Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 1

Running Head: Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community

Kenyon Stanley COMM 602 Dr. Zachary White December 3rd, 2010

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 2 Abstract

The mentally ill homeless community is a population that has not been given a voice. Until now, the sense-making and uncertainty reduction methods mentally ill homeless men and women utilize everyday has been unknown to care givers and communication scholars. Utilizing a qualitative interpretive approach, data from 10 mentally ill homeless men and women revealed reoccurring themes that has been previously unknown. The need to give a voice to the voiceless is needed in order to understand and develop programs for any marginalized group. This report sheds new light on a community that is crying out for help.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 3 In every major city, one could find tall buildings, bright lights and sounds that indicate a thriving and positive culture. However, there is a darker side. Intermingled within the normalcy of big city life, is an increasingly marginalized community of homeless people who cannot overcome barriers which relegate them to survive on the streets. Living a life of continual uncertainty, many of the homeless struggle to cope with various addictions, unemployment and finding effective treatment for a broad range of mental illnesses. Unless we listen to the voices of the mentally-ill, we will not be able to understand how this cohort of marginalized people sense make and cope with uncertainty and anxiety. We have a responsibility to ensure that the homeless men and women struggling with mental illness have the opportunities to live a life of certainty and self-sufficiency.

For the better part of ten years, I have worked in homeless shelters and faith based outreach agencies serving the needs of the homeless. In my experience, I have noticed that agencies tend to compartmentalize the treatment efforts for the mentally ill. There has been little effort to hear the voices of the mentally ill and ascertain the thought processes and coping mechanisms employed by the clients agencies endeavor to serve. Additionally, with the struggling economy, funding for new programs has dwindled, while the overall homeless population has soared. For example, in 2009, the Mens Shelter of Charlotte housed on average 450 people per night. While in 2010, the same shelter (on average), housed people per night. Understaffed and underfunded, the necessity to ensure that the clients are fed, clothed and housed is a continual challenge. Therefore, the individual stories of the homeless are not simply heard, leading to a deficiency in cultivating relationships between staff and client. The inability for shelter staff to build relationships with the clients has resulted in an overall institutional

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 4 mentality among the clients, and overall mistrust between clients and shelter staff. Perhaps now is the time to actively hear the voices of this voiceless subset of American society.

Our society is filled with different people with different histories. Hearing the stories of the mentally ill will allow both agencies serving the homeless community, and the communications community, a window into the lives of a previously voiceless population. My research will reveal patterns of sense making and uncertainty reduction in a community of individuals who view life different than mentally sound individuals. For the agencies, understanding how the mentally ill homeless sense make and deal with uncertainty will assist service providers in the development of relationally orientated programs designed to assist clients to living a self-sufficient life. For the communication community, the door for further research will be wide open as there has been very little communications research that focuses on the mentally ill homeless.

Literature Review

We first situate mentally ill homeless research within narrative paradigm and uncertainty reduction tenets, and then we focus on communication research in these areas.

Narrative Paradigm and Uncertainty Reduction in the lives of mentally ill homeless

The narrative paradigm functions as a metatheoretical lens by which the mentally ill homeless stories reveal how they view the world around them. According to Walter Fisher (1984), humans are narrative beings in who, experience and comprehend life as a series of ongoing narratives, as conflicts, characters, beginnings, middles, and ends (p. 341). Homeless people live a life of perpetual uncertainty. Every day, a typical homeless person is uncertain of

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 5 where he/she is going to sleep, how she/he is going to keep protected from the elements, is he/she going to be fed and many other uncertainties only a homeless person can identify. According to William Gudykunst (1993), uncertainty management is continually under construction. Gudykunsts view is particularly relevant to mentally ill homeless people. Depending on the particular diagnosis, a mentally ill homeless person may feel an unusual high amount of anxiety simply because although he/she may have previously navigated through a particular situation, the mental barriers may cause a mentally ill individual to deal with situations like it was the first time. Therefore, narrative paradigm and uncertainty reduction are two theories that go hand in hand when attempting to identify cognitive patterns in the mentally ill homeless community.

