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The effects of Gestalt and Cognitive-Behavioral therapy group interventions on the assertiveness and self-esteem of women with physical disabilities facing abuse

Dissertation
Author: Cilene Susan Adam Rita
Abstract:
The purpose of this study was to examine the differential effects of Gestalt and Cognitive-Behavioral group therapy interventions on assertiveness and self-esteem among women with physical disabilities facing abuse. The eleven women, who met the study criteria, were randomly assigned to one of two experimental conditions, Gestalt Therapy (GT) and Cognitive-Behavioral Therapy (CBT) group interventions. The Demographic Questionnaire (Adam Rita, 2009) documented personal characteristics of the participants. The criterion instruments were: (a) RAS (Rathus, 1973), and (b) CFSEI-2 (Form AD, Battle, 1992) measuring assertiveness and self-esteem respectively and were administered pre-and-post treatment. The research was conducted over a period of six weeks, totaling six weekly two-hour group sessions. It was hypothesized these interventions would help women with physical disabilities facing abuse increase their levels of assertiveness and self-esteem. To determine if the differences between groups were statistically significant for the two dependent variables, assertiveness and self-esteem, MANCOVAs within subjects contrasts and between subjects effects were examined. Based on these findings, neither Gestalt Therapy (GT) nor Cognitive-Behavioral Therapy (CBT) group interventions produced statistically significant outcome effects on the dependent variables, assertiveness and self-esteem. The findings did not support the research hypotheses; therefore both null hypotheses were retained.

TABLE OF CONTENTS Dedication ........................................................................................................................... ii Acknowledgments............................................................................................................... ii List of Figures .................................................................................................................... vi List of Tables .................................................................................................................... vii CHAPTER I: INTRODUCTION ................................................................................... 1 Abuse in Women with Physical Disabilities ................................................................... 1 Assertiveness .................................................................................................................. 2 Self-esteem ...................................................................................................................... 4 Group Therapy ................................................................................................................ 5 Gestalt Therapy ............................................................................................................... 6 Cognitive-Behavioral Therapy ....................................................................................... 8 Statement of the Problem ................................................................................................ 9 Research Questions ....................................................................................................... 10 Definitions of Terms ..................................................................................................... 11 Assumptions of the Study ............................................................................................. 13 Limitations of the Study ............................................................................................... 14 Summary ....................................................................................................................... 14 CHAPTER II: REVIEW OF THE LITERATURE ................................................... 15 Introduction ................................................................................................................... 15 Abuse in Women with Physical Disabilities ................................................................. 15 Self-esteem .................................................................................................................... 23 Group Therapy .............................................................................................................. 28

Gestalt Therapy ............................................................................................................. 32 Cognitive-Behavioral Therapy ..................................................................................... 38 Summary ....................................................................................................................... 43 CHAPTER III: METHODOLOGY .............................................................................. 44 Introduction ................................................................................................................... 44 Research Design ........................................................................................................... 45 Figure 1 Research Design ............................................................................................. 45 Variables ....................................................................................................................... 46 Setting ........................................................................................................................... 46 Participants .................................................................................................................... 46 Preliminary Procedures ................................................................................................. 47 Treatment Procedures ................................................................................................... 49 Criterion Instruments .................................................................................................... 52 Research Questions and Hypotheses ............................................................................ 54 Data Analysis ................................................................................................................ 55 Summary ....................................................................................................................... 58 CHAPTER IV: RESULTS OF DATA ANALYSIS .................................................... 59 Description of the Participants ...................................................................................... 59 Analysis of Pretests ....................................................................................................... 67 Correlation .................................................................................................................... 69 Research Questions and Hypotheses ............................................................................ 70 Multivariate Tests ......................................................................................................... 72 Treatment Group Summary .......................................................................................... 75

