research by at least partial completion and return of requested demographic information and a valid, signed consent form. Recruitment of volunteer participants was requested from the greater Ann Arbor-Ypsilanti area in southeastern Michigan. This recruitment process included newspaper announcements, direct mailings to 36 professionals in the intimate abuse field, and posting announcements in local women's shelters. In response to inquiries by volunteers, the primary researcher explained the purpose of the study and the eligibility requirements, estimated the participant’s time commitment, described study procedures, reviewed voluntary participation and refusal, discontinuation of participation without penalty, discussed the concepts of confidentiality and anonymity as well as potential risks and benefits during participation, and finally supplied the name and telephone number of the primary researcher and project supervisor as contact persons regarding questions or concerns that the volunteer might have had. Numbered consent forms were then mailed to volunteers along with a cover letter detailing the same information given at the time of inquiry regarding participation, and a pre-addressed, stamped response card requesting a summary of findings. The participant mailed the consent form directly to the project supervisor in a pre- addressed, stamped envelope. The project supervisor, upon receipt of valid, signed consent forms recorded the consent reference number and placed the consents 37 in a locked file where they will be maintained for a period of not less than 3 years. The project supervisor will be the only research team member with access to the consent forms (Appendix E). All volunteers submitting the response card will receive a summary of the study findings that will be mailed to the address they indicated on the card. All agencies and professionals contacted were also supplied with a response card. Those who have responded will receive a summary of findings. Participation was not a requirement for receipt of summary information. Field Procedures Field procedures were in two phases: Phase I— all volunteers, in response to interest inquiries, received by mail a letter requesting that they complete and return the consent form. Once consent was obtained, volunteers received by mail a questionnaire requesting demographic information; Phase II—eligible participants received by mail a letter requesting that they complete the Unfolding Tapestry of My Life exercise. The participants were also contacted telephone to arrange for an interview appointment. 37 in a locked file where they will be maintained for a period of not less than 3 years. The project supervisor will be the only research team member with access to the consent forms (Appendix B). All volunteers submitting the response card will receive a summary of the study findings that will be mailed to the address they indicated on the card. All agencies and professionals contacted were also supplied with a response card. Those who have responded will receive a summary of findings. Participation was not a requirement for receipt of summary information. Field Procedures Field procedures were in two phases: Phase I— all volunteers, in response to interest inquiries, received by mail a letter requesting that they complete and return the consent form. Once consent was obtained, volunteers received by mail a questionnaire requesting demographic information; Phase II—eligible participants received by mail a letter requesting that they complete the Unfolding Tapestry of My Life exercise. The participants were also contacted telephone to arrange for an interview appointment. 38 The location of the interview was at a mutually acceptable location. All participants elected to complete the interviews via telephone from their place of residence. The participants were interviewed by the primary researcher using Fowler’s Faith Development Interview Instrument (Mosley et al., 1993). The interviews were audio—taped with the participants full knowledge and consent. Data Collection Procedure and Recording The audio-tapes were transcribed by the primary researcher. Each question and response was line numbered consecutively for reference at the time of transcription. The transcribed interviews were then coded using content analysis procedures developed by Mosley, Jarvis, & Fowler (1993). The coding scores, the passages to which the scores refer, and the scoring criteria used to determine each score were entered on the Scoring Analysis Sheet (Appendix C). Procedures for Protection of Human Subjects Anonymity and confidentiality of the research participants was maintained through the use of a series of three security elements. These consisted of three separate locked files to which access was limited. 39 The first locked file, File “A”, contained the contact log and interview audio—tapes. In response to inquiries regarding participation in the research, volunteers self-assigned an alias and this alias was recorded in the contact log. Volunteers were then asked for a secure mailing address and telephone, that were also recorded in the contact log. The researcher then aSsigned a blinding code to the case and recorded this number in the contact log. Information regarding the study was sent, including the consent form, to the alias and address supplied by the volunteer. The reference number on the consent mailed to the individual volunteer was recorded in the contact log. This contact log was kept in locked File “A”. The primary researcher was the only person with access to locked File “A”. In addition to the contact log, locked File “A” contained interview audio—tapes. The audio-tapes were marked, at the time of the interview, only with the case blinding code. Interviews were conducted only by the primary researcher. The primary researcher transcribed the audio-tapes, using the case blinding code as an identifier. At the time of transcription, any identifying information given by 40 the participant was blinded from the transcript by blacking out the identifying information. Transcripts were kept in locked File “C”. The second locked file, File “B”, contained consent forms that bear the participant's signature. The Project Supervisor was the only person with direct access to File “B”. Consent forms were mailed directly to the Project Director in a pre-addressed, stamped envelope by participants. Consent forms were numbered for reference prior to distribution. The Project Supervisor prepared a list of valid consent forms by referenCe number only. This list of reference numbers was kept in locked File “C”. The consent forms will remain under the care and safekeeping of the Project Supervisor for a period of not less than 3 years. File “C”, contained demographic information questionaires, transcripts, and Scoring Analysis Worksheets. This file remained under the safekeeping of the primary researcher. All materials contained in locked File “C” bore the case blinding code as the only identifier. At the conclusion of the research, all materials contained in locked files “A” and “C” will be destroyed in the presence of the Project 41 Supervisor and the Primary Researcher. At no time will any person allow materials contained in files “A” or “C” to be compared with file “B”. Potential risks of this study were minimal and primarily psychological. These could have involved, dependent on the participant, recalling past events that could increase stress or anxiety. The primary researcher offered to provide the participants with names and telephone numbers of therapists and other appropriate resources located in the participant’s home geographic area. However, none of the participants complained of increased stress or anxiety or requested referral to a health care provider. Potential benefits to the participant included gaining insight into their own life and a sense of helping others struggling with the effects of intimate abuse. All of the participants expressed thoughts relating to insights gained at the conclusion of the interview and expressed hopes of helping others through their participation. Potential benefits to society included increasing knowledge of the process of spiritual growth as well as the effects of abuse on the individual involved 42 in an abusive intimate relationship in general, and in Nursing specifically. As a further safeguard, review of this research was obtained through an institutional internal research review board. Approval of this research by the University Committee on Research Involving Human Subjects (UCRIHS) at Michigan State University was obtained prior to initiation of the research methods. Instrumentation During Phase I, demographic information was collected. During Phase II, the Unfolding Tapestry of My Life exercise, and Fowler’s Faith Development Interview Instrument (Mosley et al., 1993) were used. Scoring and Data Summary Procedures The following steps as dictated by the 1993 Manual for Faith Development Research (Mosley et al., 1993) were taken to score and summarize the interview data: Step 1—Estimate Stage. The entire interview was read and an estimated stage assigned. The aim was to arrive at a global, intuitive approximate stage code for the interview 43 as a whole. Numbers of passages of particular significance were noted. Step 2—Confirming Estimated Stage. The estimated stage for each interview was compared with the comparable general description of that stage published in the 1993 Manual for Faith Development Research (Mosley, et. al., 1993). Where the estimated stage was generally supported by these descriptions, response by response coding was initiated. When the interview showed a mixture of stages, and a transitional stage was suspected, the interview was compared with the published stage descriptions both above and below until a better match was found. Where the stage mixture was not clarified by this procedure, all