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2022

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Full-Text Articles in Counseling Psychology

The Correlation Between Transformational Leadership And Mental Health Clinician Burnout, Rebekah E. Shutter Nov 2022

The Correlation Between Transformational Leadership And Mental Health Clinician Burnout, Rebekah E. Shutter

Electronic Theses and Dissertations

Mental health clinicians working in a hospital setting are at a high risk of experiencing burnout due to the stressful demands of their caseloads, compassion fatigue, limited resources, and unsupportive leadership. While there is ample research regarding the cause and effect of burnout on clinicians there is a gap in the literature when it comes to the impact leadership has on mental heath clinician burnout. The purpose of this quantitative, correlational study is to determine if and to what extent there is a correlation between Transformational Leadership and mental health clinician burnout. Participants for this study consisted of 200 mental …


Moderating Factors In The Relationship Between Bully Victimization And Psychosomatic Symptoms, Tonya Paulson Oct 2022

Moderating Factors In The Relationship Between Bully Victimization And Psychosomatic Symptoms, Tonya Paulson

Theses and Graduate Projects

The purpose of this study was to investigate the relationship between bully victimization and psychosomatic symptoms, and to examine the protective influence of perceived parent and peer support across developmental age groups. Bully victimization frequency, somatic symptom severity, perceived parent support, and perceived peer support were assessed using archival data from 7,304 youth who participated in the 2009-2010 Health Behavior in School-Aged Children (HBSC) U.S. survey, excluding perpetrators of bullying. Bully victimization and somatic symptoms were significantly positively correlated. Older adolescents consistently reported more severe somatic symptoms, but age did not moderate the relationship between bullying and somatic symptoms. Higher …


Emergency Care For Youth Who Experience Suicidality And Identify As Lesbian Gay Bisexual Transgender Queer/Questioning (Lgbtq+): An Interpretive Phenomenology, Theresa Schultz Aug 2022

Emergency Care For Youth Who Experience Suicidality And Identify As Lesbian Gay Bisexual Transgender Queer/Questioning (Lgbtq+): An Interpretive Phenomenology, Theresa Schultz

Electronic Theses and Dissertations

Purpose: Suicide is a leading cause of death in children; youth who identify as LGBTQ+ are at an exponentially higher risk of suicide. The purpose of this study was to explore the lived experiences of young adults who identify as LGBTQ+ and sought emergency care for suicidality when they were adolescents.

Methods: Heideggerian hermeneutics phenomenology is the research method used in this study. Youth, ages 18-25 years, who identify as LGBTQ+ and sought emergency treatment for suicidality when they were adolescents (13-17 years) were recruited to participate;fifteen youth enrolled. Individuals ranged in age from 20 to 25 years. Participants described …


A Qualitative Exploration Of Upsr, Shelby Miller Aug 2022

A Qualitative Exploration Of Upsr, Shelby Miller

Masters Theses

Person-Centered Theory (PCT, Rogers, 1959) provides the understanding of how growth-promoting relationships facilitate holistic well-being through the provision of unconditional positive regard (UPR), genuiness, and empathy. Through coaches’ provision of UPR, athletes have reported experiencing an increase of motivation, enhanced performances, and greater trust in their coach (McHenry et al., 2022). Most intriguingly, athletes created a relationship with themselves (i.e., self-regard) that mirrored their coaches’ treatment of them (McHenry et al., 2021). While UPR has just recently been studied in the coach-athlete relationship, little to no attention has been given to the relationship an athlete has with themselves (i.e., self-regard). …


An Investigation Of Healthcare Professionals’ Perspectives On The Tasks Of Mental Health Counselors In Hospital Settings, Suelle Micallef Marmara Aug 2022

An Investigation Of Healthcare Professionals’ Perspectives On The Tasks Of Mental Health Counselors In Hospital Settings, Suelle Micallef Marmara