Summary ....................................................................................................................... 78 CHAPTER V: SUMMARY AND DISCUSSION ....................................................... 79 Introduction ................................................................................................................... 79 Restatement of the Problem .......................................................................................... 79 Review of Literature Summary ..................................................................................... 80 Review of Methods and Procedures ............................................................................. 83 Restatement of the Research Questions and Associated Hypotheses ........................... 84 Summary of Findings .................................................................................................... 85 Limitations of the Study ............................................................................................... 90 Recommendations for Future Research ........................................................................ 91 Summary ....................................................................................................................... 92 APPENDIX A HIC APPROVAL FORM .................................................................... 94 APPENDIX B INFORMED CONSENT FORM ........................................................ 95 APPENDIX C CRITERION INSTRUMENTS ........................................................ 100 Demographic Questionnaire ....................................................................................... 100 Group Counseling Session Summary ......................................................................... 102 APPENDIX D CORRESPONDENCE ....................................................................... 103 Recruiting Flyer .......................................................................................................... 103 Letter from Cooperating Agency ................................................................................ 104 APPENDIX E HANDOUTS........................................................................................ 105 Handout for Cognitive-Behavioral Group .................................................................. 105 Handout for All Groups .............................................................................................. 118 Local Resources for Assistance and Support – Ann Arbor ........................................ 118

References ....................................................................................................................... 121 Abstract ........................................................................................................................... 141 Autobiographical Statement............................................................................................ 143

vi LIST OF FIGURES Figure 1: Research Design …………………………………………………………………… 45 Figure 2: Statistical Analyses ………………………………………………………………… 57 Figure 3: Group Counseling Session Summary Format of Group Therapy Sessions-Gestalt Therapy (GT) Group Interventions ………………………………………………… 75

Figure 4: Group Counseling Session Summary Format of Group Therapy Sessions-Cognitive- Behavioral Therapy (CBT) Group Interventions .......……………………………… 77

vii LIST OF TABLES Table 1: Age Distribution by Treatment Group …………………………………… 60 Table 2: Demographics by Treatment Group ……………………………………… 61 Table 3: Type of Disability by Treatment Group …………………………………. 63 Table 4: Type of Abuse Experience by Treatment Group ………………………… 65 Table 5: Past 12 months Abusive Experiences by Treatment Group ………………. 66 Table 6: Descriptive Statistics by Treatment Group ………………………………. 67 Table 7: Independent Samples t-Test ……………………………………………… 68 Table 8: Pearson Correlation Pre-and-Post Testing ……………………………….. 69 Table 9: Descriptive Statistics by Treatment Group - Assertiveness ……………… 71 Table 10: Descriptive Statistics by Treatment Group – Self-esteem ………………... 72 Table 11: Multivariate Analysis of Covariance (MANCOVA) Tests of Within Subjects Contrasts - Assertiveness ………………………………………. 73

Table 12: Multivariate Analysis of Covariance (MANCOVA) Tests of Within Subjects Contrasts – Self-esteem ………………………………………… 73

Table 13: Multivariate Analysis of Covariance (MANCOVA) Tests of Between Subjects Effects – Assertiveness and Self-esteem ………………………. 74

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CHAPTER I INTRODUCTION Women with physical disabilities are experiencing increasing rates of violence, either within their families, by acquaintances, and/or in business and social organizations (Milberger, Israel, LeRoy, Martin, Potter & Patchak-Shuster, 2003). This includes verbal, economic, emotional, physical and sexual violence. In addition, they may experience other types of abuse such as intimidation, abandonment and neglect, forced isolation, withholding of equipment, medication, transportation, or personal service assistance (Masuda, 1996). Abuse in Women with Physical Disabilities Nosek, Young & Rintala (1995) found women with disabilities were more likely to experience abuse by their health providers, and personal assistants, and the duration of the abuse was significantly longer than for women without physical disabilities. Evidence has suggested the rate of experiencing violence is twice the rate as that of women without disabilities (Powers, 2002). Women with disabilities may lack a clear understanding of the different types of abuse, due to their inability to compare experiences with others and/or validate inappropriate practices. One cause of disempowerment for women with physical disabilities may be the lack of access to information and services. Only a small amount of research exists examining the abusive experiences of women with disabilities. Thus, the need for more research is warranted. Based on a review of research, Chappell (2003) concluded, “women with disabilities face an abusive epidemic of monumental proportions” (p. 12). According to Powers, Curry, Oschwald, Maley, Saxton & Eckels (2002), “the inaccessibility, reliance on support services, poverty and isolation, is critical for understanding women’s increased risk for abuse” (p.4).