appropriate stages were included. Step 3—Response by Response Coding. On the Scoring Analysis Sheet, the passage reference number corresponding to each of the questions prompts as indicated were recorded. For each of the interview aspects (Form of Logic, Perspective Taking, Moral Judgment, Bounds of Social Awareness, Locus of Authority, Form of World Coherence, Symbolic Function) the responses were compared to the aspect description and coding 44 criteria initially estimated. Unclear or puzzling passages were compared to the aspect description and coding criteria one stage above and one stage below the estimated stage. Unclear or puzzling passages resulted when: l) the response was uncodable due to ambiguity; In this case, an attempt to find another passage within the interview indicating material for that aspect was made, and 2) The passage contained a mixture of stages; the response was coded midway between two stages (mixture of stages 2 and 3 were coded 2.5, etc.). Step 3 was repeated until all 7 aspects were coded in this way. Discrepant data is data that does not align with the stage codes being assigned other passages. Discrepant data was noted at the bottom of the scoring sheet along with any speculations as to why this might occur. Any patterns encountered in reference to discrepant data were noted. For instance, many participants consistently responded at another stage level when speaking about problem solving techniques as opposed to solving moral dilemmas. This type of discrepancy was noted. Step 4—Calculate Average Score. An average to the nearest 0.01 was calculated for each aspect. No aspect scores were based on 45 fewer than three passages. Discrepant data was added as an eighth aspect. The average of all aspect scores was calculated. This was the individual's stage score. The primary researcher has submitted three interviews (blinded and coded) gathered from three non-abused volunteers, with demographics matching the study population, to Dr. James Fowler. Dr. Fowler’s staff performed an independent analysis of the submitted interviews. An inter-rater reliability rate of 82% was returned for these interviews. Description of Research Design This study used a qualitative, directed interview design developed by Mosley, Jarvis, & Fowler and revised by Boyd-DeNicola (1993). A convenience sample population of seven adult women currently involved in abusive intimate relationships volunteered as participants. The aim of the research was to study the participant’s spiritual development and involvement in abusive intimate relationships. Plan for Data Analysis Methods for data analysis were qualitative in nature. As such, themes relating to the nature of the individual participant’s spiritual development were used to encode responses to the Faith 46 Development Interview (Mosley, et. al., 1993). These encoded responses were used to determine where, if at all, the individual fit into Fowler’s Stages of Faith (1981). There was a good fit of the model to the data. An attempt was made to tease out patterns relating to: 1) environmental influences, 2) decision-making processes, 3) adaptation to critical life experiences, and/or 4) the nature of social transactions in relation to stability and change. Data Analysis Sample Description A convience sample of participants were selected on a first come basis once eligibility criteria were satisfied and informed consent obtained. Recruitment efforts resulted in participant selections from the following sources: Bulletin board postings--1 response, 1 participant selection; referrals from professionals--4 responses, 4 participants selected; word of mouth—10 responses, 2 participants selected, 8 rejected for criteria (2-younger than required age, 3--no consent returned, 3--time since last abuse incident greater than 6 months). The sample consisted of seven female participants aged 23 to 66 years old (median age 47 41), all were white, 6 married and 1 separated, all had some college education, all were employed at least on a part-time basis, with a median household income $40,000 to $60,000, and an average of 3 persons per household. Conceptual Model Fit Each participant was interviewed using the Faith Development Interview tool (Mosley, Jarvis, and Fowler, 1986) and their answers tape recorded. All participants elected to complete the interviews via telephone from their place of residence. All participants were interviewed individually and at a time when they were alone. All participants had completed the Life Tapestry exercise prior to the interview and had this information with them at the time of the interview. Interviews lasted until all questions were answered to the satisfaction of both the interviewer and participant. Interview lengths ranged from 60 to 93 minutes. The recorded interviews were transcribed and identifying data blinded by the primary researcher. The interview transcripts were then coded for content and scored using the 1993 Manual for Faith Development (Mosley, Jarvis, and Fowler, as revised 48 by Boyd-DeNicola, 1993) and the methodology previously described. An average of the results of the coding analysis for the study participants as a whole were: Form of Logic, 3.75; Social Perspective Taking, 2.667; Form of Moral Judgment, 2.250; Bounds of Social Awareness, 2.667; Locus of Authority, 2.667; Form of World Coherence, 2.500; Symbolic Function, 2.500; Stage, 2.679. Fowler reported 97.2% of adults 21 years or older had a Stage score of Stage III or higher, and 56.6% of adults had Stage scores of Stage IV or higher (Fowler, 1981). The Stage scores of this study population are congruent with Fowler's findings. The data reflected a trend toward higher values of all domains as age increases. Upward trending with age was noted by Fowler (1981) and in fact is a precept of the Stages of Faith (Fowler, 1981). Ignoring Form of Logic scores, the rest of the domain data cluster tightly around a particular Stage on an individual basis. This finding also supports Fowler's conceptual model (Fowler, 1981). The higher Form of Logic scores appear to be a pattern of development for this population not predicted by the conceptual framework. 49 Based on growth of Stage scores with age, the average Stage scores, and the clustering of dimensional scores around a Stage on an individual basis, Fowler's Stages of Faith (1981) yeilds a relatively good fit to the study data. Further analysis to answer study questions regarding patterns of enviornmental influences, decision making, adaptation, and soCial transaction in relation to stability and change was performed. Patterns A relationship exists between partipant age and all of the domain scores and stage scores. As a group, age values depict growth over time of spirituality. Again this finding is predicted by Fowler’s conceptual framework (Fowler, 1981). Discrepant data was highly significant in that, for each and every case, Form of Logic scores were higher by nearly one stage value than the rest of the domains. A typical response to the question regarding decision making stragies was “Well I’ve started thinking a lot about how I do thatm” (thinking about thinking--a criteria of formal operational logic). All responses were then re- checked with coding criteria for the stage suggested by the logic scores. In each case and for each 50 response no criteria were met at the higher stage level to permit re-coding the data. This disproportion in Form of Logic scores relative to the other domains may actually indicate these individuals' true potential stage score with the 6 other domains showing arrested or retarded growth in response to abusive experiences. Fowler (1981) writes that life crisis and critical life events may result in retarding or arrest of spiritual growth domains. The logic domain for these participants may have been protected from growth retardation by the participants' high degree of education and/or may reflect a reliance on the defense mechanism of intelectualization in order to make meaning out of their life experiences. Intelectualization as a defense mechanism supporting denial has been reported as a common theme in abused women (Renzetti, 1992). The data set can be clearly split into two distinct groups. One group exhibits Stage scores higher than 2.75 and the other Stage scores lower than 2.75. On averge, group members with Stage scores less than 2.75 demonstrate a Stage classification of Stage II transitional while those m in the group with Stage scores greater than 2.75 are classified as Stage III. According to Fowler’s Stages of Faith (1981), the differences between Stage II transitional and Stage III lie chiefly in the degree to which the individual leaves behind the narcissism of Stage II and begins to use formal operational thought processes. In this study, the dimension of Form of Logic has exceeded the formal operational level in all cases. Therefore, the only difference between the two groups in this study is their degree of narsisism. Typically group members with Stage scores less than 2.75 were unable to construct life events from another’s perspective. Speaking about when she left home for college, one participant in this group stated, “I don’t know what my mother thought or felt about it. I’ve never tried to figure her out like that. I just remember her being upset about how much it was going to cost.” In contrast, a typical response of a group member with Stage scores greater than 2.75 spoke about the same subject (mother's thoughts and feelings regarding daughter leaving home for college): “When I was applying for colleges, Mom wanted me to go to xxxx. I think she wanted to keep me close to her. I think my leaving was harder on her emotionally than it was on me, probably 52 because I was readym it was just time for me to leave.” Bounds of Social Awareness is the only conceptual dimension in the data set which has the same value for both the group with Stage scores higher