Extinction of Homo Neanderthalensis

Summary The paper provides an in-depth and comprehensive research explaining the extinction of the Neanderthal species from the earth. It unravels how their existence and eventual extinction almost 30,000 years ago has raised heated debates amongst the scientific, historical, and archaeological communities. It has extensively identified and explained the most common theories attributed to their eventual collapse notably their inherent incapacity to cope in sudden climatic changes, competitive exclusion, emergence of new diseases, hybridization by the Cro-Magnons, and extermination by early human species. These factors combined both directly and indirectly resulting in the eventual extinction of the Neanderthals. The paper credits extensive scientific investigations, which reveals that thermal considerations were helpful in unraveling the imminent challenges of the late Paleolithic archaeology i.e., the extinction of Neanderthal species and persistence of the modern humans. Recent examinations have also revealed that harsh environmental conditions and extreme climatic fluctuations resulted in Neanderthal extinction. Moreover, the archaeological data shows that the Neanderthal species were adapted to cold conditions but only to some degree. Finally, the paper closely examines why the Neanderthal extinction coincided with the arrival of modern man. In this aspect, it concludes that the arrival of modern man directly led to rapid extermination of Neanderthals because of increased competition for large game and the emergence of new diseases to which the Neanderthals were not well adapted.

Extinction of Homo Neanderthalensis The origin of Neanderthals can be traced back to 300,000 B.P. Initially they occupied Western Europe and Asian territories until 200,000 B.P. Since the Neanderthal species was discovered in 1856, their place in the genealogy of human family and their ancestral relations to contemporary Europeans has been subject of several debates despite the fact that they are classified as separate species distinct from humans. In order to understand their existence and eventual extinction almost 30,000 years ago, archaeologists have developed various theories to explain their fate. The most common theories include their inherent incapacity to cope in sudden climatic changes, competitive exclusion, emergence of new diseases, hybridization by the Cro-Magnons, and extermination by early human species. According to Tattersall and Schwartz (2007), these factors combined both directly and indirectly resulting in the eventual extinction of the Neanderthals. Scientific and archaeological researchers have identified various hypotheses explaining the cause of Homo Neanderthalensis’ extinction from the world. These theories try to explain that the extinction of Homo Neanderthalensis was not solely a result of human interference. They suggest that there were environmental factors, which were also involved in the extinction of this species from the earth. These theories will be examined in this paper in the subsequent paragraphs. Rapid extinction by pathogens hypothesis stipulates that the species were more susceptible to various pathogens than the human species. Tattersall and Schwartz (2007) attribute this to different lifestyles between human beings and the Homo Neanderthalensis species. Besides, the occurrence of various pandemics and epidemics that killed a few human beings but caused massive mortalities in the Homo Neanderthalensis also resulted to their gradual depopulation and subsequent extinction. As a result, the Homo Neanderthalensis population declined significantly due to pathogenic causing diseases, and eventually wiped out the entire species. Among the notable diseases, which resulted in the extinction of Homo Neanderthalensis is gonorrhea. This disease spread more and faster among the Homo Neanderthalensis, resulting in high morbidity and mortality of the species eventually resulting to the extermination of the Homo Neanderthalensis species (Underdown 2008). The Homo Neanderthalensis were less adopted to evade the disease causing microorganisms. They did not have effective body defense mechanisms hence they were always susceptible to new infections, which killed them in large numbers. Their susceptibility resulted in increased and faster spread of diseases amongst the populations. This was very different from human species that had effective body defense mechanisms that inhibited rapid spread of diseases and hence were least likely to succumb to epidemics. Due to their intelligence, human beings were able to avoid close contact people suffering from particular diseases, therefore making it possible to evade the transmission of the infectious agents. For this reason, the Homo Neanderthalensis species was not able to survive in an environment full of infectious organisms (Underdown, 2008). Anthropologist of Arizona University proposed that the lack of division of labour in the Homo Neanderthalensis population resulted in their demise. These species did not have specialization like the human beings. The male and the female animals all went hunting for the big and small game together. This is as opposed to human beings who had undergone division of labour and specialisation such that the male humans were the ones hunted down big game leaving the small ones for the females. This lack of specialisation for Homo Neanderthalensis had two direct effects: first, the males were not able to become very strong to face the big animals and capture them to get food due to inadequate exposure hence resulting in less food for the Homo Neanderthalensis and their perpetual extinction from the face of the earth. Secondly, the big animals were naturally dangerous to females Homo Neanderthalensis and in most cases, they ended up killing majority of them resulting in lack of female Homo Neanderthalensis to ensure continued perpetuation of the species. Human beings were able to survive since the males specialized in hunting big animals such as bison and wild horses. The males specialised in such activity, grew stronger, and thus were able to have steady supply of food that ensured their survival. On the other hand, the female human beings were not exposed to the constant danger of being killed by the big animals during the process of hunting, thus the human species survived well than the Homo Neanderthalensis species (Gillespie, 2008). If the Homo Neanderthalensis underwent division of labour like the human beings, the males would become well adapted to attack and kill the big wild animals. They would be more adapted to hunt the big animals without being killed. They would also ensure that at the end of the day, there is sufficient food for consumption. This would result in the continued existence of the species. On the other hand, the females would be able to attack the small animals and ensure that they go home with some food. They would however not expose themselves to the dangerous and bigger game, ensuring that the females survived to preserve the perpetuation of the Homo Neanderthalensis species. The Neanderthals did not however specialize in such type of hunting resulting in massive depopulation of female species who died while hunting. In addition, the Neanderthals experienced low food supplies and there was an increased decimation of females resulting in less reproduction among the Homo Neanderthalensis species and the subsequent extinction of the entire species (Gillespie, 2008). Other researchers have proposed that there were significant anatomical differences between Homo Neanderthalensis and human beings. The species had shorter and stockier limbs and therefore were not able to run very fast like human beings hence failing to cope with severe competition for food. In order to walk and run, the Neanderthals needed more energy in fact they needed thirty percent more energy when compared to human beings hence they often failed to capture their prey as they looked for food. The animals would also not run as fast as human beings would therefore; they were not able to capture animals, which were their major source of food. In addition, they would not run fast enough to evade imminent enemies thus; they regularly died in the hands of potential enemies. Other researchers have proposed that the pelvises of Homo Neanderthalensis were not well adapted for the absorption of shock like the human beings. Therefore, bouncing off from one-step to another was a big problem for the Homo Neanderthalensis, which might have contributed to their extinction (Tattersall & Schwartz, 2008). The anatomical differences between humans and Homo Neanderthalensis species gave the humans an advantage over the Homo Neanderthalensis in competition for food and residence. The humans were able to gather enough food for their use and find suitable habitats for their shelter moreover human beings were able to fight their enemies better than the Homo Neanderthalensis. This resulted in a situation where the Homo Neanderthalensis were more exposed to food shortages and attacks by other world animals. They were not well adapted to defend themselves or run because of their anatomical differences. This resulted in a continued decrease in the population due to lack of enough food and attack by other animals leading to their subsequent extinction from the earth (Tattersall & Schwartz, 2008). Climatic changes also contributed to the extinction of Homo Neanderthalensis. Various theories have hypothesized that they were not able to adapt to the changing climate in Europe and change their hunting methods. The European continent underwent change in climate, which led to sparse vegetation growths to become a semi-desert. However, the Neanderthals were not adapted to walk faster and run long distances to look for food. This resulted in decreased food and a decrease in the Homo Neanderthalensis population (Shea, 2008). Scientific investigations and extensive research reveals that thermal considerations have been helpful in unraveling the imminent challenges of the late Paleolithic archaeology i.e., the extinction of Neanderthal species and persistence of the modern humans. Recent examinations reveal that harsh environmental conditions and extreme climatic fluctuations resulted in Neanderthal extinction. Besides, the archaeological data shows that the Neanderthal species were adapted to cold conditions but only to some degree; in fact, Gillian (2007) argues that they were more adapted to mild cold conditions but not well adapted to severe cold spells hence the emergence of very cold conditions resulted to their extinction. Throughout the world, Neanderthal extinction coincided with the arrival of Homo sapiens. Some theories suggest that Neanderthals led extremely difficult and scary lives. The arrival of modern man directly led to rapid extermination of Neanderthals because of increased competition for large game. In addition, the emergence of new diseases from Southern immigrants also resulted in their extinction. The Neanderthals inhabited most parts of Western Eurasia where contemporary fossil records “show incipient Neanderthal cranial morphologies.” Today, it is understood that they had inferior physiological and cognitive abilities compared to modern man. Various theories postulate that the Neanderthals were carnivorous and predators in ecosystems where they existed and often they competed for food with hyenas and lions but since they could not ran faster and relied on primitive weapons they were forced to extinction since they could not secure sufficient food. Other theories from recent scientific examinations claim that the Neanderthal extinction was primarily due to unprecedented population from the Cro-Magnon population hence refuting the theory underpinning climate change to their extinction. In one study, scientists reconstructed climatic data from Western Europe during the period Neanderthals were thought to have lived and analyzed archaeological data from sites they inhabited prior to the arrival of modern man and concluded that indeed the Neanderthal extinction was due to severe fluctuations in climatic conditions. This study employed geographic data from archaeological sites dated by carbon dating technology and used climatic dating 40,000 years ago in order to determine how prevailing climatic conditions shaped the areas inhabited by the Neanderthals. Through integration of archaeological and environmental data, this study reconstructed and identified regions with favorable climatic conditions occupied by specific populations. After comparing various areas occupied by Neanderthals and Homo sapiens, during the climatic phases under review, it was found that the Neanderthals occupied vast lands across the European continent during climatically favorable times known as the Greenland Interstadial but their populations declined as environmental conditions deteriorated. However, Gillian (2007) argues that the Neanderthals who occupied today’s Southern Spain were the last survivors because they avoided direct competition with Homo sapiens since they occupied and exploited different environments during severe climatic conditions. In addition, he affirms that when the Neanderthals and Homo sapiens directly competed for food, but failed to keep due to severe competition posed by early men. Another theory suggests that the Neanderthals disappeared almost 40,000 ago due to catastrophic environmental phenomenon. According to this theory, archaeological data found in “Mezmaiskaya cave suggests that volcanic eruptions, which occurred almost 40, 000 years ago had unusual abrupt and destructive effects on the environment causing severe climate shifts in the Northern Hemisphere. These data hypothesizes that the extinction of the Neanderthals occurred suddenly approximately 40,000 years ago after the most potent volcanic eruption hit “Western Eurasia during the era of Neanderthal evolutionary history” (Gillian 2007). This catastrophic event severely destroyed the environmental habitats occupied by Neanderthal populations and caused massive their massive depopulation throughout the areas they lived especially in Western Europe. This massive losses in Neanderthal populations eventually resulted in their extinction. Despite the fact that this theory is highly controversial, it is nevertheless gives a lucid perspective underlying their possible extinction. However, Gillian (2007) hardly believes that the theory is adequate to be relied upon because the Neanderthal populations inhabited wide range of habitats. In contemporary societies, the greatest mystery in scientific knowledge concerns the rise of Homo sapiens and the extinction of Neanderthals. Although there are several theories explaining the extinction of Neanderthal populations, the most prevalent Darwin’s “survival for the fittest and principle of competitive exclusion,” which accentuate that only the most efficient species will survive in face of competition whereas the least capable will certainly become extinct. Such theories of biological efficiency normally underpin physiological factors. Horan, Bulte, and Shogren (2007) have extensively discussed another possible theory hypothesizing Neanderthal extinction called the “Behavioral Model for Neanderthal Extinction.” They demonstrate how division of labor and ensuing trading patterns among the early Homo sapiens assisted them to triumph over the inherent biological deficiencies of the Neanderthal population resulting in their ultimate extinction. Neanderthal populations in Western Europe first appeared almost 300,000 years ago from the ancestry that later gave rise to modern humans. Anthropologists, historians, and scientists have searched for possible explanations that led to the sudden extinction of Homo Neanderthalensis after thousands of years in existence. Several paleontologists have maintained that their abrupt demise wasn’t coincidental with the rise of early Homo sapiens. Although they have pointed fingers to early human species, it remains unresolved as to how early man exactly contributed to Neanderthal extinction although it is well understood that they created competitive advantage over Neanderthals and introduced new diseases that attacked the less adaptive Neanderthals. Available literature suggests multiple theories that led to the extermination and eventual extinction of Neanderthals although no theory completely satisfies available scientific and archaeological data. However, using Darwin’s theory of survival for the fittest, we can deduce that Neanderthal extinction was due to the ‘efficiency’ and superiority of modern man and the ‘inefficiency’ and incompetence of Neanderthal populations. Other theories have stressed that exogenous forces governed Neanderthal demographic dynamics presumably because these forces were inherent and outside their control. Their ability to find food depended on their skills, physiology, and available hunting technologies. In this context, survival for the fittest firmly holds the idea that “huge differences existed in exogenous biological factors (as opposed to behavioral factors) such as high birth rates and lower mortality rates and physiological and technological factors like being better hunters” (Horan, Bulte, & Shogren 2007). Because the early man was competitively superior to Homo Neanderthalensis, we can authoritatively ascertain that the Homo sapiens competitively outdid Neanderthal species resulting in their extinction. However, Gillian fervently argues against this proposition by ascertaining that it is extremely impossible to determine with precision the exact “biological, physiological, and technological [causes] that led to Neanderthal extinction.” Secondly, he acknowledges the existence of physical differences between Homo Neanderthalensis and Homo sapiens and argues that it is impossible to believe that both had distinct anatomical differences. Archaeological data shows that the Homo Neanderthalensis was slightly more squat and bigger although both were stronger and intelligent and were able to make tools and hunting weapons. Additionally, even though both species had distinct differences, scientific and archaeological information is clear that these differences only favored Homo sapiens. Presumably, the Neanderthal populations were stronger and well adapted to the severe environmental and climatic conditions they endured centuries but were highly susceptible to new diseases such as gonorrhea, which killed them in their thousands. Horan, Bulte, and Shogren (2007) refute the theory of biological exclusion because they feel it is inadequate as it primarily focuses on individual traits of the Neanderthal population. Since Darwinian Theory of natural selection, biologists have focused on both the beneficial and unhelpful traits of individual organisms such as their birth rate and mortality rate, their ability to endure stressful conditions and find food but have always avoided studying these aspects on groups of individual organisms. Consequently, their efforts to replicate the theory on natural selection to group levels have failed because of its potential to extend evolutionary theory beyond unreasonable limits.   In his study, Gillespie (2008) investigates how early humans survived and addresses the question of Neanderthal extinction from behavioral perspectives, whereby individual persons devise collective ways to overcome individual constraints in order to make their circumstances endogenous. Another study by Tattersall and Schwartz (2007) found out that the principal theory underlying difficulties of co-existence lies in the “behavioral modernity of early man.” They affirm that up to today tangible and formal behavioral theories provide lucid explanations for Neanderthal extinction. They consider how interactions amongst individuals could have actually resulted in Neanderthal extinction and survival of Homo sapiens and concluded that the development of trade, specialization, and division of labor effectively allowed modern man to “seal the fate of Neanderthals.” Gillespie (2008) supports this theory as he argues that contemporary socio-economic trends are manifestations of simplified underlying capacities, which were acquired by early man but were conspicuously absent when the Neanderthals lived. Consequently, contemporary human species “experienced endogenous economic [prosperity] that resulted to production of detailed and diverse products compared to the ones produced by Neanderthals and earlier human cultures.” This partly explains why modern man survived while the Neanderthals species went extinct. Additionally, Gillian (2007) contends that there are several theories satisfactorily illuminating all aspects of Neanderthal extinction and although he believes that the widely acknowledged archaeological data is in fact poorly comprehended to judge conclusively the absolute pros of every postulated theory however; “it is necessary that we take the first step at incorporating behavioral responses to economic stimuli.” Accordingly, we should incorporate behavioral explanations of Neanderthal demise probably based on their relative capability to reclaim trade gains, which resulted from endogenous division of labor. Conversely, Tattersall and Schwartz’s maintains that the economic foundation of highly exclusive competitive principles at group level enabled modern man to survive as the Neanderthal species died because they pursued uncoordinated hunting episodes.   In conclusion, all the above theories suggest that there were other factors in addition to human interference, which caused extinction of the Homo Neanderthalensis species. The Homo Neanderthalensis species was not able to survive because of their lack of anatomical advantage over human beings resulting in increased susceptibility to food shortages and killing by other animals. They were also not able to specialise into different roles depending on their sexes, thus led to killing of more of them and lack of enough food. There were also climatic changes that resulted in severe food shortages, therefore resulting in death of the animals. Lastly, the Homo Neanderthalensis were less adopted to avoid contacting infections, and were more exposed to epidemics, which later resulted in the extinction of the species from the face of the earth. For these reasons, the Homo Neanderthalensis species is no longer existent on earth.

References Gillespie, R. (2008). Updating Martin’s global extinction model. Quaternary Science, 27(28), 2522-2529. Gilligan, I. (2007). Neanderthal extinction and modern human behavior: the role of climate  change and clothing. World Archaeology 39(4), 499–514 Horan, R., Bulte, E., & Shogren, J. (2007). How Trade Saved Humanity from Biological Exclusion: An Economic Theory of Neanderthal Extinction. New York: Harper Collins  1-48. Shea, J. (2008). Transitions or turnovers? Climatically-forced extinctions of Homo sapiens and Neanderthals in the east Mediterranean Levant. Quaternary Science, 27, (23), 2253- 2270. Tattersall, I., & Schwartz, J. H. (2008). The morphological distinctiveness of Homo sapiens and its recognition in the fossil record: Clarifying the problem. Evolutionary Anthropology, 17, 49–54. Underdown, S. (2008). A potential role for Transmissible Spongiform Encephalopathies in Neanderthal extinction. Medical Hypotheses, 71(1), 4-7.

Online Contracts; the Use of Electronic Signatures

Introduction

 

The purpose of a contract is to establish the agreement that the parties have made, and to fix their rights and duties in accordance with that agreement (Dr. Matteu, 1998). An online contract is a contract created and signed online. In other words, no paper or hard copy is involved. An electronic contract can also be in the form of ‘click to agree’ button, which is most prevalent in contracts for the purchase of software (Shmuel, 2008). E-commerce is defined as commercial dealings carried out through electronic networks including the publicity, marketing and supply, order or delivery of goods and services [Australian Guidelines for Electric Commerce]. Online contracts are becoming more prevalent in the modern world. This can be seen as a result of globalization where one can contract with another who is probably even on another continent through the internet. By contracting online, businesses are able to improve efficiencies, reduce paperwork, and streamline their operations (Elizabeth Macdonald, 2011).

However, the flipside of this is that this advancement in technology creates various challenges on the law of contracts applying specifically to online contracts (Noah, 1998). Therefore, there is a need to establish clarity on what may qualify as a legally binding contract and its elements. Online contracts are essentially not different from the regular contracts on paper. The requirements, in order to qualify as valid contracts, are the same only that the signature is electronic as opposed to hand signature. For the validity of a signature, all the other aspects of a valid contract must be present. This research will briefly look at the requirements of a valid contract before embarking on the signature. The law that deals with electronic contracts in Australia is the Electronic Transactions Act 1999. There is also the Australian Guidelines for Electronic Commerce.