According to Em Griffin (2006), The Narrative Paradigm Theory has five basic assumptions. First, people are essentially storytellers. Currently, the mentally ill homeless population does not have a platform to tell their stories. Also, the homeless shelters are simply trying to provide basic needs and short term care (e.g. shelter, food and clothing). An individuals history and perspective on life is not in the vision of care facilities. Therefore, if people are essentially storytellers, then the mentally ill homeless are not being afforded the opportunity to participate in an essential component of human interactiondialogue.

Secondly, according to Griffin (2006), people make decisions on the basis of good reasons, which vary depending on the communication situation, media, and genre (p. 343). A homeless person suffering from mental illness doesnt have very many communication situations nor do they have access to media in the same manner that others have. How a homeless mentally ill individual determines the criteria for good reasons is relatively unknown. The narratives of

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 6 the mentally ill homeless community will produce insightful and unknown data regarding their decision making, sense making and uncertainty reduction process.

Third, what we consider good reasons is determined by biography, culture and character (Griffin 2006). The mentally ill homeless are comprised of men and women of different cultures and backgrounds. Therefore, identifying common patterns of sense making and uncertainty reduction will shed light on how this marginalized and voiceless population rationalizes what is a good decision.

Fourth, according to Griffin (2006), the coherence and fidelity of our stories is the determining factor of narrative rationality. Depending on the specific diagnosis, mentally ill individuals have difficulty forming a coherent thought process. I expect that my research will show a significant lack of coherence. However, identifying the patterns of incoherence in the narrative will give researchers, care providers and scholars additional insight into the how mentally ill homeless people rationalize their past, present and future.

Finally, according to Griffin (2006), The world is a set of stories which we choose, and thus constantly create, our lives (p. 343). Quite often, mentally ill people are disconnected from reality. Some talk to imaginary people, some dont believe they have an illness. Whatever the case may be, hearing the narratives of mentally ill homeless people will provide researchers and care givers new insight regarding the histories, current situations and futures of the individuals silently crying out for new care methods. In order to create new and successful programs, agencies must understand how their clients manage uncertainty.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 7 According to Griffin (2006), uncertainty/anxiety reduction theory posits that increased uncertainty produces an increase in anxiety. Conversely, a decrease in uncertainty will produce a decrease in anxiety. Since homeless people have to navigate basic need requirements more often than a non-homeless person, homeless people generally deal with an extraordinary amount of uncertainty. The mentally ill homeless people have an even more difficult time managing uncertainty and anxiety due to their mental deficiencies. Whether an individual suffers from depression or schizophrenia, it is reasonable to assume that the uncertainty of ones past decisions, present situation and overall outlook of his/her future will heighten the anxiety of a mentally ill homeless person. My research will reveal and highlight common themes in the sense-making and uncertainty reduction process within the mentally ill homeless population.

Research on Mentally Ill Homeless People

Although psychology has conducted research within the mentally ill homeless community, Communication research has looked into this marginalized and voiceless community. Furthermore, studies have usually been limited in scope to quality of care, and the historical circumstances which led to an individual becoming homeless. Additionally, there has been some research which questions the housing methods employed by agencies in the United States and Europe. Specifically, the enhancement of the quality of life when mentally ill homeless individuals are moved from a shelter based environment to a home/community.

According to Moxam, L. & S. Pegg (2000), the manner society provides housing for the mentally ill is inadequate. Additionally, the authors suggest that providing more community based environments will lead do deinstitutionalization in the men and women who suffer from mental illness and are homeless. Lastly, the authors highlight the importance of supportive and

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 8 flexible housing alternatives, especially housing options which allow the residents more control over their options. Their voice matters.

