Evaluation of Youthife’s “Growing Through Change” Programme
on the Mental Health of Adolescents Who Have Experienced Loss
Stephen Clarke
(B00622713)
University of Ulster
2014
MSc Research Project (Module Code: PSY 824)
Submitted to the Faculty of Life and Health Sciences in part fulfilment for the degree of MSc in
Applied Psychology (Mental Health & Psychological Therapies) and except where otherwise
acknowledged is my own unaided work.
1
Acknowledgements
Thank you to all the participants who gave their time so generously. Without you this study
would not have been possible. Thanks also to my supervisor, Professor Siobhan O’Neill, Bridie
Sheridan (Project Manager, Youthlife), and Claire Mulrone (The Science Shop) for their
guidance and support throughout the study.
2
Contents
Page
Acknowledgments
2
List of figures and tables
4
Abstract
5
Introduction
6
Methodology
13
.
Quantitative Study
13
Qualitative Study
16
Results
19
Quantitative Study
19
Qualitative Study
20
Discussion
28
References
33
Appendices
39
3
List of tables and figures
Page
Table 1.0
Participant Characteristics
14
Table 2.0
List of Superordinate Themes
21
Figure 1.0
Mean RCADS Scores For Both Groups At
The Start And At The End Of The Study.
19
4
Abstract
As grief following bereavement and loss may contribute to psychological distress, this study
aimed to evaluate the impact of Youthlife’s “Growing Through Change” programme on the
mental health of grieving adolescents. A mixed methods approach was adopted, using a repeated
measures design (measuring anxiety and depression scores pre and post-intervention) combined
with an independent groups design (to measure differences between the intervention group and a
control group), whilst Interpretive Phenomenological Analysis was used to explore the
participants’ experience of the programme. Thirty participants (17 males; 13 females, with a
mean age of 13.83 years (range: 11 to 18 years, SD:2.32)) participated in the study and a
subsample of six (three males and three females, with a mean age of 13.5 years (range: 11 to 18
years, SD: 1.76)) participated in the qualitative study. The Revised Child Anxiety and
Depression Scale (RCADS) was completed by all participants at the start and the end of the
study. The intervention group reported significantly lower RCADS scores post-intervention (M =
48.13, SE = 3.88) compared with pre-intervention (M = 60.87, SE = 4.08), t(14) = 7.11, p <.01,
but there was no significant difference between the RCADS scores of the intervention group (M
= 48.13, SE = 3.88) and the comparison group (M = 46.13, SE =3.19), t(28) = 0.40, p =.35 at the
end of the study. The IPA themes were: Shared Learning, Being Valued, Psychological and
Social Factors, New Trusting Friendships and Continuing Bonds. The qualitative themes are
discussed in relation to psychological theories and recommendations for programme
development are also discussed.
5
Introduction
Grief is the subjective experience of loss (Melhem, Porta, Shamseddeen, Payne, & Brent, 2011),
and may be experienced following a wide variety of losses, including infertility, miscarriage,
abortion, illness, divorce/separation, loss or change of employment, relocation, retirement and
death of a loved one (Barnes, 1989).
Ninety-two percent of young people in the UK experience loss of a significant
relationship before their 16th birthday, which includes the 5% percent of children who
experience the death of a parent before the age of 15 (Harrison & Harrington, 2001), and the
third of children who lose the family life they once knew when their parents separate (DWP,
2013). As Tracey and Holland (2008) noted, a child whose parents separate is a bereaved child
with the potential for similar psychological effects to a child whose parent has died.
Such psychological effects of bereavement and loss in childhood were included in early
models of psychopathology (e.g. Freud, 1917; Bowlby, 1969) and may be vulnerability factors
for mental health problems in childhood and adult life (Harrison & Harrington, 2001).
Bereavement in adolescence is associated with elevated depressive symptoms, anxiety, anger,
difficulties concentrating in school, behavioural problems, low self-esteem, isolation and
difficulties maintaining a sense of social connectedness (Dowdney, 2000; Kaplow, Layne,
Pynoos, Cohen, & Lieberman, 2012; Ribbens McCarthy & Jessops, 2005; Mitchell, Wesner,
Garand, Gale, Havill, & Brownson 2007; Silverman & Worden, 1992; Spuij, Prinzie, Dekovic,
van den Bout, & Boelen, 2013; Worden & Silverman, 1996).
As both bereavement and youth can be times of transition impacting on an adolescent’s
social life and personal emotions (Ribbens McCarthy & Jessop, 2005), young people
experiencing grief due to bereavement or loss may benefit from help in order to prevent the
6
above sequelae. Youth grief therapies have become increasingly popular, and include a diversity
of approaches, such as peer counselling, support groups, weekend retreats, and group, individual,
and family therapy (Currier, Holland, & Neimeyer, 2007; Clute & Kobayashi, 2013).
Therapeutic factors that may be useful in such interventions include the instillation of
hope, catharsis, psychoeducation, improving coping skills, facilitating talk about the lost person,
facilitating the expression of grief-related feelings in a safe place, reducing isolation, and
learning from each other (Clute & Kobayashi, 2013; Currier, Holland, & Neimeyer, 2007;
Mitchell, Wesner, Garand, Gale, Havill & Brownson, 2007).
In order to ensure that the expected outcomes of grief interventions are achieved it is
necessary to evaluate their effectiveness. Early research focused on grief interventions for adults.
Farberow (1992) reviewed the Los Angeles Survivors-After-Suicide programme and found that
eight of the nine emotions assessed were reduced in the intervention group with only one
emotion being reduced in the comparison group. However, the reliability and validity of the
outcome measures were unclear (McDaid, Trowman, Golder, Hawton, & Sowden, 2008). And
although Allumbaugh and Hoyt (1999) found an aggregated effect size of 0.43 for the 35
bereavement interventions that they reviewed, they used statistical techniques to allow studies
without a no-intervention comparison group to be included (Currier, Neimeyer, & Berman,
2008).
Early findings for children’s grief interventions looked promising, when Pfeffer, Jiang,
Kakuma, Hwang, and Metsch (2002) reported that a group intervention for children who suffered
suicide of a parent was more effective at reducing anxiety and depression than no treatment.
And, Schut, Stroebe, van den Bout, and Terheggen (2001) found marginally more support for the
efficacy of interventions with children than with adults.
7
However, whilst McDaid, Trowman, Golder, Hawton, and Sowden’s (2008) systematic
review of interventions for children and adults bereaved by suicide reported that six of the eight
studies reviewed showed some positive outcome, they did not conclude that intervention is better
than none, as there were many methodological limitations such as small sample size, and nonrandomised allocation of participants. And, even the best quality study that they reviewed
reported no beneficial effect on the primary outcome thirteen months after bereavement.
Further, in a meta-analytic review of thirteen controlled studies, Currier, Holland and
Neimyer (2007) found that bereavement interventions for children did not demonstrate the
positive outcomes that would be expected of professional psychotherapeutic interventions, with
an effect size of d = 0.14. However, a limitation of this review was the small sample size. When
a more comprehensive meta-analysis of 61 controlled studies was conducted by Currier,
Neimeyer, and Berman (2008), interventions were found overall to have a significant (although
small) effect at posttreatment, but no statistically significant benefit at follow up. Although the
weighted overall findings may not seem promising, the effect sizes were closer to that of
psychotherapies for other difficulties when the interventions that targeted those with particular
difficulty adjusting to their loss were considered in isolation. This has also been found by Cohen
and Mannarino (2004) who reported improvements in traumatic grief responses from pre- to
post-intervention in child survivors of traumatic death. However, the lack of a no-treatment
comparison group limits the findings of this study (Sandler et al. 2010).
The Family Bereavement Programme has been found to lead to a reduction in
internalising and externalising problems for those with higher scores at baseline, and the effects
seemed to be gender specific, working for girls, but not boys (Sandler et al. 2003), with the
effects holding at six year follow-up (Sandler et al. 2010). And, the Trauma and Grief
8
Component Therapy for adolescents bereaved due to civil war was effective in reducing grief,
anxiety and depression (Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012; Spuij, Prinzie,
Dekovic, van den Bout, & Boelen, 2013). Further, a programme of Cognitive Behavioural
Therapy for Childhood Traumatic Grief was found to improve childhood traumatic grief and
PTSD symptoms (Cohen, Mannarino, & Staron, 2006).
However, the above three interventions focus on restricted groups (parentally bereaved,
and children exposed to traumatic deaths) and may, therefore, be unsuitable for use with other
groups of bereaved children (Spuij, Prinzie, Dekovic, van den Bout, & Boelen, 2013). Further,
researchers and those who deliver grief intervention programmes for young people have
restricted their focus to parental and sibling deaths, largely ignoring other areas of bereavement
and loss (Ribbens McCarthy & Jessop, 2005). Therefore, there is a need to evaluate programmes
that cater for children experiencing bereavement and loss from a wider range of causes. One such
study focusing on losses other than that of a parent or sibling was conducted by Spuij, Prinzie,
Dekovic, van den Bout, and Boelen (2013) and found that a cognitive behavioural treatment
programme "Grief-Help" resulted in improvement in depression and parent-reported internalising
and externalising problems. Their programme used imagery exposure (focusing on the most
painful aspects of their loss when telling their story), and confrontational writing (writing a letter
to the lost person). These two components are used in the “Growing Through Change” (GTC)
programme, which is delivered by Youthlife, a community organisation based in Derry, Northern
Ireland, offering services to young people who have experienced bereavement, loss and
separation. Youthlife are registered with the Science Shop, which matches students to
community organisations looking for research to be completed. The present study was derived
from this arrangement, with Youthlife seeking an evaluation of the GTC programme.