 

Offer versus invitation to treat

In Australian law, the conclusion of a contract is normally broken into three: an invitation to treat, an offer, and acceptance. The mere display of an item on a window shop is not the offer itself, but just an invitation to treat. An invitation to treat in legal terms comes before the offer, and it is an indication that the seller may be prepared to enter into a contract with any potential buyer (Collins, 1999). The offer is made only when the buyer walks into the shop and expresses an intention to buy an item. It is not necessary that the offer needs to be accepted, and the seller may refuse to accept for any various reasons. Only when the seller agrees to sell the item is when the issue of contract comes into play.

This analysis of a normal contract gives an overview of the process in online contracting. The display of items on the website may be compared to the display of items on a window shop, which is merely an invitation to treat. The offer is made when the buyer places an order, and the seller at that point will still have the discretion of either accepting or refusing the offer. That is why there is a proposal that all the sellers online should put an indication in their terms, and conditions that the display of their items is just an invitation to treat.

Acceptance in online contracts

As the law stands, it is not clear when acceptance in online contracts can be held to have occurred. However, the general rule is that acceptance must be at all times communicated. The question, therefore, is when it can be said that acceptance has been communicated, for instance, if an offer is made online by the buyer and the seller processes the acceptance by Email, if the acceptance made when the seller presses the ‘send’ button, or when it leaves the seller’s email server, or when it reaches the buyer’s email server, or when the buyer reads his email. There are two ways of signifying acceptance online: either through email or through the website. The exchange of emails is essentially similar to the exchange of correspondence in normal signatures. The email containing the acceptance should contain the same terms as the email containing the offer. In normal correspondences, the date of acceptance is the date of posting the letter. Regarding the online transactions, acceptance is held to have occurred when it becomes available for the addressee to retrieve it [Electronics Transactions Act, section 9A].

Legal validity of electronic signatures

The parties to a contract have to agree to all the terms and conditions. Placing the terms and conditions on the agreement does not signify that they are obligatory. The parties must expressly agree to the terms either before or at the time of contracting in order for them to be bound legally (Robert, 2006). The best practice in online contracts is for the seller to indicate the terms as well as conditions preferably on a different page, and require that the buyer agree to the terms and conditions before signing the contract. This may be achieved by requiring that the buyer click the ‘I agree’ button before signing the contract.

For most transactions from a website, the client will key in his or her names and contact information before sending the order. Sending this information – by hitting ‘send’ – in effect is creating an electronic signature, and this mark will be given the same legal legitimacy as if the client signed a written deal and mailed it.

In 1996, the United Nations (UN) adopted a model law regarding electronic commerce, and in 2001, the UN adopted a model law on electronic signatures. These model laws have been used to implement the legal principles inherent to electronic signatures in a number of countries. In Australia, for instance, there is the Electronic Transactions Act of 1999. Section 10 of this Act requires a signature of a person under Commonwealth Law, and that signature be held to have been made if there is a system to recognize the person, and to establish his intention as regards the signature. The method used should be reliable as effective for the purpose, which the electronic communication was granted in the light of all circumstances including any relevant agreements.

In light of these mentioned trends, it is clear that electronic signatures are legally valid, and they involve a person affixing a mark alongside their names within a contract with the intention of indicating their willingness to enter into that contract. For this purpose, contracts for the goods sale can be held to be enforceable after the buyer presses the ‘I agree’ button [I. Lan Systems, Inc. vs. Net scout Service Level Corp]. In this case, the court found out that the party to a deal was bound by the terms and conditions of the contract between it and the website owner.  Clicking of the ‘I agree’ button at the bottom of the contract was held to be an indication that the buyer was willing to be legally bound.

There are also some circumstances that do not relate to the sale of goods contracts but under which a contract may be made. These are such as agreeing to be a member of a certain website or even agreeing to be bound by other agreements contained in the website. In such situations, a binding contract can be inferred if a signature is affixed. However, the test is that of whether the terms and conditions are displayed in a conspicuous manner, in such that any prudent buyer, affixing a signature would be able to take notice of (Robert, 2006). If the terms and conditions are not conspicuous, then the buyer cannot be bound [Pecht vs. Netscape Communications Corp] In this case, the issue was whether the buyer of software agreed to be bound by the contractual terms of the software. The court found that the contractual terms had been placed below the purchase button; therefore, even a reasonable and prudent buyer would not have foreseen the existence of such. It was held that the buyer could not be bound by inconspicuous terms and conditions that he is not aware of.

In contrast, where the terms and conditions are clearly displayed, the contract will be held as valid if a signature is affixed [Groff vs. America Online]. In this case, the terms and conditions of a certain site were presented in a way that guests to the site should scroll through them first and agree to be bound before he could proceed to the site itself. The court found that there is no any way one could have enrolled to the site without pressing the ‘I agree’ button placed next to the ‘I disagree’ button. The subscriber was bound by the terms therein.

In some scenarios too, even when the user has not expressly signed to be bound by the terms and conditions, his consent may be implied from his conduct (Mark, 2006). These are essentially implied contracts. If the conduct is in such a way as to suggest that the subscriber or buyer holds himself to be bound by the terms and conditions, then he can be held to be so bound just as if he had put a signature to be bound. [Register.com, Inc. v. Verio, Inc] The court found that the terms and conditions on a certain site were binding on the person even though he did not pass through the screen, and signify its intention to be bound. The user had gone ahead and submitted a document through the site without first agreeing to the terms and conditions, and it was found that its conduct implied consent.

On the contrary, though, if the site does not mandate the user to approve the terms and conditions first, then his conduct cannot be said to imply consent [Ticketmaster Corp., et al. v. Tickets.Com, Inc.]. The issue in this case was whether in situations where the site does not mandate the user to agree to the terms and conditions first, such can be binding on the user. It was held that such terms and conditions are not held as mandatory; therefore, they are not legally binding.

Conclusion

Although the use of paper contracts is still prevalent, current trends signify to the fact that, in the future, the use of online contracts will be more rampant than ever before. It is, therefore, important to establish guidelines, which will enable enforcement of the same in the future to be clear. Both parties to the contract should establish authenticity in the contract before signing to ensure that issues of fraud are reduced (Allan, 1991). Accuracy of the information contained in the contract has to be established too to make sure that it has not been interfered with in any way through the channels it goes before finally being published. This will prevent one from signing an un-enforceable contract.

In in addition to the requirement, the author of the contract should not repudiate the information or even deny the contents of the contract. Before signing, contracting parties should have mutual consent as to the contents of the contract without any contradiction at all. It is, therefore, evident that, with clear legal guidelines on how to create an online contract, such contracts, when signed, can be of a great value to the economic growth and advancement in the wake of globalization.

 

 

 

 

 

References

Journals

 

1. 1.      Alan, S. (1991). Unconscionability and Imperfect Information: A Research Agenda. 19 Can. Bus. L.J. 437.

 

1. 2.      Gillette, C.P. (2005). Pre-approved Contracts for Internet Commerce. HOUS. L. REV.

 

3. Hillman, R. (2006). Online      Boilerplate: Would Mandatory Website Disclosure of E-Standard Terms      Backfire? 104 MICH. L. REV, 852.

 

4. Lemley, M. (2006). Terms of Use. 91      MINN. L. REV.

 

1. 5.      Macdonald, E. (2011). Incorporation of Standard Terms in Website Contracting: Clicking I Agree. 27 Journal of Contract Law, 198.

 

1. 6.      Moringiellou, J. (2006). Signals, Assent and Internet Contracting. 57 RUTGERS L. REV.

 

7. ShmuelI. (2008). Asymmetric      Information in Consumer Contracts: A Challenge that Is Yet to be Met.      45 Am. Bus. L.J. (forthcoming 2008).

 

1. 8.      Winn, J., & Bix, B. (2006). Diverging Perspectives in Electronic Contracting in the US and the EU. 54 CLEV.ST.L.REV.

 

1. 9.      Zats, N. (1998). Sidewalks in Cyberspace: Making Space for Public Forums in the Electronic Environment. 12 Harv.J.L. & Tech, 149.

 

Books

1. Collins, H. (1999).Regulating Contracts. New York: Oxford University Press.
2. Dr. Matteu, Larry, A. (1998) Contract Theory: The Evolution of Contractual Intent; East Lansing Michigan State University Press.

Cases

1. Groff vs. America OnlineFile No.C.A. No.PC 97-0331, 1998 W L 307001 (R.I. Superior Ct., May 27, 1998).

2. Lan Systems, Inc. vs. Net      scout Service Level Corp; 183 F.Supp.2d 328, Civ. Act.No. 00-11489-WGY, 2002      US Dist.

 

1. Register.com, Inc. v. Verio, Inc,126F.Supp 2.d at 248.(S.D.N.Y 2000).

4. Specht vs. Netscape      Communications Corp;306 F.3d 17(2nd circ.2002).

 

1. Ticketmaster Corp., et al. v. Tickets.Com, Inc.[2000] U.S. Dist. Lexis 12987 (C.D. Ca., August 10, 2000)

Statutes

1. Electronics Transactions Act, 1999, Laws of Australia

The Australian Guidelines for Electronics Comme

Music as a Stimulus

Department of Counseling

Scientific Merit Review (SMR)

Qualitative Methods Version

 

Scientific Merit Process

Dissertation researchers will use this form to complete the process of scientific merit review (SMR). The goals of this process are to (a) facilitate the planning of a dissertation research project in consultation with your mentor, (b) evaluate scientific merit, and (c) evaluate your proposed methodology. You must obtain scientific merit approval before writing the dissertation proposal. In the Department of Counseling, scientific merit approval satisfies dissertation milestone 5. This form replaces the dissertation worksheet and the school level review of the proposal.

Scientific Merit

The following criteria will be used to establish scientific merit. The purpose of the review will be to evaluate if the study:

• Advances the scientific knowledge base.
• Makes a contribution to the field.
• Meets certain “Hallmarks” of good research methodology.

GENERAL INSTRUCTIONS

You and your mentor should use this form in a step by step way to plan your design and to submit for scientific merit review. Expect that this process will require revisions and reviews so please allocate your time and resources appropriately. Here are the steps to follow:

1. Talk with your mentor about your ideas for your dissertation topic and a possible methodological approach.
2. Collaborate with your mentor to refine your topic into a specific research project that will add to the existing literature on your topic.
3. Then, complete the sections on topic and basic methodology (sections 1 & 2) and submit to your mentor for approval.
4. Collaborate with your mentor until you have mentor approval for the topic and the basic methodology (sections 1 & 2) you plan to use.
5. After you have received mentor approval for sections 1 & 2, your mentor will submit sections 1 & 2 to your program chair for topic approval.
6. After you have your Program Chair Approval for your topic, collaborate with your mentor to plan the details of your design. Now is the time for your mentor to seek any input from your dissertation committee about the proposed methodology. If you do have a committee member with methodology expertise, now is the time for your mentor to arrange for a consultation with the dissertation committee members about your research design plans or your mentor may prefer for you to complete the SMR form and submit it to your committee for feedback. The mentor and committee members can decide how they want to work through this step. However, any input on the research design from the Dissertation Committee must occur before the SMR is approved.  The proposal approval is an approval of chapters 1-3 as written. The methodology approval occurs at SMR approval. The Dissertation Committee’s opportunity to provide input on the research methodology occurs before SMR approval is obtained.
7. After you, your mentor and your committee have agreed on clear plans for the details of the methodology, complete the rest of the form and submit this to your mentor for approval.
8. Expect that you will go through several revisions.
9. After you have a polished version, you and your mentor should both review the SMR criteria for each section to make sure you have provided the information needed to demonstrate that you have met each of the criteria.
10. After you have obtained mentor approval for the SMR, your mentor may want to submit this form to the committee for input. When your mentor feels the form is ready for review, the mentor will submit the form for Scientific Merit Review.
11. The Scientific merit reviewer will review each item to determine whether or not you have met each of the criteria. You must meet all the criteria to obtain approval. The reviewer will provide feedback on any criteria that you have not met.
12.  The SMR will be approved, deferred for minor or major revisions, or disapproved.
13. If the SMR has been deferred, you will need to make the necessary revisions and obtain approval for the revisions from your mentor.
14. Once you have mentor approval for your revisions, your mentor will submit your SMR for a second review.
15. You will be notified if your SMR has been approved, deferred for major or minor revisions, or not approved.

16     If a researcher does not pass the scientific merit review on the 3^rd attempt, then the case will be referred back to the Mentor,  the Scientific Merit Research Lead and the Program Chair or the Research Chair for the School of Social and Behavioral Sciences for review, evaluation and intervention. Interventions might include the recommendation or requirement that the learner take a writing course, take an additional research course, attend the dissertation writer’s retreat or attend a Track 4 colloquia event. The purpose of any intervention would be to help the researcher develop research or writing skills that could help them succeed.

17    Once you obtain SMR approval, proceed to write the dissertation proposal and prepare your IRB application. This should be easy because the methodology sections on the SMR correspond to the sections that are included in the School of Social and Behavioral Sciences Dissertation Chapter 3 Guide.

18    Scientific Merit approval is required before IRB approval but does not indicate that IRB approval will follow scientific merit approval.

Researchers, please insert your answers to the questions that appear in bold black font, using a black font that is not in bold.  Please insert your answers directly into the expandable boxes that have been provided! Do not write in the sections that are in Capella Red. Reserve this for the Reviewers to respond.

 

SMR Reviewers, please respond to each review question by checking either yes or no. Then, please provide comments, including detailed feedback or recommendations ONLY for items that do NOT meet the criteria. A submission must meet all of the criteria to obtain scientific merit approval. Once you have responded to each section please complete the Scientific Merit Status assessment for this submission and insert your electronic signature and date on the form. If the SMR did not meet all of the criteria, then it should be deferred for minor or major revisions or disapproved. If it has been deferred for Major revisions, you may want to schedule a conference call with the mentor and the researcher to discuss the study. If you would like to require this, please indicate this on the form. If Final Scientific Merit Status (approved or disapproved) has been determined, please also indicate this in the final section on the form and insert your signature and date in the section at the end of the form.

 

Section 1: Learner and Topic Information

1.1 Learner Information

Learner Name:

Learner Email:

Learner Phone number:

Mentor Name:

Mentor Email:

Mentor Phone Number:

Program:

Program Chair:

1.2 Research Question (What do you really want to know? The rest of this form derives from and should constantly be guided by your research question.  Always consider your research question in addressing all following components of this design form.)

 

List the primary research question. A qualitative study should answer the question: What is it like…? (A. Giorgi, personal communication, October 11, 2010). Qualitative studies conducted in the Psychology Department should be led by one open-ended question.  In the Counseling Department, there can be an exception to this rule. For example, a case study or a grounded theory study may have two or three research questions. List the Primary research question. If the study does seek to answer an additional research question or two, list these as well. 

1. What is the role of music therapy in the treatment of sleep disorders among adults suffering from depression?

2. How do adults suffering from sleep disorders and depression experience group and individual music therapy?

3. What are the indicating and contra-indicating factors for music therapy on sleep disorders with these adults suffering from depression?

4. How do participants believe music therapy impacts their overall treatment?

1.3 Proposed Dissertation Title: (Usually a statement based on the research question–short and to the point.)

MUSIC AS A STIMULUS: EFFECTIVENESS OF MUSIC THERAPY INTERVENTION ON SLEEP DISORDERS IN ADULTS SUFFERING FROM DEPRESSION

1.4 Research Topic

Describe the specific topic to be studied in a paragraph. (Be certain that the research question relates to the topic.)

Music Therapy (MT) is one of the expressive therapies that are applied in within the perspective of psychotherapy, rehabilitation, counseling, or health care. Music therapy and its various forms of intervention create music stimuli that stimulate the central nervous system processes. Stimulation of such processes will evoke strong memories in the adults with mental disorders as the vibration will dissolve the blockages in nadis, meridians, arteries, veins, or nerves, causing a relieving effect that will intern help to relieve the mental illnesses (Unkefer & Thaut, 2005, p. 23).

1.5 Need for the Study

Describe the need for the study. Provide a rationale or need for studying a particular issue or phenomenon.

The main rationale of this study is the missing link between music therapy intervention on sleeping disorders in adults with depression and its success rating (effectiveness); this was expressed by Crowe and Colwell (2007) in their study that was aimed at identifying effective clinical practices in music therapy application for children, adolescents, and adults with mental disorders. Though they did a good study, they never identified the efficiency/effectiveness of this therapy among adults with depression. There have been several follow-up researches on children and adolescents with mental disorders who are under music therapy but little has been done on adults (Ulrich et al, 2007).

 

 

Section 2: Methodology

2.0 Methodology

 

The qualitative approaches accepted for Counseling are ethnography, case study, grounded theory, phenomenology and generic qualitative research.  Heuristic studies are not encouraged in the Department of Counseling but may be conducted with special permission if the researcher and the mentor have expertise in this methodology. The researcher should submit a letter outlining both the researcher and mentor’s expertise and knowledge in heuristics.  The documentation will be received by the Research Chair or Research Lead and considered. Providing documentation does not guarantee permission.  

 

 

Describe the qualitative methodology (for example phenomenology) and research model (for example Giorgi – empirical phenomenology or Moustakas – transcendental phenomenology) you propose to use.

 

Briefly identify the method(s) will you use to collect the data, such as: open-ended conversational interviews, journaling, letters, pictures, observations, field notes, focus groups – focus groups are only used for ethnography grounded theory, case study and generic qualitative research only.

 

 

 

     The study will make use of an approach based on the phenomenological philosophy so as to enable the researcher to gather reliable and valid results. This approach will be used by the researcher to define the beliefs, assumptions and the nature of reality of this research study. The researcher will analyze every situation in its totality. In order to develop and come up with ideas from the target population, induction will be used during the research process. Additionally, the study sample will be investigated over a given period of time and a natural setting will also be used to implement this research. For this reason, a qualitative induction design will be utilized to achieve the study’s objectives (Easterby, 2008).

This study will utilize questionnaires and interviews as methods of data collection. The researcher will administer the questionnaires to the target respondents online through electronic mails. The questionnaire will be accompanied by consent forms and introductory letters. The researcher will request the respondents to deliver their feedbacks through emails. On the other hand, secondary data will be gathered by performing a thorough document search in books, journals and magazines that contain relevant information to the question under investigation (Schwab, 2005).

 

 

 

 

 

 

Directions for Mentors

 

Your submission of the SMR topic section to the Program chair indicates your approval of the mentee’s work. This indicates that you have consulted with the mentee and that you approve of the topic and basic methodology.  Be sure to work with your mentee to fully polish Sections 1 & 2 before submitting it to your specialization chair for topic approval.  Then provide your electronic signature and date and submit it to your specialization chair for topic approval.

 

Mentor Topic Approval

 

 

Mentor Signature ________________________      Date _____________________

 

 

 

 

Program Chairs

 

Please review the sections on dissertation topic and basic methodology (sections 1 & 2) and make a determination as to whether or not this topic is appropriate for the Department of Counseling and the Program area.  If the topic is not approved, please check no and provide comments. If the topic is approved, please check yes, then insert your electronic signature and date the form below.