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The discrimination and prejudice experienced by persons with disabilities, if internalized, sends the message that they are less worthy (Nosek & Hughes, 2001). While some research suggests disability is reported as the main reason why one has low self-esteem, others suggest that it is not the disability per se but the impact it has on the social, emotional, physical and environmental aspects of one’s life that influences their self-esteem. Nosek, Hughes, Swedlund, Taylor & Swank (2003) conducted a study that indicated women with disabilities had significantly lower self-esteem, self-cognition, as well as greater social isolation than women without disabilities. According to Hughes, Robinson-Whelen, Taylor, Swedlund & Nosek (2004), the self-esteem of women with physical disabilities and chronic conditions can be affected by many reasons, including the exclusion they may feel, as well as the “devaluation that society often imposes on persons with physical impairment” (Goffman, 1963, as cited in Hughes, et. al., 2004). Counseling approaches that target increasing assertiveness and self-esteem of persons with disabilities may help them in preventing or reducing the abuse. Young, Nosek, Howland, Chanpong & Rintala (1997) addressed the need for prevention services addressing the negative perception that women with disabilities have of their self- esteem, and body image. A study conducted by Saxton, Curry, Powers, Maley, Eckels & Gross (2001) revealed one of the barriers women with disabilities face regarding abuse is the difficulty in recognizing it and having their experiences validated. Research examining the effects of counseling interventions on the assertiveness and self-esteem of women with physical disabilities facing abuse is warranted. Assertiveness Assertiveness is believed to be an interpersonal behavior resulting from an intrapersonal cognitive state. In other words, assertiveness is seen as the ability one has to assert oneself as

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well as the capability of saying no to requests that one does not want to fulfill. In recent decades however, the concept of assertiveness has broadened and includes interpersonal competence in conflicts, and capacity to maintain relationships (Bekker, Croon, van Belkom & Vermee, 2008) . Assertiveness skills practiced in a safe environment, such as a group setting, may help women with physical disabilities to express themselves more effectively, and understand their capacity for self-growth and self-realization (Vail & Xenakis, 2007). Duckworth & Mercer (2006) suggested assertive behavior is in fact an acquired behavior that develops according to the individual’s opportunity for practice and refinement. The goal of assertive communication and behavior is mutual respect. Duckworth & Mercer (2006) imply assertiveness increases the probability of having needs met and opinions appreciated. The maintenance of relationships is also a hypothesized positive outcome of assertive behavior and communication. Women with physical disabilities exhibit high levels of stress, which may be accounted for by their perception of being unable to control events (Hughes, Taylor, Robinson-Whelen & Nosek, 2005). The choice of using more assertive behaviors to overcome many fears and lack of control is based on personal experiences and satisfaction. Enns (1992) suggested personal change involves the practice of new attitudes toward the self. Many women with physical disabilities compare themselves to others in their ability to do something. “Social comparative standards also affect self esteem in how much satisfaction an individual derives from his/her accomplishments” (Bandura, 1993, p. 121). Self-esteem is defined by Rosenberg (1979) “as the sense of self-respect, worthiness, and adequacy and the self evaluation of one’s self concept” (as cited in Hughes, Robinson, Whelen, Taylor, Swedlund & Nosek, 2004). Interventions that help women to be assertive, to stand up for their own rights while not stepping on the rights of others, is crucial for women if they are not to be powerless