Moxam et al (2000) provides an out of the box idea that directly challenges the current methodology agencies employ when housing indigent mentally ill patients. The notion of institutionalization is a reality that I witness every night when attempting to serve the needs of mentally ill homeless women and men. While my research is designed to give a marginalized group a voice, out of the box ideas need to be explored if effective treatment is ever going to be actualized. Right now, the mentally ill homeless population is housed in homeless shelters. Their needs are expected to be met by staff that is not qualified to diagnose or treat mental illness. My research will provide insight into some of the functional and dysfunctional sense making patterns through the stories of individuals who have been silenced by society. If progress is ever to be achieved in effectively treating the mentally ill homeless community, researchers and care givers must understand how cultural values affect their clientele.

In 2009, E. Youngs provided a qualitative analysis of four individuals stories highlighting the detrimental impact that cultural values have in effectively treating mental illness. Additionally, Young examines how each individual was forced to deal with the guilt and shame that arose when their mentally ill condition left them unable meet the cultural expectation of society. Furthermore, Young highlights how superimposing cultural values and expectations on mentally ill subjects made the diagnosis and treatment more difficult. Lastly, Young posits that the mentally ill are a voiceless group that is in desperate need of further exposure.

Youngs report focuses on the clinical diagnosis of depression. For many years, depression was not taken seriously in society. Many people believed (and still believe) that

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 9 people diagnosed with depression should simply suck it up, pull up their boot straps and take responsibility. Depression is a serious problem within the homeless community. Depression leads to suicidal thoughts, fatigue and many other factors which can render a homeless individual simply incapable of appropriately navigating him or herself to a life of self-sufficiency. While Youngs report highlights the dysfunctional social construction methods which mentally ill subjects employ, my research will reveal needed sense-making and uncertainty reduction methods mentally ill homeless subjects engage in during narrative discourse. Thus providing care providers and communication scholars with additional insight into the communication practices of the homeless mentally ill; provided that concrete reoccurring themes emerge during the interviews.

In order to discover reoccurring themes, L. Ritchie (2009) attempted to utilize peer group discussions of homeless individuals in order to discover reoccurring themes and metaphors. The group sessions were recorded and transcribed by students of Dr. Ritchie. The analysis revealed several reoccurring themes. One of the themes exposed was that several of the subjects chose to blame others for their situation and/or the system. There were absolutely no occurrences where the subjects blamed themselves for their failure to live a self-sufficient life. Additionally, the subjects unanimously agreed that substance abuse was a coping mechanism for their hard life instead of a barrier to better their situations. Again, many of the subjects blamed the system for inadequate drug treatment programs, thus exemplifying the blame the system metaphor. I will be interested to see if the mentally ill homeless population has a propensity to blame others instead of taking responsibility for their situation.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 10 Ritchie provides a great study where the voices of homeless people are given a platform. Ritchie effectively exposes that many homeless people blame others for their situation, thus suggesting that while constructing reality, taking personal responsibility is secondary while blaming others is a primary coping mechanism. Considering my report deals with mentally ill homeless people, it will be interesting to see whether or not the reoccurring metaphors in Ritchies study occur in my study. Ritchies qualitative analysis will provide a platform to compare the sense making process between mentally ill homeless individuals with a cohort of mentally sound homeless people

In 2006, B. Heuchemer & S. Josephssons conducted a qualitative analysis of two homeless women who suffer from chemical dependency issues. The authors use a comparative analysis between the two homeless drug abusers and two individuals who dont have substance abuse issues or homeless situations. By utilizing a narrative approach, the researchers found that the homeless women initially thought that drugs would provide a solution to their problems but soon realized that using drugs turned out to be a significant barrier to self-sufficiency. Additionally, the researchers found that the women suffering from homelessness and chemical dependency viewed life in the short term and intense. In contrast, the women who didnt suffer from homelessness or drug addiction viewed life through a long term lens and were less intense. Lastly, the report gives the reader a unique snapshot into the lives of a vulnerable and marginalized faction of society that doesnt get much exposure.