than 2.75 and the group with Stage scores lower than 2.75. A typical response to questions about group identification was: “I don’t really go with groups or really join themmI don’t have any real friends outside my family, but then we're real tight knit. I guess I’ve got everything I need from my family. They are the ones who know me anyway (inability to criticize family norms, family centered to exclusion of others—Stage 2 criteria).” This finding describes a similarity between the 2 groups which is consistent with Fowler’s (1981) framework. Interpretation of Findings Conceptual Framework For this population of abused women, two distinct groups can be discerned based principally on their diferences in dimensional scores on Form of World Coherence, Form of Moral Judgment, Locus of Authority, and Social Perspective Taking. One group had Stage scores higher than 2.75, the other had Stage scores lower than 2.75. Those in the first group (Stage > 2.75) were principally older than those in the second group (Stage < 2.75). This finding is 53 consistant with the structure of the Stages of Faith (Fowler, 1981) as well as with Fowler's and others findings (Carroll, 1993; Chychula, 1995; Fowler, 1981; Grossman, 1991; Hoffman, 1993; Morgan, 1993). The data supports an age dependant, staged structure to spiritual development. For each participant, very little variability in domain scores was seen (the only exception being Form of Logic score which was higher than all other domains for each participant). Stage scores, without exception, increased with age. The fact that the dividing Stage score separating the two groups is less than Stage 3.0, coupled with the fact that all participants are functioning adults within their communities (held jobs, contributed to households) suggests that relatively low Stage scores are compatible with adult lifestyles. This is also ccmuyistent with Fowler's and other’s findings (Carroll, 1993; Chychula, 1995; Grossman, 1991; Hoffman, 1993; Morgan, 1993). The simple fact that the participants were abused does not preclude their development past Stage III or higher. The two oldest study participants were rated at Stage IV. The ability of these participants to achieve a high Stage score points out the uniqueness and variability of the individual as a holistic being as well as growth over time throughout the lifespan despite their experiences. Still, the pattern 54 of their development fits the pattern of the other participants. That is, these two participants score high on the Form of Logic domain and lower by at least one stage on all of the rest of the domains. This group of women demonstrates some of the basic assumptions of the Stages of Faith (Fowler, 1981). The assumption that spiritual development is unidirectional cannot be determined within the confines of this study. However, the assumption that that spiritual development is dimensionally interdependent explains how abuse has affected these participants. Retarded or arrested growth of all dimensions except Form of Logic may be due, at least in part, to the abusive relationships in which the participants are involved. One explanation of the discrepancies seen in the Form of Logic dimension offered by the Stages of Faith model (Fowler, 1981) is that critical life events can arrest or retard domains of spiritual development (Fowler, 1981). Rather than viewing the domain of form of logic as exceptionally elevated in this population the other domains are depressed. The concepts of the conceptual framework, namely unidirectionality of growth, staged development, dimensional interdependence, and adaptation to critical life events, point to impeded development in the domains of perspective taking, moral judgment, social awareness, locus of 55 authority, and form of world Coherence as a direct result of abusive life experiences. The pattern seen in this data set may be characteristic of the abused population and as such, an adaptive mechanism to the abuse experience. Further assessment of these concepts, within this population, would be necessary to make this linkage. The data reveal that the study participants can be classisifed either as Stage 2.5 transitional or Stage 3. The chief differences between adults at Stage 2 and Stage 3 involve changes to Social Perspective Taking and use of formal operational thought to synthesize new meanings (Mosley, Jarvis, & Fowler, as revised by Boyd DeNicola, 1993). The individual at Stage II transitional exhibits rudimentary skills and values in the area of mutual interpersonal perspective taking and systhesis of ideas and concepts. In other words, the Stage II transitional individual is more narcisistic than a Stage III individual. The adult individual at Stage III is intensely concerned with building and maintaining interpersonal harmony and concordance, toward meeting the expectations of others, and towards keeping up appearances (Mosley, Jarvis, and Fowler, as revised by Boyd DeNicola, 1993). These values are indeed in keeping with the profiles of abused women discussed in the literature. To review, abused women have been described as protective of their abusers, evasive 56 regarding the circumstances of their abuse, and narcissistic with deflated self worth (Dutton & Painter, 1993; Koss & Hart, 1992; Toomey & Mitchell, 1990). Intra-personal characteristics common to individuals involved in abusive relationships are: external locus of control, and rigidly enmeshed familial boundaries (Hastings & Harmberger; 1988, Lie et. al., 1991; Renzetti, 1992; Stets & Straus, 1990). Viewed from the conceptual framework of Fowler's Stages of Faith (1981) the described protectiveness of the abuser by the abused can be more readily understood as an attempt to maintain interpersonal harmony and concordance with the abuser, a characteristic task of Stage II transitional and Stage III individuals. Evasiveness to questions about injuries may be an attempt to keep up appearances, again characteristic of the Stages identified in this analysis. One participant spoke about her first boyfriend whom she described as abusive stating, “There were a few times when he hurt me, you know, physically. But there were a lot of times when things were good. I never thought he was abusive. Not then.”. Narcissism is a characteristic of Stage II and Stage II transitional individuals. One participant who was at Stage II spoke about the birth of her first child stating, “I didn’t like being pregnant. I was so fat and ugly. But then 57 everybody came around after it was born--my mom, dad-- and I felt like I’d really done something!”. “Deflated” self worth may incorrectly imply a decline in self worth when according to the model, an explicit sense of self does not develop until Stage IV. A participant at Stage III responded to the question “ Are there any beliefs, values, or commitments that seem important to your life right now?” in this way: I believe in God. That’s important. And it’s important to me not to hurt anyone—you know, do unto others—but I think everyone believes that. My marriage is a commitment. And that's important. Other than that I can't think of anything. Another participant at Stage III responded to the question “Do you feel that your life has meaning at present? What makes life meaningful to you?” in this way: “Taking care of my children and my husband, that gives my life meaning. The job that I do, taking care of others, that gives my life meaning.”. In contrast to the above two respondants, one of the participants was able to relate an explicit sense of self. This participant was classified at Stage III transitional. Responding to the question “ Are there any beliefs, values, or commitments that seem important to your life right now?” she stated: 58 I believe in God. I believe in His power acting in my life to make things better for me and the people I love. And I devote time to pray for that every day. I value honesty and integrity and look for that in my friends and the people I associate with. I am committed to my marriage and family, and to xxxx (a social service group) so that I can leave the world a better place for my children and grandchildren. Interpersonal characteristics of the abused are also explained by this model. The external locus of authority described is predictable since Locus of Authority does not become internal until Stage IV. A Stage III participant related explicitly “I have always taken the opinion of others over my own. They just know more than I could ever hope to.”. Rigidly enmeshed familial boundaries can also be better understood since familial membership and maintenance of interpersonal bonds is the primary concern of the Stage 2.5 transitional to Stage III individual. A participant stated, “In my family, we pretty much keep to ourselves. I guess we just feel more secure and happy that way.”. This data supports the notion that the spiritual development of individuals involved in abusive interpersonal relationships is indeed at the Stage II transitional to Stage III level. 59 In sum, it may be induced that the characteristics of individuals at Stage II transitional to Stage III place them at risk for the development and maintenance of abusive interpersonal relationships due in part to their tendency to be members of ridigidly enmeshed families, have an external locus of authority with a perference for familial authority figures, a lack of explicit personal identity, and evasivness with Others, including health care professionals, when relational problems arise.