 

1. 1.      Program Chairs: Are the dissertation title, topic and basic methodology appropriate for the Counseling Department and the program area? Please comment if not approved.

 

_____YES or____ NO

 

Program Chair Comments:

 

 

 

 

 

 

 

Program Chair Topic Approval

 

Signature ________________________     Date _________________________

 

Next Steps for Learners and Mentors

 

1. If you did not obtain program chair approval, collaborate with your mentor to make appropriate revisions until you obtain program chair topic approval.
2. Once Topic approval from your program chair has been obtained, complete the sections on advancing the scientific knowledge base and contributing to research theory (Sections 3 & 4) and collaborate with your mentor until you obtain approval for sections 3 & 4.
3. Then work with your mentor to agree on the details of how you will conduct the study.
4. Complete section 5 to describe the details of the methodology. Be sure to provide the step by step detail needed so that someone else would be able to replicate the study.
5. Expect to go through revisions.
6. Once you have received approval for the SMR form by your mentor, your mentor will submit the SMR for formal scientific merit review.

 

 

Section 3: Advancing the Scientific Knowledge base

Your study should advance the scientific knowledge base in your field by meeting one or more of these four criteria:

 

1. A.     The study should address something that is not known or has not been studied before.
2. B.     The study should be new or different from other studies in some way.
3. C.     The study should extend prior research on the topic in some way.
4. D.    The study should fill a gap in the existing literature.

Specifically describe how your research will advance scientific knowledge on your topic by answering all of these 3 questions. Include in-text citations as needed.

3.1 Advancing Scientific Knowledge

Demonstrate how the study (a) will advance the scientific knowledge base; (b) is grounded in the field of counseling; and (c) addresses something that is not known, something that is new or different from prior research, something that extends prior research, or something that fills a gap in the existing literature. Describe precisely how your study will add to the existing body of literature on your topic. It can be a small step forward in a line of current research but it must add to the body of scientific knowledge in your program area and on the topic.

 

To respond to this question you will need to:

1. Provide a paragraph that describes the background for your study and how your research question relates to the background of the study.
2. Then, in a second paragraph discuss previous research and demonstrate exactly how answering your research question will advance the scientific knowledge base on this topic. Include in-text citations to demonstrate exactly how this study will fill a gap in the existing literature and place the references in the reference section.

 

 

The recognition of music as a dominant instrument of operation towards wellness for an individual dates back to ancient times. However, music therapy as a professional field application is a recent occurrence. Music therapy began as a field in the 1940s, as several specialists in the field of psychiatry instigated treatment in a more holistic way (Nolan, 2003). Karl Menninger is an example of one of these prominent psychiatrists who intended to meet client needs using a broad variation of modalities. The purpose of this study is to examine the effectiveness of music therapy interventions on sleep disorders among adults suffering from depression. Another is to identify the obstacles that hinder the success of music therapy interventions on sleep disorders among adults suffering from depression. Finally, through qualitative inquiry via the questionnaire survey, the purpose of this study will be to collect and tabulate available data on music therapy interventions on sleep disorders among adults suffering from depression.

There is limited available information on success rates of music therapy interventions on sleep disorders among adults with depression; thus, this study will significantly contribute to information boost in this sector. The constant research on how to improve existing and new interventions on mental disorders depends greatly on the available information; therefore, the awareness that will be created by this study will greatly contribute to identification of the weaknesses of music therapy, with the aim of improving its application and finding out other alternatives. Pursuing this topic will avail a deep understanding of clinical psychology scenario and improve the level of comfort when handling sleep disorder cases among adults with depression. Crowe and Colwell (2007) did a study that was aimed at identifying effective clinical practices in music therapy application for children, adolescents, and adults with mental disorders. Though they did a good study, they never identified the efficiency/effectiveness of this therapy among adults with depression. There have been several follow-up researches on children and adolescents with mental disorders who are under music therapy but little has been done on adults (Ulrich et al, 2007).

 

 

 

 

 

 

 

 

 

3.2 Theoretical Implications

 

Describe any theoretical implications that the proposed study may have for understanding phenomena. For example, will the study generate new theory, provide a description of the lived experience of the participants or provide a description of a cultural phenomena?

 

This study seeks to fill the gap that exists in provision of information on effectiveness of music therapy in treating adult depression. It also examines the effectiveness of music therapy interventions on sleep disorders among adults suffering from depression. Another is to identify the obstacles that hinder the success of music therapy interventions on sleep disorders among adults suffering from depression.

 

 

 

3.3 Practical Implications

 

Describe any practical implications that may result from your research.  Specifically, describe any implications the research may have for understanding phenomena for practitioners, the population being studied, or a particular type of work, mental health, educational, community, stakeholders or other setting.

 

Pursuing this topic will avail a deep understanding of clinical psychology scenario and improve the level of comfort when handling sleep disorder cases among adults with depression. It can significantly impact on healthcare provision for those with mental illnesses. The health care professionals can utilize the information generated to improve service delivery and outcome of treatment.

 

 

 

 

Reviewers

3        Does the study advance scientific knowledge in the field and the program area by meeting one or more of these four criteria?

Does the study address something that is not known or has not been studied before?

Is this study new or different from other studies in some way?

Does the study extend prior research on the topic in some way?

Does the study fill a gap in the existing literature?

_____YES or____ NO

 

Reviewer Comments

 

 

 

Section 4: Contributions of the Proposed Study to the Field

 

 

4.1 Contributions to the Field

 

Your study should make a contribution to your field based on the approach used to conduct the research:

 

1. A.     Ethnography – The study should produce a description of some dimensions of a culture.
2. B.     Case Study – The study should develop a lesson to be learned from the case.
3. C.     Grounded theory – The study should generate new theory or point to an emergent theory.
4. D.    Phenomenology – The study should yield a description of the lived experience of the participants.
5. E.     Heuristics – The study should yield a description of lived experience which includes the experience of the researcher as well as those of the participants. Please see note above under section 2.0. This type of research requires special permission and expertise in this methodology.
6. F.      Generic Qualitative Research – The study should answer the question using qualitative data.

Describe how your study is grounded in and/or adds to knowledge in the field.

Significance of the Study

 There is limited available information on success rates of music therapy interventions on sleep disorders among adults with depression; thus, this study will significantly contribute to information boost in this sector. The constant research on how to improve existing and new interventions on mental disorders depends greatly on the available information; therefore, the awareness that will be created by this study will greatly contribute to identification of the weaknesses of music therapy, with the aim of improving its application and finding out other alternatives. My study will contribute to increasing the well of information that can be used in healthcare provision.

 

Reviewers

4.1  Does the Research make a contribution to your field in one of these ways?

• Ethnography – The study should produce a description of some dimensions of a culture.
• Case Study – The study should develop a lesson to be learned.
• Grounded theory – The study should generate theory or point to an emergent theory.
• Phenomenology – The study should yield a description of the lived experience of the participants.
• Heuristics – The study should yield a description of lived experience which includes the experience of the research as well as those of the participants. This type of research would require special permission and expertise in this methodology.
• Generic Qualitative Research – The study should answer the research question using qualitative data.

 

_____YES   or____ NO

 

Reviewer Comments

 

4.2 Theoretical Foundations

 

Briefly describe the theoretical basis for the study.  Describe the major theory (or theories) that may serve as the foundation for investigating the research topic,  inform the research questions and provide any corresponding citations. 

 

 

Though the research in music therapy and mental disorders is active, the adult factor is missing in these researches. The adult population is very prone to mental illnesses; thus, more research should be done targeting this population. Vick (2003) mentions that research in music therapy should be more specific because it works differently in different groups; this is the essence of this study.  The information so far in this paper mainly gives support to the success of music therapy in relative terms like positive, successful, and improved but more quantitative data is needed so that the percentage of effectiveness of music therapy intervention on mental illnesses can be calculated and known.  There are a lot of research on other interventions on adult mental illnesses like psychoactive drugs, psychotherapy, and anti-depressants but there is minimum research on music therapy as one of the interventions.  It seeks to describe the effectiveness of music therapy as an intervention in mental illness, the impact it will have on the patients and the experience that they will undergo in their encounter with it.

 

 

 

 

 

Reviewers

 

4.2  Is any relevant theoretical basis for the study appropriately described?

 

_____YES   or____ NO

 

Reviewer Comments

 

 

 

 

Section 5: Methodology Details

5.1 Purpose of the Study

 

Describe the purpose of the study.

Why are you doing it?  (The answer must be grounded in the literature in what has been done–hasn’t been done or needs to be done.)

 

       How will the methods to be used actually answer the research question?

 

Does the study address something that is not known or has not been studied before?

Is this study new or different from other studies in some way? Does the study extend prior research on the topic in some way? Does the study fill a gap in the existing literature?

 

 

 

The purpose of the study is to identify the effectiveness of music therapy in adults and to identify the obstacles that inhibit use of music therapy in treatment of sleeping disorders in adults with depression.

The study fills the gap of unavailable information on effectiveness of therapy in adults. Literature only exists on several follow-up researches on children and adolescents with mental disorders who are under music therapy, but little has been done on adults.

 

 

 

 

 

 

 

 

 

 

 

 

1.1  Purpose of the study

Is the purpose of the study clearly stated?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

 

 

 

 

5.2 Research  Methodology

 

The qualitative methodologies accepted for psychology and counseling are ethnography, case study, grounded theory, phenomenology, heuristics (with special permission) and generic qualitative research.  Describe the qualitative methodology (for example phenomenology) and research model (for example Giorgi – empirical phenomenology or Moustakas – transcendental phenomenology) you propose to use, supported and referenced by primary sources. Describe in detail the method(s) will you use to collect the data, such as: open-ended conversational interviews, journaling, letters, pictures, observations, field notes and/or focus groups.  Focus groups are only used for ethnography, grounded theory, case study, and generic qualitative research only.

 

Briefly describe how the study will be conducted.  (Describe how you are going to carry out the study.)

This research will be based on the phenomenological methodology. The study will make use of an approach based on the phenomenological philosophy so as to enable the researcher to gather reliable and valid results. This approach will be used by the researcher to define the beliefs, assumptions and the nature of reality of this research study. The researcher will analyze every situation in its totality. In order to develop and come up with ideas from the target population, induction will be used during the research process. Additionally, the study sample will be investigated over a given period of time and a natural setting will also be used to implement this research. For this reason, a qualitative induction design will be utilized to achieve the study’s objectives (Easterby,           2008).

 

5.2  Research Methodology

Does the research design proposed seem appropriate for the research question? Is the research design clearly and accurately described?  Can the design answer the research question?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

 

 

 

 

5.3 Population and Sample

 

Describe the characteristics of the larger population from which the sample (study participants) will be drawn. Next describe the sample that will participate in the study and the sample size.  Justify the sample size with support from the literature.

 

The study will be located in a Psychosocial Rehabilitation Centers (PSRs). The population selected will focus on adults with mental disorders, who were admitted to the acute psychiatric unit of the PRC. Ages were restricted between 18 to 65 years due to current limitations established by the behavioral health unit (Flick, 2009). The major participants or target population of this study will be selected by psychological therapists, psychiatrists and patients from selected rehabilitation centers that practice the use of music therapy interventions in the treatment of sleep disorders among people with depression. Other qualities of participants include; the presence of already diagnosed mental health condition, the capacity to understand and speak in English, voluntarily admission to the rehabilitation center, and the nonexistence of other active psychotic symptoms.

 

 

 

 

 

 

5.3  Population and Sample

Are the population and the sample adequately and accurately described? Is the sample size appropriate?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

 

 

 

5.4 Sampling Procedures

 

Describe how you plan to select the sample. Be sure to list the name of the specific sampling strategy you will use ((e.g. snowball, purposeful, etc). Describe each of the steps from recruitment through contact and screening to consenting to participate in the study. Be sure to describe the site from which you expect to draw your sample and indicate who is authorized to provide permission to use this site.  Describe whether or not the site has an IRB and what do you would need to do to obtain permission. Please avoid recruitment sites which could present a conflict of interest or present the appearance of coercive strategies, such as, proposing employment sites with current clients, patients, students, consumers and so on

 

 The sampling method will be purposeful.

Recruitment-The population will be selected from psychological rehabilitation centers that provide consent.

Screening- The major participants or target population of this study will be selected by psychological therapists, psychiatrists and patients from selected rehabilitation centers that practice the use of music therapy interventions in the treatment of sleep disorders among people with depression.

Participant consent- Once selected the participants will be required to sign a consent form providing permission for the study.

 

 

 

 

5.4 Sampling Procedures

Is participant involvement and participant selection fully described and appropriate for the study?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

 

 

5.5 Data Collection Procedures

 

Describe where and how will you get the data and describe the exact procedure(s) that will be used to collect the data.  This is a step-by-step description of exactly how the research will be conducted. This should read like a recipe for the data collection procedures to be followed in your study. Be sure to include all the necessary details so that someone else will be able to clearly understand how you will obtain your data.

 

The researcher will administer the questionnaires to the target respondents online through electronic mails. The questionnaire will be accompanied by consent forms and introductory letters. The researcher will request the respondents to deliver their feedbacks through emails. On the other hand, secondary data will be gathered by performing a thorough document search in books, journals and magazines that contain relevant information to the question under investigation (Schwab, 2005).

The procedure involved of the following steps:

1. The psychiatrist, the social worker and the music therapist in the rehabilitation center will screen the adults with mental disorders upon admission to the adult psychiatric unit of the Psychosocial Rehabilitation Centre (PRC). The adults who are allowed to participate in the study must be diagnosed with sleep disorders and depression and then the suitable participants are referred to the researcher.

2. The researcher then conducts an extra informal screening to gauge if the participant meets the standards of the study.

3. Once a potential participant is identified, the researcher meets with the participant and explains to him/her the procedure and purpose of the study.

4. When the consent has been sorted, the patient is incorporated as a participant in the study.

5. Before each session, the researcher creates a session plan with the help of the music therapist and based on the treatment objectives and relevant graph reviews of the participants. A treasured input into this process is also taken from the researcher’s spontaneous logs.

6. 7. After each and every session, the researcher must reflect on what has taken place in the group or individual sessions and make notes on feelings, ideas and thoughts of the participants.

8. Data is collected from the researcher’s reflexive logs and observations during the music therapy sessions. This field data is analyzed after every music therapy session. It is vital to note that this portion of the data is not used to guide the structure of the interviews

9. In case the participants are well off to be discharged by the treatment team, the researcher selects one or two of them and interviews them as they fill the final questionnaire.

10. On completion of all interviews and transcriptions, the transcripts are analyzed.

11. Finally after 12 weeks, the treatment team is interviewed and they will fill the questionnaire for the final data analysis.

 

 

 

 

5.5 Procedure

Does the researcher describe in detail the procedure to be followed in a step-by- step way so that it is completely clear how the research will be conducted? Is the data collection appropriate for the proposed study?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

 

 

 

 

5.6 Guiding Interview Questions and Field Testing

 

Describe the interview method will you use and how you will conduct the interviews.  List any guiding interview questions to be used to guide the open-ended qualitative interviews with the participants. Provide a rationale for how and why you are using the interview technique you will use to address the primary research question. Be sure to discuss the results of any field test that was conducted as a part of the process of developing the final version of the guiding interview questions. For the Counseling Department, a field test with a panel of experts is required. This is different from a pilot test. A field test involves asking a panel of experts to review your interview questions to make sure that the questions do focus on the exact research question. You want to ensure that they are appropriate for the topic and population and that they are open ended questions that are appropriate for qualitative inquiry. Please identify 3 to 5 non-Capella faculty field-experts to review your research questions. Please attach your initial interview questions, the field-testing results and your final Guiding interview questions to this application.

 

This study will mainly explore a reliable method and instrument of data collection which will be the use of a questionnaire survey. The use of questionnaires has been acknowledged by many researchers to be a reliable method (Foddy, 1993). This is because the questionnaires are developed under the guidance of the research objectives to ensure that the questions constructed are relevant to the study. In addition, they are user friendly, inexpensive to construct and administer to the research respondents. Robson (1993) established that a well-developed questionnaire assists the researcher in generating uniform answers from various respondents.

The use of open-ended questions also helps the respondents to put across their observations freely because they do not get restricted in any way. The guiding questions include:

1. Did you find the sessions beneficial or a waste of time?

2. Have found you experienced disturbed sleep lately?

3. Do you wake up feeling more rested or tired?

4. Have you developed interest in your surroundings and your friends?

 

 

5.6 Guiding Questions

Are the guiding questions appropriate to be used to facilitate the interviews? Are the guiding questions directly related to the research question and appropriate for the proposed methodology and model to be used in this proposed study?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

5.7 Other Data Collection Procedures

 

For those studies in which alternative data will be collected such as archival data,  medical/psychiatric/substance abuse records or any pre-recorded data, please describe the methods you will use to collect and analyze this alternative data.  Provide a rationale for how and why you are using this alternative data and how you will analyze it.

 

 

Alternative data will be gathered by going through the patient registers and by interviewing the staff at the rehabilitation center. Qualitative data analysis methods will be used to analyze the qualitative data that will be collected. Such methods include the use of tables, graphs and pie-charts (Schwab, 2005). Alternative data will be used to provide an in depth understanding of the therapy conducted and its effectiveness. It will also help to understand the patient’s experience during the sessions.

 

 

 

 

 

5.7 Other Data Colllection Procodures

For studies in which alternative data will be collected, did the researcher describe the alternative data that will be used, describe the methods that will be used to collect the data, analyze the data and provide a rationale for how and why the alternative data will be used?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

5.8 Proposed Data Analyses

 

Provide a step-by-step description of the procedures to be used to conduct the data analysis. Support this process by identification and reference to primary descriptive sources, such as Moustakas, Giorgi, Stevick–Colaizzi–Keen, Stake Yin, Charmaz, or Braun et al.  Check that that the data analysis process is consistent with the accepted analytical steps for the specific qualitative methodology chosen to conduct this study.

 

For the Department of Counseling, a qualitative software program is recommended to assist with data analysis and data management.  If you plan to use Qualitative data analysis software, list the software you will use and describe how it will be used. Describe how the software will be used at each step to ensure to guard against personal bias in the data analysis procedures.  It is recommended that you plan to have your mentor review the analysis of the first few transcripts to ensure that you are following the proper data analysis procedures and to guard against bias.

 

 

Once I have collected the categorical data using questionnaires and interviews, it will be processed using software programs. For Giorgi the most important thing in a research is to describe. The steps in data analysis are as follows:

Tables, graphs and pie charts will be used in analyzing the data.

1. Understand the data by reading through it as many times as necessary.

2. Identify the key question that the analysis should answer.

3.  Put the data into categories by coding or indexing it.

4. Identify the relationships between the different categories.

5. Interpret the data by integrating the relationships found.

 

 

 

 

 

5.8 Proposed Data Analyses

Is the data analysis that is proposed appropriate? Is there alignment between the research questions, proposed methodology, type or types of data to be collected and proposed data analysis? Is the language used to describe the type of design and data analysis plans consistent throughout?

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

5.9 Role of the Researcher

 

Provide a description of the researcher’s pre-understandings, preconceptions and biases about the topic and about how the researcher will set them aside?