Counseling & Human Services Theses & Dissertations

With the global mental health implications reported by the spread of COVID 19 (Javed et al., 2020) and the amplified mental health illnesses reported by the State of Mental Health in America (Reinert et al., 2021), there is an increased need to address psychological and emotional health along with physical health. Mental Health Counselors (MHCs) can be the next professional body to support the multidisciplinary teams within hospital settings to complement holistic care focusing on physical and emotional well-being. Researchers have demonstrated addressing the psychological needs of patients from their first admissions to the hospital has significant positive implications on …


Supporting Post-Secondary Implementation Of Recovery-Oriented Practice In A Stepped Care Model, Janis Campbell Jul 2022

Supporting Post-Secondary Implementation Of Recovery-Oriented Practice In A Stepped Care Model, Janis Campbell

The Dissertation in Practice at Western University

Student mental health has been a growing concern for higher education communities for many years. Campuses have been struggling to keep up with the increasing demand for services which has been complicated further by the COVID-19 pandemic. A Stepped Care model (SCM) developed at a Canadian university has been offering new ways of organizing mental health resources based on open access, student choice, and recovery principles. There are diverse definitions of recovery in the literature and are usually based on values such as empowerment, respect, and self-determination. SCMs have been shown to increase access to resources and reduce or eliminate …


Combined Treatment Model Program For Survivors Of Intimate Partner Violence, Hillary Jeanne May Jun 2022

Combined Treatment Model Program For Survivors Of Intimate Partner Violence, Hillary Jeanne May

Loma Linda University Electronic Theses, Dissertations & Projects

This project seeks to fill a void in the mental health field by providing a combined treatment model program to address the needs of survivors of intimate partner violence. As such, the primary purpose of this project is the development of a treatment program with services that are easily accessible by survivors that is intended for future implementation in shelters or agencies that have contact with this population of women. This program offers a means to engage an underserved population in access to services and self-development to improve overall mental and physical health outcomes and attempt to prevent recurrent intimate …


Where I’M From: Internal Manifestations Among Cambodian Women Using The Expressive Arts A Literature Review, Noeun Chhim May 2022

Where I’M From: Internal Manifestations Among Cambodian Women Using The Expressive Arts A Literature Review, Noeun Chhim

Expressive Therapies Capstone Theses

Chronic mental illness has affected many Cambodian people, but, culturally, Cambodians aren’t accustomed to opening up and discussing their feelings, rather defining mental illness to craziness and seeking help is presumed taboo. Thus, Cambodians are often reluctant to talk about their experiences and/or their related illnesses. Though Cambodians have experienced inconceivable suffering and violence during the Khmer Rouge era, for the purpose of this thesis, I will be discussing the role of Cambodian women and investigate the extent of what they’ve witnessed and experienced. Cambodian women have suffered through many years of trauma and grief, during and after the Khmer …


The Neurobiology Of The Healing Arts: Expressive Arts Therapy As An Effective Treatment For Adults Diagnosed With Complex Ptsd Due To Complex Trauma In Childhood: A Literature Review, Cheryl Ratliff May 2022

The Neurobiology Of The Healing Arts: Expressive Arts Therapy As An Effective Treatment For Adults Diagnosed With Complex Ptsd Due To Complex Trauma In Childhood: A Literature Review, Cheryl Ratliff

Expressive Therapies Capstone Theses

Empirically based therapies for posttraumatic stress disorder (PTSD) have been found to be less effective in treating more severe trauma presentations such as complex PTSD (CPTSD). Neurobiological investigation provides a framework for examining the physical and psychological effects of trauma on brain and nerve structures and provides insight into how to effectively treat CPTSD. This literature review examined symptomology of CPTSD resulting from complex trauma in childhood, neurobiological effects of trauma and their implications for treatment, and the efficacy of the current treatment models, primarily those of eye movement desensitization and reprocessing (EMDR), narrative exposure therapy (NET), and somatic psychotherapies. …


Toward Holistic Mental Wellness: A Literature Review Of Mindfulness-Based And Focusing-Oriented Art Therapies, Lesley Vernon May 2022

Toward Holistic Mental Wellness: A Literature Review Of Mindfulness-Based And Focusing-Oriented Art Therapies, Lesley Vernon