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victims (Worell & Remer, 2003). The impact of a short-term therapy intervention on the assertiveness and self-esteem of women with physical disabilities who have experienced abuse will be explored by this study. Self-esteem Self-esteem, according to Coopersmith (1968), is defined as the self-appraisal of one’s significance, worth, competence, and success, when comparing one’s self with others. A study conducted by Nosek, Howland, Rintala, Young & Chanpong (2001) revealed women with physical disabilities experience problems associated with low self-esteem, such as depression, unemployment, social isolation, limited opportunities to establish satisfying relationships, and emotional, physical, and sexual abuse. Self-esteem plays a major role in the lives of women with physical disabilities (Nosek, Hughes, Swedlund, Taylor & Swank, 2003). The social stigma, and devaluation society often inflicts on women with physical disabilities affects their self-esteem. Due to the pressure and responses from society that women with physical disabilities may receive, their perceived self- beliefs of efficacy are affected and places diverse effects on their psychosocial functioning (Bandura, 1989). Neve (1996) points out women with physical disabilities that have experienced some kind of abuse often feel isolated, different and powerless, and often have low self-esteem. It is assumed people tend to avoid activities they believe surpass their capabilities, but do undertake activities and social events where they believe themselves capable of managing. Ozer & Bandura (1990) stated a person’s “judgments of personal efficacy affect choice of activities and selection of environments” (p.472). The self-esteem of women with physical disabilities may be compromised by a series of factors. Self-esteem is jeopardized by experiences of loss (Cornwell & Schmitt, 1990). In times

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of health problems, symptom exacerbation, and/or an augment of functional limitations, self- esteem is affected placing doubt and resulting in signs (i.e., hopelessness, excessive worry and anxiety) of lower self-esteem. Self-beliefs about one’s efficacy can be altered by a series of factors, such as mastery experiences, coping strategies modeling comparative self-appraisal, and positive social assessment by strengthening beliefs in graduated steps (Ozer & Bandura, 1990). The levels of self-esteem among women with physical disabilities were expected to increase after participating in the Gestalt and Cognitive-Behavioral therapy group interventions. Group Therapy Groups can range from couples to families to larger groups of anonymous members. Across a range of different groups compositions, group therapy common goals include self- understanding, personal growth, and building upon inner resources (Corey & Corey, 2001). According to Corey (2008), a group provides the empathy and support atmosphere necessary to create trust that leads to sharing and exploring concerns one may have. The development of a group process is defined by literature differently, although all authors agree the character of a group evolves in a predictable process. The group process can constitute the treatment intervention (Huebner as cited in Chan, Berven & Thomas, 2004). The group process and interactions of members are the mechanisms that produce the therapeutic effects (Corey & Corey, 2001). Yalom (1995) defined eleven therapeutic factors as improvers of group members learning and growth. They are defined as: instillation of hope, universality, imparting of information, altruism, the corrective recapitulation of early family experiences, the development of socialization techniques, imitative learning, interpersonal learning, cohesion, catharsis and existential.

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For women with physical disabilities participating in a group may be particularly important since they share common feelings, emotions and expectations. Participation in a group may intensify the instillation of hope and a sense of universality, where members may understand that their particular problems are not unique (Huebner as cited in Chan et al., 2004). Brabender and Fallon (1993) posited group gives the protected environment where members are encouraged to practice their newly acquired and modified behaviors spontaneously and without fear of negative consequences. Group therapy provides an environment that encourages self-disclosure between group members (Riva, as cited in Seligman & Marshak, 1990). It is believed women with physical disabilities that are victims of abuse, experience low self-esteem and powerlessness. Shaller & Fieberg (1998) studied the problem of abuse of women with physical disabilities and concluded it may have a negative impact on woman’s self-esteem and may also involve economic and social deprivation. Gestalt and Cognitive-Behavioral group therapy interventions have been demonstrated as effective in the work with people with disabilities. Gestalt therapy group in rehabilitation settings may help individuals to experience and identify emotions in the here-and-now facilitating their fully experience, expression, exploration and acceptance of genuine aspects of self (Huebner as cited in Chan et al., 2004). Cognitive-Behavioral group therapy’s main goals include providing symptom relief, assisting members in finding solutions and resolving their most pressing problems and consequently teaching relapse prevention strategies (Corey, 2008). Gestalt Therapy Gestalt therapy is an existential and experiential psychotherapy that focuses on the individual’s experience in the present moment, therapeutic relationship, environment and social