 

 The researcher will be a part time worker at the rehabilitation facility; he will have a strong understanding of the research topic and will make observations as therapy proceeds. The researcher will keep an open mind and report any observations without steering them towards a particular direction. No information will be falsified and the responses of the participants will not be influenced in any way. The researcher is to observe patient confidentiality and will have an unbiased point of view. He will keep the identity of the respondents anonymous and will obtain consent before including them in the study.

 

5.9  Role of the Researcher

Does the researcher describe the process by which he/she will identify and set aside pre-understandings, pre-conceived ideas and biases that could interfere with conducting the proposed study?

 

 

 

 

 

 

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

 

5.10 Credibility, Dependability and Transferability

 

5.10 Credibility, Dependability, and Transferability

Present a strategy to ensure credibility, dependability, and transferability in the proposed study. Because the researcher is the primary instrument of research in qualitative studies, describe how you will establish credibility for the research.  Describe the training and experience you have in regards to your methods for collecting and for analyzing your data.  Credibility refers to confidence in the accuracy of the data as reported as well as a systematic and thorough interpretation by the researcher.  Credibility involves carrying out the study in a way that enhances the believability of the findings of the data over time and over conditions. Credibility is assessed by how well you demonstrate your understanding of your research methodology and how well you apply the methodology to data collection and data analysis. Credibility is assessed by how well you demonstrate your understanding of your research methodology and how well you apply the methodology to data collection and data analysis. Describe how you will demonstrate your expertise in regards to your research design.Transferability is demonstrated by showing that the sample fairly represents the target population, as well as by showing that the sample participants have the knowledge, experience, or expertise necessary to provide information that the discipline or field and the target population would find meaningful in regard to the topic. Dependability is demonstrated by providing clear, detailed, and sequential descriptions of all procedures and methods, such that another researcher could repeat each of them faithfully.

 

 

After the study is conducted it will be submitted to peer review. Any scholarly sources will be properly cited. The information that is generated will be sound and reproducible. The researcher will be unbiased and have no vested interests in the results of the study. There shall be no monetary incentives offered to the participants.

 

 

 

5.10          Credibility, Dependability and Transferability

Does the researcher present a strategy to ensure credibility, dependability and transferability in the proposed study?

 

 

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

 

6.0 References

 

Provide references for all citations in APA style. Submit your reference list below.

 

 

 

 

 

Crowe, B. J. & Colwell, C. (Eds.). (2007). Effective clinical practice in music therapy:                                Music therapy for children, adolescents, and adults with mental disorders. Silver      Spring,             MD: American Music Therapy Association

Easterby-Smith, M., Thorpe, R. & Lowe, A. (2008).Management Research: An Introduction,

            2nd Ed. London: Sage Publications. 67-69

Foddy, W. (1993). Constructing questions for interviews & questionnaires. NY: CUP, Cambridge University Press, 1993. 93-100

Flick, U. (2009). An introduction to qualitative research. Thousand Oaks, CA: SAGE.

Nolan, P. (2003). “Through music to therapeutic attachment: Psychodynamic music         psychotherapy with a musician with dysthymic disorder”. In S. Hadley (Ed.),     Psychodynamic music therapy: Case studies (pp. 317–338). Gilsum, NH: Barcelona.

Robson, C. (1993). Real World Research. Oxford: Blackwell

Schwab, D. (2005). Research Methods for Organizational Studies. Mahwah, NJ: Lawrence         Erlbaum Associates

Unkefer, F. R. & Thaut, H. M. (2005). Music Therapy in the Treatment of Adults with         Mental Disorders: Theoretical Buses and Clinical Intervention. St. Louis: MMB   Music, Inc.

Vick, R. M. (2003). “A brief history of art therapy”. In C. A. Malchiodi (Ed.), Handbook of

        art therapy (pp. 5–15). New York: Guilford Press

 

6.0 References

Has the researcher presented appropriate citations and references in APA style?

 

 

_____YES or____ NO

 

Reviewer Comments

 

 

 

6.1 Scholarly Writing

Does the Researcher communicate in a scholarly, professional manner that is consistent with the expectations of academia?

 

 

_____YES or____ NO

 

Reviewer Comments:

 

Optional Space for Reviewer Comments

 

This section is not part of determining SMR approval.  This is an optional space for the SMR Reviewer to make note of any practical or ethical concerns. Reviewers are not expected to comment on these issues but they can make comments or recommendations if they believe these may be helpful.  It is recommended that mentors and researchers carefully consider any comments made here as it may help flag issues or problems that need to be addressed before the researcher moves forward or before the study is submitted for ethical review which will be conducted by the IRB.

 

Optional Reviewer Comments:

 

 

 

 

 

 

 

 

 

Submitting for Scientific Merit Review

 

After you have Mentor approval for the SMR, then your mentor submits the SMR for formal scientific merit review. Mentors, your submission of the SMR to the SMR committee for review indicates your approval of the mentee’s work. This indicates that you have consulted with the mentee on the details of the methodology and that the mentee does have your approval. Before Submitting the SMR, each researcher and mentor should check the information that has been provided with the criteria for obtaining approval for each section of the SMR to make certain that all the necessary information has been included for each section in a clear and concise way. Use this like a check list!

 

Mentors, please sign and date below to indicate that you have approved this topic, reviewed the topic for scientific merit and that you have approved the details of the methodology. Then submit the form to: CompDIssSupport@Capella.edu

 

Mentor SMR Approval

 

 

Signature ________________________      Date _________________________

 

 

 

Department of Counseling

Scientific Merit Review (SMR) Evaluation

 

Scientific Merit Status

 

The Reviewer determines if the scientific Merit Review (SMR) is approved, deferred for minor or major revisions or disapproved. An SMR is approved if the reviewer has been able to answer “YES” to all of the evaluation questions.

 

1. If any of the items have been checked as “NO”, then the reviewer is asked to comment specifically and provide recommendations.  Most of the time recommendations will lead to the reviewer requesting minor or major revisions. Minor revisions are things like needing to include more detail or issues related to APA style. Major revisions are issues where there are major design flaws, potential ethical concerns or a clear inconsistency in terms of the research questions, the design and the proposed data analysis.  Disapproval occurs if the researcher fails to pass the SMR review on the third attempt or it could occur earlier in the process if it is clear that the study does not have any potential for scientific merit or the study has major ethical or methodological flaws that can’t be corrected. If a researcher does not pass the scientific merit review on the 3^rd attempt, then the case will be referred back to the Mentor,  the Scientific Merit Research Lead and the Program Chair or the Research Chair for the School of Social and Behavioral Sciences for review, evaluation and intervention. Interventions might include the requirement that the learner take a writing course, take an additional research course, attend the dissertation writer’s retreat or attend a Track 4 colloquia event. The purpose of any intervention would be to help the researcher develop research or writing skills that could help them succeed.

 

 

Directions for Reviewers

 

Please indicate your decision for this review in the correct place (First Review, Second Review, Third Review) and insert your electronic signature and the date below.  If the SMR has a Final Status of “Approved” or “Disapproved”, please be sure indicate this Final Scientific Merit Review status below as well.  If you have deferred the SMR for major revisions, you may want to require a phone conference with the mentor and researcher.

 

First Review

 

______Approved

______Disapproved

______Deferred for Minor Revisions

______Deferred for Major Revisions

_____ Conference call needed with mentor and researcher

 

 

______________________________________________________________________ 

 

Reviewer Name:

Reviewer  signature ______________________  Date______________________

 

Second Review

 

______Approved

______Disapproved

______Deferred for minor revisions

______Deferred for major revisions

______ Conference call needed with mentor and researcher

 

 

 

Reviewer Name:

Reviewer Signature ______________________  Date______________________

 

Third Review

 

______Approved

______ Referred to Research Lead, Research Chair and/or Program Chair for intervention. Interventions might include the recommendation or the requirement that the learner take a writing course, an additional research course, attend the dissertation writer’s retreat or attend a Track 4 colloquia event. The purpose of any intervention would be to help the researcher develop research or writing skills that could help them succeed. 

 

 

Reviewer Name:

Reviewer Signature ______________________  Date______________________

 

 

Final Scientific Merit Review Status

 

__________ Approved   __________   Disapproved  Date__________________

 

Reviewer Signature ______________________ Date______________________

 

This has been a Scientific Merit Review.  Obtaining Scientific Merit approval does not mean you will obtain IRB approval.

 

Once you have obtained scientific merit approval move forward to write your dissertation proposal. It should be easy because the methodology section of the SMR corresponds directly to the sections included in the Psychology Department’s Dissertation Chapter 3 Guide which is also used by Counseling and Public Safety Leadership.

 

If a researcher does not pass the scientific merit review on the 3^rd attempt, then the case will be referred to the Research Lead, the Research Chair and/or the Program Chair for review, evaluation and intervention. Researchers, mentors and reviewers should make every attempt possible to resolve issues before the SMR is failed on a 3^rd attempt.

MUSIC AS A STIMULUS: EFFECTIVENESS OF MUSIC THERAPY INTERVENTION ON SLEEP DISORDERS IN ADULTS SUFFERING FROM DEPRESSION

Table of Contents

CHAPTER 1:  INTRODUCTION.. 4

Introduction to the Problem.. 4

Background of the Study. 4

Description of Music Therapy. 4

History and Theories of Music Therapy. 6

Music Therapy and Mental Illnesses Research is Active. 7

Statement of the Problem.. 8

Purpose of the Study. 9

Rationale. 9

Research Questions and Hypothesis. 9

Significance of the Study. 10

Definition of Terms. 11

Assumptions and Limitations. 13

Assumptions. 13

Limitations. 13

Nature of the Study (or Theoretical/Conceptual Framework) 14

Population and Site Selection, Overall Research Approach and Rationale. 14

Organization of the Remainder of the Study. 15

CHAPTER 2: LITRATURE REVIEW… 16

Introduction to the Literature Review.. 16

History and Theoretical Orientation for the Study of Music Therapy. 17

History of music therapy. 17

The application of music therapy interventions on sleep disorders among adults suffering from depression. 17

Theoretical orientation. 19

Review of Research Literature and Methodological Literature. 22

Review of research on the music therapy among adult with mental disorders. 22

Review of methodological literature relevant to this study. 24

Synthesis of Research Findings. 27

Critique of previous research. 28

Summary. 29

CHAPTER 3: METHODOLOGY.. 30

Purposes of the Study. 30

Site Selection, Target Population and Participant Selection. 31

Research Procedure. 33

Research Questions and Hypotheses. 35

Expected Findings. 37

REFERENCES. 39

CHAPTER 1.  INTRODUCTION.. 4

Introduction to the Problem.. 4

Background of the Study. 4

Description of Music Therapy. 4

Music Therapy and Adult Mental Disorders. 5

History and Theories of Music Therapy. 6

Music Therapy and Mental Illnesses Research is Active. 7

Statement of the Problem.. 8

Purpose of the Study. 8

Rationale. 9

Research Questions and Hypothesis. 9

Significance of the Study. 10

Definition of Terms. 11

Assumptions and Limitations. 12

Assumptions. 12

Limitations. Error! Bookmark not defined.

Nature of the Study (or Theoretical/Conceptual Framework) 13

Population and Site Selection, Overall Research Approach and Rationale. Error! Bookmark not defined.

Organization of the Remainder of the Study. Error! Bookmark not defined.

CHAPTER 2. LITRATURE REVIEW… Error! Bookmark not defined.

Introduction to the Literature Review.. Error! Bookmark not defined.

History and Theoretical Orientation for the Study of Music Therapy. Error! Bookmark not defined.

History of music therapy. Error! Bookmark not defined.

The application of music therapy. Error! Bookmark not defined.

Theoretical orientation. Error! Bookmark not defined.

Review of Research Literature and Methodological Literature. Error! Bookmark not defined.

Review of research on the music therapy among adult with mental disorders. Error! Bookmark not defined.

Review of methodological literature relevant to this study. Error! Bookmark not defined.

Synthesis of Research Findings. Error! Bookmark not defined.

Critique of previous research. Error! Bookmark not defined.

Summary. Error! Bookmark not defined.

CHAPTER 3. METHODOLOGY.. 29

Purposes of the Study. 29

Research Design and Strategy. 30

Site Selection, Target Population and Participant Selection. 30

Sampling method. 31

Research Procedure. 32

Data collection. 33

Instrumentation. 33

Research Questions and Hypotheses. 34

Data Analyses. 35

Secondary Data Analyses. 35

Ethical Consideration. 36

Expected Findings. 36

REFERENCES. 38

 

 

 

 

 

 

CHAPTER 1:  INTRODUCTION

Introduction to the Problem

Mental disorder is a psychological human problem and has a high prevalence rate in adults for various reasons. There are various interventions that are applied to mental disorders and music therapy is one of these interventions. The evaluation of the effectiveness of music therapy intervention on sleep disorders in people with depression calls for research and that is the essence for this study. This study is influenced by the availability of general information on music therapy as an expressive intervention therapy and its application sleep disorders among adults with depression. It is seeking to find more specific details and the exact success score in its application to adults with depression. This chapter is going to give an in-depth introduction to this problem, focusing on the rationale behind this study.

Background of the Study

The background of this problem will be given through appraisal of available data on music therapy and adult mental disorders. This will be done by giving a description of music therapy, history, theories, and practice of music therapy. The background will be organized in various subheadings to make it more sensible and easy to understand.

Description of Music Therapy

Music Therapy (MT) is one of the expressive therapies that are applied in within the perspective of psychotherapy, rehabilitation, counseling, or health care. The American Music Therapy Association (2004) describes music therapy as using prescribed music to influence positive changes in the physical, social, cognitive or psychological functioning of persons with educational or health problems. Music therapy employs music and music associated activities to adjust unproductive learning patterns, support emotional, mental, social, and physical development as well as to develop non-musical goals. Music therapy is a fully established and recognized by healthcare professionals as it can positively affect adults and children alike, as identified earlier by Bruscia (1998). This therapy can make the modification concerning isolation and interaction and has been proven through scientific research in situations concerning autism, pain, depression (and mental illnesses), anger, stress, time management, grief, loss, motivation, growth, procrastination, change, and improving communication (Crowe & Colwell, 2007).

Music Therapy and Adult Mental Disorders

Music therapists are trained specialists who have completed at least a Bachelor’s degree in Music Therapy and have been clinically supervised for 1,200 hours in a wide-range of settings like psychiatric facilities, hospitals, and schools. They are the people allowed by law to offer music therapy services to people/adults with mental health disorders (Crowe & Coldwell, 2007). The most common mental disorders in the United Kingdom (UK) comprises of depression, bipolar disorders, schizophrenia, anxiety disorders, post-traumatic stress disorder, and obsessive compulsive disorders (Scovel & Gardstrom, 2002). There are many forms of music therapy intervention. Some of the widely applied are improvisatory music (where music is improvised using instruments and/or found objects, body sounds, voices, etc.), re-creative (where vocal singing is done and/or playing pre-existing songs), composition (where the formation and documentation of a freshly composed song by the client with the assistance of the music therapist), and receptive (where clients do the listening to recordings of music) (Widiger & Shea, 1991; Scovel & Gardstrom, 2002).

The client needs are the main determinant of the kind of music therapy interventions to be used on him or her. Music therapy can be used to address the following: 1) to create a means of communication and interaction; 2) offers a passage for self-expression; 3) discovering self or other relationships; 4) advancing creativity and impulse, arouse sense, as well as improve perceptual and cognitive skills; 5) improving sensory-motor skills, substitute sequenced behaviors, increasing short-term and long-term memory; 6) to express and foster emotional integration; 7) improving behavioral organizational skills; 8) improving coping and self-reliance skills; 9) improving problem-solving skills; 10) improving and integrating communication experiences; 11) assimilating parts into whole; 12) supporting  body awareness; and 13) advancing auditory skills (Vick, 2003).

Music therapy and its various forms of intervention create music stimuli that stimulate the central nervous system processes. Stimulation of such processes will evoke strong memories in the adults with mental disorders as the vibration will dissolve the blockages in nadis, meridians, arteries, veins, or nerves, causing a relieving effect that will intern help to relieve the mental illnesses (Unkefer & Thaut, 2005, p. 23).

History and Theories of Music Therapy

The recognition of music as a dominant instrument of operation towards wellness for an individual dates back to ancient times. However, music therapy as a professional field application is a recent occurrence. Music therapy began as a field in the 1940s, as several specialists in the field of psychiatry instigated treatment in a more holistic way (Nolan, 2003). Karl Menninger is an example of one of these prominent psychiatrists who intended to meet client needs using a broad variation of modalities. During this period, music was discovered to be containing essential fundamentals of therapeutic procedures and through scientific-based research, these qualities were confirmed empirically (Smith et al, 2002). After this crucial discovery, music therapy increased its acceptance into the medical field in Britain and globally. It developed considerably during World War II, as it was used to help veterans and its positive effects are seen in their recovery. Today, many music therapists work within a wide variety of locations and backgrounds, from hospital, to education, in private psychotherapy practices, as well as in applied mental illness intervention (Malchiodi, 2003).

Thaut and Unkefer (2005) discovered two most relevant theories of music therapy that are relevant to date. First is the theory of emotion arousal in music. This is very applicable in adult mental illness in the sense that when we listen to music, thoughts, and feelings are evoked that can be of great assistance in resetting the mental state of an adult with mental disorder. Second is the music stimuli and central nervous system processing (Weiner, 1999). Currently, neuro-scientific research have been used to discover neuro-substrates underlying music perception to improve various health conditions. The response is that music stimulates body nervous processes to give relieving and desired effects (American Psychiatric Association, 2003).

Music Therapy and Mental Illnesses Research is Active

In Europe and North-America, there are numerous universities that are actively involved in music therapy. Some of the most successful researches under this topic are Gold (2007), who discovered that music therapy improves symptoms in adults hospitalized with schizophrenia. Earlier in 2005, Gold had colluded with Heldal, Dahle, and Wigram (2005) to conduct a research on music therapy for schizophrenia or schizophrenia-like illnesses and the results were positive. Silverman (2003) did a meta-analysis of influence of music on the symptoms of psychosis. Ulrich, Houtmans, and Gold (2007), did a randomized study on the additional therapeutic effect of group music therapy for schizophrenic patients. Silverman (2006) interacted with adults with mental illnesses when he examined psychiatric patients’ perception of music therapy and other psych-educational programming. All these relevant studies and others will be discussed in detail in the subsequent chapter.

Statement of the Problem

Though the research in music therapy and mental disorders is active, the adult factor is missing in these researches. The adult population is very prone to mental illnesses; thus, more research should be done targeting this population. Vick (2003) mentions that research in music therapy should be more specific because it works differently in different groups; this is the essence of this study.  The information so far in this paper mainly gives support to the success of music therapy in relative terms like positive, successful, and improved but more quantitative data is needed so that the percentage of effectiveness of music therapy intervention on mental illnesses can be calculated and known.  There are a lot of research on other interventions on adult mental illnesses like psychoactive drugs, psychotherapy, and anti-depressants but there is minimum research on music therapy as one of the interventions.