Expressive Therapies Capstone Theses

Modern day living, for all its benefits, is synonymous with record levels of stress. The mental health clinician’s role is to assist clients in accessing the skills and tools necessary to reduce and alleviate the symptoms of stress-induced anxiety. Mindfulness is emerging as a potent and effective tool to restore one’s state of well-being. Likewise, engaging in art therapy has been shown to reduce stress and foster resilience. Grounded in humanistic and existential theories, this literature review aimed to assess the impact and effectiveness of two intermodal holistic therapies, specifically mindfulness-based art therapy (MBAT) and focusing-oriented art therapy (FOAT). A …


Moving Through Loss: The Experience Of Ambiguous Loss With Hospitalized Children, The Development Of A Method, Peyton Edington May 2022

Moving Through Loss: The Experience Of Ambiguous Loss With Hospitalized Children, The Development Of A Method, Peyton Edington

Expressive Therapies Capstone Theses

The current method examined the effects of ambiguous loss with medical transplant patients in a pediatric hospital by utilizing a dance/movement therapy intervention. The development of this method was based on ambiguous loss theory with a dance/movement therapy approach. The explored literature identified central themes of ambiguous loss, such as resilience. These themes were connected to the practice of dance/movement therapy, such as embodiment. With this connection, the intervention was developed and implemented with participants. The central themes that emerged from the intervention were change, loss, meaning-making, and hope. One child and two adolescents were participants in this intervention, and …


Healing Our Connection With Nature: An Expressive Arts Community Engagement Project, Meghan Mccrillis May 2022

Healing Our Connection With Nature: An Expressive Arts Community Engagement Project, Meghan Mccrillis

Expressive Therapies Capstone Theses

A community engagement project was created and implemented, comprised of two events for which the author facilitated nature-based expressive arts experiences to explore the integration of nature and expressive arts therapy. The events were offered to two different groups of community members, one for nature-curious adults held outdoors on the trails of a local conservation trust, and another for young children at a local library. The healing impact of nature connection and nature connection experiences are explored through a literature review, event methods, and the author’s personal experiences of the project via artmaking. The results include an emphasis on nature …


How Geek Therapy Plays Into Expressive Arts Therapy: A Literature Review, Caroline Bryan May 2022

How Geek Therapy Plays Into Expressive Arts Therapy: A Literature Review, Caroline Bryan

Expressive Therapies Capstone Theses

Within this paper, I explore how geek therapy plays well with the methods of expressive arts therapy. The combination of geek therapy and expressive arts therapy can assist clinicians in immediately connecting with their clients and identifying strength-oriented narratives that honor the client’s preferences, modes of expression, and pop culture affinities. This engagement with expressive approaches utilizing affinity-based interventions can lead to a deeper sense of understanding of the client’s intra-, inter-, and extra-personal relationships. Through this literature review of expressive arts therapy and geek therapy, primarily focusing on video games in therapy, clinicians from all walks of life can …


Trauma Healing With The Neurosequential Model Of Therapy And Bal-A-Vis-X, Becky Johnston May 2022

Trauma Healing With The Neurosequential Model Of Therapy And Bal-A-Vis-X, Becky Johnston

Educational Specialist, 2020-current

Stigma related to childhood trauma is shifting with the help of advancements in the understanding of neurobiology and interventions that are proving to be effective for healing. There are immense costs and consequences for survivors of childhood trauma and their loved ones that were not so long ago considered irrelevant and the notion that kids bounce back from adversity was previously popular in the psychological community (Perry & Szalavitz, 2017). The broad strokes of Dr. Bruce Perry’s clinical intervention model, The Neurosequential Model of Therapy (NMT) describes a trauma-sensitive, sequential approach to changing the stress response within mental health counseling. …


Barriers To The Use Of Palliative And Hospice Care Among The Latino Population, Diana Ramirez May 2022

Barriers To The Use Of Palliative And Hospice Care Among The Latino Population, Diana Ramirez