9
The programme aims to help young people work through their grief with support from
peers. Although the programme is anchored in the stages of grief model (Kübler-Ross, 1969), it
is also informed by a number of other theories. The dual-processing model of bereavement
suggests that adaptation involves oscillating between orientation to the loss, (i.e. expressing and
exploring grief and reconnecting with the memory of the loved one) and restoration of contact
with a changed world, i.e. re-engaging relationships and study (Neimeyer & Currier, 2009;
Furnes & Dysvik, 2010). In the GTC programme, participants revisit the story of their loss,
whilst other tasks involve reorganising future goals. For example, in revisiting the story of their
loss, participants are encouraged to express all their feelings and thoughts about their loss, as
bereaved children can experience many intense and different feelings and thoughts about their
loss, and they can learn to cope with those feelings by expressing them (Spuij, Prinzie, Dekovic,
van den Bout, & Boelen, 2013).
The programme also employs a writing component. Language is related to thought
according to process-oriented theory, and as participants engage in writing they explore their
thoughts, images and feelings, and putting them into words can lead to clarification,
understanding and structure, factors that may help with grief (Furnes & Dysvik, 2010). And,
writing in groups provides a sense of community, enabling individuals to be in touch with others
with similar problems, which can result in better understanding of grief and their own behaviour,
thoughts and feelings (Furnes & Dysvik, 2010). In their Meaning-Based Group Counselling for
Bereavement programme, MacKinnon et al. (2014) found that written exercises promoted
adaptation, and participants benefited from being with others in grief. One session in this
programme encourages writing a letter to the lost person, emphasizing continuing bonds (Klass,
Silverman, & Nickman, 1996), which is also used in the GTC programme.
10
The present study aimed to evaluate the GTC programme using a mixed methods
approach. As noted above, numerous studies evaluating grief interventions had methodological
limitations. For example, a number of studies did not use a control group, including a recent
evaluation of another Youthlife programme “Safe Futures” (Belford, 2013). Therefore, the
quantitative component of this study compared an intervention group with a waiting list control
group.
Further, the need for a qualitative approach was discussed in a number of studies above,
as the sometimes unimpressive results from quantitative studies may be due to a reliance on
generic measurements of psychopathology ignoring outcomes such as sense-making and
posttraumatic growth, with many studies not seeking the views of participants (Ribbens
McCarthy & Jessop, 2005; Clute & Kobayashi, 2013; McDaid, Trowman, Golder, Hawton, &
Sowden, 2008). Further, calls for qualitative research were made by Jordan and McMenamy
(2004) who reported that research should include both quantitative and qualitative methods for
participants to describe their own understanding of what aspects of the group experience are
most helpful. The benefits of a mixed methods approach was demonstrated by Stokes, Wyer, and
Crossley (1997) who found no significant change in scores on their quantitative measure, but the
qualitative part of their study highlighted benefits such as learning coping skills and sharing
feelings, thus highlighting the suitability for the mixed methods approach in the present study.
The quantitative part aimed to measure change in depression and anxiety in the intervention
group compared with a control group, whilst the qualitative part sought to understand the
experience of the programme from the perspective of a subsample from the intervention group.
To summarize, the present study aimed to:
1) Measure the impact of the Growing Through Change programme on the mental health of
11
adolescents, by comparing pre and post intervention anxiety and depression scores. It was
hypothesised that the anxiety and depression scores would be lower following participation in
the programme.
2) Compare the differences in scores on anxiety and depression between the intervention group
and a waiting list control group. It was hypothesised that the intervention group scores would be
significantly lower than the control group at the end of the study.
3) Explore how the participants experienced the Growing Through Change programme through
Interpretive Phenomenological Analysis (IPA; Smith & Osborn, 2003).
12
Method (Quantitative Study)
Design
The study employed a quasi-experimental approach combining a repeated measures design
(measuring participants’ anxiety and depression pre and post intervention), and an independent
groups design (measuring differences between the intervention group and a waiting list group).
The independent variable was time (pre and post intervention), and the dependent variables were
the mean scores on a depression and anxiety rating scale.
Materials
The Revised Child Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto &
Francis, 2000) is a 47-item questionnaire of youth anxiety and depression with subscales of
separation anxiety, social phobia, major depressive disorder, generalized anxiety, panic disorder,
and obsessive-compulsive disorder. Respondents rate how often each item applies to them with
scores of: 0 (Never), 1 (Sometimes), 2 (Often), and 3 (Always). As well as the subscales there is
a Total Score, which was used in the present study, as this measure has strong psychometric
properties, with an internal consistency of α=0.95, and high convergent, divergent, and
discriminant validity (Chorpita, Yim, Moffitt, Umemoto & Francis, 2000; de Ross, Gullone, &
Chorpita, 2002; Ebesutani, Bernstein, Nakamura, Chorpita, & Weisz, 2010b). Despite criticisms
by Currier, Holland & Neimeyer (2007) that many studies are limited by their use of mental
health problems rather than grief measures, the reason is that there is no standardized wellvalidated measure of grief reaction in children (Kaplow, Layne, Pynoos, Cohen, & Lieberman,
2012), justifying the use of the RCADS in the present study. (See Appendix A for a copy of the
RCADS). SPSS Version 21 (SPSS, Inc., Chicago, IL., USA) was used to provide descriptive
13
statistics i.e. number of males/females, mean age (range of age), and mean and standard
deviations for outcome measures. As the data were interval scaled, parametric tests (dependent ttest) were used to test the change over time within each group, whilst independent measures ttest was used to compare the mean RCADS scores of the two groups.
Participants
As shown in Table 1.0 a total of 30 participants (17 males, 13 females) took part in the study,
with a mean age of 13.83 years (range: 11 to 18 years, SD: 2.32). Fifteen participants (8 females,
7 males) with a mean age of 13.87 (range: 11 to 18 years, SD: 1.85) were allocated to the
intervention group. Fifteen participants (10 males, 5 females) with a mean age of 14.13 (range:
11 to 18 years, SD: 2.72) were allocated to the comparison group. The inclusion criterion was
eligibility for the GTC programme. Anyone engaged in another intervention or being treated for
mental illness was excluded from the study, to prevent a possible overestimation of the efficacy
of the Growing Through Change programme. All participants were residents of Counties Derry
and Donegal and had completed primary education, with English as their first language.
Table 1.0 Participant characteristics.
______________________________________________________________________________
Gender
Ave. age
Age range
SD
______________________________________________________________________________
Full sample
17 males,
13.83 years
11 to 18 years
2.32
13 females
Intervention Group
7 males
8 females
13.87 years
11 to 18 years
1.85
Control Group
10 males
14.13 years
11 to 18 years
2.72
5 females
______________________________________________________________________________
14
Procedure
Following ethical approval, the researcher forwarded an invitation letter (Appendix B) to
Youthlife staff who sent it to everyone registered on the waiting list and to those who were
registered in the next run of the Growing Through Change programme. All potential participants
had self-selected to the programme. Information Sheets (Appendix C) and Assent / Consent
Forms (Appendix D) were forwarded to anyone wishing to participate in the study. Both the
participants and their parent/guardian signed forms before participants could take part in the
study.
Following informed consent, the researcher pre-coded the RCADS questionnaires and
sent them to Youthlife staff, who assigned a coded questionnaire to the name of each participant.
A list of participants’ details with their corresponding codes was kept in Youthlife’s office.
Therefore, the research team was unable to identify participants from the questionnaires, but if a
questionnaire were to show that a participant was at risk of harm, s/he could be identified by
Youthlife staff, who could instigate appropriate risk management.
On the first day of the programme, the researcher attended the residential centre in the
Sanctuary, White Oaks Centre, County Donegal and provided an information session to ensure
that those who had given consent were happy to continue, emphasising the right to withdraw and
the limitations of confidentiality, i.e. confidentiality would be broken where someone may be at
risk of harm. Youthlife staff and volunteers then distributed RCADS questionnaires before the
programme commenced. Written instructions were included on the questionnaire page to aid the
participants in completing the questionnaires. The second round of questionnaires were
completed at the end of the programme. Participants in the waiting list control group completed
the questionnaires in their own home. The questionnaires were scored using the RCADS scoring
15
programme, available from: http://www.childfirst.ucla.edu/Resources.html. The scores were then
entered into SPSS (V21) for analysis.
Method (Qualitative Study)
Design and Rationale
Semi-structured interviews were analysed using Interpretative Phenomenological Analysis (IPA;
Smith & Osborn, 2003) to explore participants’ personal experiences and provide themes to
allow an understanding of what it was like to experience the programme. IPA is useful when
trying to understand experiences that have a particular significance for people and carry meaning
for them as they engage in reflecting, thinking and feeling in trying to work out what the
experience actually means for them (Smith, Flowers, & Larkin, 2009).
This focus on phenomenology is coupled with interpretation. As experience is recounted
from the participant’s perspective, the researcher tries to make sense of the account in order to
understand the experience. This is achieved through reflective interpretation by the researcher to
arrive at a fuller, more meaningful understanding of the account (Moustakas, 1994). Therefore,
IPA is phenomenological as it involves trying to get as close as possible to the participant’s
personal experience, but this can only be done through interpretation by the participant first, and
then the researcher (Smith, Flowers, & Larkin, 2009), in what has been described as a double
hermeneutic (Smith & Osborn, 2003).