Purpose of the Study

The purpose of this study is to examine the effectiveness of music therapy interventions on sleep disorders among adults suffering from depression. Another is to identify the obstacles that hinder the success of music therapy interventions on sleep disorders among adults suffering from depression. Finally, Tthrough qualitative inquiry via the the use of interviewsquestionnaire survey, the purpose of this study will be to collect and tabulate available data on music therapy interventions on sleep disorders among adults suffering from depression.

Rationale

The rationale of this study is evident throughout this chapter. The main rationale of this study is the missing link between music therapy intervention on sleeping disorders in adults with depression and its success rating (effectiveness); this was expressed by Crowe and Colwell (2007) in their study that was aimed at identifying effective clinical practices in music therapy application for children, adolescents, and adults with mental disorders. Though they did a good study, they never identified the efficiency/effectiveness of this therapy among adults with depression. There have been several follow-up researches on children and adolescents with mental disorders who are under music therapy but little has been done on adults (Ulrich et al, 2007).

Research Questions and Hypothesis

Four ive main research questions were considered in this study:

• What is the effect of music therapy interventions in the treatment of sleep disorders among adults suffering from depression?
• How do adults suffering from sleep disorders and depression experience group and individual music therapy interventions?
• What are the advantages and disadvantages of music therapy interventions on sleep disorders in adults suffering from depression?
• What is the perception of adults suffering from depression about the use of music therapy on sleep disorders?

1. What is the role of music therapy in the treatment of sleep disorders among adults suffering from depression?

2. How do adults suffering from sleep disorders and depression experience group and individual music therapy?

3. What are the indicating and contra-indicating factors for music therapy on sleep disorders with these adults suffering from depression?

4. How do participants believe music therapy impacts their overall treatment?

There are two key outcome expected in this study. The first is the overall effectiveness of the music therapy on sleep disorders among adult people with depression. The second is the level of effectiveness measured by success rate of music therapy on the same group.

The key hypothesis of this study is:

HO: Music therapy intervention on sleep disorders among adults suffering from depression is effective.

This will be tested against the alternative:

HA: Music therapy intervention on sleep disorders among adults suffering from sleep disorders is not effective.

Significance of the Study

There is limited available information on success rates of music therapy interventions on sleep disorders among adults with depression; thus, this study will significantly contribute to information boost in this sector. The constant research on how to improve existing and new interventions on mental disorders depends greatly on the available information; therefore, the awareness that will be created by this study will greatly contribute to identification of the weaknesses of music therapy, with the aim of improving its application and finding out other alternatives. Pursuing this topic will avail a deep understanding of clinical psychology scenario and improve the level of comfort when handling sleep disorder cases among adults with depression.

Definition of Terms

Adult: A person who is 18 years and above.

ADHD: Attention Deficit Hyperactivity Disorder.

Biofeedback: A process of treatment that applies monitors to feed back to patients physiological information of which they are normally uninformed.

Bipolar disorder: A mood disorder also referred to as manic-depressive illness or manic-depression that typically comprises series of depression and ecstasy or obsession.

Brain: The part of the central nervous system that is situated within the cranium/skull. The brain is the primary receiver, distributor, and organizer of information for the body. It has the right and the left hemispheres.

Chronic: This is very important term in this study and clinical psychology; it means “on-going for a long time”.

Depression: A mental illness that affects the body, mood, and thoughts; it disturbs the way a person eats and sleeps, the personal perception, and thinking. A depressive disorder is not similar as a passing blue mood.

Electroconvulsive Therapy (ECT): It is the process of passing electric current through the brain to create controlled convulsions (seizures) to treat patients with depression, mainly people who cannot take or respond to antidepressants while they are experiencing severe depression or are at high risk for suicide.

Group Therapy: This is a psychiatric care method in which numerous patients encounter with the supervision of one or more therapists at the same time. It is very effective for psychiatric illnesses that are support-intensive, like anxiety disorders. It can also be used to refer to psychoanalysis in which patients examine each other with the help of one or more psychotherapists.

Music Therapy: This is the application of prescribed music to influence positive changes in the physical, social, cognitive, or psychological functioning of persons with education or health problems.

Mental Disorder or Mental Illness: This is a psychological or behavioral array, normally related to personal distress or disability that transpires in a person. It is usually not part of culture or norms. They are characterized by behavioral, affective, and perceptual components as well as cognitive disorders. They are well-elaborated in the introduction.

Psychiatry: The medical specialty that deals with the diagnosis, prevention, and treatment of mental illnesses.

Psychology: The study of the mind and mental processes, particularly in relation to behavior.

Psychotherapy: The process of treating a behavioral disorder, mental illness, or any other condition by psychological means.

Schizophrenia: This is one of the mental disorders whose dominant symptoms are the loss of personality/flat affect, confusion, catatonia, psychosis, unusual behavior, agitation, and withdrawal. The illness mostly starts in early adulthood.

Therapy: this is the treatment of various diseases using an intervention.

Assumptions and Limitations

Assumptions

Some aspects of correlation and naturalistic paradigm are applicable, given several similar assumptions in this study: (a) individual adult participant will build his or her own reality, contributing to the compound realities within the group to be studied; (b) this is a group that need high guidance and the researcher will be present with the participants during filling of the questionnaires; thus, the researcher’s actions will influence participant reactions; (c) the already done sampling was context bound; (d) it is possible to differentiate course from effect and outcome as the research progresses; finally, (e) the morals and ethics of the participants and the researcher are vital to the meaning of the outcome of the study (Leedy & Ormrod, 2005).

Limitations

This study was restricted to short term treatment of sleep disorders using music therapy. It is limited to adults whose ages range from 18 to 65 years, who have been identified and were diagnosed with depression, and already admitted to in-patient treatment. On the other hand (though of least limitation), participants in the study are people whose ages range from 18 to 65 years. This study focused on the use of music therapy intervention in a mainly group setting. The study focused more on identifying success/effectiveness of the music therapy and less on the quality and contents of the therapy within each session. The lack of cooperation with the participants after the interviews may affect data analysis (Howitt & Cramer, 2000).

Nature of the Study (or Theoretical/Conceptual Framework)

Population and Site Selection, Overall Research Approach and Rationale

The overall research approach and rationale of this study is based on a successful research by Gold (2007) on the role and how music therapy improves sleep disorder symptoms in adults hospitalized with depression. This research dealt with the adult population with depression and music therapy; its methodology was very relevant given the similarities in the purpose with this study. The natural rehabilitation center setting is very necessary given the availability of adult people with depression and sleep disorders.

This study is based in a Psychosocial Rehabilitation Center (PSR) in the United States of America (USA); where there are adults who have already been primarily diagnosed with sleep disorders and depression. Eliminations or segregations, that is, secondary diagnoses of dementia or organic psychosis, were also looked upon. The music therapy intervention is applied in this center; has a range of musical instruments; every patient has a weekly individual session, which takes a period up to 45 minutes. They will be observed for up to 12 weeks. The center has already given permission to be involved. After passing all the necessary steps, this study also will be approved by the Capella University Institutional Review Board (IRB); this is very necessary to ensure protection of the rights of both respondents and researchers. The primary outcome is measured by the symptoms’ total score using the Positive and Negative Syndrome Scale (PANSS). The secondary outcome is measured by the satisfaction with care, where the adults will be required to fill up the Client Satisfaction Questionnaire (CSQ); under this, the Global Assessment of Functioning Scale (GAF) is applied. A mandatory patient follow-up of 85% is observed. The study was intended to include the participants’ input through researcher’s observation, interviews, and filling up of questionnaire (Rubin & Rubin, 2005).

Organization of the Remainder of the Study

The next chapter will take an in-depth analysis of the available literature on this topic in the form of a literature review. The literature review will be arranged under various relevant subtopics. Then, chapter three will now define and elaborate the methodology of this study. It will give all the necessary details and describe all the processes that are undertaken to come up with the data to be used to solve the problem. Chapter four will avail the collected data and will show analysis to give meaning and sense to them. Finally, chapter five of this documentation will give results, conclusion, and recommendation.

CHAPTER 2: LITRATURE REVIEW

Introduction to the Literature Review

The literatures reviewed for this study will mainly focus on the general information regarding music therapy as an intervention on sleep disorders among adults with depression, the theoretical frameworks of music therapy and on the use of music therapy in psychiatric settings. This review provides an overall picture of the state of music therapy application as an intervention among adults suffering from depression and research information on how music therapy has been implemented in depression treatment. The literatures highlighted in this study have been filtered according to relevance and date of publication. Some aspects of methodology that were also considered in the literatures of the studies reviewed were: if the methodology violated the policies of scientific research or ethical violations. The outcomes of the studies highlighted in this literature review had also to be processed using reliable social science research tools to validate their consistency. The tool for checking validity that was commonly applied in these studies by previous researchers was the T-Test.

History and Theoretical Orientation for the Study of Music Therapy

History of music therapy

Music therapy, as a term used currently, was established during World War II when congestion in the military hospitals provided motivation for engaging alternative therapies in hospitals (Pratt, 2008, p. 238). The National Association for Music Therapy (NAMT) was structured in 1950 to regulate training and encourage unity among those who were already functioning as volunteers and specialists in music therapy application to patients, mainly in hospitals with recovering veterans (Schneider, Unkefer & Gaston, 2009, p.3). The formation of America Music Therapy Association (AMTA) followed the coming together of both the NAMT and the American Association for Music Therapy in 1998. Currently AMTA is the responsible body for music therapy application in America. Its main function is the development of the therapeutic use of music in special education, various rehabilitation, and community settings. AMTA also registers music therapists.

The application of music therapy interventions on sleep disorders among adults suffering from depression

Music therapy is currently applied as an intervention to those with brain injuries and various mental disorders including depression. According to earlier studies, patients who are in the initial stages of severe craniocerebral trauma show a good response to music therapy based on chordal tones hence the use of music interventions as a stimulus can be used to treat such patients. A report by Jochims (2006) indicated positive results of musical interventions on patients who are in a comatose state and music therapy may help children with severe traumatic brain injuries recover faster from a coma and then rehabilitate them.

The results of a study by Rosenfeld (2009) showed changes in heart rate in children with severe traumatic brain injury after a variety of orientating sounds and vocalizations, and they even regained their speech  after singing songs (Rosenfeld, 2009, p.41).  Wilson and Pressing (2009) reported that a musician who suffered amnesia caused by a stroke was treated with a componential intervention to cognitive functioning, whereby subjective partitions between anterior and posterior brain structures were avoided and substituted by integrated and purposeful networks that can involve more than one lobe of the brain, by way of cortical and subcortical connections (Wilson & Pressing, 2009, p.50).

When the complete neural pathways and cerebral areas a person’s brain is damaged, language and music are used therapeutically with better effect than when therapists only use language. Several reports from music therapists demonstrate the success of music therapy, even though there is little concrete data available (O’Callaghan, 2009, p.90). An extensive bibliography of the then recent research on music therapy and neuro-rehabilitation in 2008 gives 320 references on music therapy, mental disorders, and cerebral vascular accidents (Coast Music Therapy, 2008). Nayak et.al (2000) contributed a great milestone when they published concrete data which showed that music therapy can improve mood and social interaction among patients who had experienced acute traumatic brain injury and stroke. Lastly, music therapy can be used as a perfect tool for improving the brain’s ability to carry out complex cognitive tasks (Knox & Jutai, 2006).

Theoretical orientation

Music therapy has several different rationales that enable communication among people with diverse theoretical traditions. Music therapy is used in analyzing the theoretical growth of this discipline, while encouraging and stimulating the growth of more complex theories. Such theories are solutions to practical complications; these rationales can be used in connecting the theoretical concepts of this study into an amalgamated idea. The theory of quantum was formulated by Charles Eagle in 1991. This theory gives an opinion on the perception of clinical music therapy based on four principles from quantum physics (Wheeler, 2005). According to Eagle’s theory, the world is founded on four quantum principles—trained music therapists who apply these principles in music therapy interventions are very successful. This psychologist mainly advocated for the therapist’s sound observation and actual participation in the music therapy.  In the footsteps of Eagle, music therapy as a discipline has embraced several approaches, one of the most significant and influential approach is: Kenneth Bruscia’s improvisational model of music therapy. This model required that each and every approach used in music therapy must have theoretical orientation (Knox & Jutai, 2006).  

This study is based mainly on psycho dynamic orientation, which is the most popular practice in the available literature on music therapy application on adult mental disorders, it formed about 42% of the literature that was reviewed in this study and it is greatly related to an individual understanding.  This theory was applied in describing the effectiveness of music therapy, the nature and application of this intervention in adults suffering from mental disorders.  Psychodynamic in general represents an approach that has grown from the traditional psychoanalytic practices, that involves behavior interpretation and observation of the client (Kern, Wolery & Aldrige, 2006).

In the context of music therapy application to adults with mental disorders; it involves the interpretation of music choices, responses, composition and physical expression of the adults during a music therapy session. To give more explanation we can take for instance that music choices can be interpreted to represent more than the music taste, it can show the needs and defenses of the person.  The instruments preferred by the person can give a symbolic meaning and the way the person plays it can also show the emotional feelings of the person. This psychodynamic approach is used to help the adults with mental disorders in planning their recovery and gauging their recovery progress (Kern, Wolery & Aldrige, 2006). This theory is primarily applied in a situation where music therapy is open to a personal choice of instruments. In this case, the therapist can gauge the adult’s recovery progress based on the advancements of his playing skills. The messages expressed while playing the particular instrument can also be used to understand the past of the mentally disturbed adult much better. The participants’ music choices and behaviors are interpreted through close monitoring of their responses to the music used.

Behavioral approaches were not very strongly represented in the reviewed literature in this study. This is because they are mostly unified with cognitive behavioral therapy (CBT). The behavior approach doesn’t apply in most mental disorders because of the severity these disorders can bring in the people’s behavior (Lambert, 2010). But, in the later stages of healing, behavioral stance can be applied with some learning theories, where the central life of the adult with mental disorder is now not a concern but the concern shifts to raising capability in observable behavior.  Behavior can be taken to represent the cognitive understanding or external emotional experiences and in this case the therapist will target the behavior to achieve the desired results. In music therapy, the music is mainly used as an enforcer, at the general level; demonstrating the required behavior implies that the client is able to select an instrument, listen to the chosen music and other musical rewards. On the other hand failure to behave will imply that the therapist will withdraw the music until the client has improved his behavior (Lambert, 2010). The current application of the behavior theory is within a more electric framework, stopping the music is not an alternative, but improvement is the main focus of the music sessions and the clients are closely monitored through observable responses (O’Callaghan, 2009). In between the emphasis on observable behavior and conscious actions is the ground of humanistic theory approaches.

Those using the humanistic approach believe that every person has the potential to grow with an integral tendency (Wheeler, 2005), hence music therapy is classified broadly as a humanistic approach because of the creativity involved in it and this relates to the ideas of Steiner and the anthroposorphic movement in humanistic psychology (Jochims, 2006). Creative experiences are greatly viewed as humanistic approaches and the best example is the free sessions offered in music therapy where the interest of the adult decides the flow of the session.

Review of Research Literature and Methodological Literature

This section will provide information on the existing literature to research done in earlier studies, in relation to the use of music therapy interventions in the treatment of adults with depression. In addition, methods that were used in carrying out the previous studies will be highlighted together with their outcomes.

Review of research on the music therapy among adult with mental disorders

In the investigation carried out by Gold (2007), the objective was to inspect if music therapy improves the symptoms among adults hospitalized with schizophrenia. The outcome of this investigation expressed improvement among the people hospitalized with schizophrenia, after fusing music therapy with the regular routine patient care. The fusion of music therapy and normal care lead to better improvement in symptoms compared with normal care applied alone. This was after 12 weeks of application of music therapy plus the routine care, the observable change in Positive and Negative Syndrome Scale (PANSS) had an entire score from baseline of -9.00 as compared to -2.96 score of applying the normal care alone; and p = 0.045. Further results from this study showed that there was no substantial difference in patient contentment with care and global function between the groups (Gold, 2007, p.77).

An earlier study by Gold et.al (2005) was centered at making a comparison between the effects of music therapy combined with standard care, and standard care alone for treating people with severe mental disorders such as schizophrenia. After inclusion of four more studies that evaluated the effects of music therapy over the short to medium period mainly between 1 to 3 months. The outcome of the study revealed that a combination of music therapy and standard care was more successful as compared to the use of standard care.

Pavlicevic, Trevarthen and Duncan (2006) also examined the improvisational music therapy and the rehabilitation of persons suffering from prolonged schizophrenia. They found out that patients with schizophrenia showed recognizable difference and improved rating in the Brief Psychiatric Rating Scale (BSRS) at the end of 10 music therapy sessions and encouraged the therapists to raise their level of musical interaction. Silverman (2003) did a meta-analysis on the existing quantitative research data by then, he wanted to evaluate the influence of music on symptoms of psychosis. In his conclusions, Silverman reported that music had confirmed to be considerably effective in relieving and reducing the symptoms of psychosis.

Ulrich, Houtmans and Gold (2007) did a randomized study examining the additional therapeutic effect of group music therapy for schizophrenic patients, based on the fact that Schizophrenia is one of the most serious mental disorders. When they were carrying out their research, music therapy was introduced as a form of treatment thus the purpose of this study was to examine the effect of music therapy for schizophrenic in-patients requiring acute care. The outcome of this study showed a substantial effect of music therapy after self-evaluation of the psychosocial alignment and undesirable symptoms on the patients. No changes were found in the quality of life of the patients (research participants).  In their conclusion, the above researchers noted that musical activity reduces negative symptoms and develops social contact in the patients. Furthermore, the researchers ascertained that positive effects of music therapy could increase the patient’s abilities to adapt to the social environment in the public after being discharged from the hospital (Ulrich, Houtmans and Gold, 2007).

Silverman (2006) did a study to quantitatively evaluate psychiatric patients’ awareness of music therapy and other psycho-educational programs. The results of this study specified that that the sampled patients rated music therapy as considerably more helpful compared to other standardized programs (p < 0.05). Additional scrutiny showed that patients admitted to a psychiatric institution only once regarded their music therapy classes as more supportive as compared to patients who had been admitted numerous times. Furthermore, patients who were minorities regarded programming as more helpful than patients who were Caucasian. The patients regularly rated music therapy as highly effective compared to other standardized programs in solving specific psychiatric discrepancy areas. Also, 57% of sampled patients distinguished that music therapy was their preferred class/therapy.

Finally, researchers at Stanford University School of Medicine, USA examined 30 adults who had been diagnosed with major or minor depressive disorder. The sampled participants were randomly given one of the three, eight-week settings. In the first scenario, the participants were required to listen to music at home, following a weekly home visit by a qualified music therapist. In the second case, the patients were subjected to equivalent practices with moderate therapist assistance. Assistance from the music therapist was in the form of a self-administered program where participants made a weekly telephone call. The third case is where the participants were put on a waiting list and used as a regulator. The outcomes of this study showed that the participants in the first two cases achieved considerably better results than the controls on standardized tests of distress, mood, self-esteem, and depression. These developments were clinically significant to the music therapy researchers; they noted that these benefits were maintained over a nine month follow-up duration (Porter, 2011, p.61).