- Patterns What patterns of interest to nursing such as: 1) environmental influences, 2) decision-making processes, 3) adaptation to critical life experiences, and/or 4) the nature of social transactions in relation to stability and change can be teased out of the data? It is not possible to discern the relationship between the measured environmental influences such as race, marital status, education, occupation, income, or household size, in this set to the data due to the small sample size. A quantitative study using a larger data set and more demographically varied population may return different results. Within the context of the Stages of Faith (Fowler, 1981), decision making processes are not specifically defined. Presumably, an individual would make decisions 60 based on their Stage development. Since the data show that the participants are at Stage 2.5 transitional to Stage 3 with special consideration given to Form of Logic, some inferences can be made regarding decision making. First, thought processes for this group of participants are at least at the formal operational level. This means abstractions can be handled with little difficulty and the individual is capable of thinking about thinking and devising problem solving plans.. Limiting their logical ability are patterns of perspective taking, moral judgment, social awareness, locus of authority, and form of world coherence. For these participants, each of these domains is geared toward building and maintenance of relationship with family and others within the individual’s relational network (Fowler, 1981). The decision by one of these participants to leave their abuser, for instance, would be predictably very difficult for them to implement without outside intervention. Acting on such a decision would leave the individual without a life center or personal identity. This may help explain the rate of treatment failure for those working with the abused. The age related, staged development of spirituality apparent in this data set is evidence of adaptation to 61 structural life crisis events..As age increases so too Stage increases. Within the context of the Stages of Faith (Fowler, 1981), patterns of social transaction in relation to stability and change are a implicit part of the content. The dimensions Social Perspective Taking, Form of Moral Judgment, Bounds of Social Awareness, and Locus of Authority would each be involved in social transactions at the stages calculated for this study population. In fact, the only dimension found to be similar between the 2 groups, other than a history of abuse, is Bounds of Social Awareness. This similarity may or may not imply a connection between Bounds of Social Awareness and current history of abuse. Conceptually, a relationship between Bounds of Social Awareness and history of abuse is appealing. The group average for Bounds of Social Awareness is 2.90. When interviewed, participants had evidence of only rudimentary skills of synthesizing a unique personal identity. The participants, as a whole, found it extremely difficult to describe themselves except in terms of others. For example, they were unable to verbalize their values, mores, and ideals except in terms of “we” and in most instances had difficulty simply stating, describing, and defining their personal beliefs. One typical participant related, “Xxxx (her husband) and I have been talking about how we believe. 62 We’ll have to talk more about it because it is so hard to put into words.”. Within the Bounds of Social Awareness dimension, the individual at Stage 2 is described by Fowler (1981) as associating with peer groups and other non—familial systems but does not yet begin to form a sense of identity from these associations. The Stage 2 individual often sees non- familial groups stereotypically. At Stage 3 the individual begins to construct a rudimentary and tacit sense of self by adopting a composite of images and ideas from those with whom they most frequently associate. Groups outside the Stage 3 individual’s relational network are often harshly stereotyped (Mosley, Jarvis and Fowler, as revised by Byod DeNicola, 1993). Considering the process of self identification typical of Stages 2 and 3, the described characteristics of abused persons being protective, evasive, externally motivated, and rigidly enmeshed in family boundaries are consistent with the study findings as well as the conceptual model. Further, since self identity is so closely tied to relationships at this level, a strong barrier to disolving the abusive relationship can be infered. Considering the methodology, the study supports the use of qualitative study techniques to describe characteristics of a group. Sample size was very small (n=7), as is typical 63 of qualitative data. None the less, the coding criteria (Mosley, Jarvis, and Fowler, and revised by Boyd DeNicola, 1993) returned consistent dimensional scores within cases. The study design provided information which could be used to verify the fit of the conceptual model to the study population. The interview questions and coding criteria returned enough data that the model fit could be verified based on three of the assumptions of the model: 1) spiritual development is age related, 2) spiritual development occurs in distinct and orderly phases or stages, and 3) the dimensions of spiritual development are interdependant. The fourth assumption that spiritual development is unidirectional could not be used to validate model fit due to the single measurement design of the research. The study design provided information that could be grouped in various ways to tease out patterns of importance to nursing. Among these were patterns of 1) decision-making processes, 2) adaptation to critical life experiences, and 3) the nature of social transactions in relation to stability and change exhibited by abused women. Discussion While some of the underlying assumptions, structure, and content of the Stages of Faith model (Fowler, 1981) have been supported by this study, no attempt has been made to validate the conceptual 64 framework. Analysis of this sort is beyond the scope and dimension of the present project. The conceptual framework did provide a structure for understanding, a place to begin to examine the concept of spiritual development, and a tool to compare study results to information perviously published. The study also supports the notion that the Stages of Faith model can be applied to a nursing problem with the outcome being improved understanding of the phenomena. Valuable linkages between the observed behavior of abused persons and possible explinations for those behaviors can be infered from the structure and content of the framework. Validation of those linkages has not been attempted, as this is beyond the scope and intent of this study. However, this study has provided information for futher research and suggests several hypotheses regarding intimate abuse. Two of the hypotheses suggested are: 1) persons at risk for abuse will have spiritual development Stage scores in the Stage 2-3 range, and 2) the ability to explicitly construct a self identity as a separate being from others precludes current involvment in abusive relationships. 65 The literature survey is by no means exhaustive or complete. While most of the literature on the concept of spirituality in nursing has been reviewed over 10 years (1984-1994), there is a derth of nursing literature on this subject. Literature related to abuse was surveyed more extensively. There is no current lack of literature related to abuse, however, there is an apparent lack of concensus as to design, and methodological approach including operational definitions and measurement problems. This study does little to resolve these issues. The major limitations of this study are found in the demographics of the participants. The sample size is very small (n=7), all were white, employed, had a relatively high household income to household population ratio, and had at least some college education. Results from this study may in fact be dependent on this demographic profile. With respect to the methodology, the findings of this study can only be considered anecdotal evidence particularly in view of the magnitude of the problem of abuse and the importance of developing a conceptual framework for the concept of spiritual 66 development in nursing. A much larger data set would be helpful in limiting error. Much more data could have been gathered that would be of interest and possible impact on the results. For example, whether the participant had or was currently undergoing counseling for abuse, degree of daily contact with abuser, number of abusive and/or non—abusive relationships in the participant’s lifetime, duration of the abusive relationship, descriptions of what the participants defined as abuse, religious background and practices, just to name a few of the themes some of which were mentioned by the participants. Interview lengths varied widely. It is conceivable that data that might have changed the study outcome was misssed during the shorter interviews. A second researcher, independently coding the interviews, could have provided the data needed to establish inter-rater reliability of the study. The possibility of violating participant confidentiality would be increased in such a research design. 67 Implications for Advanced Nursing Practice and Primary Care Advanced Practice Nurses (APN) should take note of the population demographics. The study clearly demonstrates the falicy of stereotyping abused persons as uneducated, poor, middleaged housewives. None of the participants met those criteria. Participants all had some College education, were middle-class, working women who spaned the ages from young adult to elderly. In a primary care setting, the APN should be aware that any client may be experiencing an abusive relationship. The literature review suggests that men as well as women have been abused and the population, furthermore, includes homosexual as well as heterosexual relationships. The study also supports literature relating to the protectiveness and evasiveness of abused persons with their health care team. The APN should be aware that the first time the problem of intimate abuse is suspected in a client may be when the presenting problem is an acute and/or serious injury. That is not to imply that the APN should not attempt to assess clients for abuse routinely, just that the client may decline to answer such inquiries or deny abusive incidents during such screening. 