IPA is also idiographic, exploring personal perspectives within particular contexts, which
starts with a detailed examination of each individual case (Smith, Flowers, & Larkin 2009). This
approach was useful for the present study as it allowed each case to be analysed on its own merit,
allowing new themes to emerge with each new case. IPA was therefore used to provide a rich
analysis of the participants’ experiences and sense-making of the programme and to permit
16
dialogue with extant literature and theories (Smith, Flowers, & Larkin 2009).
Materials
An interview schedule, which was constructed in association with Youthlife staff, was used for
the semi-structured interviews. It covered areas such as prior knowledge of the programme,
arrival at the centre, group activities, and what was learned from the programme. A copy is
available in Appendix E. A digital voice recorder was used to record the interviews.
Participants
Everyone who participated in the quantitative study was invited to take part in the qualitative
study. A subsample of six (three females and three males) participants with an average age of
13.5 years (range: 11 to 18 years, SD: 1.76) agreed to take part.
Procedure
Both participant assent and parental consent was obtained before conducting the face-to-face
semi-structured interviews in Youthlife’s office. The duration of the interviews averaged 28
minutes 28 seconds (range: 21 minutes 24 seconds to 33 minutes 50 seconds, SD: 5 minutes, 11
seconds). As detailed in Smith and Osborn (2003), the interviews were audio recorded and
transcribed verbatim, before being read several times to enable immersion in the text, with the
left-hand margin being used to note initial observations. It was expected that themes of shared
experience, hope, growth and positive change might emerge from the data, given the rationale of
the programme. (A copy of the programme information is available in Appendix F.)
After making initial observations a line-by-line analysis was conducted, making notes of
17
emerging themes in the right-hand margin. The themes were then organised, using psychological
theory, with text being used to provide evidence for the psychological themes. Due to the
idiographic nature of IPA, this process was done for each interview, allowing new themes to
emerge with each text. As the analysis of each case was completed, previous cases were re-read
checking for themes that had arisen in subsequent cases. This iterative process presented clusters
of themes that were contained across cases, which were presented in a hierarchy of superordinate
and subordinate themes in a table supported by data from each interview.
Ethics
In accordance with the Generic Professional Practice Guidelines of the British Psychological
Society (BPS, 2008) a study proposal was submitted to the University of Ulster Research Ethical
Committee and ethical approval was granted in November 2013 (see Approval Notification in
Appendix G). Informed assent from children under the age of 18 was obtained and informed
consent from their parent/guardian was also obtained. One participant (aged 18) did not require
parent/guardian consent. All participants were informed of their right to withdraw from the study
at any time without having to give any reason and without any adverse consequences.
Participants were informed that their data would be processed and stored in line with the Data
Protection Act (1998), and would be destroyed after a period of ten years. Pseudonyms were
used to anonymize participants in this report. Youthlife counsellors) were available during the
completion of questionnaires and were in the building (not in the interview room) during the
interviews so that they could intervene if any participant were to become distressed. A debrief
sheet (see Appendix H) was given to each participant following participation. It was agreed that
confidentiality would be broken in the event of potential risk of harm.
18
Results
Quantitative Study.
There was a significant difference in mean RCADS scores at the start of the study between the
intervention group (M = 60.87 SE = 4.08) and the control group (M = 47.40 SE=2.58) t(28) =
2.79 p = .01. At the end of the study the intervention group reported significantly lower RCADS
scores (M = 48.13, SE = 3.88) compared with pre-intervention (M = 60.87, SE = 4.08), t(14) =
7.11, p <.01, whilst the control group did not report significantly different scores (M = 46.13, SE
= 3.19) post-intervention compared with pre-intervention (M = 47.40, SE = 2.58), t(14) = 0.80, p
= .44. Further there was no significant difference between the mean RCADS scores of the
intervention group (M = 48.13, SE = 3.88) and the comparison group (M = 46.13, SE =3.19),
t(28) = 0.40, p =.35, at the end of the study. Figure 1 shows the mean RCADS scores for both
groups at the start and the end of the study.
Figure 1. Mean RCADS scores for both
groups at the start and the end of the study.
19
Qualitative Study.
There were five superordinate themes: Shared Learning, Being Valued, Psychological and Social
Factors, New Trusting Friendships and Continuing Bonds, and Change (see Table 2.0).
Table 2.0 Superordinate and subordinate themes
______________________________________________________________________________
Superordinate themes
Subordinate themes
______________________________________________________________________________
Opening up and sharing narratives
Shared Learning
Learning about self from others
Learning new coping strategies
______________________________________________________________________________
Inclusion (accepted without judgement)
Being Valued
Being listened to and being understood
Feeling cared about
Giving a voice
______________________________________________________________________________
Confidence and self-esteem
Improved Communication
and Interpersonal Relationships
Gradual self-disclosure
Reduced Isolation
______________________________________________________________________________
Psychological and
Social Factors
New Trusting Friendships
And Continuing Bonds
Trust
Starting New Relationships
Continuing Old Relationships
______________________________________________________________________________
Contemplating Change
Change
New beginnings
Positive Outlook
Back for More and Reaching Out to Others
______________________________________________________________________________
20
Theme 1: Shared Learning.
The group did not know what to expect when travelling to the residential centre and reported
feeling “really really nervous” (Padraig, Louise, Kevin) with one participant being so anxious
that she did not want to continue to the centre, “I was, like, worried...when I was driving along I
didn’t want to go” (Mary). The group cited "not knowing anybody or anything" (Louise) as the
reason for their apprehension. Therefore, at the most basic level, the learning experience
involved getting to know each other and learning about the programme as it unfolded. This new
knowledge assuaged any fears that the group had as they ended up not wanting the weekend to
end, “as time went on I actually made friends and I felt happier and I didn’t want to go home”
(Kevin).
Through getting to know each other, deeper levels of learning occurred as the group
began to gradually open up and share narratives in their small groups, which facilitated shared
learning, (see Appendix I). The initial opening up was difficult for the group, with most
remaining quiet during the first meeting. This reluctance to share their story was what they had
been used to prior to the programme, “I don’t talk about my feelings” (Mary), “I don’t really like
talking about my feelings in real life, not real life, but outside the residential” (Louise). This
suggests a fear of self-disclosure, as each individual was afraid that their own story was unusual,
resulting in a sense of isolation, as they had felt different from others before the weekend, “I
thought I was the only one that kept thinking that way” (David).
However, learning that others had been going through “the same” (all participants),
helped the group to learn about themselves and seemed to provide some reassurance that what
they had been experiencing was normal following loss, and that their grief reactions were not
wrong or something to be ashamed of. Learning about this universality helped participants to
21
make sense of their own thoughts, feelings and behaviour. Putting their grief experiences into
this context reduced their sense of isolation, “I wasn’t alone” (Kevin) and appeared to teach the
group that talking and sharing their worries can be helpful.
No one person was the expert providing all the information from which the others could
learn. Rather, each individual was the expert of their own story, but taken together the group
learned lessons from their collective experience. As the group learned coping strategies from
each other, it suggests that had they viewed their own coping strategies up to that point as
inadequate or perhaps inappropriate, as some were judgemental of their coping mechanisms and
labelled their externalising behaviour as “stupid” (Padraig) or having “no point” (Kevin).
Learning more adaptive coping strategies from others seemed to provide a better understanding
of what they were going through with a new perspective on their situation, and instilled hope that
they would get through it.
Theme 2: Being Valued.
The theme of being valued (see Appendix J) was reflected in the experience of inclusion as the
participants were accepted without judgement. As being included and accepted as part of an ingroup was so important to the participants it suggests a fear of peer rejection. Indeed most of the
group had previous experience of rejection and exclusion (including being ostracised at school
and being rejected by absent parents). For example, Bernadette talked about how “normally
people don’t care about my feelings”. As such previous experiences could contribute to a feeling
of worthlessness, the sense of being cared about within the group allowed the participants to feel
valued, thus alleviating feelings of worthlessness.
The group also felt understood, which they attributed to the fact that others in the group
actively listened to them, which contrasted with previous experience where people had pretended
22
to listen to them when they had tried to talk, which may have resulted in them closing up.
Therefore, being listened to empathetically and being understood allowed them to open up as
they felt that all the other group members viewed their story as important. This created an
atmosphere of genuineness that served to validate the participants’ narratives, which they had
previously been reluctant to talk about. Being understood by their peers was important to the
group, as they felt that people outside the residential did not understand them, including parents,
counsellors and friends who had not experienced loss.
As the group indicated that they do not normally talk about their feelings, the residential
gave them a voice, giving them permission to talk about the feelings that they had been having
difficulty coping with and had “bottled up” (Bernadette). For example, prior to the weekend,
Louise had struggled with articulating her wants and needs to her absent father, but after the
residential she spoke to him and now “he realises that I have to have a say in it too” (Louise).
Theme 3: Psychological and Social Factors
Psychological and social factors, (see Appendix K), included themes around relationship with the
self, e.g. confidence and self-esteem, and themes around relationships with others, e.g. gradual
self-disclosure, reduced isolation, and improved communication and interpersonal relationships.