While the research was conducted in Sweden, chemical dependency and homelessness are mutually inclusive. Drugs are a major factor as to why society has struggled to understand and effectively end homelessness. Although my research will focus on the mentally ill homeless,

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 11 many mentally ill homeless people suffer from chemical dependency issues as well. Furthermore, when substance abuse is added as a barrier to the mentally ill homeless, the combination of prescribed medication and mind-altering drugs further disrupt the mentally ill homeless from connecting with their own socially constructed reality. Therefore, it is quite possible, that in order to treat the mentally ill homeless, effective substance abuse treatment may need to be addressed as well. By highlighting the similarities that the women in Heuchemer & S. Josephssons 2006 study share with the subject(s) in my research, the complexity mutually inclusive relationship between homelessness, chemical dependency and homelessness will be highlighted.

In an attempt to evaluate supportive housing, Nelson, Clarke, Febbraro & Hatzipantelis (2006) hear the stories of twenty homeless individuals who suffer from mental illness. The purpose of the study is to evaluate the effectiveness supportive housing has on the mentally ill homeless population. Using a qualitative approach, the researchers discover that the quality of life before the individuals entered supportive housing was filled with anxiety and generally dark Nelson et al (2006). In contrast, following the participants entrance into supportive housing, the participants reported a significant brighter perspective on life in general. Although the quality of life of the participants were enhanced after entering a supportive housing system, some of the subjects reported negative aspects about their supportive housing environment (e.g. struggles with substance abuse & access to medication).

While this report evaluates supportive housing, there is a great deal of information that my research can glean off of. For example, the report is a narrative approach. By hearing the voices of the mentally ill, patterns of sense making emerge and give the reader a snapshot into

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 12 the lives of some of our most vulnerable citizens. The sense making patterns in this report will complement the patterns which show themselves in my study.

In an attempt to evaluate supportive housing, Nelson, Clarke, Febbraro & Hatzipantelis (2006) hear the stories of twenty homeless individuals who suffer from mental illness. The purpose of the study is to evaluate the effectiveness supportive housing has on the mentally ill homeless population. Using a qualitative approach, the researchers discover that the quality of life before the individuals entered supportive housing was filled with anxiety and generally dark.

In contrast, following the participants entrance into supportive housing, the participants reported a significant brighter perspective on life in general. Although the quality of life of the participants were enhanced after entering a supportive housing system, some of the subjects reported negative aspects about their supportive housing environment (e.g. struggles with substance abuse & access to medication).

While Nelson et al (2006) evaluate supportive housing, there is a great deal of information which will enhance my research proposal. For example, the report is a narrative approach. By hearing the voices of the mentally ill, patterns of sense making emerge and give the reader a snapshot into the lives of some of our most vulnerable citizens. The sense making patterns in this report will complement the patterns which show themselves in my study.

Another study was conducted by J. Theiss and D. Solomons in 2008. Their article examines uncertainty, openness of communication and the uncertainty reduction process as they simultaneously affect intimacy in romantic relationships. Using a quantitative approach, the

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 13 study surveys a cohort of traditional college age students over a six week period. The results of the study indicate that reducing uncertainty is the only significant predictor of intimacy.

As my research will explore sense and sense making and uncertainty reduction within the mentally ill homeless population, it is critical to reduce uncertainty and increase self-disclosure of the subject(s) who will be studied. In my experience, I have noticed that homeless men in general are skeptical and generally dont trust others. The mentally ill homeless men I encounter are even more difficult to reach. Therefore, decreasing the uncertainty of the subjects about the nature of my study will increase the level of intimacy (trust) the interviewer has with the subject(s).

Research Questions

How people make sense out of sense making has been a question frequently researched by communication scholars. However, identifying patterns of sense making and uncertainty reduction within the cohort of mentally ill homeless individuals has not been done. By utilizing a narrative approach my research will identify how mentally ill homeless men and women sense make and reduce anxiety in their unique and obvious uncertain world. Furthermore, my study will add and break new ground to the current scholarship by taking a discursive lens to find out the sense making and uncertainty reduction process utilized by mentally ill men and women who are struggling with homelessness.