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contexts in which the individual resides, and self-regulating adjustment people make as a result of the overall situation (Yontef, 1993). The main premise of Gestalt therapy is the process, in the present moment, rather than the content. Corey (1995) posited the goal of Gestalt therapy is the development of awareness with in the individual. Enns (1992) stated “awareness of current issues and social forces is still essential for helping women clearly identify the complexity of their experiences” (p.9). The Gestalt approach allows the individual to express his/her feelings being more “relational and expressive rather than introspective” (Bowman & Leakey, 2006, p.44). Through the interventions used in Gestalt therapy, an array of opportunities can be offered inviting participants, in a safe environment, to express outwardly their internal experiences. Gestalt therapy benefits those individuals who like to explore rather than modify a behavior (Yontef, 1993). The goal in therapy is “growth and autonomy through an increase in consciousness” (Yontef, 1993, p. 16). Bowman & Leakey (2006) stated “acceptance of the moment in Gestalt becomes an opportunity to experience the totally unconditioned self in relation to others” (p. 44). Women with physical disabilities facing abuse may benefit from Gestalt therapy because it does not rely exclusively on talk, but uses other channels of expression and awareness allowing the individual to fully experience the process. Bowman & Leakey (2006) posited Gestalt therapy can be “extremely helpful in working through issues of physical difference and disability” (p.45). Nichols & Fine (1980) posited awareness in therapy facilitates change. The change occurs in terms of how individuals perceive themselves, and what they value as being important to them. The numerous techniques and experiments in therapy facilitate these changes. According to Corey (2004), techniques are exercises used to bring out action and interaction. On

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the other hand, experiments are “phenomenologicaly based” (p. 312), in other words, individuals are invited to try some new behaviors and pay attention and become aware of what they experience (Corey, 2004). Examples of experiments might include dramatizing a painful memory, imagining a fearful encounter, creating a dialogue between two parts within oneself, and exaggerating certain postures (Polster, 1987). Cognitive-Behavioral Therapy The premise of Cognitive-Behavioral therapy is to assist individuals by restructuring negative thoughts, and re-establishing positive cognitions (Prochaska & Norcross, 2003). Cognitive-behavioral theory and strategies embrace a broad range of learning-based and cognitive approaches (Worell & Remer 2003). According to Phemister (2001), cognitive- behavioral therapy assists individuals in “setting and achieving short-term goals that work to build self-esteem and confidence and promote responsibility” (p. 9). Women with physical disabilities, who have been victims of abuse, generally need considerable help to cope with their feelings about the abuse and are in need of abuse intervention services to the same extent as women without disabilities (Swedlund & Nosek, 2000). Cognitive-Behavioral interventions can be used with individuals of different ages, abilities, or gender, and from diverse ethnic and cultural backgrounds (Worell & Remer, 2003). Cognitive-Behavioral interventions include stress reduction, relaxation, cognitive restructuring, role-playing, skills development, problem solving, and use of imagery (Freeman, Simon, Beutler, & Arkowitz, 1989). These techniques may be applied toward developing assertiveness skills and addressing cognitions that have be developed as a function of the abuse, such as low self-esteem (Dutton, 1992).