Regarding the relationship with the self, Padraig hinted that he wanted to return to his former
confident self as he had recognised that his new self had become withdrawn and quiet due to low
self-esteem, “…it’ll help me like build up my confidence again, because I had very low self selfesteem”
However, the process of gaining confidence and improving self-esteem for Padraig and
the rest of the group began with them being initially worried about the opinions of others towards
23
them, with the anticipation of the residential raising levels of self-consciousness further, as they
engaged in self-monitoring in an attempt to manage others’ impression of them, e.g. “I don’t like
people knowing anything about me…” (Mary). However, over the weekend their selfconsciousness dissipated as they engaged in gradual mutual self-disclosure. Being no longer
embarrassed or ashamed of their narrative seemed to have a positive impact on the participants’
confidence and self-esteem, as they felt proud of being able to share their story with others, “I
felt quite proud of myself that I’ve built my confidence up to read this out” (Padraig), “it’s
something that I’m proud of” (Louise).
This improved relationship with the self (better confidence, self-esteem and pride)
allowed the group to view themselves as worthy of having positive relationships with others,
relationships that perhaps had previously been damaged following the loss/bereavement event.
By realising at the residential that they can self-disclose and feel understood the group began to
engage in improved communication with significant others in their lives, leading to improved
interpersonal relationships, and resulting in reduced isolation. As some had previously felt alone
and misunderstood they learned how to trust others and therefore feel less isolated as they now
have someone they can talk to, whether in Youthlife or within their circle of family and friends,
as before they had no-one to talk to which lead to feelings of isolation.
Theme 4: New Trusting Friendships and Continuing Bonds
The theme of new trusting relationships and continuing bonds, (see Appendix L), refers to the
fact that the group made new friendships during the programme whist also reconnecting with lost
relationships. The element of trust was paramount for the group in allowing this to occur. Not
only did they have to trust their fellow group members to abide with the principle of
confidentiality, but they also surrendered themselves to the process of the programme as it
24
unfolded over the weekend, showing a trust in the Youthlife staff and volunteers to ensure that
they came to no harm. The group process allowed the participants to make meaningful
relationships quickly, as mutual trust was built, providing a sense of safety and comfort, and the
sharing of similar narratives seemed to create a sense of connectedness.
Where participants may have focused on their own negative feelings before the
programme, these new relationships encouraged them to begin to think about the feelings of
others and through understanding others, they appeared to gain an understanding of themselves,
something for which the group was “really grateful” (Louise). The new trusting friendships
contributed to participants building new sources of support, with participants often looking
forward to meeting the other group members again in Youthlife’s HeadStart programme so that
they can talk to their new friends.
As well as gaining new relationships where they could trust others, the group also
reconnected with their lost loved one through writing a letter to them in the theme of continuing
bonds. Although everyone agreed that this was the most difficult part of the weekend, there was
some divergence in the reasons for this. Some participants sorely missed their deceased relative,
as demonstrated in visiting the grave and continuing to engage in conversation with the
deceased. For example, in continuing the relationship with his deceased father, Kevin still
wanted his father to be proud of him. However, others held feelings of anger towards a parent
who had left them, yet yearned for some form of reconciliation, where they could continue their
relationship in a more positive frame:
“I just wrote about that, and how I was really really angry with him. Not just for not
not being there for me, but for not being there for my Mammy either. He didn’t like give
any support whatsoever, like. It was just awful the way he treated her and...just, like… I
just wrote about that and how I wanted a better relationship with him…” (Louise).
25
Theme 5: Change
Appendix M shows evidence of the different elements of change that occurred for the group, as
the experience of the weekend replaced apathy with motivation, as some of the group began
contemplating change, whilst others actually started new beginnings, changing some of their
behaviours and attitudes. For example, Louise stopped self-harming as she learned to express her
pain in other ways, and others (e.g. Bernadette, Kevin) started to apply themselves more to their
schoolwork, suggesting that the difficulties associated with their losses had impacted on their
education. The renewed effort at school reflected a renewed aspirational outlook, as the group
looked forward to the future where they saw themselves going to university and getting good
careers.
Feeling better about themselves also probably contributed to the more positive outlook
about themselves, the world and their future, and eliminated some of the negative feelings of the
past. For example, Kevin had carried a lot of guilt before the residential and wondered if was he
being punished by God. Gaining the understanding that guilt can be a normal response in
bereavement allowed him to let go of that burden and reconstruct new meaning about his loss.
One of the methods that seemed to contribute to the group’s keenness to make changes
was seen in the benefits of writing, which helped the participants to make sense of their thoughts,
feelings and behaviour, allowing them to see things “..in a different way… To see, like, what my
mind is thinking, but from, like, my eye’s view” (David). Seeing things from a different
perspective appeared to bring some clarity that allowed the group to organise their thoughts,
feelings and behaviour and put them into context, freeing them to focus on other areas of their
life e.g. school and relationships with their friends and family.
Another notable change is how the participants began the programme looking inward,
26
with all their worries and fears about doing the programme, but in the end their feelings had
changed. Not only did they not want the weekend to end, they also reported wanting to reach out
to others by going back to another residential as volunteers, reflecting a change from being
insular and isolated prior to the programme to feeling part of something, and having received
benefit from it they became more outward looking, wanting to help others. Whilst the whole
group wanted to do this, some felt that they were not quite ready, but would like to go back as a
participant again to further their own progress before trying to help others. This reflected a
change in that they are no longer afraid to engage with feelings but perhaps need more time to
process their own grief before feeling ready to help others.
27
Discussion
The quantitative results supported the first hypothesis that the mean RCADS score for the
intervention group would be significantly lower following participation in the programme, as
shown in Figure 1. However, the second hypothesis was not supported. Whilst the intervention
group’s mean RCADS score was lower than the mean RCADS score of the control group at the
end of the study, the difference was not statistically significant. This may have been because
there was a significant difference between the groups at the start of the study (Figure 1), with the
intervention group reporting significantly higher RCADS scores at baseline.
A possible reason for this is that the RCADS questionnaires were completed shortly after
arriving at the residential centre, and as reported in the qualitative study, the participants were
very anxious at this time, whereas the control group completed their questionnaires in familiar
surroundings. So, although the reduced anxiety and depression scores in the intervention group
are consistent with previous studies (e.g. Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002;
Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012; Spuij, Prinzie, Dekovic, van den Bout, &
Boelen, 2013), no causal inference can be drawn in the present study.
The findings of the qualitative study were similar to those found in an evaluation of
Youthlife’s “Safe Futures” programme for adults bereaved by suicide, which found that there
was reduced isolation and improved well-being among participants (Belford, 2013), with the
present study also revealing themes that were helpful for participants in working through their
grief, i.e. Shared Learning, Being Valued, Psychological and Social Factors, New Trusting
Friendships and Continuing Bonds, and Change (Table 2.0).
The shared learning theme may have emerged as meaning based theories of bereavement
in support groups present the opportunity for collective meaning-making (MacKinnon et al.,
28
2014). In normalising grief reactions through shared learning, participants discovered that their
thoughts, behaviour changes and disruptions in emotional processing were not unusual or
something to be ashamed of. Further, as loss and bereavement can challenge a child’s coping
skills (Clute & Kobayashi, 2013), it was promising to find that participants learned how to cope
in more prosocial ways by channelling their emotions into writing and talking, rather than
engaging in destructive behaviours (e.g. self-harm, and punching and kicking things). The
opportunity to learn coping strategies from each other may have resulted from participants being
at various stages of their adjustment to loss, as participants could identify with others who have
learned to cope effectively with situations similar to their own, as was found by Mitchell,
Wesner, Garand, Gale, Havill & Brownson (2007).
The theme of being valued (which included giving a voice, being accepted without
judgement, being listened to and understood, and being cared about) demonstrated how Rogerian
unconditional positive regard can help reduce psychological distress, allowing participants to
grow through change. And, given the name of the programme it was expected that this theme of
change would emerge, which was evident with participants being at different stages of change
such as contemplation, preparation and action (Prochaska & Diclemente, 1982). The changes in
behaviour and attitude to school work and future aspirations reflects a positive development,
given that Brent, Melhem, Masten, Porta, & Payne (2012) had found bereaved youth to have less
well-elaborated plans for career development and diminished educational aspirations.
The theme of Psychological and Social Factors carries importance as Sandler (2001)
noted that children construe themselves in relation to their social context around their basic needs
through self-system beliefs. And, as bereavement and loss stressors and caregiver relationship
quality can influence these self-system beliefs (Wolchik et al. 2009) the improved parent-child
29
communication and interpersonal relationships in the present study may buffer the adverse
effects of loss (Kaplow, Layne, Pynoos, Cohen, and Lieberman, 2012). Such buffering effects
may be explained by stress and coping social support theory, which suggests that social support
provides a buffer against stress by promoting adaptive appraisal and coping (Cohen & Wills,
1985).
As there can be a sense of diminished connectedness among grieving individuals and
because social detachment is strongly linked to mental health problems and adaptive functioning
(Sandler et al., 2010), and given that Brent, Melhem, Masten, Porta, & Payne (2012) found that
bereaved youth had lower peer attachment, the New Trusting Friendships and Continuing Bonds
theme in the present study is to be welcomed, as Clute and Kobayashi (2013) found that peer
connection contributed to a reduction in feelings of isolation and helped normalise the effects of
grief. Further, rather than just reaching acceptance in the Kubler-Ross (1969) model, the theme
of continuing bonds suggests that whilst the participants may have accepted the loss of a loved
one, s/he wanted to continue to have a connection with that person (Klass, Silverman, &
Nickman, 1996).