Review of methodological literature relevant to this study

This section will present various methodologies that were used in the previous researches earlier reviewed in the former paragraphs.

The methodology of the reviewed studies are very diverse, they range from meta-analysis, qualitative to quantitative research. The methodology that will be utilized in this research is closely linked to the one used by Gold (2007). This study applied a good sampling system with discrete distribution and single blind, and then the follow-up period was three months after the music therapy treatment was applied to the patients.  The study being carried out in four London hospitals, gave it a base to crosscheck the similarity in four hospitals as a form of validation. The sampled adults had a major diagnosis of schizophrenia or schizophrenia-like psychosis.

Notably, eliminations were tributary diagnoses of organic psychosis or dementia. The main intervention included music therapy by means of a variety of musical instruments as well as reassurance to the adults so as to express their selves which was supervised by a trained, certified, and licensed music therapist.  Arguably, the sampled people underwent a weekly individual session of up to 45 min, and additional standard care involving application of social, occupational, nursing care and other activities. This was compared to the standard care for only a period of up to 12 weeks, which is enough time for a sensible study. This is a very relevant methodology for this study, since between the two groups of set ups, there is one group that is purely on music therapy intervention alone; this can give a relatively reliable outcome.

The study also borrows closely on the methodology used by Gold et.al (2005). It had a very effective research strategy that was useful in identifying quantitative data. The researchers examined the July 2002 Cochrane Schizophrenia Group’s Register. They then went ahead and supplemented the data obtained with more information obtained from performing a thorough document search for literature and data from music therapy journals, books and reference lists. In addition, they also communicated with relevant authors, giving this study a high score in accuracy since they were certain and clear with the credibility of the primary data they were analyzing.

All randomized controlled trials were used as the selection criteria that compared music therapy with other psychosocial interventions or standard care for schizophrenia; this was very unique. The data collection and analysis in this study was done after the selected studies were assessed for quality and then data was mined. In addition to the quality assurances, data was omitted in instances where more than 30 percent of sampled participants in any group were missing in the follow up. Non-skewed incessant endpoint data from effective scales were amalgamated by using a standardized mean difference (SMD). If statistical heterogeneity was discovered, treatment approach and drug usage were scrutinized as conceivable sources of heterogeneity. This methodology is relevant to the research mainly because the sources of data to be used should be verified through communication with other authors; extra measures to test for consistency should be used as well (Ther, 2008).

Some methodological aspects of the study done by Silverman (2006) are very useful in the research of music therapy. The researcher examined the effect of four emotionally distinctive types of music (fear, anger, sadness and happiness). It focused on 31 healthy controls (Healthy Control Group) and 14 hospitalized patients with major depressive disorder (Major Depressive Disorder Group). The sampled participants were asked to select emotional descriptors that exactly conveyed the feelings they experienced. The diversity that this study brought to the music therapy research is very important; it brought all the dimensions of music therapy in terms of what the distinctive types of music are.

The research will also be based on the methodological aspects used in the meta-analysis that was conducted on 19 studies by Silverman (2003). It also shares some methodological aspects used in  thein the study done by Silverman (2006) and Ulrich et al., (2007).

Synthesis of Research Findings[JW1]

Based on lLiterature from previous studies, there is  done by other researchers have reported a marked improvement in the mental disorder of older adults and middle aged people with atherosclerotic encephalopathy. After undergoing purely 10 music therapy sessions, the patients exhibited a 20 percent improvement (Wilson & Pressing, 2009).

Additionally, music therapy also improved the stimulation of imagination in older adults and middle aged people with atherosclerotic encephalopathy. As the patients listened to the music, several of them experienced a feeling of flowing water, wood, sunlight or the lake and had several other positive experiences. Lastly, under this mental disorder, research proved to have an increased capacity to concentrate among older adults and middle aged people. After undergoing 10 music therapy sessions, the capacity of patients to concentrate had developed by an average of 18 percent (Crowe & Colwell, 2007).

Music therapy also worked well among patients with multiple sclerosis and in the reassessment of previously unaddressed experiences of patients with multiple sclerosis. When the individual experiences were recognized by the patients, including other things, the group reported that the music therapy had an effect of thorough and effective reappraisal of these past experiences. This caused dispersion of the previous mental stress situations and in the long run, the problem of mental disorder was managed (Ulrich & Gold, 2007).

In general, the studies have proven the positive effect of music therapy intervention on adults with various mental disorders. The major application is on group and individual music therapy with already recorded music; this is done with the guidance of a trained music therapist.

Critique of previous research

Music therapy has been expressed in this chapter as an advancing, cost-effective and available intervention for adults suffering from mental disorders like those undergoing symptoms of depression, anxiety and distress. Although Music therapy profession is relatively undeveloped and small in size, the reviewed studies demonstrated that it can be used to manage or treat a wide range of clinical populations diagnosed with mental disorders and other psychological conditions. These findings are very important because they have established a diverse research base for this study and more studies still to come. However, while the profession initiated working with people diagnosed with mental disorders, there is a substantial lack of quantitative research regarding the effects and efficiency of music therapy intervention applied to adults suffering from mental disorders (Leedy & Omrod, 2005).

Music therapist and researchers have testified on this shortage of quantitative information and the trouble in caring out psychosocial research on this intervention (Silverman, 2003). Although available studies have given propositions for future research, none of these studies have given comprehensive suggestions for the methodology and design of thorough high quality randomized meticulous psychiatric music therapy study/research. The crucial question that we must ask ourselves is: in what ways do other psychotherapies achieve their databases and can the music therapy field borrow from their effective methodological best practices, to build up its own literature base? Consequently, as the America Music Therapy Association (AMTA), National Institutes of Mental Health (NIMH) give guidance and mention the treatment to be selected for evidence-based psychotherapy as cognitive behavioral therapy (CBT), though the characteristics of music therapy literature base were analyzed, they should conduct more recent research to come up with recent literature that gives more alternatives.

Summary

This literature review has analyzed and identified constituents of high-quality quantitative music therapy research for adults with depression. It has also analyzed and identified the variables and other elements of current quantitative psychiatric music therapy research for adults with mental disorders. Thirdly, it has compared the study’s data sets and used them to identify the best methodological designs and variables for this study and future quantitative music therapy research among adults with depression. The next chapter of this paper discusses the methodology of this study; this chapter will give more insight on how this study is going to be carried out.

 

 

CHAPTER 3: METHODOLOGY

Purposes of the Study

The main purpose of this study is to gauge the effectiveness of music therapy interventions on sleep disorders among adults suffering from mental disorders. It will also identify the challenges, obstacle and issues in music therapy interventions among adults suffering from depression.

Research Design and Strategy

There are two broad strategies which can be applied in research and they include the phenomenological and positivist research strategy. These two strategies are differentiated based on the following factors: method of formulation of research objective, type of research methods employed, data collection methods and the significance of target respondents in the research process. This research will be based on the phenomenological approach because of the following:

• Data      will be collected from the target respondents through administration of      questionnaires. In the positivist paradigm approach, the researcher uses      prepared information frameworks through which the respondents are      evaluated.
• Objectives      in this research will be set in a manner that would lead to the      understanding of facts on the issue under investigation. This will be      accomplished by use of both primary and secondary data collection. In      addition, the study will also rely on existing literature review. On the      contrary, the positivist approach aims at collection of empirical data.

The study will make use of an approach based on the phenomenological philosophy so as          to enable the researcher to gather reliable and valid results. This approach will be used by      the researcher to define the beliefs, assumptions and the nature of reality of this research      study. The researcher will analyze every situation in its totality. In order to develop and    come up with ideas from the target population, induction will be used during the research             process. Additionally, the study sample will be investigated over a given period of time   and a natural setting will also be used to implement this research. For this reason, a    qualitative induction design will be utilized to achieve the study’s objectives (Easterby,    2008).

Site Selection, Target Population and Participant Selection

The study will be located in a Psychosocial Rehabilitation Centers (PSRs). These locations give the study credibility in several ways: first, there is ready support from the psychiatric and trained music therapist in case of any misunderstanding or extreme cases. Since most of the clients are confined in the center, it is easier to make follow ups and attain a follow up percentage above 85 percent. Last is the availability of records that can be used in further evolutions to give this study more meaning. The center must first grant permission to conduct the study in their premises so as to ensure that they are safe guarding the rights of the patients.  Suitable consents are sorted to improve the validity of this project. It is important to note that with this study, there are eliminated video and audio recording for data collection, because most of the rehabilitation centers have policies that basically prohibit the use of this data recording method, as a means of protecting the confidentiality of their clients.

To ensure more confidentiality, all participants are recognized by a participant code or pseudonym, and no real names appear on labels of any collected data materials, observation analyses or transcripts. All materials are stored in the social work office, in a locked cabinet used wholly for this study. The population selected focused on adults with mental disorders, who were admitted to the acute psychiatric unit of the PRC. Ages were restricted between 18 to 65 years due to current limitations established by the behavioral health unit (Flick, 2009).

The major participants or target population of this study will be selected by psychological therapists, psychiatrists and patients from selected rehabilitation centers that practice the use of music therapy interventions in the treatment of sleep disorders among people with depression. The researcher is confident that these participants will be in a position to provide reliable and relevant information required in this research because they have experience in matters related to the use of music therapy interventions on sleep disorders among people with depression. The researcher in the study has to be partly employed in the rehabilitation center. The presence of the researcher in all group and individual secessions is normally recognized as a necessary component in effective music therapy study (Flowers, 2009).

Sampling method

In research, getting the correct sample is of great significance for the researcher to obtain the correct information and to ensure that the research objectives are properly met with an element of logic and judgment. In this research, it will be essential to seek for specific information from the respondents. Therefore, an appropriate method of sampling will be used whereby the researcher will target only specific people in the rehabilitation centers that will participate in the research process. This will be very necessary in obtaining the relevant data required for this research. There is a high turnover rate and frequent sudden discharge of clients from rehabilitation centers, thus sampling emerges as the study that advances and not pre-selected. Selection measures are established leading to screening participants for the study. These include the presence of already diagnosed mental health condition, the capacity to understand and speak in English, voluntarily admission to the rehabilitation center, and the nonexistence of other active psychotic symptoms. The duration of treatment varies, such as number of sessions attended but the final data analysis will capture only those who have attended more than 12 sessions, for the simple reason that the research which has proven the effects of music therapy can be evaluated after at least 10 therapy sessions (Saunders, 2005).

Research Procedure

The study is designed to include the participants’ input through interviews and filling of questionnaires. The procedure involved of the following steps:

1. The psychiatrist, the social worker and the music therapist in the rehabilitation center will screen the adults with mental disorders upon admission to the adult psychiatric unit of the Psychosocial Rehabilitation Centre (PRC). The adults who are allowed to participate in the study must be diagnosed with sleep disorders and depression and then the suitable participants are referred to the researcher.

2. The researcher then conducts an extra informal screening to gauge if the participant meets the standards of the study.

3. Once a potential participant is identified, the researcher meets with the participant and explains to him/her the procedure and purpose of the study.

4. When the consent has been sorted, the patient is incorporated as a participant in the study.

5. Before each session, the researcher creates a session plan with the help of the music therapist and based on the treatment objectives and relevant graph reviews of the participants. A treasured input into this process is also taken from the researcher’s spontaneous logs.

6. 7. After each and every session, the researcher must reflect on what has taken place in the group or individual sessions and make notes on feelings, ideas and thoughts of the participants.

8. Data is collected from the researcher’s reflexive logs and observations during the music therapy sessions. This field data is analyzed after every music therapy session. It is vital to note that this portion of the data is not used to guide the structure of the interviews

9. In case the participants are well off to be discharged by the treatment team, the researcher selects one or two of them and interviews them as they fill the final questionnaire.

10. On completion of all interviews and transcriptions, the transcripts are analyzed.

11. Finally after 12 weeks, the treatment team is interviewed and they will fill the questionnaire for the final data analysis.

Data Collection

The researcher will administer the questionnaires to the target respondents online through electronic mails. The questionnaire will be accompanied by consent forms and introductory letters. The researcher will request the respondents to deliver their feedbacks through emails. On the other hand, secondary data will be gathered by performing a thorough document search in books, journals and magazines that contain relevant information to the question under investigation (Schwab, 2005).

Instrumentation

This study will mainly explore a reliable method and instrument of primary data collection, which is the use of semi-structured interviews.

Semi-structured Interviews

In this method of data collection, the researcher engaged the respondents in live interviews. In preparing the interviews, the researcher used the guide of the crucial stages of interview preparation according to Kvale (1996, p.27).These included the following steps of preparation:

• Thematization: This refers to      the adoption of a general theme for the interview and it is guided by the      primary research question.
• Designing: This included      restructuring of the interview questions and locating the set ups in a      manner in which the respondents would find it simple to collect data.
• Actual interview and      transcribing phase
• Analysis of respondents’      feedback, verification and reporting

The researcher used similar questions for all the interview sessions in order to ensure that the responses obtained were related. This would also make the process of data analysis much easier. The following are some of the advantages of using semi-structured interviews in this research study (Foddy 1993, p.2):

• Total expression is      experienced from the target respondents. Interviews overcame the      limitation of total expression experienced from other data collection      methods like the use of questionnaires. The researcher was present to give      clarifications to the meaning of the questions that were not well      understood by the respondents.
• Through the semi-structured      interviews, the researcher was able to obtain more information that would      otherwise not be obtained in other data collection methods like use of      questionnaires. For example, expressions that were inherent in facial      expressions and signs were experienced in the use of interviews and they      added much more value to the information gathered.

The following are some of the few limitations of semi-structured interviews included the following:

• Some of the respondents exhibit bias by generalizing the interview questions hence leading to a bulky and diverse response. This is disadvantageous because it may interfere with the quality of the responses that could be obtained. In addition, it may also reduce the reliability of the study.
• There is also a lack of motivation in the target responses because some respondents would fear that the interviews would interfere with their schedules. To overcome this, the researcher will convince them that the interviews would be short and less-time consuming in order to win their interest and to create a sense of ownership in them regarding the issue under investigation.

The use of questionnaires has been acknowledged by many researchers to be a reliable method (Foddy, 1993). This is because the questionnaires are developed under the guidance of the research objectives to ensure that the questions constructed are relevant to the study. In addition, they are user friendly, inexpensive to construct and administer to the research respondents. Robson (1993) established that a well-developed questionnaire assists the researcher in generating uniform answers from various respondents.

The use of open-ended questions also helps the respondents to put across their observations freely because they do not get restricted in any way. During the construction of the questionnaire, several efforts will be made to connect the questions with literature, to devise and organize the questions in a way that is easy to use and coherent to avoid the inclusion of negative questions (Foddy, 1993). Among the things that the researcher will also put in consideration are the weaknesses that can be encountered while using questionnaires. Such weaknesses include: absence of the respondents which may force the researcher to use unintended people in answering the questions, and inability to evaluate complex views and opinions.

The developed questionnaire will then be taken through various stages aimed at improving its content. The first stage that the questionnaire will be exposed to is the pilot test (Foddy, 1993).

Research Questions and Hypotheses

Five main research questions were considered in this study:

1. What is the role of music therapy interventions on sleep disorders in the treatment of adults suffering from depression?

2. How do adults suffering from depression experience group and individual music therapy interventions?

3. What are the indicating and contra-indicating factors for music therapy interventions on sleep disorders with these adults suffering from depression?

4. How do participants believe music therapy impacts their overall treatment?

There are two key outcomes expected in this study. The first is the overall effectiveness of the music therapy among adult people with mental disorders. The second is the level of effectiveness measured by success rate of music therapy on the same group.

The key hypothesis of this study is:

HO: Music therapy intervention on sleep disorders among adults suffering from depression is very effective.

This will be tested against the alternative:

HA: Music therapy intervention on sleep disorders among adults suffering from depression is not effective.

Data Analyses

The qualitative data that will be obtained from this study will be analyzed qualitatively using the appropriate qualitative data analysis methods to derive the significance of the facts and opinions that were expressed by the respondents. Qualitative data analysis methods will be used to analyze the qualitative data that will be collected. Such methods include the use of tables, graphs and pie-charts (Schwab, 2005).

Secondary Data Analysis

The researcher will also rely heavily on secondary data analysis to obtain literature that will be important in the correlation of primary data and already existing or established facts. The secondary data will be obtained from books, research journals, news reports from broadsheets and current affairs magazines. This will play a significant role in providing authenticity, backup and making a comparison to the primary data (Patton, 2002).

Ethical considerations

In any given research, the major requirement is to guard the welfare and self-esteem of the research respondents. The following are key ethical considerations that have been looked into in this research (Patton, 2002):

• The confidentiality of the      information provided by the target respondents will be maintained and the      data will primarily be used for research.
• The identity of the      respondents will be kept anonymous hence the respondents will not be      required to provide their names on the questionnaires.
• The researcher will seek      consent from all relevant authorities before the commencement of data      collection in order to avoid any legal disputes.
• The respondents will be      required to sign a consent form before participating in the study in order      to show that they will be taking part in the study at their own will      without being coerced.

Expected Findings

The expected outcome of this study is presented by category.  A very strong positive relationship is expected between music therapy intervention on sleep disorders and depression symptoms.  After the analysis of data, various themes are expected to come out consistent to the research purpose and hypothesis. The main categories to be discovered using data analysis and interpretation in relation to the aim of this study are: personal perspective, experience of the music therapy sessions and the effectiveness of music therapy to this group of people. Personal perspectives of the sampled people could include their beliefs, values and history. The experience of the music therapy sessions is expected to include: options, change, connection, triggers, impact, the role of music, and feelings. The calculated percentage of effectiveness of music therapy is expected to be above 60%, and the other sub themes expected are: affirmations, change or shift and transfer or association.

REFERENCES

American Psychiatric Association. (2003). Practice guidelines for the assessment and                                   treatment of patients with suicidal behaviour. Accessed on: 23 October 2011, from:     http://www.psych.org

American Music Therapy Association. (2004). Definition of music therapy. Accessed on: 23 October 2011, from: www.musictherapy.org.

Bruscia, K. (ed.) (1998). The dynamics of music psychotherapy. Gilsum, NH: Barcelona       Publishers.

Crowe, B. J. & Colwell, C. (Eds.). (2007). Effective clinical practice in music therapy:                                Music therapy for children, adolescents, and adults with mental disorders. Silver   Spring,             MD: American Music Therapy Association.

Coast Music Therapy (2008). Music Therapy Comprehensive Research Bibliography, San Diego, California, accessed on 03 November, 2001 from: http://www.coastmusictherapy.com

Easterby-Smith, M., Thorpe, R. & Lowe, A. (2008).Management Research: An Introduction, 2nd Ed. London: Sage Publications. 67-69

Foddy, W. (1993). Constructing questions for interviews & questionnaires. NY: CUP, Cambridge University Press, 1993. 93-100

Flick, U. (2009). An introduction to qualitative research. Thousand Oaks, CA: SAGE.

Flowers, P. (2009).Research Philosophies-Importance and Relevance.Leading, learning and change .Cranfield school of management.