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When they become more able to make decisions and increase their sense of power, self- esteem and assertiveness are expected to increase. The empowerment of women can be encouraged by the use of Cognitive-Behavioral strategies. The main purpose of this study is to use a Cognitive-Behavioral group focused on building skills and improving the participants’ current levels of functioning. Statement of the Problem The number of women with physical disabilities who have suffered some type of abuse in the United States is viewed as an epidemic. According to Young, Nosek, Howland & Chanpong (1997), an estimated “eight to twelve million women in the United States are at risk for abuse” (p. 34). In other words, they posit women with physical disabilities will be abused by someone at some point in their lives. The overall aim of this study was to compare the differential effects of a Gestalt and Cognitive-Behavioral group interventions increase assertiveness and self-esteem among women with physical disabilities who have experienced abuse. The Gestalt therapy group intervention was designed to assist these women become more aware, and to use this awareness to increase their level of assertiveness and self-esteem. Improving the ability to experience and express emotions has long been a major curative factor in psychotherapy. Therefore, the experiment of having women with physical disabilities participate in the Gestalt therapy process was expected to increase assertiveness and self-esteem. Gestalt therapy is focused more on action; it is expected to facilitate awareness and effect changes on the “whole self”, more efficiently (Farnsworth, Wood & Ayers, 1975 as cited in Coven, 1977). It is assumed by this researcher that assertiveness and self-esteem are part of the whole self. Using techniques such as role-playing, fantasy, empty chair as well as, Gestalt psychodrama experiments created in the here-and-now, were expected to facilitate awareness and

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increase assertiveness and self-esteem. According to Harman (1996), Gestalt techniques are developed to help the client at an impasse, facilitate the client’s awareness, and help the client make clearer contact with self. The Cognitive-Behavioral therapy group intervention attempted to assist the women with physical disabilities to learn how to modify their thinking process so to influence their emotions and behaviors. Cognitive-behavioral therapy will allow one to investigate “the combination of psychological and situational problems which may be contributing to the patient’s distress” (Blackburn & Davidson, 1995, p. 16). Cognitive-Behavioral therapy addresses the irrational cognitions and negative assumptions that contribute to negative emotional states women with physical disabilities face (Hays & Iwamassa, 2006). The goal of Cognitive-Behavioral therapy in this study was to identify and target these cognitive distortions in treatment while balancing empathy and validation. The psychological effects of abuse can be evidence for distorted cognition, indicators of psychological distress, and relational disturbances (Dutton, 1992). Thus, cognitive-behavioral intervention may help women with physical disabilities facing abuse reconceptualize their problems in a way that will increase their chances of finding solutions. Research Questions This study examined the differential effects of two theoretical orientations, Gestalt and Cognitive-Behavioral group therapy interventions on the levels of assertiveness and self-esteem of women with physical disabilities facing abuse. To increase assertiveness and self-esteem, this study was conducted in two-hour segments over a period of six weeks. The research questions guiding this study were:

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1. Will the level of assertiveness in women with physical disabilities facing abuse, who participate in Gestalt Therapy (GT) group interventions, be increased significantly more than those who are in the Cognitive-Behavioral Therapy (CBT) group interventions? 2. Will the level of self-esteem in women with physical disabilities facing abuse, who participate in Gestalt Therapy (GT) group interventions, be increased significantly more than those who are in the Cognitive-Behavioral Therapy (CBT) group interventions? Definitions of Terms The following definitions were relevant to this study: Assertiveness Assertiveness is an interpersonal expressive behavior which promotes equality in human relationships, enabling an individual to act in his or her own best interest, to stand up for himself or herself without anxiety, to express honest feelings comfortably, and to exercise his or her own rights without denying the rights of others (Alberti & Emmons, 1995). Self-esteem Self-esteem is defined as “the attitudinal component of the self; the affective judgments placed on the self-concept. Self-esteem consists of feelings of worth and acceptance and develops as a consequence of a sense of identity, awareness of competence, and feedback from the external world” (Gladding, 2006, p. 128). Gestalt Therapy Gestalt Therapy is existential, given that it is grounded in the here-and-now; it focuses on personal choice, responsibility, and awareness (Corey, 2004). Gestalt therapy is best understood