Although the above findings demonstrate the usefulness of the GTC programme there are
limitations in the present study. The number of participants was small, so it is not possible to
draw inferences from the results. Further, the lack of follow up means it is not possible to
determine if the lower anxiety and depression scores remained long after the intervention. It may
be that anxiety and depression increased again in the ensuing months, as was found by Currier,
Neimeyer, and Berman (2008) who found that immediately following interventions the
participants had noticed an improvement in symptoms, but there was no benefit at follow-up.
Therefore, future research employing a follow-up measurement is recommended to
30
ascertain if the benefits are maintained. A further limitation is the use of self-rating measures.
Future research using parent or teacher rating scales and interviews may be useful to get a fuller
picture of changes in participants following the intervention. Further, some of the results may be
partially explained by referral bias, in that those who were more troubled by their grief may have
been more likely to self-select to the programme. However, as Currier, Neimeyer, and Berman
(2008) noted, programmes that are targeted at those in greatest distress demonstrate more
benefits. Future research could also identify the mechanisms through which GTC achieved its
positive outcomes. Such research may highlight gender differences, which was not studied here,
but the typical structure of support interventions (e.g. self-disclosure and sharing of feelings)
may be less effective for males who tend to have a more avoidant orientation to coping (Jordan
& McMenamy, 2004).
The potential for gender differences presents a recommendation for Youthlife to consider
when further developing the GTC programme. Another recommendation would be to consider
involving parents in the programme, given the data in the present study where some participants
reported improved relationships with family members, whereas others continued to have
problems, and seeing as parental well-being after bereavement is a significant predictor of
adolescent well-being, and working with the surviving parent can improve outcomes for
parentally bereaved adolescents (Melhem, Porta, Shamseddeen, Payne, & Brent, 2011).
In conclusion, the GTC programme benefited the participants in the present study, with
outcomes such as improved relationships with the self (better confidence and self-esteem) and
improved interpersonal relationships, including reduced externalising behaviour and better
communication. This appeared to be facilitated through participants being able to share their
narrative with others who had similar experiences and being listened non-judgmentally, thereby
31
validating each other’s experience, and demonstrating the benefits of talking about their
experience. Further, learning more prosocial coping strategies from each other also helped
participants to better manage their emotions. With further development of the programme e.g.
involving parents, it is hoped the Growing Through Change programme will continue to provide
a valuable service for adolescents experiencing difficulties following bereavement, loss or
separation.
32
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Appendix A
Revised Child Anxiety and Depression Scale
Revised Child Anxiety and Depression Scale
Age:__________Please circle: female / male
Date: ________ID: ________
Please put a circle around the word that shows how often each of these things happen to
you. There are no right or wrong answers.
1. I worry about things.
Never Sometimes Often Always
2. I feel sad or empty
Never Sometimes Often Always
3. When I have a problem, I get a funny feeling in my stomach
Never Sometimes Often Always
4. I worry when I think I have done poorly at something Never Sometimes Often Always
5. I would feel afraid of being on my own at home
Never Sometimes Often Always
6. Nothing is much fun anymore
Never Sometimes Often Always
7. I feel scared when I have to take a test
Never Sometimes Often Always
8. I feel worried when I think someone is angry with me Never Sometimes Often Always
9. I worry about being away from my parents
Never Sometimes Often Always
10. I get bothered by bad or silly thoughts or pictures in my mind
Never Sometimes Often Always
11. I have trouble sleeping
Never Sometimes Often Always
12. I worry that I will do badly at my school work
Never Sometimes Often Always
13. I worry that something awful will happen to someone in my family
Never Sometimes Often Always
14. I suddenly feel as if I can't breathe when there is no reason for this
Never Sometimes Often Always
39
15. I have problems with my appetite
Never Sometimes Often Always
16. I have to keep checking that I have done things right (like the switch is off, or the door
is locked)
Never Sometimes Often Always
17. I feel scared if I have to sleep on my own
Never Sometimes Often Always
18. I have trouble going to school in the mornings because I feel nervous or afraid
Never Sometimes Often Always
19. I have no energy for things
Never Sometimes Often Always
20. I worry I might look foolish
Never Sometimes Often Always
21. I am tired a lot
Never Sometimes Often Always
22. I worry that bad things will happen to me
Never Sometimes Often Always
23. I can't seem to get bad or silly thoughts out of my head
Never Sometimes Often Always
24. When I have a problem, my heart beats really fast
Never Sometimes Often Always
25. I cannot think clearly
Never Sometimes Often Always
26. I suddenly start to tremble or shake when there is no reason for this
Never Sometimes Often Always
27. I worry that something bad will happen to me
Never Sometimes Often Always
28. When I have a problem, I feel shaky
Never Sometimes Often Always
29. I feel worthless
Never Sometimes Often Always
30. I worry about making mistake
Never Sometimes Often Always
31. I have to think of special thoughts (like numbers or words) to stop bad things from
happening
Never Sometimes Often Always
32. I worry what other people think of me
Never Sometimes Often Always
33. I am afraid of being in crowded places (like shopping centres, the cinema, buses, busy
playgrounds)
Never Sometimes Often Always
34. All of a sudden I feel really scared for no reason at all
40
Never Sometimes Often Always
35. I worry about what is going to happen
Never Sometimes Often Always
36. I suddenly become dizzy or faint when there is no reason for this
Never Sometimes Often Always
37. I think about death
Never Sometimes Often Always
38. I feel afraid if I have to talk in front of my class
Never Sometimes Often Always
39. My heart suddenly starts to beat too quickly for no reason
Never Sometimes Often Always
40. I feel like I don’t want to move
Never Sometimes Often Always
41. I worry that I will suddenly get a scared feeling when there is nothing to be afraid of
Never Sometimes Often Always
42. I have to do some things over and over again (like washing my hands, cleaning or
putting things in a certain order)
Never Sometimes Often Always
43. I feel afraid that I will make a fool of myself in front of people
Never Sometimes Often Always
44. I have to do some things in just the right way to stop bad things from happening
Never Sometimes Often Always
45. I worry when I go to bed at night
Never Sometimes Often Always
46. I would feel scared if I had to stay away from home overnight
Never Sometimes Often Always
47. I feel restless
Never Sometimes Often Always
41
Appendix B
Invitation to participate in the study
School of Psychology
Invitation letter
To: Anyone wishing to take part in Youthlife’s Growing Through Change Programme.
My name is Stephen Clarke. I am carrying out research for an MSc. in Applied Psychology
course at the University of Ulster, and I am inviting you to take part in this research.
I am interested in young people’s experience of the Growing Through Change programme,
which is run by Youthlife. The aim of the study is to find out if the programme benefits those
who participate in it.
Whilst taking part in the study will not provide a direct benefit to study participants, the
knowledge gathered in this research will help to evaluate the programme, which may allow
others to see the benefit of taking part in it, and enable improvements to be made to the
programme.
If you would like further information about the study, please let a member of Youthlife staff
know, or contact a member of the research team by email: Clarke-s34@email.ulster.ac.uk.
May I take this opportunity to thank you for taking the time to consider this study.
Thanks you
Stephen Clarke
42
Appendix C
Participant Information sheets (intervention group and waiting list group)
School of Psychology
Participant Information Sheet
Project Title:
Evaluation of the Growing Through Change Programme on the Mental
Health of Adolescents Who Have Experienced Loss
Chief Investigator:
Professor Siobhan O’Neill
Intervention Group
My name is Stephen Clarke. I am carrying out research as part of the MSc. in Applied
Psychology at the University of Ulster.
I am inviting you to take part in this study. Before deciding whether to take part or not, you and
your parent / guardian must understand what the research is for and what you will be asked to do.
Please read the following information and ask any questions about anything that might not be
clear to you.
The aim of the study is to find out if Youthlife’s Growing Through Change programme benefits
those who participate in it. Whilst taking part in the study will not provide a direct benefit to you,
the knowledge gathered in this research will help to evaluate the programme, which may allow
others to see the benefit of taking part in it, and may aid service development.
The study involves completing a questionnaire before the start of the programme and again after
completion of the programme. Each questionnaire should take no longer than ten minutes to
complete.
Six people will also be invited to speak to me about their experiences of the programme. This
informal interview (which will be audio recorded) will last about 45 minutes, and will be written
up for analysis, but any information that could identify you or others (e.g. people’s names) will
be changed.
All personal data will be handled confidentially in line with the Data Protection Act (1998).
Questionnaires and interview recordings will not have real names in them, and will be kept in a
locked file in the University of Ulster for ten years, after which time they will be confidentially
destroyed. Your name will not be used in any report, and anything that could identify you will be
removed before publication. However, confidentiality will be broken if anyone appears to be at
risk of harm. And, Freedom of Information legislation allows access to certain non-personal data.
If you do decide to take part, you and your parent / guardian will also be asked to complete a
43
consent form. So, your parent/guardian must read this information sheet and ask any questions
that s/he may have before you both complete the consent forms. If you choose to take part, you
can change your mind at any time and withdraw from the study without giving a reason. If you
want to withdraw from the study, tell a member of the research team (Stephen Clarke or Siobhan
O’Neill), who will arrange for the information that you provided to be destroyed
Other people who are knowledgeable in the subject area have reviewed this study and the
University’s Research Ethics Committee has reviewed and approved it.