68 When planning intervention for an abused client the APN must remain aware that the characteristics of spiritual development at Stages II transitional to Stage III are to create and maintain an interpersonal relationship with the very person who is commiting the acts of abuse. The conceptual framework suggests that it is through these same relationships that the abuSed person creates their sense of self and self identity, other, world, eternity, and gives meaning to their life. Offering to support the abused with a safe—house admission is to ask the client to not only give up their current living situation but also to leave behind their identity and life meaning. It should be no surprise that it often takes many interventions before abused clients leave their abusers. Keys to working with abused clients are patience, respect, and developing a trusting personal transitional relationship through which the client can grow out of the abusive relationship. Another implication for advanced practice nursing is the demonstrated need to further define the concepts of spirituality and spiritual development in nursing. This study shows that even given the problems and limitations a small study is 69 prone to, any attempt to do research in the area is better than no attempt. This study has generated two hypotheses about the nature of spiritual development in relationship to intimate abuse. The study has also added support to the conceptual framework as well as supported previous literature in both the field of intimate abuse and spiritual development. The study has suggested possible linkages between abused individuals decision making processes, adaptation to critical life events, and social transaction in relation to stability and change. A clear pattern of spiritual development emerged in which domains of spiritual development were impeded in relation to the domain of form of logic. This pattern may be in response to abusive experiences. Just as clearly, the ability of abused women to achieve high levels of spiritual development is not precluded by their experiences. These two facts demonstrate the holism of the individual and the continuing capicity for wellness and growth despite individual circumstance. The pattern defines areas of potential growth where the individual could be helped by the APN to maximize growth and wellness. 70 The APN also has an imperitive to teach. Based on this study and the work of Fowler and others the beginning nursing student can be taught the following about spiritual development: 1) spiritual development begins at birth or before and continues throughout the lifespan until death., 2) spiritual development has structural domains., 3) within the structural domains, individuals express their spiritual development in predictable stages., 4) the stage of an individual’s spiritual development can be assessed through the content of his/her expressed thoughts and actions., 5) the spiritual field includes abstract concepts such as connectedness, trancendance, belongingness, forgiveness, and life meaning and purpose. The advanced nursing student should understand the concepts of spiritual development. Emphasis for the advanced student should be placed on: 1) the holism of the unique individual., 2) the interdependence of domains., 3) assessment of spiritual development as a component of individual and family health and wellness., 4) the need to listen to the experiences and stories told by the client to gather content data for assessment., and 71 5) identification of at risk populations and areas of strength and potential growth in the individual. In sumary, the folowing acrostic on spirit: Savor all of your challanges for these are the Portals of wisdom. In your daily life encounters, Realize that facing your private fear and Insecurity is key to the process of spiritual growth. Through this personal expansion comes wisdom. APPENDIX A 72 UHmn mCOHquwuu HonE>m on» zHHMQOHm msHm>|u0HH QHsm :H mmumccH .pmum :63 mo mm>Hu IGOHHMHmu wocmp umzoa quwE >HHmo Imucmmwuamu Hmcomuodumu Iuoocoo m>Humuo>m “ IHHOQE>m acuuoz >HHm IGH mm: oco paw mCOHu mCOHu HmconcoEHp mOCHcmmE Icowuoa :H can noHs3 CH Imuomdxm Hmcom Imummo IHpHSE uHmw .Ewu museum pmsHm> masoum mo Hmcom lummumucH HmEHom mHonE>w Imam uHome wo msmcmmcoo muHmanoo lummuwucH Hmsusz >Humm HHH Amfiumu mmwcmeMHmu mSOHmHHmu Hmcomumm cam mmMHo AmmwcuHmu an pwmmmHUCH .HMHomu Hmo wocwHHmm .ochum IouaHommv mcmeu HmumuHH « .mmH0u .HMHHHEMM Echopwn m>Hu HMGOHU HMCOHmcmEHU UHumEMHQ huHuonudm GHV :m: HmucmE Iommmumm Iwummo loco Im>Humuuwz uo mucmnfisocH mxHH whose: IsuumcH mHQEHm mumuocou HH muHuonusm no mHonfimm anHmH> AUHuucmo .Hmzom .mNHm loamy .maHanOHuMHmH mumnuo anummam HmCOHu msocHfisz mocmpcmmmp HMEHHQ Unmzmul >umu Imummo IHmonmz UHpomHmm \ucmEzomuud .>HHEmm ucmfiancsm IcwEHpsm nmum H icmmHHHHo mwH UHGOA Uqumzwm mo Zmom m0 mDUOA mo mQZDOm mo Zmom leommmmmm mo Zmom .w .m .m .Q .0 .m .d Bummmfi mBUmmm< wm BZmZmOQm>mo AdDBHmHmm d XHQmem< 73 “How on» CH mmmooua wCOHomCooC: mo HMZOQ CH mcoHanmuu UCM Honsam uwnuo UCm UC0>0Q mmsoumuso pCm CH Ho :mEHmHo: quHmmu on» EoomHz CmEsC pCm CH quumzCH w>HumHCECU =mnusuus uwzoq mo mCOHmmmuwa ou >u 0>Humoo>m mCOHum> HHHnmumCHs> Czo w.mCo .qCHCmmE pCm muwauo Hm Cmnu HMCOHummUH Ho mEHmHo UHGOHOHmoUH AHmoHuHuo zuwCuo: m pCm umzom COHuMHpmfi w>HuomHmmu meHHQHUmHQ UCm COHqumuu UHHOQE>m HmsumwoCoo Cqu mommmooua .mumwuuCH Hmwuw>HCsv UCm AHmoH mHnmospmuuH pCm mOCwHHmwa pCm 36H umcmHC mommMHo pomHmHov mo oCHCHOn UHHonfiwm IuCOEmUCn mEHOC mmmHo pmHQHoCHum .mmzouo mC HCUHuHuo UHEwumxm Mo mCHCHOn UCo>m£ .wumHoom nuHB OHDMHOQO lumom IHUHCZ HmoHuowHMHo mUCmuxm 0» HOHHm Hmsusz HmEuom > mHonfiam an Uw>w>Coo OCHCmoE Emumzm CH mmumCCH mo mCOHu umzoa IosuumCoo mHCu CuHB muCOHmCH w>Humoo>m HwCCH UCm qusumCoo on pCm mEHOC EmH .mCOHummpH mmHHmUCson umCE mEHOC pCm Comono nHmmum>HCC A on usonm meuHHOCus< lunw ou UmmMHn HauwHoomv Avmosvmuv muHHMHo .m>HuoQOuma mUCMSCOCoo ImmMHo ou ImmMHU COHMHmCmuB .p®HMHme HMUHmOHompH CDHZ EmH>HCMku no msouo AmCHINHE .prHHonfiam >HHm UmeHumuluHmm meuHCCEEoo m>Huomewm UwuomHmm ouonoHQv Eoum IsuQmoCoo m >3 UmEHowCH anHquEoo .m>Hu IMHmm mCOHu pmumummmm .Ewummm mm quEmpsfl >HHmo loomwumm Cqu Imumao mHonfixm uHoHmem C30 m.wCo IHmOHomUH HmumHoom .Hmsusz HmEuom >H muzmmmmoo mmmzmm<3< Bzmzmwabb wszH OHOOH UHAOmZMm mo 2Com mo mDUOA ho mozsom mo Smom Iaummmmmm mo Zmom .w .m .m .Q .U .m .< wommmfi 74 mCHmn Ho uHmw mHQHoCHHQ OCH may UCw on COHuHsuCH mHonfimm an UmCHHQHUmHU vmumHnms an vmxcHH >UHHmmu UCm .mCH>Huum Ho COHu :>CmE 0Homm UmHHHHCQ oCHmn IMUHHHC: may UCoawn .mwmmum Ho m>0H Canons» 0C0: Ho m30H>qu UHumHmmHo UmNHHmCuom >uHCs pound Ho mcusuu IHCCImCmuB OCHmn AUHuwCu mHonfixm no IHoHuHMQ UCm mmonHquxm .mmHoQO mo nuHmoz ICamv umzom mHn pCm uHmw on» an UmEuomCH may ICoEEoo mCOHu IHUCUmuuH wHHmsuom quEmpzfl Cqu COHumo mCHmn may CuHZ Imummo 0>Humoo>m m>HuHCD HMCowqu m CH IHwHqupH on >UHC>OH .stusz HmEHom H> mozmmmmoo mmmzmm<3< BZMZmOQDh wszde onBozam QACOB wBHmomebd AdHOOm Admoz m>H UHOOH UHHOmem mo Zach mo mDUOA mo mQZDOm mo Zmom :Bommmmmm mo zmom .w .m .m .Q .0 .m .< poonC APPENDIX B 75 APPENDIX B FOWLER'S STAGES OF FAITH DEVELOPMENT ‘\ \ \ / /' a’ 0 Fowler's Stages of Faith Development APPENDIX C 76 APPENDIX C INSTRUMENTS Code # Demographic Information Age at last birthday: Sex (circle): male female Race (OPTIONAL): Current marital/couple (please circle) - status(circle): white never married black living together other (specify) married __ separated divorced widowed Education (please circle the highest level completed): less than 7th grade jr. high school (completed 9th grade) partial high school high school (completed 12th grade) partial college (completed at least one year) Four-year college degree graduate degree Occupation: Current employment (circle): employed full-time unemployed employed part-time disabled full-time student retired homemaker other Approximate gross annual household income last year (OPTIONAL): (please circle) under $20,000 $20,000 - $40,000 $40,001 - $60,000 over $60,000 Number of persons being supported with this income. Using the Life Tapestry Exercise: 77 Instructions for the Respondent Take a moment to look over the work sheets that you have in front of you. After you have looked at the chart for a few minutes, turn back to this page for some explanation of the categories at the top of the work sheet. As you work on the chart, make brief notes to your— self indicating the insights or thoughts you have under each of the columns. It is not necessary to fill out the columns in great detail. You are doing the exercise by yourself, so use shorthand or brief notes Later you can use the second work sheet to make a copy of your tapestry to bring to the interview. 1. Calendar Years from Birth. Starting at the left column of the work sheet, number down the column from the year of your birth to the present year. If there are a substantial number of years in your life, you may wish to number the columns in two, three, five year intervals. or 2. Age by Year. This column simply gives you another chronological point of reference. Fill it in with the same intervals you used for calendar 3. .of the Self. years on the left—hand side of the chart. Place--Geographic and Socioeconomic. Here you may record your sense of place in several different ways. It could be the physical place you lived in at different times in your life, including the geographic area where you lived, or it could be your sense of your position in society or in the community. Record your sense of place in whatever way it seems most appropriate to you. Key Relationships. These can be any type of relationship that you feel had a significant impact on your life at the time. The persons mentioned need not be living presently, and you need not have known them personally. (That is, they could be persons who influenced you through your reading or hearing about them, etc.). Uses and Directions Here you can record not only how you spent your time but also what you thought you were doing at that time. 6. .in Society. 