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by the experiential opportunity it gives individuals to experiment with new behaviors fostering the increase of self-awareness (Yontef, 1995). The effectiveness of Gestalt therapy is in focusing special attention on the surface of the behavior, the individual’s gestures, voice, posture, movements, language and interaction with others. In this study, the aim of the Gestalt therapy group interventions will be to provide women with physical disabilities the possibility of becoming more aware of their thinking, feeling, and doing. According to Coven (1977), people with disabilities often feel unsure about their feelings of acceptance and denial of the disability. These conflicted feelings may generate tension and stress. The limitation in movement, caused by the physical disability, may make it difficult for the individual to be aware that they can control their lives. The exercises and experiments of Gestalt Therapy will provide these individuals with the support and opportunity to observe other women and identify with other women’s strengths and vulnerabilities, facilitating otheir awareness and growth. Cognitive-Behavioral Therapy Cognitive-Behavioral therapy is based on the theory of personality which maintains that people respond to life events through a combination of cognitive, affective, motivational, and behavioral responses (Beck & Weishaar, 2005). This approach focuses on developing a detailed case conceptualization as a way to understand how people view their world (Corey, 2001). The Cognitive-behavioral group therapy approach is very optimistic and positive about the prospects for developing effective interventions to address human distress (Worell & Remer, 2003). The techniques used in cognitive-behavioral therapy are expected to help women with physical disabilities facing abuse to recognize irrational cognitions and negative assumptions that contribute to their negative emotional state (Hays & Iwamasa, 2006).

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Physical Disability Physical disability is defined as “having a significant limitation in mobility and /or self- care and constitutes a chronic life strain” (Hughes, Taylor, Robinson-Whelen & Nosek, 2005, p.14). Abuse Abuse of women with physical disabilities is here defined as “any intentional act that results in, or is likely to result in, harm or suffering, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life” (Hassouneh-Phillips, 2005, p. 70). Assumptions of the Study Assumptions of this research study included: 1. All women with a self-reported physical disability and abusive experience, participating in this research study, will be similar in characteristics pertaining to their economic resources, living conditions, and will be in the 18-70 years of age group. 2. That by being assured anonymity, participants will answer the questions honestly and without significant bias. 3. Individual differences in personality characteristics will be greatly reduced by the use of random assignment. 4. All individuals participating in this study will be able to read and understand at a minimum eighth-grade level.

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Limitations of the Study This study considered the following limitations: 1. This study was limited to women with a self-reported physical disability and abusive experience who volunteer to participate and may not be representative of all women or ethnicities. Generalizations to other populations of women with disabilities must be made with caution. 2. This study relied on paper and pencil instruments and self-reported which are subject to socially desirable responses. 3. Individuals were expected to self-report experienced abuse. 4. Additional unknown factors may have influenced the women’s levels of assertiveness and self-esteem and not be accounted for in this study. Summary This chapter introduced the problem to be addressed in this study. Research variables, questions, and definition of terms were described. The basic assumptions and limitations of the study were presented. Chapter II presents the literature review and existing research on assertiveness and self-esteem, women with physical disabilities facing abuse, Gestalt Therapy (GT) and Cognitive-Behavioral Therapy (CBT) group interventions.