May I take this opportunity to thank you for considering this research project and I hope that you
take part. Your contribution will be much appreciated. If you have any queries about the study
you can contact me by email: Clarke-s34@email.ulster.ac.uk. You can also contact my
supervisor, Professor Siobhan O’Neill by email: sm.oneill@ulster.ac.uk, or by phone: (028) 7137
5354.
Thank you.
Stephen Clarke
Approved by
Professor Siobhan O’Neill
Lecturer in School of Psychology
University of Ulster
(Magee Campus)
44
School of Psychology
Participant Information Sheet
Project Title:
Evaluation of the Growing Through Change Programme on Mental
Health of Adolescents Who Have Experienced Loss
Chief Investigator:
Professor Siobhan O’Neill
Waiting List Group
My name is Stephen Clarke. I am carrying out research as part of the MSc. in Applied
Psychology at the University of Ulster.
I am inviting you to take part in this study. Before deciding whether to take part or not, you and
your parent / guardian must understand what the research is for and what you will be asked to do.
Please read the following information and ask any questions about anything that might not be
clear to you.
The aim of the study is to find out if Youthlife’s Growing Through Change programme benefits
those who participate in it. Whilst taking part in the study will not provide a direct benefit to you,
the knowledge gathered in this research will help to evaluate the programme, which may allow
others to see the benefit of taking part in it, and enable improvements to be made to the
programme.
The study involves completing a questionnaire twice, approximately six weeks apart. Each
questionnaire should take no longer than ten minutes to complete.
All personal data will be handled confidentially in line with the Data Protection Act (1998).
Questionnaires will not have real names on them, and will be kept in a locked file in the
University of Ulster for ten years, after which time they will be confidentially destroyed. Your
name will not be used in any report, and anything that could identify you will be removed before
publication. However, confidentiality will be broken if anyone appears to be at risk of harm.
And, Freedom of Information legislation allows access to certain non-personal data.
If you do decide to take part, you and your parent / guardian will also be asked to complete a
consent form. So, your parent/guardian must read this information sheet and ask any questions
that s/he may have before you both complete the consent forms. If you choose to take part, you
can change your mind at any time and withdraw from the study without giving a reason. If you
want to withdraw from the study, tell a member of the research team (Stephen Clarke or Siobhan
O’Neill), who will arrange for the information that you provided to be destroyed
45
Other people who are knowledgeable in the subject area have reviewed this study and the
University’s Research Ethics Committee has reviewed and approved it.
May I take this opportunity to thank you for considering this research project and I hope that you
take part. Your contribution will be much appreciated. If you have any queries about the study
you can contact me by email: Clarke-s34@email.ulster.ac.uk. You can also contact my
supervisor, Professor Siobhan O’Neill by email: sm.oneill@ulster.ac.uk, or by phone: (028) 7137
5354.
Thank you.
Stephen Clarke
Approved by
Professor Siobhan O’Neill
Lecturer in School of Psychology
University of Ulster
(Magee Campus)
46
Appendix D
Participant and Parental Consent Forms (both groups)
Participant Assent / Consent Form
Intervention Group
_____________________________________________________________________
Title of Project “Evaluation of the Growing Through Change Programme on Mental Health of
Adolescents Who Have Experienced Loss”
_____________________________________________________________________
Name of Chief Investigator: Professor Siobhan O’Neill
• I confirm that I have been given, and have read and understood, the
information sheet for the above study and have asked and
received answers to any questions raised
Please initial
[
]
• I understand that my participation is voluntary and that I am free to
withdraw at any time without giving a reason and without my rights
being affected in any way
[
]
• I understand that the researchers will hold all information and data
collected securely and in confidence and that all efforts will be made
to ensure that I cannot be identified as a participant in the study
and I give permission for the researchers to hold relevant personal data.
[
]
• I understand that, although confidentiality exists throughout the
study, it may be necessary to break confidence if it is believed
that there is a risk of harm
.
[
]
• I agree to take part in questionnaire part of the above study
[
]
• I agree to take part in the interview part of the above study, which will
be audio recorded
[
]
__________________________________________________________________
47
Participant Assent / Consent Form
Waiting List Control Group
_____________________________________________________________________
Title of Project “Evaluation of the Growing Through Change Programme on Mental Health of
Adolescents Who Have Experienced Loss”
_____________________________________________________________________
Name of Chief Investigator: Professor Siobhan O’Neill
• I confirm that I have been given, and have read and understood, the
information sheet for the above study and have asked and
received answers to any questions raised
Please initial
[
]
• I understand that my participation is voluntary and that I am free to
withdraw at any time without giving a reason and without my rights
being affected in any way
[
]
• I understand that the researchers will hold all information and data
collected securely and in confidence and that all efforts will be made
to ensure that I cannot be identified as a participant in the study
and I give permission for the researchers to hold relevant personal data.
[
]
• I understand that, although confidentiality exists throughout the
study, it may be necessary to break confidence if it is believed
that there is a risk of harm
.
[
]
• I agree to take part in the above study
[
]
__________________________________________________________________
48
Parent / Guardian Consent Form
Intervention Group
_____________________________________________________________________
Title of Project “Evaluation of the Growing Through Change Programme on Mental Health of
Adolescents Who Have Experiences Loss”
_____________________________________________________________________
Name of Chief Investigator: Professor Siobhan O’Neill
• I confirm that I have been given, and have read and understood, the
information sheet for the above study and have asked and
received answers to any questions raised
• I understand that my child’s participation is voluntary and that
he / she is free to withdraw at any time without giving a reason
and without his / her rights being affected in any way
Please initial
[
]
[
]
[
]
• I understand that, although confidentiality exists throughout the
study, it may be necessary to break confidence if it is believed
that there is a risk of harm
.
[
]
• I agree that my child may take part in questionnaire part of the
above study
[
]
• I agree that my child may take part in the interview part of the
above study, which will be audio recorded
[
]
• I understand that the researchers will hold all information and data
collected securely and in confidence and that all efforts will be made
to ensure that participants in the study cannot be identified and I give
permission for the researchers to hold relevant personal data
49
Parent / Guardian Consent Form
Waiting List Group
_____________________________________________________________________
Title of Project “Evaluation of the Growing Through Change Programme on Mental Health of
Adolescents Who Have Experienced Loss”
_____________________________________________________________________
Name of Chief Investigator: Professor Siobhan O’Neill
• I confirm that I have been given, and have read and understood, the
information sheet for the above study and have asked and
received answers to any questions raised
• I understand that my child’s participation is voluntary and that
he / she is free to withdraw at any time without giving a reason
and without his / her rights being affected in any way
Please initial
[
]
[
]
[
]
• I understand that, although confidentiality exists throughout the
study, it may be necessary to break confidence if it is believed
that there is a risk of harm
.
[
]
• I agree that my child may take part in the above study
[
]
• I understand that the researchers will hold all information and data
collected securely and in confidence and that all efforts will be made
to ensure that participants in the study cannot be identified and I give
permission for the researchers to hold relevant personal data
50
Appendix E
Interview Schedule
Interview Schedule
Hello, my name is Stephen Clarke. Thank you for meeting with me today. As you know, I am
conducting a study on the Growing Through Change Programme that you were on recently, and I
would like to ask you some questions about that. I would like to record our conversation, so that I
can get your words accurately. If at any time during our talk you feel uncomfortable answering a question
please let me know, and you don’t have to answer it. Or, if you want to answer a question but do not want
it recorded, please let me know and I will turn off the machine. If at any time you want to withdraw from
this study please tell me and I will erase the recording of our conversation. I will not reveal the content of
our conversation beyond myself and people helping me whom I trust to maintain your confidentiality,
unless I believe that you may be at risk of harm, in which case I will need to break confidentiality. After
our conversation I will write up the conversation for analysis. I will do everything I can to protect your
privacy, (e.g. not using your real name or those of other people you mention). However, there is always a
slight chance that someone could find out about our conversation. Do you agree to participate, and to
allow me to record our conversation?
How did you find out about Youthlife’s “Growing Through Change” programme?
Do you know anyone else who went on the programme before?
What made you interested in going on the programme?
How did you feel about going on the residential and the rest of the programme?
What were you expecting the programme to be like before you started it?
What was it like when you got to the residential centre?
How did the facilitators welcome you to the residential?
How was everyone introduced to each other?
What were the other people like?
What were the Youthlife facilitators like at the residential?
How did you feel meeting others who were bereaved?
How was the weekend structured? E.g. what group activities were arranged? Was there
any time to be alone and reflect?
13. How did you feel taking part in the group activities?
14. What did you learn on the residential?
15. What was your overall experiences of Youthlife’s residential weekend like?
16. How did you feel when leaving the residential weekend?
17. What did you find most useful about the residential weekend?
18. What did you find least useful about the residential weekend?
19. What did you find most useful about the programme overall?
20. What did you find least useful about the programme overall?
21. How do you think the programme could have been improved?
22. How did you cope with the loss before you went on Youthlife’s residential?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
51
23. Could you tell me in more detail how Youthlife’s “Growing Through Change
Programme” has helped you cope with your loss?
24. Can you tell me about any changes in how you deal with your loss since you did the
programme?
25. Have you kept in contact with anyone else who did the programme? If so, what contact
do you have e.g. meet up, social events, talk / text on the phone, Facebook?
26. Do you find support in keeping in contact with others from the programme?
27. Is there anything else that you would like to discuss in relation to the programme?
General probes:
● Can you tell me more about that?
● What did you think about that?
● What did you feel about that?
● Could you give me some more examples about that?