78 Marker Events. Here you may record the events that you remember which marked turning points in your life—moves, marriages, divorces, etc. Major events occur and things are never the same again. Events or conditions In this column we ask you to record what you remember of what was going on in the world at various times in your life. Record this as an image or phrase, or series of images or phrases, that best sums up the period for you. Image of God. This is an invitation for you to record briefly, in a phrase or two, what your thoughts or images of God-positive and negative-were at different times of your life. If you had no image of God, or cannot remember one, answer appropriately. Centers of Value. What were the persons, objects, institutions, or goals that formed a center for your life at this time? What attracted you, what repelled you, what did you commit your time and energy to, and what did you choose to avoid? Record only the one or two most important ones. 10. Authorities. This column asks to whom or what did you look for guidance, or to ratify your decisions and choices at various points in your life. After you have finished your work with the chart, spend some time thinking about your life as a whole. Try to feel its movement and its flow, its continuities and discontinuities. As you look at the tapestry of your life, let .yourself imagine it as a drama or a play. Where would the divisions of it naturally fall? If you were to divide it into chapters or episodes, how would they be titled? When you have a sense of how your life might be divided, draw lines through these areas on the chart and jot down the titles on the right-hand side of the work sheet. This is the unfolding tapestry of your life at this particular time. In the coming days or months you may want to return to it for further reflection, or to add to it things that may come to you later. Some people find that the Unfolding Tapestry exercise is a beginning for keeping a regular journal or diary. You may find too, that If you come back to this exercise after some time has passed, the chapters and titles in your life will be different as you look at them in light of new experiences. We hope you have enjoyed doing this exercise. 79 UHEO -ZOUm ”Emw .OHUOm MNBOA QAMOB win. no up as m24<> \>.Hm~UOm mZOE. .amw UHTEHSHO wmah m0 Q00 LO ZH ZOFEQZOU wFZm>m -UMMSQ -ZOFCmemm -Ommv m0< -MOIHD< ~52.sz WIOm mmMmm¥ immu mHHq >2 Ho Huummmme ochHouc: mgH 80 Faith Development Interview LIFE TAPESTRY/LIFE REVIEW 0 REFLECTING ON YOUR LIFE, IDENTIFY ITS MAJOR CHAPTERS. WHAT MARKER EVENTS STAND OUT AS ESPECIALLY IMPORTANT? O ARE THERE PAST RELATIONSHIPS THAT. HAVE BEEN IMPORTANT TO YOUR DEVELOPMENT AS A PERSON? 0 DO YOU RECALL ANY CHANGES IN RELATIONSHIPS THAT HAVE HAD A SIGNIFICANT IMPACT ON YOUR LIFE OR YOUR WAY OF THINKING ABOUT THINGS? 0 HOW HAS YOUR IMAGE OF GOD AND RELATION TO GOD CHANGED ACROSS YOUR LIFE'S CHAPTERS? WHO OR WHAT IS GOD TO YOU NOW? 0 HAVE YOU EVER HAD MOMENTS OF INTENSE JOY OR BREAKTHROUGH EXPERIENCES THAT HAVE AFFIRMED OR CHANGED YOUR SENSE OF LIFE'S MEANING? O HAVE YOU EXPERIENCED TIMES OF CRISIS OR SUFFERING IN YOUR LIFE, OR TIMES WHEN YOU FELT PROFOUND DISILLUSIONMENT, OR THAT LIFE HAD NO MEANING? WHAT HAPPENED TO YOU AT THESE TIMES? How HAVE THESE EXPERIENCES AFFECTED YOU? RELATIONSHIPS .. FOCUSING NOW ON THE PRESENT, HOW WOULD YOU DESCRIBE YOUR PARENTS AND YOUR CURRENT RELATIONSHIP TO THEM? HAVE THERE 81 BEEN ANY CHANGES IN YOUR PERCEPTIONS OF YOUR PARENTS OVER THE YEARS? IF SO, WHAT CAUSED THE CHANGE? O ARE THERE ANY OTHER CURRENT RELATIONSHIPS THAT SEEM IMPORTANT TO YOU? 0 WHAT GROUPS, INSTITUTIONS, OR CAUSES, DO YOU IDENTIFY WITH? WHY DO YOU THINK THAT THESE ARE IMPORTANT TO YOU? PRESENT VALUES AND COMMITMENTS 0 DO YOU FEEL THAT YOUR LIFE HAS MEANING AT PRESENT? WHAT MAKES LIFE MEANINGFUL TO YOU? 0 IF YOU COULD CHANGE ONE THING ABOUT YOURSELF OR YOUR LIFE, WHAT WOULD YOU MOST WANT TO CHANGE? ‘0 ARE THERE ANY BELIEFS, VALUES, OR COMMITMENTS THAT SEEM IMPORTANT TO YOUR LIFE RIGHT NOW? 9 WHEN OR WHERE DO YOU FIND YOURSELF MOST IN COMMUNION OR HARMONY WITH GOD OR THE UNIVERSE? 9 WHAT IS YOUR IMAGE OR MODEL (AN IDEA.OR A PERSON) OF MATURE FAITH? 6 WHEN YOU HAVE AN IMPORTANT DECISION TO MAKE, HOW DO YOU GENERALLY GO ABOUT MAKING IT? CAN YOU GIVE ME AN EXAMPLE? IF YOU HAVE A VERY DIFFICULT PROBLEM TO SOLVE, TO WHOM OR WHAT WOULD YOU LOOK FOR GUIDANCE? 0 Do YOU THINK THAT.ACTIONS CAN BE RIGHT OR WRONG? IF SO, WHAT MAKES AN ACTION RIGHT IN YOUR OPINION? 82 O ARE THERE CERTAIN ACTIONS OR TYPES OF ACTIONS THAT ARE ALWAYS RIGHT UNDER ANY CIRCUMSTANCES? ARE THERE CERTAIN MORAL OPINIONS THAT YOU THINK EVERYONE SHOULD AGREE ON? RELIGION 0 DO YOU THINK THAT HUMAN LIFE HAS A PURPOSE? IF SO, WHAT DO YOU THINK IT IS? IS THERE A PLAN FOR OUR LIVES, OR ARE WE AFFECTED BY A POWER OR POWERS BEYOND OUR CONTROL? 9 WHAT DOES DEATH MEAN TO YOU? WHAT HAPPENS TO US WHEN WE DIE? 0 DO YOU CONSIDER YOURSELF A RELIGIOUS PERSON? WHAT DOES THIS MEAN TO YOU? 0 ARE THERE ANY RELIGIOUS IDEAS, SYMBOLS OR RITUALS THAT ARE IMPORTANT TO YOU, OR HAVE BEEN IMPORTANT TO YOU? IF SO, WHAT ARE THESE AND WHY ARE THEY IMPORTANT? 9 DO YOU PRAY, MEDITATE, OR PERFORM ANY OTHER SPIRITUAL DISCIPLINE? 0 WHAT IS SIN, TO YOUR UNDERSTANDING? 0 HOW DO YOU EXPLAIN THE PRESENCE OF EVIL IN OUR WORLD? 0 IF PEOPLE DISAGREE ABOUT A RELIGIOUS ISSUE, HOW CAN SUCH RELIGIOUS CONFLICTS BE RESOLVED? 83 Scoring Analysis Sheet Code #: Scorer: NOte: The prompts are printed in bold in the Interview. Interview Question, Criteria A. LOGIC Decisions passage # / stageScoring Average (Carry average to nearest one— hundredth) Breakthroughs Crises Change in Self \\\\\ B. PERSPECTIVE TAKING Past Relationships Average Logic Score: Current Relationships Parents \‘\c\ C. MORAL JUDGMENT Right Action Average Perspective Taking Score: Sin Evil Religious Conflicts \\\\\ Average Moral Judgment Score: D. BOUNDS OF SOCIAL AWARENESS Marker Events / Groups / Changes in Relationships / / / Average Bounds of Social Awareness Score: E. LOCUS OF AUTHORITY Your Life Meaning 84 Beliefs Always Right \\\\ F. FORM OF WORLD COHERENCE Purpose of Human Life Average Locus of Authority Score: Death Religious Person Mature Faith \\\\\ G. SYMBOLIC FUNCTION Average Form of World Coherence Score: Image of God / Symbols, Rituals / Spiritual Discipline / Harmony / / Average Symbolic Function Score: Other: DISCREPANT DATA / / Average Discrepant Score: AVERAGE OF ALL ASPECTS: APPENDIX D 85 APPENDIX D UNIVERSITY COMMITTEE ON RESEARCH INVOLVING HUMAN SUBJECTS ZXPE?R£TVJXL MICHIGAN STATE U N l v :5 R s I T Y March 3, 1997 To: Ma Jo Arndt all Life Sciences RE: RBI: 97-136 TITLE: SPIRITUAL DEVEIDPMENT AND INTIMATE ABUSE REVISION REQUESTED: N/lé APPROVAL'DATE: 02/28/97 The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complet am pleased to adVise that rights md welfare of the human subjects appear to ”qua rotected and methods to obtain informedc onaent are appropn te. herefore, the UCRIHS approved this project and any reVisions .listed RBNBHAL: UCRIHS approval is valid for one calendar year, beginning with the approval date csh own above. eInvestigators plm ngt continue pr m5 Mgond us the en renewal fom (enclosed with t “original casproval lett ter or whene a project is rm wed) to eku rtification. Ther is a of four suc ch expedite renewals ssible. Investigators wishmum ing to continue a project beyond tha time need to submit it again or complete revzew REVISIONS: UCRIHS must review any changes in Brocgsures igvolving hu§2n e his is one at subjects, rior to initiation of t ng the time o renewal, please use the reen renew revrse an app oved protocol a 0 her time during the se you ritten equest to the C IRS Chair, reque ting reVised approval and seferencmg _ oject's IRS “a le. I l d nyour reques a description of thee change and any re vi instruments, consent tom or advertisements that are applicable. snosnms/ CHAN ES: Should either of the followingU arise during the course of the ork estigators must noti UCRIHS promptly (11) Eroblems (une xpecteds Side effects‘ comps ints , etc.) involving subjects or (2) changes in the: esearch envi onment or new infom tio on indicating greater riskt to the humans subgec cts than UTWEN existed when the pro otocol was previously reviewed an approved. RESEARCH AND Ifw mbe of any future help, lease do not hesitate to contact us at (517)355- 2180 or FAX (Sl7)4 2-171. GRADUATE STUDES Sincerely. cakytsmmmuoan Results lanM Human Sub (“cam Vid E. Wright , Ph . D CRIRS Chair > cmmmsae :amminm-on Building B" = bed Ens! lamina. MM M44046 'cc: Kathy C. Belonga FAX 517/432-1111 lwumsuuwuw :snmmruaumq fiafinrnknm Wamlwmwann "mannmflnflmm APPENDIX E 86 APPENDIX E CONSENT FORM w FORM College of Nursing Michigan State University East Lansing, Michigan Reference Number Participant’s Name: Project Title: Spiritual Growth and Intimate Abuse This form is to certify that I agree to participate in the following study conducted by Kathy C. Belonga, R. N., BSN under the supervision of Mary Jo Amdt, Ph.D., both of the College of Nursing, Michigan State University. I understand that this research is for the purpose of learning more about the process of spiritual growth. I am willing to participate in an interview lasting approximately 11/2 hours. I understand that these interviews will be audio-taped. I understand that I will also be asked to respond to 2 questionnaires. I understand that no risks are involved, however, I will be asked to answer some very personal questions about myself. I also understand that the psychological risks of participating are minimal but may involve my recalling memories of past events. If, during