RQ1: What are the reoccurring patterns of sense making that mentally ill homeless men and women share in their narratives of their past, coping with their present situation and planning their future?

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 14 RQ2: How do mentally ill homeless men and women reduce uncertainty and anxiety?

Method

To explore the sense making and uncertainty reduction process in the mentally ill homeless population, I will conduct an in-depth qualitative study of 20 homeless people who suffer from at least one diagnosed mental illness. After the study, I will be better able to better understand the thought patterns of the mentally ill homeless population.

Organization

The participants will be pooled from two agencies serving the homeless. The first agency is The Harvest Center in Charlotte, North Carolina. The second agency is Union Gospel Mission in Seattle, Washington. Both of these agencies are faith based, and both provide housing for the homeless; many of whom suffer from various mental illnesses. As Program Director of the Harvest Center, I am able to gain full access to the interviewees currently being housed at our facility. The Director of the Union Gospel Mission in Seattle, Washington has given me unfettered access to the mentally ill homeless men and women housed at the Seattle facility.

Participants

Ten men and ten women who are mentally ill and homeless will be recruited and interviewed. Ideally, I will interview eight African American men and women and two Caucasian men and women. I hope to find a broad generational demographic within the interviewees. Ideally, the majority will fall into the 30-50 year-old age range. The interviews

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 15 will be conducted on a volunteer basis and each will be paid ten dollars for their participation. Additionally interviewees will be given a consent form to sign prior to being interviewed.

Procedures

As a qualitative ethnographic study, data will be gathered using a semi-structured interview protocol which focuses on sense making and uncertainty reduction. The interviewees will be asked four basic sample questions with follow up questions designed to encourage selfdisclosure from the interviewees (see appendix A).

As a participant observer, I will be conducting the interviews and recording the answers and transcribing them at a later time. The environment will be as comfortable and nonthreatening as possible. It is our goal to provide an atmosphere that produces as little anxiety as possible.

Limitations

While there should be a lower level of uncertainty with the participants at The Harvest center (where I am Program Director). My status and intimate relationship with the clients at at The Harvest Cent However may cause the interviewees to reveal information that they perceive I want to hear instead of how they honestly navigate through the situations presented in the interview questions. Additionally, both The Harvest Center and The Union Gospel mission are agencies that are isolated from the community surrounding them. The isolated atmosphere from both the Seattle and Charlotte location may reveal reoccurring themes which occur only in their immediate environment instead of the overall mentally ill homeless population.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 16 Discussion

The life of a homeless person is filled with uncertainty and turmoil. For A mentally ill homeless person to be restored to self-sufficiency, agencies serving the needs of the homeless need to understand the sense making and uncertainty reduction process of their clients. Unfortunately, the current philosophy of agencies nationwide focuses less on case management and more on providing homeless men and women with basic services.

After conducting this study, communication scholars and homeless service agencies will benefit from the results. Service agencies will benefit from the study because they will have a better understanding of the patterns of sense making and common uncertainty/anxiety reduction methods employed by their clients. Having that knowledge will better enable agencies to design and implement programs specific to the unique needs of the mentally ill. The communications community will benefit from this study for the simple fact that there is little research focusing on the mentally ill homeless. By using a qualitative approach, and revealing common themes in both how mentally ill homeless men and women sense-make and navigate uncertainty, a previously silenced voice will be given a much needed microphone.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 17
References

Fisher, W. Narration as a Human Communication Paradigm: The Case of Public Moral Argument, Communication Monographs, Vol. 51, 1984, pp. 1-22. Griffin, E. (2006). A First Look at Communication Literacy. San Francisco, CA: McGraw Hill Publications. Gudykunst, W.B., Toward a Theory of Effective Interpersonal and Intergroup Communication: An Anxiety/Uncertainty Management (AUM) Perspective, in Intercultural Communication Competence, R.L. Wiseman & J. Koester (eds.) Sage, Newbury Park, CA, 1993, pp. 33-71. Heuchemer, B., & Josephsson, S. (2006). Leaving homelessness and addiction: Narratives of an occupational transition. Scandinavian Journal of Occupational Therapy, 13(3), 160-169. doi:10.1080/11038120500360648.