● Can I take you back to something you said earlier, you said ______ could I ask you
about that?
● You said ______ what do you mean by that?
The above interview schedule was adapted from an interview schedule created by Belford (2013)
when interviewing adults who participated in Youthlife’s “Safe Futures” programme.
52
Appendix F
Youthlife’s Growing Through Change Programme Information Leaflet
Growing Through Change Residential Weekends
The focus of the weekend is working through the stages of the grief process as identified by Dr.
Elizabeth Kubler Ross. It draws on a structured programme designed to help young people
understand, process and work through the feelings of grief experienced through the loss of a
loved one.
The young people are divided into small groups of 4-5 people appropriate to their age and remain
in these small groups for most of the weekend. This small group will also have two trained
volunteers, one youth and one adult.
The activities of the weekend consist of:
● Personal experience talks by young volunteers
● Small discussion groups
● Audio and visual presentations
● Small group activities
● Structured play and recreational activities
The flow of the weekend develops self-awareness and self-confidence in the participants. It
enables young people to experience a sense of uniqueness and importance. At the same time, it
shows that feelings such as anger, sadness, guilt and fear are not unique, but are shared by others
and can be safely discussed. The young people are thus enabled to re-evaluate themselves and
their family in a more positive light. They are also able to learn new ways of dealing with
feelings and problems they may encounter later in their lives.
53
Appendix G
Ethical Approval Notification
McCormick, Elaine <e.mccormick@ulster.ac.uk>
Tue 05/11/2013 15:19
To:
Stephen Clarke;
O'Neill, Siobhan <sm.oneill@ulster.ac.uk>;
RE: Application No REC/13/0223
Dear Siobhan/Stephen
Thanks you for sending your response to the UREC’s comments.
I am pleased to confirm, on behalf of UREC, that this study has been approved to proceed. I will send a
more formal approval letter and other documents. These should be kept on file. Return the original CI
undertaking form to me and please keep a copy on file.
Best wishes
Elaine
This email and any attachments are confidential and intended solely for the use of the addressee and may contain information which is covered by
legal, professional or other privilege. If you have received this email in error please notify the system manager at postmaster@ulster.ac.uk and
delete this email immediately. Any views or opinions expressed are solely those of the author and do not necessarily represent those of the
University of Ulster. The University's computer systems may be monitored and communications carried out on them may be recorded to secure
the effective operation of the system and for other lawful purposes. The University of Ulster does not guarantee that this email or any attachments
are free from viruses or 100% secure. Unless expressly stated in the body of a separate attachment, the text of email is not intended to form a
binding contract. Correspondence to and from the University may be subject to requests for disclosure by 3rd parties under relevant legislation.
The University of Ulster was founded by Royal Charter in 1984 and is registered with company number RC000726 and VAT registered number
GB672390524.The primary contact address for the University of Ulster in Northern Ireland is,Cromore Road, Coleraine, Co. Londonderry BT52
1SA
54
Appendix H
Debrief Sheet
Debriefing Form:
Evaluation of the Growing Through Change Programme on Mental
Health of Adolescents Who Have Experienced Loss.
Thank you for agreeing to participate in this study. The general purpose of this research is to find
out if the Growing Through Change programme benefits those who participate in it.
We invited young people to complete a questionnaire at the start of the study and again after the
programme was completed. The questionnaire rated anxiety and depression scores, and it was
predicting that these scores would reduce following completion of the programme.
There was also a subsample of participants who took part in a recorded interview about their
experience of the Growing Through Change programme, to allow the researcher to see what
areas of the programme were most beneficial and to see if there were any areas where the
programme could be improved.
If you are worried about any aspect of the study, please feel free to contact me by email: Clarkes34@email.ulster.ac.uk. or you can contact my supervisor, Professor Siobhan O’Neill by email:
sm.oneill@ulster.ac.uk, or by phone: (028) 7137 5354.
If you wish to discuss any of the issues raised in this study, or the programme, the following
agencies may be able to help:
23 Bishop Street, Derry. Tel: 028 7137 7227 or 07912507388
Tel: 0808 808 8000. Hard of hearing Textphone users can call 18001 0808 808 8000
Tel: 0800 1111
or The Samaritans on: 08457 90 90 90
May I take this opportunity to thank you once again for taking part in this study. Your
participation is much appreciated.
Many thanks
Stephen Clarke
55
Appendix I
Table Showing Evidence of Shared Learning Theme with Subordinate Themes
_____________________________________________________________________________________
Superordinate Theme: Shared Learning
_____________________________________________________________________________________
Subordinate Theme: Opening up and sharing narratives
Padraig:
… at first, I didn’t really speak to anybody, but then I realised I can start speaking
again...and started speaking out in my group...They shared their story, so I’ll share mine.
Bernadette:
We could share stories with each other, which was nice.
Mary:
The first time I went into our small groups I didn’t say why I’m here...then, when
we went into our groups again, Shauna made me feel better, so I, like, talked...about it
more.
Louise:
I just couldn’t talk to them at first. And, then...because it seemed like they trusted me, so
I could trust them too, and I just, like, told them everything, then...I felt, like, better if I
shared it with everybody…
Kevin:
...learning about this group... experiencing other people’s views and what happened
to them.
David:
Just to share with someone I don’t know.
_____________________________________________________________________________________
Subordinate theme: Learning about self from others.
Padraig:
I realised how to...how to manage my feelings... I realised that I can talk to people
that went through the same thing I did. I realise, like, I can cry if I want to in front
of them, ‘cos they know...they know what it’s like, they know how the pain is.
Bernadette:
...talking has helped me learn about my feelings.
Mary:
I thought, like, you’re not by yourself and stuff like that there, and there’s people
in the same situation as you and stuff like that there... Like, knowing that you can
get through it... It was good, like, you can, there was like a difference in yourself
Louise:
It made me actually realise how angry I was.
Kevin:
...when the loss happened, em...I felt like it was only me, like it’s only happened to me
and why me and, and then other people were like...some had very similar, like,
circumstances... knowing too that I wasn’t alone and there was a help...
I got to know more about the five stages of grief...It’s, like, knowing what I’m going
through.
_____________________________________________________________________________________
David:
56
Subordinate theme: Coping Strategies Learned from Others
Padraig:
...quite bad difficulty managing them [emotions] before. Like, instead of sitting down and
writing it in the book, I would punch things and kick things.
Bernadette:
I learnt how to deal with my feelings. Like, I have lost my temper less since the
weekend, and my attitude has got better, so I’ve learnt how to deal with everything.
Mary:
... they give you ways to help and talk about your feelings and all.
Louise:
I actually used to, em...self-harm before the residential, but, like, I told my group
about it like and they were, just telling me, you know, how I could, like, try and stop it...I
haven’t done it in, like, two months or something now, so, like it’s something that I’m
proud of...
Kevin:
...they explained, like, who helped them or what helped them. And, then did it work for
them. So maybe I would do the same, not do the exact same, but, like adjust it to, like,
my personality, I suppose.
David:
Because they would have got through something I was stuck at...like acceptance
...and they would help me with that.
_____________________________________________________________________________________
57
Appendix J
Table Showing Evidence of Being Valued Theme with Subordinate Themes
_____________________________________________________________________________________
Superordinate Theme: Being Valued
_____________________________________________________________________________________
Subordinate theme: Inclusion (accepted without judgement)
Bernadette:
It made me feel like I wasn’t being judged... they weren’t leaving me out. They weren’t
ignoring me.
Mary:
They were, like, really nice and all and made you feel, like, at home and stuff.
Louise:
...they weren’t, like, judging me either...They weren’t saying it [self-harm] was right or
wrong.
Kevin:
...you know, they’d make you feel part of it and like, you know, they’d try and
talk to you, and you know, and they have like respect for you too...
David:
Like, they greeted you when you came in...everyone made each other, like, feel at
home and welcome.
_____________________________________________________________________________________
Subordinate theme: Being listened to and being understood
Padraig:
They were really good at listening...I realised that people actually out there do
listen, rather than just, like, pretend they’re listening.
Bernadette:
...you can actually tell somebody and you know that they would be listening
because they’d acknowledge what you said, and it’s nice when they acknowledge what
you said, instead of going off just not listening, completing ignoring you...they
understand me...it’s nice having somebody that’s been through the same thing. Because,
my friend, she still has both her parents living with her...
Louise:
...like I think it was just the fact that they were actually just there and someone
was listening to me...sharing it with people who could actually understand, like, how I’m
actually feeling.
Kevin:
[talking about previous counselling experience] ...sitting by yourself with some
stranger who could be older, like a lot older than you, so they couldn’t actually relate to
you as well as others can, like someone around your own age, or someone who’s been
through the same. So that works, em.., a lot better than talking to somebody, like, five
times your age.
David:
They sat there and listened.
_____________________________________________________________________________________
58
Subordinate theme: Feeling cared about.
Bernadette:
They were all nice and caring...they did care...like...about my feelings...but
like...normally people don’t care about my feelings.
Mary:
Like people actually do care about you.
Louise:
...to know that somebody is actually there and they actually do really care. It
kinda made me stop [self-harming]
Kevin:
...they wanted to hug you and you hugged them back and it made you feel nice.
David:
They passed over tissues...they hugged me.
_____________________________________________________________________________________
Subordinate theme: Giving a voice
Padraig:
I could talk about something serious, and like, I knew, I could talk to them and they’d
actually listen...
Bernadette:
I felt like I could like express myself more.