or after my participation, I experience undue anxiety or stress from participating, Ms. Belonga will provide me with names and phone numbers of therapists and other appropriate resources. I understand that confidentiality will be maintained. My name will not appear on any of the results. The questionnaires, audio-tapes and transcriptions will be used only for research purposes and will be destroyed after the research is complete. I fully understand the program of the research study and the procedures that I will be asked to perform. I have had an adequate chance to ask questions, and I understand that I may contact the researcher to ask additional questions at any time while the study is in progress. I understand that my participation is strictly voluntary. I am free not to answer any particular question and am free to withdraw my consent and participation in the study at any time. Date Signature of Participant APPENDIX F 87 APPENDIX F LETTERS Date Dear (Intimate Abuse Professional): I am writing you asking for your help in finding volunteers to participate in a research project on spiritual growth. I am a graduate student doing research for my masters in nursing at Michigan State University. The purpose of this research is to learn more about the process of spiritual growth of women with current histories of intimate abuse. To be eligible, volunteers for this research must women with a current history of active intimate abuse. Participation in this study would involve completing a questionnaire and participating in an interview. The interviews will be at a mutually convenient location. The interviews will be audio-taped and transcribed. Confidentiality of responses will be protected, the means for doing this will be explained in detail. Participants will contribute to our knowledge of the spiritual growth process so that nurses and others will be better able to help other people who also are struggling with the effects of intimate abuse. Also, participants may gain insight into their own lives by helping the researcher to understahd what has contributed to their spiritual growth. If you have any questions. please feel free to call me at (313) 485-2368 and I will be glad to talk with you. My supervisor, Dr. Mary Jo Amdt, Professor at the College of Nursing would also be glad to answer any questions. Her phone number is (517) 432-1720. Enclosed are flyers describing the research. If you would like more flyers, please let me know. Thank you very much for your help in getting this information to potential volunteers. Sincerely, Kathy C. Belonga, R. N., BSN MSN candidate, Michigan State University 88 Date Dear Participant: Thank you for volunteering to participate in this research. Through your experience with the efl‘ects of intimate abuse, you may have unique insight into the spiritual growth process. Your participation will contribute to others' growth. Participation in this study has two phases. Enclosed is the material for Phase I: the Consent Form, the Demographic Information Form. I anticipate that the questionnaires will take about 15 minutes to complete. I believe that the material is self-explanatory. However, if you have any questions, please feel free to contact me at (313) 485-2368. I hope that within the next few days you will be able to answer the enclosed questionnaires. After completing them, please return to me all the materials (Consent Form, Demographic lnforrnation Form) in the enclosed addressed stamped envelope. At no time will your identity be revealed. Safeguards as described in the Consent Form will be taken to insure and guarantee that the information you provide will be kept confidential. Some of you will be asked to participate in the subsequent phases of this research. Phase [1 involves your describing your life history during an interview. If you are one of the volunteers to participate further, I will be contacting you to schedule the interview. Again, thank you for your participation. Sincerely, Kathy Belonga, R. N., BSN MSN candidate, MSU 89 Date Dear Participant: Thank you for completing and returning the initial questionnaires and for volunteering to participate further in this research. As I explained on the phone, the interview will have specific questions as you look at your life as a whole and will provide an opportunity for you to talk about your intimate abuse experiences and spiritual growth. Enclosed is a worksheet chart, Unfolding Tapestg of My Life, which may be helpful as you reflect on your life before the interview. In working on the chart, you may want to make brief notes that will help you to recall your own insights, thoughts, and memories. The chart is simply a guide for you and you will not need to show it to anyone. However, please bring it with you and feel free to refer to it during the interview. If you have any questions, please feel free to call me at (313) 485-2368. Sincerely, Kathy Belonga, R. N., BSN MSN candidate, MSU Date Dear Thank you very much for participating in my research on spiritual growth and intimate abuse. I particularly value and appreciate the amount of time, thought, and energy that you put into participating. Your contribution will certainly add to our knowledge of intimate abuse and spiritual growth. Again, my thanks, Sincerely, Kathy Belonga, R. N., BSN MSN candidate, MSU APPENDIX G 90 APPENDIX G RE CRUI TMENT ANNOUNCEMENT S Research on Spiritua/iy and Intimate A lease OULENTEERS are needed to participate in a research project studying the process of spiritual growth during domestic abuse. Participants must be experiencing active intimate abuse. If you are interested in receiving more information or in participating in this study, please call Kathy Belonga, R. N., BSN (313) 485—2368. (Spm’fua/I’iy (Q DOMESTIC VIOLENCE Has intimate abuse been a part of your life? What effect has this had on your spiritual development? Would you like to share your journey with others? If so, consider participating in a research project exploring spiritual growth and intimate abuse. For more information, contact Kathy Belonga, R. N., BSN (313) 485-2368 91 SPIRITUAL GROWTH AND Intimate Abuse m: Volunteers to participate in a research project studying the process of spiritual development and intimate abuse. This research is being conducted by Kathy C. Belonga, R. N, BSN who is completing her Masters degree in nursing at Michigan State University. PLJRPQSE: The goal of this research is to learn more about the process of spiritual growth and abusive intimate relationships. ELIQIBILITY: Volunteers must be: female; aged 25-55; currently involved in a relationship that the volunteer characterizes as intimate and in which she believes a pattern of physically, emotionally, and/or spiritually violent and/or coercive behavior has occurred within the past 6 months; can articulate their thoughts verbally in English; have a self-defined secure and confidential mailing address (or other secure means of sending and receiving confidential messages); and demonstrates a willingness to participate in the research by return of a valid, signed Consent Form and at least partial completion of requested demographic information. PRQIEQQI: Your participation would involve completing a questionnaire and participating in an interview. The interview will be held at a location mutually agreed upon by the interviewer and each participant. The interviews will be audio—taped and transcribed. Confidentiality of your responses will be protected; the means for doing this will be explained in detail. Your participation is completely voluntary. You may decline to participate in any part of the research once you begin and may leave the study at any time. VALUE TS) YQU: Your participation will contribute to our knowledge of spiritual growth process so that nurses and others will be better able to help people who are struggling with the effects of intimate abuse. Also, you may gain insight into your own life by helping the researcher to understand what has contributed to your spiritual growth. CM: If you are interested in being a part of this study, please call me and I will be glad to answer any questions and to explain the research procedures more frilly. If you feel that you would prefer to ask questions of another person, or have complaints that I cannot address, please feel free to call my supervisor, Mrs. Mary Jo Amdt, who’s telephone number appears below. Thank you. Primary Researcher Project Supervisor Kathy C. Belonga, R. N, BSN Mary Jo Amdt, PhD. MSN candidate, MSU. Associate Professor of Nursing, MSU (313) 410-1142 (517) 432-1720 REFERENCES 92 References Banks, R., Poehler, D., & Russell, R., (1984). Spirit and human—spiritualinteractin as a factor in health and in health education. Health Education, 15(5), 16-18. Benoliel, J. Q. (1984). Advancing nursing science: Qualitative approaches. Western Journal of Nursing Research, 6, 1—8. Bland, R., & Orn, H., (1986)} Family violence and psychiatric disorder. Canadian Journal of Psychiatry, 31, 129-37. Bograd, M. (1988). Feminist perspectives on wife abuse: An introduction. In M. Bograd & K. Yllo (Eds.), Feminist perspectives on wife abuse (pp.ll—26). Beverly Hills: Sage. Bologna, M.J, Waterman, C. K., & Dawson, L. J. (1987).Violence in gay male and lesbian relationships: Implications for practitioners and policy makers. Paper presented at the Third National Conference of Family violence Researchers, Durham, NH. Burkhardt, M. A. (1989). Spirituality: Analysis of the concept. Holistic Nursing Practice, 3(3), 69-77. 