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CHAPTER II REVIEW OF THE LITERATURE This chapter focuses on the literature and existing research pertinent to this study. A review of the literature and existing research of the differential effects of Gestalt Therapy (GT) and Cognitive-Behavioral Therapy (CBT) group interventions on levels of assertiveness and self- esteem in women with physical disabilities facing abuse are presented. The dependent variables examined are assertiveness and self-esteem. The significant findings and relevance of those findings to the current study are discussed. Introduction Abuse among women with physical disabilities is an issue that is obtaining the attention of many researches in the area of disabilities. The prevalence of abuse among women in general has been fairly well documented, yet only a few studies have examined it among women with disabilities. A national study of women with physical disabilities conducted by Nosek, Howland, Rintala, Young & Chanpong (2001) suggests the same percentage of women with and without disabilities had experienced emotional, physical, or sexual abuse, but the women with disabilities experienced the abuse for longer periods of time. The study also implies women with disabilities have even fewer options of escaping or resolving the abuse than women without disabilities due to their difficulties in locomotion. This chapter focuses on the review of literature on the effects of assertiveness and self-esteem in women with physical disabilities facing abuse and coping strategies that allow them to continue living and cope with the abuse. Abuse in Women with Physical Disabilities Abuse has been identified as the most important health issue of women with physical disabilities (Hassouneh-Phillips, 2005). According to Tyiska (1998), women with physical

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disabilities not only are at higher risk of abuse compared to women without disabilities, but the abuse may also have a greater negative impact on their well-being. It is thus understandable that the women who have suffered any kind of abuse may show signs of low self-esteem, powerlessness, as well as feelings of sadness, shame, guilt and depression (Dutton, 1992). Women with physical disabilities have described numerous forms of abuse, including physical, sexual and financial abuse, medication manipulation, equipment disablement or destruction, neglecting to provide needed services, abuse of children and pets, and devastating verbal abuse (Saxton et al., 2001). A survey of 200 women conducted by Powers et al. (2002) substantiated the negative impact of abuse on women with disabilities’ lives. Abuse prevented 29% of the participant’s from being employed; 64% from taking care of their health; and 61% from living independently. According to Melcombe (2003), the unemployment rate among women with disabilities has been identified as being as high as 75%. Women with disabilities face many barriers in their struggle for access and equality (Tilley, 1998). According to Saxton et al. (2001), “women with disabilities have lived their lives in a world that devalues and discriminates against both disabled people and women” (p. 407). The Center for Research on Women with Disabilities conducted an extensive national study of women with physical disabilities, which included a comprehensive assessment of emotional, physical, and sexual abuse. In this study they found 62% of women with physical disabilities as well as women without disabilities had experienced emotional, physical, or sexual abuse, but women with disabilities experienced abuse for longer periods of time. In addition, the abuse might have been withholding needed orthotic equipment (i.e, wheelchairs, braces), medications, transportation, or essential assistance with personal tasks, such as dressing or getting out of bed (Nosek, Howland, Rintala, Young & Chanpong, 2001).

Full document contains 154 pages
Abstract: The purpose of this study was to examine the differential effects of Gestalt and Cognitive-Behavioral group therapy interventions on assertiveness and self-esteem among women with physical disabilities facing abuse. The eleven women, who met the study criteria, were randomly assigned to one of two experimental conditions, Gestalt Therapy (GT) and Cognitive-Behavioral Therapy (CBT) group interventions. The Demographic Questionnaire (Adam Rita, 2009) documented personal characteristics of the participants. The criterion instruments were: (a) RAS (Rathus, 1973), and (b) CFSEI-2 (Form AD, Battle, 1992) measuring assertiveness and self-esteem respectively and were administered pre-and-post treatment. The research was conducted over a period of six weeks, totaling six weekly two-hour group sessions. It was hypothesized these interventions would help women with physical disabilities facing abuse increase their levels of assertiveness and self-esteem. To determine if the differences between groups were statistically significant for the two dependent variables, assertiveness and self-esteem, MANCOVAs within subjects contrasts and between subjects effects were examined. Based on these findings, neither Gestalt Therapy (GT) nor Cognitive-Behavioral Therapy (CBT) group interventions produced statistically significant outcome effects on the dependent variables, assertiveness and self-esteem. The findings did not support the research hypotheses; therefore both null hypotheses were retained.