Gold, C. (2007). “Music therapy improves symptoms in adults hospitalized with                        schizophrenia”. Evidence-Based Mental Health. 10(3), 77

Gold, C., Heldal, T. O., Dahle, T., & Wigram, T. (2005). “Music therapy for schizophrenia or schizophrenia-like illnesses”. Cochrane Database of Systematic Reviews, 3.

Howitt, D. & Cramer, D. (2000). First steps in research and statistics: A practical   workbook for psychology students. London, UK and Philadelphia, PA:    Rutledge/Taylor and Francis.

Jochims S. (2006). Establishing contact in the early stage of severe craniocerebral trauma:           sound as a bridge to mute patients. Rehabilitation (Stuttg)33(1):8–13 [in German].

Kern, P., Wolery, M., & Aldrige, D. (2006). Use of songs to promote independence in morning       greeting routines for young children with autism.  Journal of Autism and Developmental                        Disorders, Nov. 22.

Knox, R., & Jutai, J. (2006). Music-based rehabilitation of attention following brain injury.            Canadian Journal of Rehabilitation; 9(3):169–81.

Kvale, S. (1996). Interviews: introduction to Qualitative research Interviews. California: Sage publications.

Leedy, P. D. & Ormrod, J. E. (2005). Practical research: Planning and design, 8th Edition.            Upper Saddle River, NJ: Pearson Prentice Hall.

Lambert, M. J. (2010). Bergin and Garfield’s handbook of psychotherapy and behavior change,                lavoisier.fr

Nolan, P. (2003). “Through music to therapeutic attachment: Psychodynamic music       psychotherapy with a musician with dysthymic disorder”. In S. Hadley (Ed.),           Psychodynamic music therapy: Case studies (pp. 317–338). Gilsum, NH: Barcelona.

Malchiodi, C. A. (Ed.). (2003). Handbook of art therapy. New York: Guilford Press.

Nayak, S., Wheeler, B. L., Shiflett, S. C. & Agostinielli, S. (2000). Effect of music therapy on           mood and social interaction among individuals with acute traumatic brain injury and                       stroke. Rehabilitation Psychology; 45(3):274–83.

O’Callaghan, C. (2009). Recent findings about neural correlates of music pertinent to music                      therapy across the lifespan. In: Pratt RR, Grocke DE, editors. Music Medicine 3.        Melbourne (Australia): University of Australia; p. 88–100.

Patton, M. (2002). Qualitative research and evaluation methods. Thousand Oaks: sage publications.

Pratt, R. R., (2008). The historical relationship between music and medicine. In: Pratt RR,             editor. The 3rd International Symposium on Music in Medicine, Education, and Therapy          for the Handicapped. Lanham (MD): University Press of America; p. 237–69.

Rubin, H. J. & Rubin, I. (2005). Qualitative interviewing: The art of hearing data (2^nd Ed.).            Newbury Park, CA: Sage.

Robson, C. (1993). Real World Research. Oxford: Blackwell

Saunders, M., Lewis, P.,& Thornhill, A. (2007)..Research Methods for Business Students, ed 5. Essex: Pearson Education Ltd.

Schwab, D. (2005). Research Methods for Organizational Studies. Mahwah, NJ: Lawrence Erlbaum Associates.

Schneider, E. H., Unkefer, R. F. & Gaston, E. T. (2009), Introduction. In: Gaston ET, editor.               Music in therapy. New York: Macmillan; p. 2–4.

Rosenfeld, J. V. (2009). Music therapy in children with severe traumatic brain injury. In: Pratt      RR, Grocke DE, editors. Music Medicine 3. Melbourne (Australia): University of           Australia; p. 35–46.

Scovel, M. & Gardstrom, S. (2002). Music therapy within the context of psychotherapeutic      models. In R.F. Unkefer & M.H. Thaut (Eds.), Music therapy in the treatment of            adults with mental disorders: Theoretical bases and clinical interventions (2^nd Ed.) (pp. 117-         132). St. Louis, MO: MMB Music.

Silverman, M. J. (2003). “The influence of music on the symptoms of psychosis: A meta-           analysis”. Journal of Music Therapy, 40(1), 27–40.

Silverman, M.J. (2006). “Psychiatric patients’ perception of music therapy and other      psychoeducational programming”. Journal of Music Therapy, 43(2), 111-22.

Smith, D., Fisher, L., & Goldney, R. (2002). “Do suicidal ideation and behaviour influence        duration of psychiatric hospitalization?” International Journal of Mental Health                    Nursing, 11, 220–224.

Ther, J. M., (2008). Quantitative comparison of cognitive behavioral therapy and music therapy               research: a methodological best-practices analysis to guide future investigation for adult         psychiatric patients. Silverman MJ. University of Minnesota, USA. Winter;45(4):457-         506.

Ulrich, G., Houtmans, T., & Gold, C. (2007). “The additional therapeutic effect of group           music    therapy for schizophrenic patients: a randomized study”. Acta Psychiatrica            Scandinavica. 116(5), 362-70.

Unkefer, F. R. & Thaut, H. M. (2005). Music Therapy in the Treatment of Adults with         Mental Disorders: Theoretical Buses and Clinical Intervention. St. Louis: MMB            Music, Inc.

Vick, R. M. (2003). “A brief history of art therapy”. In C. A. Malchiodi (Ed.), Handbook of

art therapy (pp. 5–15). New York: Guilford Press.

Weiner, D. (1999). Beyond talk therapy: Using movement and expressive techniques in

clinical practice. Washington, DC: American Psychological Association.

Wheeler, B. L. (2005), Music therapy research, Health & Fitness, p.286 pages

Widiger, T. A. & Shea T. (1991). “Differentiation of Axis I and Axis II Disorders.”                   Journal of Abnormal Psychology, 100, 399-406.

Wilson, S. J. & Pressing, J. (2009). Neuropsychological assessment and modeling of musical                     deficits. In: Pratt RR, Grocke DE, editors. Music Medicine 3. Melbourne (Australia):        University of Australia;.p. 47–76.

---

 [JW1]Refer to my comments on the previous version.  It doesn’t look like much changed.

PATIENT’S EXPERIENCE IF ILLNESS

Cover Letter (Name) (Address) Dear Mr./Ms/Dr/Prof. In the course of carrying out the interview, I was surprised at how the patient was willing to be engaged even on personal issues. The patient was more than willing to share his experiences with me something I did not anticipate. The most important thing I learned was that having prior knowledge in any matter helps in finding why it exists. In this regard, being emphatic helped in drawing the attention of the interviewee an aspect that made the interview successful. The hardest part of completing this assignment was convincing the interviewee that the interview was purely for informational purpose. In addition, selecting the most appropriate candidate for this interview was another problem. The easiest part, on the other hand, was the organization part, particularly, communications with the interviewee. This assignment can be improved by interviewing many people and not just one. This is based on the fact that one person’s information cannot act as a representative sample for other groups. This, therefore, makes generalization hard. If you have any questions, do not hesitate to call me (Phone Number) or email me at (email Address). Thank you for your consideration and time. Sincerely (Name) Enclosure

 

Patient’s Experience of Illness Name Instructor

 

 

 

 

 

 

 

Abstract In health care, a patient’s experience of illness is often not well understood, misperceived, or simply not taken into consideration by not only his or her doctors but also by any other person around.  This paper has considered one of the less discussed, and almost unknown disease, yet it ranks among the fist killers in United States. Idiopathic Dilated cardiomyopathy once known to be an old mans disease today is common among the middle age generation.  To know how its impact on the patients well-being are, the paper has considered a 45 year old man, a dilated cardiomyopathy survivor. Through an interview, the man has narrated his experiences with the disease especially in the context of work place, friends, and family members. The paper finally wraps up by connecting the emerging issues from the interview with the known literature.

 

 

 

 

 

 

Introduction In health care, a sick person’s experience of illness is misperceived, poorly understood, or simply not considered by her or his health care providers. For instance, when a professional person becomes sick, he or she unexpectedly assumes the role or becomes patient.  During this time, the patient is overcome by frustration, feelings of helplessness, and lack of control on his or her illness. However, most patients do not experience illness personally but develop empathy. This is a way of attracting assistance or help from other people.  Empathy does not come without immediate persons understanding the weight behind the illness. This can only be understood by considering the diagnosis and symptoms and exploring deep into the connotations of illness of the sick person. Also, it is only via empathic communication with the sick person can people begin to understand the experience of patients. This paper specifically discusses the experience of John, a dilated cardiomyopathy survivor. The paper also discusses in depth the issues that emerged from the interview. Brief History of the Patient John Simpson is aged forty-five and married to Annette Simpson with two kids, Maureen and Kathleen.  John works as a consultant in security matters with a local firm based in the suburbs of Washington D.C.  His wife works in a local bank as branch manager. Therefore, with these responsibilities, it goes without saying that the family leads a busy life. I first met John in his office as part of the arrangement we had made. The man looked cool, receptive, welcoming and jovial. After a brief chat, John revealed that, in the course of his service at the company, he had developed Idiopathic Dilated Cardiomyopathy. He confined in me how it had almost exhausted his finances thanks to Medicare and insurance. In the course of our talk, the mood of the conversation changed when he related how the condition had affected his relationship with the employer. Description and Management of the Disease Dilated cardiomyopathy affects heart muscles, primarily affecting the left ventricle. The chamber becomes dilated and cannot pump blood as strong as a healthy heart does (Chan & Veinot, 2011). It may also cause arrhythmia (irregular heartbeats), blood clot or sudden death. Some patients develop symptoms of right-and left-sided congestive heart failure. Syncope and systemic embolism usually occur alongside vague chest pain, which at some point may occur. At a mature stage, the patient shows some cardiac enlargements and even congestive heart failure. Also, tricuspid regurgitation caused by systolic murmurs is evident during this time. In terms of medication, patients are normally put of heart failure therapy. Salt restriction, diuretics, ACE inhibitors, anticoagulants and digitalis may be also be utilized. To a large degree, these treatments forms have been found to reduce hospitalization and to improve symptoms. However, cardiac transplantation is used in case of patients in mature stages of the disease and must be refractory to medical therapy. Incidence and Prognosis In the US, 3 to 10 cases are reported per 100,000. Besides, 20,000 new cases are usually reported every year. Stabilization, on the other hand, is reported in 20-50 percent of patients. Normally, complete recovery is rare. In addition, death from progressive pump failure is as indicated below. 1-year            25 percent   2-year            35-40 percent  5-year            40-80 percent  In the US, it accounts for over 10,000 deaths annually and over 50,000 hospitalizations—and these statistics are set to rise. Interview Mr. John, it is a pleasure to meet you. Let us kick off from the beginning. At what age were you when the disease was first discovered? I was 45 yrs old. And how old are you now? I’m 55 years old. You have stayed with the condition for ten good years? Yes, but all along it has not been that hard for me How did you feel when the doctors broke the news? In point of fact, I did not have a lot of information concerning the disease. In addition, idiopathic, as everybody knows, means the cause is not well known, and when the cause of something is not well known, medication to it is unknown too, so, this made me a little nervous. Then, what did the doctor tell you after that? He told me the condition was not rare, and that it was a manageable disease. That is all. How has the illness changed your life in terms of daily activities, family and work life?  When the news broke out, I was at the height of my profession, but with the management that came with it I had to relinquish most of my responsibilities at the place of work. In addition, I had to trim down my daily activities like going to clubs for a drink etc. My family, on the other hand, supported me greatly by giving me moral support, reminding me of the time I was supposed to take the medicine etc.  In addition, my sexual life completely changed as I was put on PDE-5 inhibitors, drugs which had some side effects on me. What happed then? I talked to my wife and my doctor about it, but today things are okay. How relationships changed—with family, friends, co-workers/peers Definitely when you are sick, everything almost changes. Being a father, my family thought I would die, or something like that. Co-workers and friends, on the other hand, thought that maybe I was kidding as the disease I had been diagnosed with was typical amongst old people, nonetheless, they gave me full support. In addition, my friends, especially whom we used to spend sometime with in clubs thought I was just taking a break before getting back to business. In a nutshell, everything happened so fast and unexpectedly. What changes were lasting? What were temporary? Initially, I was diagnosed with Asymptomatic IDCM. During this time, the cardiologist diagnosed me with intra ventricular blood clots and EF of 25.  The temporary changes were associated with the treatment of Coreg (100mg/day). The permanent change is that the size of my heart shrunk back to normal. In addition, I’m now back in my working spirit, at times going for forty hours in a week. The Coreg medication was atrocious particularly when going to 100mg from 50mg/day. Thank God I’m on Toprol XL maintenance these days. Also, every time I took a flight I always had someone in my company. This did not last long, but it increased expenses as insurance companies do not recognize thirty-party assistance. Did you encounter any kind of experience with health care providers—doctors, nurses, technicians, specialists? Yes, but not the humiliating type Then, what was the best interaction with a health care provider? In other words, what was the worst? What made it good/bad? My doctor was always dedicated. In fact, we did not only meet on a regular basis, but also phoned to inquire how I was doing. Working together for over five years, I continued to be stunned by his drive to see me recover, despite the emotional and physical health concerns that went beyond my health.  My best interaction with the doctor was when he always committed his time for my sake, listening to my concerns, sharing his personal experiences, and linking in a human level, while offering outstanding medical care. What made it good is that the doctor took the essence of having a good relationship with the patient seriously. He made everything painless and simple for me to feel at ease trusting that he recognizes my struggles and concerns and is always eager to assist me.  What advice would give to other patients, health-care professionals, family members and friends? To my fellow Idiopathic Dilated Cardiomyopathies, stay strong and always remember that God never forsakes his people, and at the same time, he does not give us more than what we can bear. To health care professionals, keep up with the good work that you have been undertaking; you will one day be rewarded.  To my family members and friends, always keep heart, I cherished your support. Keep on supporting other people who have similar problems too.

What did you learn about yourself through the experience of being ill?  I learned that anybody can get sick regardless of status and position in society.  In addition, being optimistic in life can easily contribute to managing the disease effectively. Discussion What emerges from the interview is that the patient was much disturbed as the disease had no cure. In addition, the patient did not know the cause of the disease. Therefore, this section explores in depth, and at the same time, serves to understand how Idiopathic Dilated Cardiomyopathy can be managed. To begin with, Idiopathic Dilated Cardiomyopathy is just a manageable disease, which means that the patient and physician must always keep in touch. This is based on the fact, that different stages of the disease demand different treatment approaches. In addition, Idiopathic Dilated Cardiomyopathy does not make people change their way of life, although there are many things that must be observed in order to manage it effectively. Exercises According to Mohan et al., (2002) the heart is a muscle, therefore, it needs exercise to maintain healthy. Some people with Idiopathic Dilated Cardiomyopathy always fall short of breath, therefore, must maintain their activities to the minimum. Minimum means activities that can enable the patient to breathe without difficulty (Mokenna & Elliot, n.d). It must be put into consideration that this does not affect everybody, but if the patient has to engage in any level of exercise, then, he or she must discuss with the physician in charge. Alcohol, Diet, Smoking, and Weight According to Mokenna and Elliot, excess weight overburdens the heart. A good diet reduces the chance of being overweight. Besides, drinking excess alcohol increases high blood pressure and can damage the health of one’s heart (Mokenna & Elliot, n.d). Alcohol is a depressant, and therefore, it can make the heart condition worse. Although smoking is not directly linked to Idiopathic Dilated Cardiomyopathy, its effects can easily trigger the disease. Smoking reduces the flow of blood to heart muscles and increase chances of getting coronary heart diseases.  Also, smoking limits the amount of oxygen flown to the blood, thus, overworking the heart. Sexual Life Erectile dysfunction and loss of sex drive are just some issues that Idiopathic Dilated Cardiomyopathy patients have. According to Mokenna and Elliot (n.d) knowing your limitations alongside things that bring symptoms can assist one to enjoy the fullness of his sexual life. Sex, as indicated by the author, is a form of physical exercise, although to some patients, it can increase heart-beat rate and blood pressure. This aspect can increase the activity of the heart, and for some people, it may lead to chest pain or discomfort. Loss of sex drive is not common among Idiopathic Dilated Cardiomyopathy patients. Nonetheless, some men experience impotence (Mokenna & Elliot, n.d). Some drugs like bet-blockers, which have effects of the sexual appetite may cause this condition. It may also result in poor blood circulation or even emotional stress, which has a direct effect on sexual drive. The author suggests that the best way to solve impotence is through couples talking to another as it helps to lessen its effect. For those who have heart conditions or problems, one should be careful when it comes to drugs like PDE-5 inhibitors. In fact, one should completely refrain from taking these taking particularly when on medication like GTN or any other drugs that have nitrates.

Work, Holidays and Travel Insurance Many people who are diagnosed with Idiopathic Dilated Cardiomyopathy get on normally with their daily responsibilities. However, the author indicates that if the work load is strenuous the patient should discuss the way forward with the physician (Mokenna & Elliot, n.d). Provided that ones symptoms are well managed, no restrictions will be imposed upon traveling or even flying. However, the author indicates that if one has breathing complications due to Idiopathic Dilated Cardiomyopathy, he should inform the concerned flight management for supply of oxygen bags. Conclusion It is vivid that people experience a lot of things when they are sick. These experiences range from personal to family to friends and co-workers. From the interview, the story of John is not different.  It is evident that John witnessed many things in the course of his sickness. First, his family gave him full support; co-workers and friends also showed empathy, and stepped in to help both physically and morally. John’s case sounds rare. Most people get fired from their job immediately when diagnosed with a disease that might demand a lot of money and time to manage. To some extent, even friends may segregate him. Nonetheless, his condition was not critical. In addition, he must have gotten doctors who were willing to assist. Some went outside their normal schedule just to ensure John recovered. However, John encountered a few problems here and there. First, the medication he was put on had some side effects. He almost lost his sexual drive. Second, every time he was travelling via airplane, he had to inform the management in advance for the supply of oxygen bag. On top of this, he had to find a willing friend to accompany him in case something goes wrong.

List of References Chan, K.-L., & Veinot, J. (2011). Anatomic basis of echocardiographic diagnosis. London: Springer. Mohan, S., Parker, M., Wehbi, M., & Douglass, P. (2002). Idiopathic Dilated Cardiomypathy: A common but mystifying cause of heart failure. Cleveland Clinical Journal of medicine, 69 (4), pp.481-487. Mokenna, W., & Elliot, P. (n.d). Inheritaed Heart conditions: Dilated cardiomypathy. British Heart foundation, pp. 1-66.

MINNESOTA V. RONALD RIFF: A POLICE INCIDENT REPORT

Minnesota v. Ronald Riff: A Police Incident Report Introduction This is a police incident report on how I conducted a search and a consequent arrest of Ronald Riff who was suspected of burglary. It contains the terms of reference for my obtaining of a warrant of arrest, search and arrest of suspects as provided by Amendment IV and the Court guidelines. It also contains a description of the actual search and arrest of the suspect. Terms of Reference According to the Court guidelines, a police officer cannot receive a warrant of arrest and consequently search a suspect’s premises unless the officer has established a probable cause for the arrest. These guidelines have been informed by the Fourth Amendment. I was therefore required to do thorough research to mine information that would render Riff a suspect. Secondly, it is required that an officer being supplied with an arrest warrant takes an oath that the information she or she shall give is factual and true. Therefore, I had a duty to establish to the best of my knowledge that the information I was to supply was correct. Thirdly, the warrant to be issue must be backed by a strong concise description of the person to be searched. In this case I had to give full details of Ronald Riff. If the police officer satisfied these conditions, the warrant should be issued: it must be issued by a judge. In addition, this warrant is does not authorize a general search: It is specific.