Mary:
Just, like, knowing like you can talk to somebody every Thursday, and like you
don’t have to keep it all in. That’s what I like about it.
Louise:
...that was my only chance, like, ‘cos I don’t really, like talking about my
feelings...so I kinda felt relieved to say it to someone, because I probably wouldn’t have
said it if I didn’t go, like.
Kevin:
I wrote it down and talked to my brother and talked to my Mammy…
David:
I would talk to my mum more now, like about more private stuff, like my feelings
_____________________________________________________________________________________
59
Appendix K
Table Showing Evidence of Psychological and Social Factors Theme with Subordinate Themes
_____________________________________________________________________________________
Superordinate Theme: Psychological and Social Factors
_____________________________________________________________________________________
Subordinate theme: Confidence and self-esteem
Padraig:
Aye, it’s built up my confidence a big bit, like... on Friday night my self-esteem was like
a 3, and then by Sunday it was like 7.
Bernadette:
…it boosted my self-esteem a little.
Mary:
It was good, like, you can... there was like a difference in yourself and all, and in your
confidence...
Louise:
I didn’t have a lot of confidence, if you know what I mean. And, it like, increased a
whole lot...
Kevin:
…talking in front of people, you know, has raised my confidence a good bit, you know
David:
I felt more confident in my surroundings and with the people there.
_____________________________________________________________________________________
Subordinate theme: Improved Communication and Interpersonal relationships.
Padraig:
I couldn’t really tell my mum anything, but like...that’s, like, really building
up...cos I’m starting to tell her wee things, but then it’ll, like, get better and better so we
can start talking about normal things.
Bernadette:
I didn’t fight with the teachers. I normally fight with my teachers. And on Wednesday,
this one teacher that I really hate I was really nice to her.
Mary:
And, then, like after school, then, it was OK, like we weren't fighting, like we’re
not getting into big serious fights like we usually do.
Louise:
I just wrote about that and how I wanted a better relationship with him...I want to
kinda mend the relationships.
Kevin:
I listen to people more, you know. And, I take...see things from their point of view, not
just my own.
David:
It’s made it [relationship with mother] a lot stronger.
_____________________________________________________________________________________
Subordinate theme: Gradual self-disclosure.
Padraig:
...on the Sunday I read out my full letter, like, but like on Saturday I was reading more
60
than I did on Friday...
Bernadette:
I didn’t share my letter, but I shared everything else...but like they wanted me to share it,
but they didn’t want me to be upset by sharing it.
Mary:
I thought the small groups were better because, like, there was only, like, five people in
the group, and stuff. It was far better, because, like, you weren’t, like, sharing it with
everybody.
Louise:
I just couldn’t talk to them at first...And, then, like, you know, they kinda read out all
theirs, you know all, like, whatever they were writing, and then I kinda, like, because it
seemed like they trusted me, so I could trust them too, and I just, like, told them
everything, then.
Kevin:
Em, and then over time then they were just, like...I don’t know, you feel comfortable,
because they wouldn’t force you to do anything that you wouldn’t, like, I don't know, just
you feel comfortable as long as you’re getting your feelings out as well….
I knew it wouldn’t go anywhere because of confidentiality. It was, like, stressed a
lot, and then I knew people wouldn't spread.
_____________________________________________________________________________________
David:
Subordinate theme: Reduced Isolation
Padraig:
Knowing that people went through this, the same like, nearly the same as me...you realise
they’ve went through loss and grief, the same time I have...
Bernadette:
…somebody that listened to me and like they've went through like nearly the
same as me...it was nice having the people around you…
Mary:
She was like, she had, like, the same situation as well as me and all. And I think that
there made me feel better...I talk to, like, people in Youthlife, like all the team leaders and
stuff, and Shauna and all that there…
Louise:
I don’t think they [parents] actually understand unless you’re actually in that situation,
and then I found out, you know, from people in the group in similar situations
…when the loss happened, em...I felt like it was only me, like it’s only happened to me
and why me and, and then other people were like...some had very similar, like,
circumstances...knowing too that I wasn’t alone and there was help and stuff... you know
I could make friends and I could, you know, relate to people and they could relate to me.
_____________________________________________________________________________________
Kevin:
61
Appendix L
Table Showing Evidence of New Trusting Friendships and Continuing Bonds Theme with Subordinate
Themes
_____________________________________________________________________________________
Superordinate Theme: New Trusting Friendships and Continuing Bonds.
_____________________________________________________________________________________
Subordinate theme: Trust.
Padraig:
I feel, like, I feel like I can trust them more than I used to be able to.
Bernadette:
I felt like I could trust them, and I normally can’t trust anybody.
Mary:
Aye, I only tell like, I only tell Carol, because I really like her and all, and I really really
trust her...
Louise:
...it seemed like they trusted me, so I could trust them too, and I just, like, told them
everything, then...
Kevin:
Well, I was wondering, like, you know, could I trust them, but by now I thought, yeah
maybe I could.
David:
Aye, you could trust them, like.
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Subordinate theme: Start of new relationships
Padraig:
...then I started chatting to them, and then we all became friends from there…we text
through Facebook me, or... we...we snapchat each other, me, George and Sharon, and
Patricia.
Mary:
Aye I’ve made quite a lot of new friends.
Bernadette:
I have him on xbox, and I have Kevin on xbox, and I’ve Kevin on Facebook, and me and
Stephanie snapchat each other...Sometimes, we like, talk about what we’re doing like
sometimes we talk about music that we’re listening to, or like sometimes we play
minecraft...stuff like that….sometimes like we talk about our feelings...
Mary:
Aye, I talk to Mairead and Caroline...I'm starting to go out to my friend's house and stuff
after school to do my homework and all.
Louise:
I keep in touch with the majority of them like.
Kevin:
I knew when I was leaving the residential that there would be this HeadStart going on,
and I thought sure I’ll see all my friends there.
David:
I made a couple of friends.
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Subordinate theme: Continuing old relationships
Padraig:
...when I was writing it I was OK, but then when...before I read it… I was really
emotional and stuff, but then after it then I realised, “oh aye, I can do this” and then I read
it out.
Bernadette:
...it helped me like, knowing that I could write a letter.
Mary:
The letter helped me a bit. I felt like I was actually talking to her [deceased
Grandmother]...I like to see her grave and all, and her picture on the grave.
Louise:
And, then I just said to him [absent father], like, just straight away, just like, you know I
want to spend more time with you....
Kevin:
And I'm sure I done my Dad proud.
David:
I would just sit and think about it...How did it happen and stuff.
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Appendix M
Table Showing Evidence of Change Theme with Subordinate Themes
_____________________________________________________________________________________
Superordinate Theme: Change
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Subordinate theme: Contemplating Change.
Padraig:
I don’t have the confidence yet to speak out in the big group, but hopefully, in October
we’ll be able to go out in the next residential and I’ll be able to speak out.
Bernadette:
Maybe I could push myself more at school...do like school work or like push myself more
and talk about exams and try to trust people more.
Mary:
I might, like, start trying it, like ...writing it down.
Louise:
I just can’t seem to find the time, like. But, like, I know I need to do start, like, I really
do, like soon, I need to do something, like. If it’s just, like, writing or just doing
something or talking to someone.
Kevin:
You'd be recommended to, like, you know, even scribble on a sheet.
David:
Sometimes I would write stuff. But, I wouldn’t do the letter.
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Subordinate theme: Positive outlook
Padraig:
...it was all perfect...I can, like, respect myself even more than I used to.
Bernadette:
...my attitude has got better...
Mary:
...Just, like, believe in yourself and stuff...
Louise:
...I want to, like, get a good job and go to university and stuff like that there...
I kinda tried to add to a wee bit of, kinda... I wouldn’t say funny, but I want to say, like,
just a wee bit of humour.
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Kevin:
Subordinate theme: New beginnings
Padraig:
When I went back to school I started talking out more, and stuff like that, ‘cos I was quite
quiet for ages...I haven’t, like, punched things and kicked things, like
Bernadette:
On Tuesday I tried harder at my work. Like, I done my homework, I tried to do all my
work and I didn’t fight with the teachers…
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Mary:
I'm getting out more and stuff like that there, more with my friends. Well, the last couple
of days, me and my brother we haven't, like, been fighting and stuff.
Louise:
I used to, like, take my anger out on my family and friends. I wouldn’t like hurt them, or
anything like that. I would just, like, usually just, like shout at them and like just be like
really really mean to them, so like, I have changed that since the weekend, like, I’ve
learned, like...I’m more aware of people’s feelings
Kevin:
Aye, I’ve tried a few things, aye. Some, some worked, like, you know, like the team
would always say write in your book, you know, and don’t get agitated. I did, I did that.
It worked well.
David:
It’s made me less angry. I would talk to my mum more now...
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Subordinate theme: Back for more and reaching Out
Padraig:
It made me feel quite, like, emotional, but then, like, now I would like to speak out in the
big group, but, like...
Bernadette:
Like, they would be going through the same thing. And they might, like it’s a weight off
their shoulders that there’s other people with the same feelings that they’ve got. So, like,
knowing that it’s not just them...
Mary:
I just think I need to, like, build my self-esteem more, and stuff.
Louise:
I would love to do it [volunteer] at some stage like. But, I think I need to build my
confidence up a wee bit more to kinda do it
Kevin:
I wanna help people who has been through the same. You know there is help out there.
And, you know, I received help from my team, so I may as well join the team and help
others.
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