Moxham, L. & Pegg, S.(2000). Permanent and stable housing for individuals living with a mental illness in the community: A paradigm shift in attitude for mental health nurses. Australian & New Zealand Journal of Mental Health Nursing, 9(2), 82-88. doi:10.1046/j.1440-0979.2000.00162.x.

Nelson, G., Clarke, J., Febbraro, A., & Hatzipantelis, M. (2005). A narrative approach to the evaluation of supportive housing: Stories of homeless people who have experienced serious mental illness. Psychiatric Rehabilitation Journal, 29(2), 98-104. Retrieved from Academic Search Premier database.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 18 Ritchie, L. (2009). Metaphor, narrative, and social reality in a conversation about homelessness. Conference Papers -- International Communication Association, 1-30. Retrieved from Communication & Mass Media Complete database.

Theiss, J., & Solomon, D. (2008). Parsing the mechanisms that increase relational intimacy: The effects of uncertainty amount, open communication about uncertainty, and the reduction of uncertainty. Human Communication Research, 34(4), 625-654. doi:10.1111/j.14682958.2008.00335.x

Young, E. (2009). Memoirs: Rewriting the social construction of mental illness. Narrative Inquiry, 19(1), 52-68. doi:10.1075/ni.19.1.04you.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 19 Appendix A Research Sample and Follow up Questions Read aloud: Homeless people have to deal with many circumstances which many people may not be fully aware of, it is the goal of this interview to get your interpretation, through your stories so that others may be better able to understand your thought process. Interview Question #1 What are some of the reasons why you are (or have been) homeless? Follow up: Who do you feel is/was responsible for the circumstances you just described? Follow up: Why do you feel that way? Follow up: What specifically happened during that event? Interview Question # 2 What mental illness have you been diagnosed with? Follow up: Do you agree with the diagnosis? Follow up: What medications are you currently taking? Follow up: Do you feel better after taking the medication? Follow up: Please tell me about a time you felt afraid when you were on and off your prescribed medication.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 20 Question #3 What does a regular week look like for you? Follow up: What did a regular week look like for you when you were on the streets? Follow up: Tell me how you felt and what you did during those weeks. Follow up: Please give me one example. Interview Question # 4 Tell me about the last time you felt that you wouldnt be able to eat or find shelter? Follow up: Who do you blame? Follow up: What did you do to ensure that you ate and were out of the elements? Follow up: What advice would you give to someone who is new to a homeless environment.

Making Sense Out of Sense-Making: A qualitative analysis on sense-making and uncertainty reduction in the mentally ill homeless community 21 Appendix B Letter to the ISB Dear Sir/Madam, My name is Kenyon Stanley and I am a graduate student at Queens University of Charlotte. I am writing you this letter in hopes that I will be able to get approval for my attached research proposal. The purpose of my proposal is to gain insight into how the mentally ill homeless population sense-make and reduce uncertainty and anxiety. If approved, my research will shed new light on how the mentally ill homeless community process and navigate through their hard lives. The method for the research will be qualitative and dialogic in nature. Mentally ill homeless men and women have not had a voice in the communication or therapeutic society. While my sampling will be limited in scope, the results will provide care providers and communication scholars data that will open the doors for further studies. Thank you in advance for considering my research proposal. If you have any questions, or if you require any additional information, please feel free to contact me at your convenience. Regards, Kenyon Stanley kenyon.stanley@qmail.queens.edu