 

The Search and Arrest It was on April 20, 2012 at around 0800 hrs when it was reported that robbers had stolen money from Marquette’s Market. As a result, I was tasked by the head of police, Minnesota Police Department, to do the necessary investigation and make arrests the same day. So as to establish any suspects, I began my investigations immediately. I interviewed a few people in the market including the business people and the private security guards. After interviewing the some guards, I was able to establish the registration number of the vehicle that had sped off a few hours ago. The merchants at the market also described one of the men who they saw rushing into the car before it sped off. In addition, earlier that day, the neighbor of Ronald Reef had seen him offload some items from a car that she had never seen Riff with before.  With this information, I had every reason to suspect Mr. Riff and it was logical that I searched his home. However, I needed to have an arrest warrant from the Court judges. At around 1035 hrs, I was able to get a warrant of arrest of the suspect. I therefore began my pursuit immediately. At around 1300 hrs, I went to the suspect’s home but he was not there. The neighbor told me that Mr. Riff was usually at the market during that time; so I went to the market. From the descriptions I had earlier received, I was able to recognize the suspect. When he saw me, he ran towards his house after which I pursued him. I entered his house and searched every room. I was able to find a bag of money amounting to $910,000, checks made from the market and a hammer. Within the first hour after the arrest, I was able to compile my first report which the prosecution was to use to incriminate the suspect

 

 

 

 

 

 

 

Reference Curran, P. & Strauch, G. (n.d). Minnesota v. Ronald Riff: A criminal mock trial. Retrieved: http://civicallyspeaking.org/minnesota_riff.pdf

CHILD REFUSING TREATMENT: MODULE ON MANAGEMENT, ETHICS AND LAW

Child Refusing Treatment: Module On Management, Ethics and Law

Introduction The right to self-determination, which is the principle behind informed consent, is a basic human right and is in fact the basis for the promotion and strengthening of other human rights (Commission on Human Rights, 1984). Is this right absolute, and how does it relate to the case of refusal of treatment by a child? Refusal of treatment happens from time to time, particularly when the treatment entails patients to undergo a painful or uncomfortable process such as chemotherapy or radiotherapy, or when the treatment itself could be life-threatening, such as a surgical brain operation.  Refusal of treatment is a patient’s right, embodied in individuals’ right to self-determination, and, with some exceptions, upheld by UK laws (Family Law Reform Act, 1969; Mental Capacity Act 2005; Mental Health Act, 1992). However, when the patient refusing treatment is a child below 16 years of age, what legal and ethical guidance could medical practitioners, including nurses, turn to? The case has drawn the researcher’s interest due to the complexity of the issues at the heart of the case.  The paper will discuss the legal and ethical issues involved, in the context of nursing practice. Child Refusal of Treatment in the Context of Nursing Practice The core concept behind a patient’s refusal of treatment is informed consent, which is very important in the medical and research fields, because informed consent is necessary prior to any treatment or investigation proposed to a patient (Selinger, 2009). So crucial is informed consent that patients even have the right to refuse treatment, even if it will spell the difference between life and death (Mental Capacity Act, 2005). As crucial as this right is, it is also wrought with uncertainties. For instance, when the patient refusing treatment is a child below 16 years of age, health care providers could get confused as to the right decision to take. Decisions to allow patients to decide for themselves, even if this will be to their detriment, are normally done by general practitioners (Schermer, 2002). But due to the ever-expanding roles of nurse practitioners (BMJ, 2000; Norton and Kamm, 2002; NursingTimes.net, 2009), it may eventually fall under the purview of such nurse practitioners to decide on cases such as patient refusal of treatment.  Thus, learning about and understanding the legal, ethical, and professional issues surrounding such cases would be a good preparation for nursing practice.

Identification of Legal, Ethical, and Professional Issues in Children’s Refusal of Treatment The following issues have been identified by the researcher as pertaining to the topic of children’s refusal of treatment: 1. Ethical Issue: Is it ethical to respect a child patient’s decision to refuse treatment if it will be against their best interests? According to Gillon (1994), the four major principles of medical ethics are autonomy, non-malificence, justice, and beneficence. Of these, the principle of autonomy is at the heart of the concept of informed consent, since it is about patients’ right to self-determination – the right to determine what treatments to undergo (Schermer, 2002).  The right to self-determination gives people the right to “freely pursue their economic, social and cultural development” (Commission on Human Rights, 1984). However, if such right results in harm to the child, should the nurse allow it? Ethical principles will be used to discuss this issue. 2. Professional Issue: Do nurses have the right to go against a child patient’s decision if this is going to be detrimental for the child, based on the principle of ‘duty of care’? As nurses, we have a professional ‘duty of care’ to our patients and must promote their interests. According to the Nursing and Midwifery Council (NMC), nurses “must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbor” (2008). 3. Legal Issue: In cases where a child refuses treatment which would prolong his or her life, what alternatives are open to the health care providers in order to help prolong the patient’s life?  In the UK, the patient’s right to self-determination and more specifically to informed consent, is upheld through the Mental Capacity Act (2005), which mandates that a patient’s capacity to make decisions should be assumed to be present, unless there are reasonable grounds for believing the person is not competent. Such a right includes refusal of treatment. Evaluation of Identified Issues  There is much debate and confusion surrounding this right (to informed consent), because of the exceptional cases such as where children are involved and when their decision not to accept treatment would severely affect their health and well-being (Brazier and Lobjoit, 1991). The researcher opines that the following issues are involved in the specific case of a child refusing treatment, and will discuss them as thoroughly as possible: 1. Ethical Issue: Is it ethical to respect a child patient’s decision to refuse treatment if it will be against their best interests? Teleological ethics considers the outcome of an act as the determiner of whether or not it is ethical (Wolf, 2004). An act is considered ethical, according to teleological ethicists, if it results in “the greatest good for the greatest number” (Mill, 1863), or in preventing “the greatest amount of suffering for the greatest number” (Wolf, 2004). From this perspective, respecting a child patient’s (or his/her parents’) decision to refuse treatment may be thought of as not preventing suffering for the important stakeholders in the situation. Firstly, the child concerned would suffer by their own decision, because they may die if not given the treatment. The parents would also suffer because they would lose their child if the treatment is not given. Finally, the nurse or attending physician could be harmed professionally, since they could lose their practitioner license if a court of law finds them guilty of professional negligence. Thus, teleological ethics seems to advice that a child patient’s refusal of treatment should be overruled. Deontological ethics is less straightforward. From the deontological perspective, an act is ethical only if it was done because of duty (Beauchamp, 1991, p. 171). Deontological ethicists argue that people have a duty to promote the physical well-being and moral welfare of others (Kant, 1780). If the child’s physical well-being is considered, then the nurse has a duty to override the child’s decision to refuse treatment, since this will harm him physically. However, if the treatment reduces the child’s quality of life, as in the cases of painful treatments such as chemotherapy, radiotherapy, constant injections, and other invasive treatments, then imposing on a child to accept a treatment may not be in the best interests of the child  (Kleinman, 1991, p. 1219). On the other hand, if his moral welfare is considered, then the nurse may have to respect the child’s autonomy or right to self-determination, and therefore his wish to die with dignity, which the treatment may not afford him. Deontological ethics therefore fails to provide clear guidance on the issue. 2. Professional Issue: Do nurses have the right to go against a child patient’s decision if this is going to be detrimental for the child, based on the principle of ‘duty of care’? If a nurse fails to perform care and such failure results in harm to a patient, then they could be liable for negligence (Hendrick, 2000). Thus, according to the NMC guidance, nurses could be considered to have the right to go against a child patient’s decision if this is going to be detrimental for the child (Wooley, 2005). However, referring the matter to courts of law is the safer way to overrule a child patient’s decision, since medical intervention without valid informed consent is a criminal offence and the provider can be charged with battery (MRHA guidance, 2007) In addition, according to Carrese (2006), ‘duty of care’ also involves properly informing patients of their rights and ensuring that they have the necessary information to make an informed decision. Such duty involves properly informing a patient of all the risks involved in a treatment, as well as the consequences of not taking the treatment, so that the patient could make an informed decision (Hammaker and Tomlinson, 2011). 3. Legal Issue: In cases where a child refuses treatment which would prolong his or her life, what alternatives are open to the health care providers in order to help prolong the patient’s life?  The law mandates that, when the patient is below 16 years of age, health workers would need to determine the child’s competence to decide through the Gilick test (Spriggs, 2005, p. 45). Children who do not pass the Gilick test cannot withhold or give consent, leaving that decision to their parents (Brazier, 2003, p 85). Parents are also mandated by law to make the decision on children’s behalf (Children and Young Persons Act, 2008). This means that in case parents oppose a child’s wish, this opposition has some weight on the final decision (Donna and Sarah, 2011, p. 554). Proper communication between nurses and parents is therefore needed when it comes to the final decision making (Kupfer, 1990, pp. 30). In extreme cases where both the child and the parents decide to refuse treatment, nurses could go to court in order to stop parents from making what to these providers is an unwise decision. For instance, Wooley (2005) cites Jehovah’s witness parents who refuse blood products for their children. When their decisions threaten the life of their child unreasonably, parents are no longer considered to be acting in their best interests (Wooley, 2005). Implications for Practice 1. Transformational leadership In the context of nursing management and leadership, the issue brings to mind what, the most applicable concept to the case is the concept of transformational leadership. According to Burns (1978), a transformational leader motivates the team to be effective and efficient, and effective communication is the main avenue for motivating.  Applying this concept to the case of a child’s refusal of treatment, a nurse need not go against a patient’s decision if he or she can convince the patient to make, in the nurse’s informed opinion, the right decision. The process involves communicating the benefits and risks of a treatment, and offering alternative treatments to the patient, so that they could make an informed decision. The nurse should consider that a child may refuse treatment due to the fear of the risks involved, as well as due to fear of pain. Therefore giving them enough information to make an informed decision is not only a duty, but also the morally courageous path to take. Such issue brings to mind Corley’s (2002) definition of the nurse’s role – as moral agent in the healthcare system – wherein “the patient, nurse, and organization all benefit from nurses’ acts of moral courage”.  If the nurse succeeds in motivating the child patient to undergo treatment, even if they initially refused to do so, then the nurse could be said to have applied the concept of transformational leadership, because they have communicated effectively to the patient and influenced and motivated the patient to take the right path.  The concept of transformational leadership is consistent with the principle of beneficence, which consists of activities done by the nurses and health officers to give the best care and treatment to a child refusing treatment (Irwin, 2007, p. 46). By maximizing the benefits to the child patient without forcing the child to undergo treatment against their wishes, the nurse minimizes the risks to the child (Kilpi, 2000, p. 23). 2. Contingency Approach Not all situations where a patient exercises their right to informed consent could be treated in just one way. As the discussion of the above issues demonstrates, every situation is different and thus calls for a different approach, which is what contingency theory (also called the situational approach), is all about. The contingency approach is based on the idea that there is no one best way to handle a situation (Kieser and Kubicek, 1992). The approach tells nurse leaders that there is no universal answer to any case because people and situations are different, and perhaps the best answer is “it depends”. Therefore, a technique used with one patient refusing treatment may not work with another patient. The case highlights the importance of this theory to the nurses’ work. 3. Chaos Theory The case also validates the chaos theory, first advocated by Tom Peters (1987). The theory suggests that situations and organizations become more complex over time, and therefore also more chaotic (Peters, 1987). Thus managing by controlling events, or setting limitations and rules, will not always work. Instead of trying to control our work as nurses, we therefore should strive to adjust to the complex situations and issues that our work as nurses bring to us. Conclusion The issues examined in this paper point to conflicting values of respect for patient’s autonomy and acting in their best interests or beneficence (Phelps & Hassed, 2011, p 78). It is evident that a child’s consent to medication is a delicate issue, considering that at that age, the child may not have all the facts necessary in making a conscious decision (Deci and Ryan, 1995). Thus, in order to enhance respect for children’s autonomy, there is the need for proper communication skills between the nurses and parents when it comes to the final decision making (Kupfer, 1990, p. 30). In such cases, the best approach may be transformational leadership, in order to convince the patient to make a decision that is in their best interests. Transformational leadership is consistent with the principle of informed consent, wherein, the health care practitioner should endeavor to provide the patient with complete information regarding the risks of the treatment (Spriggs, 2005). References Beauchamp, T.L., 1991. Philosophical Ethics: An Introduction to Moral Philosophy, 2nd Ed. New York: McGraw Hill, p. 171. BMJ, 2000. Editorial: Doctors and nurses: doing it differently. British Medical Journal, 320, p. 1019. doi: 10.1136/bmj.320.7241.1019  BMJ, 2001. Editorial: Engaging patients in medical decision making. British Medical Journal, 323, p. 584.  doi: 10.1136/bmj.323.7313.584 Brazier, M. and Lobjoit, M., 1991. Protecting the vulnerable: autonomy and consent in health care. London:  Routledge. Brazier, M., 2003.Medicine, patients and the law. 3rd ed. London: Penguin. Burns, J.M., 1978. Leadership. New York: Harper & Row. Carrese, J.A., 2006.  Refusal of care: patients’ well-being and physicians’ ethical obligations. Journal of the American Medical Association, 296(6), pp. 691-695.  doi:10.1001/jama.296.6.691 Commission on Human Rights, 1984. General Comment No. 12. The right to self-determination of peoples (Art. 1). Covenant on Civil and Political Rights, Office of the High Commissioner on Human Rights 03/13/1984. Available at < http://www.unhchr.ch/tbs/ doc.nsf/0/f3c99406d528f37fc12563ed004960b4? Opendocument > [Accessed 14, February 2012]. Deci, E. L., & Ryan, R. M. (1995). Human autonomy: The basis for true self-esteem. In M. Kernis (Ed.), Efficacy, agency, and self-esteem (pp. 3149). New York: Plenum. Donna, H., and Sarah, J., 2011. Health Care Management and the Law: Principles and Applications. New York: Delmar, Cengage Learning. Gillon R., 1994. Medical ethics: Four principles plus attention to scope. British Medical Journal, 309, pp. 184-188. Hammaker, D. K., & Tomlinson, S.J., 2011. Health care management and the law: principles  and applications. Clifton Park, NY: Delmar, Cengage Learning. Hendrick, J., 2000. Law and ethics in nursing and health care. Cheltenham: Stanley Thornes. Hill, M., Lockyer, A., & Stone, F. H. 2007. Youth justice and child protection. London: J.  Kingsley Publishers. Hope, R.A., Savulescu, J. & Hendrick, J., 2003. Medical ethics and law: the core curriculum.  Elsevier Health Sciences, p. 43. Irwin, D., 2007. Ethics for speech-language pathologists and audiologists: an illustrative casebook. Clifton Park, NY: Thomson Delmar Learning. Jackie, V., 2009.Consent & refusal: selective respect for a young persons autonomy. Journal of  Community Nursing, 23( 4) p. 31-33. Kant, I., 1780. The Metaphysical Elements of Ethics. Translated by Abbott, T.K. [online] Available at <http://www.marxists.org/reference/subject/ethics/kant/morals/ch01.htm> [Accessed 13 February, 2012]. Kieser, A., and Kubicek, H., 1992. Organisation, 3rd ed. New York: De Gruyter. Kilpi, H., 2000. Patient’s autonomy, privacy, and informed consent. Amsterdam: IOS Press. Kimmel, A. J., 2007. Ethical issues in behavioral research: basic and applied perspectives (2nd  ed.). Malden, MA: Blackwell Pub. Kleinman, I., 1991. The right to refuse treatment: ethical considerations for the competent patient. Canadian Medical Association Journal, May 15, 144(10), pp. 1219–1222. Kupfer, J. H. 1990. Autonomy and social interaction. Albany: State University of New York  Press. NMC, 2008. The code: Standards of conduct, performance and ethics for nurses and midwives. Nursing and Midwifery Council [online] Available at < http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_TextVersion.pdf > [Accessed 10 February 2012]. Maclean, A. 2004. Briefcase on medical law (2nd ed.). London: Cavendish Pub. Mccafferty C.,1999. Won’t consent? Can’t consent! Refusal of medical treatment. Family Law, 29, p.335. Mill, J.S., 1859. On Liberty. Oxford University Press. Mill, J.S., 1863. Utilitarianism. Project Gutenberg online edition [online] Available at <http://www.gutenberg.org/files/11224/11224-h/11224-h.htm#CHAPTER_II> [Accessed 14 February, 2012]. Norton, C. and Kamm, M.A., 2002. Specialist nurses in gastroenterology. Journal of the Royal Society of Medicine, July, 95(7), pp. 331–335. NursingTimes.net, 2009. Trespassers on medical ground? [online] Available at < http://www.nursingtimes.net/whats-new-in-nursing/acute-care/trespassers-on-medical-ground/5006643.article > [Accessed 10 February 2012]. Peters, T., 1987. Thriving on chaos. New York: HarperCollins. Phelps, K., & Hassed, C. 2011. General practice: the integrative approach. Sydney: Churchill  Livingstone/Elsevier. Schermer, M., 2002. The different faces of autonomy: patient autonomy in ethical theory and  hospital practice. Dordrecht: Kluwer Academic Publishers. Selinger, C.P., 2009. The right to consent: Is it absolute? British Journal of Medical Practitioners, 2(2), pp. 50-54 [online] Available at <http://www.bjmp.org/content/right-consent-it-absolute> [Accessed 10 February 2012]. Spriggs, M. 2005. Autonomy and patients’ decisions. Lanham, Md.: Lexington Books. United Nations, 1959. Declaration of the rights of the child, G.A. res. 1386 (XIV), 14 U.N. GAOR Supp. (No. 16) at 19, U.N. Doc. A/4354 (1959). Wolf, C., 2004. “Repugnance, where is thy sting?” In The repugnant conclusion, essays on population ethics, pp. 61-80. Dordrecht, Holland: Kluwer Academic Publishers. Wooley, S., 2005. Children of Jehovah’s Witnesses and adolescent Jehovah’s Witnesses: what are their rights? Archives of Disease in Childhood, 90, pp. 715 – 719.    doi:10.1136/adc.2004.067843 UK Acts Children Act, 1988. Available at <http://www.legislation.gov.uk> [Accesed14 February, 2012]. Children and Young Persons Act, 2008. Available at < http://www.legislation.gov.uk>  [Accesed14 February, 2012]. Mental Capacity Act, 2005.Available at < http://www.legislation.gov.uk> [accesed14 February,  2012]. The Mental Health Act. 1983.  Available at <http://www.legislation.gov.uk> [Accesed14 February, 2012]. Nurses-and-midwives Council. April 2008.[online] Available at < http://www.nmc-uk.org>  [Accessed 14 February, 2012]. MRHA Guidance, 2007. [online] Available at < http://www.mhra.gov.uk> [Accessed 14 February, 2012].