93 Burkhardt, M. A., (1994). Becoming and connecting: elements of spirituality for women. Holistic Nursing Practice, 8(4), 12-21. Campbell, J., (1985). The beating of wives: A cross- cultural perspective. Victimology,10,l74—80. Campbell, J., (1992). Prevention of wife battering: Insights from cultural analysis. Response 80, (14), 18'24. Carroll, M., (1993). Spiritual growth and recovering alcoholic adult children of alcoholics. Unpublished doctoral dessertation, University of Maryland, Baltimore, School of Social Work and Community Planning. Carson, V. B., Winkelstein, M., Soeken, K., & Bruinins, M., (1986). The effect of didatic teaching on spiritual attitudes. Image, 18(4), 161—164. Cascardi, M., Langhinrichsen, J., Vivian, D., (1992). Marital aggression. Impact, injury, and health correlates for husbands and wives. Archives of Internal Medicine, 152(6), 1178—84. Chapman, J. D., (1989). A longitudinal study of sexuality and gynecologic health in abused women. Journal of the American Osteopathic Association, 89(5), 619-24. 93 Burkhardt, M. A., (1994). Becoming and connecting: elements of spirituality for women. Holistic Nursing Practice, 8(4), 12-21. Campbell, J., (1985). The beating of wives: A cross- cultural perspective. Victimology,lO,174—80. Campbell, J., (1992). Prevention of wife battering: Insights from cultural analysis. Response 80, (l4), l8-24. Carroll, M., (1993). Spiritual growth and recovering alcoholic adult children of alcoholics. Unpublished doctoral dessertation, University of Maryland, Baltimore, School of Social Work and Community Planning. Carson, V. B., Winkelstein, M., Soeken, K., & Bruinins, M., (1986). The effect of didatic teaching on spiritual attitudes. Image, 18(4), 161-164. Cascardi, M., Langhinrichsen, J., Vivian, D., (1992). Marital aggression. Impact, injury, and health correlates for husbands and wives. Archives of Internal Medicine, 152(6), 1178-84. Chapman, J. D., (1989). A longitudinal study of sexuality and gynecologic health in abused women. Journal of the American Osteopathic Association, 89(5), 619-24. 94 Chychula, N. (1995). Faith development of males recovering from chemical dependancy. Unpublished doctoral dessertation, Temple University, Philladelphia,PA. Coleman, V. E. (1994) Lesbian battering: The relationship between personality and perpetration of violence. Violence and Victims, (9)2, 139-51. Coleman, D. H., & Straus, N. A., (1986). Marital power, conflict, and violence. Violence and Victims, 1(2), 141—57. Daly, N., Wilson, N., & Weghorst, S. J., (1982). Male sexual jealousy. Ethology and Sociobiology, (3), 11-27. Dan, A. J., (1994). Reframing Women's Health: multidisciplinary research and practice. Thousand Oaks,CA: Sage. Dennis, P. M., (1991). Components of spiritual nursing care from the nurse's perspective. Journal of Holistic Nursing 9(1), 27-42. Dobash, R. B., & Dobash, R. P. (1979). Violence against wives: A case against the patriarchy. New York: Free Press. Drossman D. A., Leserman, J., Nachman, G., Li, Z., Gluck,H., Toomey, T., Mitchell, C., (1990). 95 Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of Intern Medicine, 113(ll), 829-33. Dutton, D. G., _(1994a) . Behavioral and affective correlates of borderline personality organization in wife assaulters. International Journal of Law and Psychiatry, 17(3), 265-79. Dutton, D. G., (1994b) . Patriarchy and wife assault: the ecological fallacy. Violence and Victims, (9)2, 167—82. Dutton, D. G., & Hart, S. G. (1992a) . Risk markers for family violence in a federally incarcerated population. International Journal of Law and Psychiatry,(15),lOl-12. Dutton, D. G., & Hart, S. G. (1992b). Evidence for long-term, specific effects of childhood abuse and neglect on criminal behavior in men. International Journal of Offender Therapy and Comparative Criminology, 36(2), 129-38. Dutton, D. 0., & Painter, S. L. (1993). Emotional attachments in abusive relationships: A test of traumatic bonding theory. Violence and Victims, 8(2), 105-20. 96 Emblen, J. D., (1992). Religion and spirituality defined according to current use in nursing literature. Journal of Professional Nursing, 8(1), 41-47. Faulkz, N. (1974). Men who assault their wives. Medicine, Science and Law, (14), 180-83. Fawcett, J., 1984. Tht metaparadigm of nursing: present status and future refinements. Image, 6(3), 84-86. Fowler, J. W. (1981). Stages of faith: The psychology of human development and the quest for meaning. New York, NY: Harper Collins Publishers. Grossman, B. (1991). Faith development and psychosocial accomplishment: trends in adult intimacy growth and higher faith stages. Dissertation Abstracts International, ??. (University Microfilms No. AAD92-00183) Haase, J., Britt, T., Coward, D., Leidy, N., & Penn, P., (1992). Simultaneous concept analysis of spiritual perspective, hope, acceptance and self transcendence. Image, 24(2), 141-147. Hamberger, L. K., & Hastings, J. E. (1986). Characteristics of male §pouse abusers: Is psychopathology part of the picture? Paper 97 presented at American Society of Criminology, Atlanta, GA. Henderson, V. (1966). The nature of nursing. New York, NY: The Macmillan Co.. Hess, J. S. (1983). Spiritual needs survey. In Fish, S. & Shelly, J. (Eds.), Spiritual Care: The Nurse’s Role. Downers Grove, IL: Intervarsity Press. Hoffman, D. (1993). An assessment of the cognative and moral aspects of Fowler’s theory of Faith Development with first year college students participating in a developmental spiritual program. Unpublished doctoral dessertation. University of Maryland at College Park. Kennedy, L. W., & Dutton, D. O. (1989). The incidence of wife assault in Alberta. Canadian Journal of Behavioural Science, 21 ,40-54. Koss, N. & Heslet, L, . (1992) Somatic consequences of violence against women. Archives of Family Medicine, 1(1), 53-9. Leininger, M. M. (1979). Transcultural nursing. New York, NY: Masson Publishing, USA, Inc.. Letellier, P., (1994). Gay and bisexual male domestic violence victimization: Challenges to 98 feminist theory and response to violence. Violence and Victims, (9)2,95-106. Lie, 6., Schilit, R., Bush, J., Montague, N., & Reyes, L. (1991). Lesbians in currently aggressive relationships:How frequently do they report aggressive past relationships. Violence and Victims, 6, 121—35. McEnvoy (1990). In E. A. Barrett (Ed.), Visions of Rogers' science-based nursing. New York, NY: National League for Nursing. Miller, S. L., (1994). Expanding the boundaries: Toward a more inclusive and integrated study of intimate violence. Violence and Victims, (9)2, 183-94. Moberg, D., (1971). Spiritual well-being: background and issues. Washington, D. C. Whitehouse Conference on Aging. Morgan, P.A., (1990). The faith development of women in crisis: a constructivist window to intervention. Unpublished doctoral dissertation, University of Houston. Mosley, R. M., Jarvis, D., & Fowler, J. W. and revised by Boyd-DeNicola, K. B., (1993). 1993 Manual For Faith Development Research. Center 99 for Research in Faith and Moral Development, Atlanta, GA: Emory University. Nagi-Jacobson, M. G. & Burkhardt, M. A. (1989). Spirituality: Cornerstone of holistic nursing practice. Holistic Nursing Practice, 3(3), 18- 26. Newman, M. A. (1989). The spirit of nursing. Holistic Nursing Practice, 3(3), 1-6. Nightingale, F. (reprint, 1992). Notes on Nursing: what it is and what it is not, commemorative ed. Philadelphia, PA: J. B. Lippincott. North American Nursing Diagnosis Association, (1989). Taxonomy I revised—1989. St. Louis: North American Nursing Diagnosis Association. Paletta 1990. In E. A. Barrett (Ed.), Visions of Rogers' science-based nursing. New York, NY: National League for Nursing. Paloutzian, R., Ellison, C. W., & Lonelines, S. (1983). Spiritual well-being and quality of life. In Piplar, A. & Perlman, D. (Eds.), Loneliness: Sourcebook of Current Theory, Research, and Therapy.. New York, NY: Wiley Interscience. um Polit, D. F. & Hungler, B. P., (1995). Nursing Research: gprinciples and methods, SM'edition. Philadelphia, PA: J. B. Lippincott Co.. Rapacz, 1990. In E. A. Barrett (Ed.), Visions of Rogers' science-based nursing. New York, NY: National League for Nursing. Reed, P. G., (1991). Preferences for spiritually related nursing interventions among terminally ill and non-terminally ill hospitalized adults and well adults. Applied Nursing Research, 4(3), 122-128. Renzetti, C. M., (1992). Violent Betrayal. Newberry Park:Sage Renzetti, C. M., (1994). On dancing with a bear: Reflections on some of the current debates among domestic violence theorists. Violence and Victims, (9)2, 195-200. Rogers, M. E. (1990). Nursing: Science of Unitary, Irreducible, Human Beings: Update 1990. In E. A. Barrett (Ed.), Visions of Rogers' science-based nursing. New York, NY: National League for Nursing. Roy, C. & Andrews, H. A. (1991). The Roy adaptation model: The definitive statement. Norwalk, CT: Appleton & Lange. 101 Soeken, K. & Carson, V., (1986). Responding to the spiritual needs of the chronically ill. Nursing Clinics of North America, 22, 603-611. Sorenson, S. B., & Telles, C. A. (1991). Self- reports of spousal violence in a Mexican- American and non-Hispanic white population. Violence and Victims, 6, 3-16. Stoll, R. I., (1979). Guidelines for spiritual assessment. American Journal of Nursing, 79, 1574-1577. Straus, N. A., & Gelles, R. J. (1985, November) Is family violence increasing? A comparison of 1975 and 1985 national survey rates. Paper presented at the American Society of Criminology, San Diego, CA. Toomey, T. & Mitchell, C., (1990). Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of Intern Medicine, 113(ll), 829—33. Vivian, D. & Langhinrichsen, J., (1994). Are bi- directionally violent couples mutually victimized? A gender-sensitive comparison. Violence and Victims, (9)2, 107—20. Warnken, W., Rosenbaum, A., Fletcher, K., Hoge, 8., & Adelman, 5., (1994). Head-injured males: a nu population at risk for relationship aggression? Violence and Victims, (9)2, 153-66. Watson, J. (1988). Nursing: Human science and human care. A theory of nursing. New York, NY: National League for Nursing. Wilson, E. O. (1975). Sociobiology Cambridge: Harvard University Press. Yllo, K. (1988) Political and methodological debates in wife abuse research. In K. Yllo & N. Bograd (Eds.), Feminist perspectives on wife abuse. Beverly Hills: Sage.