Electronic Theses, Projects, and Dissertations

Patients suffering from irreversible and terminal illnesses may benefit from the services provided by Palliative and Hospice Care to control any symptom burden and assist in navigating complex medical decisions. Many patients may express hesitation in accepting and enrolling to this service due to misconceptions. Language barriers may add an additional layer of complexity. This study explored the challenges Palliative Care providers encounter when introducing concept of hospice to Spanish-speaking patients their families for the first time. This study implemented qualitative research methods by using semi-structured one-on-one interviews. Ten members of an In-patient Palliative Care Team at a University Hospital …


Complex Thought For Complex Work: Preparing Cognitively Complex Counselors For Work In Diverse Settings, Alexandra C. Gantt May 2022

Complex Thought For Complex Work: Preparing Cognitively Complex Counselors For Work In Diverse Settings, Alexandra C. Gantt

Counseling & Human Services Theses & Dissertations

Counselor education researchers have explored the need for high levels of cognitive complexity (CC) in mental health counselors due to its relationship with high quality counseling skills and counselor ways of being (e.g., Castillo, 2018; McAuliffe & Lovell, 2006; Ridley et al., 2011; Welfare & Borders, 2010b). In these studies, researchers have called for continued study of means of enhancing CC in counselors in training (CITs) through andragogical efforts (e.g., Castillo, 2018; Duys & Hedstrom, 2000; Welfare & Borders, 2010a). However, we do not have an understanding of minimally acceptable CC for graduating CITs. In this study, I explored counselor …


Understanding Factors Associated With Clinician Confidence To Identify And Treat Ptsd And Complex Ptsd, Parad Meier Apr 2022

Understanding Factors Associated With Clinician Confidence To Identify And Treat Ptsd And Complex Ptsd, Parad Meier

Counseling and Psychology Dissertations

ABSTRACT

This dissertation explores mental health clinicians’ experiences and self-identified confidence to identify and treat post-traumatic stress disorder (PTSD) and Complex PTSD. PTSD is a highly prevalent mental health condition that impacts an estimated 24.4 million individuals in the United States (PTSD United, 2019). Complex PTSD has just emerged for the first time with official diagnostic criteria in the publication of the ICD-11 in 2019 for use beginning in January 2022 (WHO, 2019). There is very little existing research that considers the experience or confidence of clinicians who work with clients who have PTSD and Complex PTSD, which is troubling …


Generation Status, Ethnic Identity, Colonial Mentality, And Enculturation In Filipino Americans, Kamille Patricia Urmaza La Rosa Apr 2022

Generation Status, Ethnic Identity, Colonial Mentality, And Enculturation In Filipino Americans, Kamille Patricia Urmaza La Rosa

Dissertations

Filipino Americans’ psychological experiences pertaining to their generation status, ethnic identity, enculturation, and colonial mentality are rarely studied in counseling psychology due to inconsistent disaggregation of Asian American and Pacific Islander (AA&PI) data (Agbayani-Siewert, 2004; Espiritu, 2003; Nadal et al., 2010; Okamura, 2013). Literature suggests that the study of these constructs related to their mental health can guide more culturally informed care for this historically excluded population (David & Nadal, 2013; Nadal, 2020). The current study used an exploratory design to test six research hypotheses and accomplish the following: examine relationships between the constructs, investigate intergenerational differences, validate a measure …


Testing Barriers To Non-Suicidal Self-Injury With College Students: Narcissistic Traits As Moderators, Philip Stoner Feb 2022

Testing Barriers To Non-Suicidal Self-Injury With College Students: Narcissistic Traits As Moderators, Philip Stoner

Dissertations

Research on non-suicidal self-injury (NSSI) has produced mixed findings, resulting in a lack of clarity regarding these behaviors (Klonsky & Meuhlenkamp, 2007). To address this, Hooley and Franklin (2018) developed the Benefits and Barriers Model (BBM) to provide a comprehensive understanding of NSSI, in which they identified the barriers that commonly prevent people from engaging in these behaviors (e.g., self-esteem, shame, and peer-bonding motivations/social norms). They also identified adverse childhood experiences (ACEs) as a distal predictor of NSSI, which aids people in overcoming the barriers to engaging in these behaviors. Recent NSSI literature has shown that college women in the …


Rural Pregnant Women’S Experiences With Substance Use Disorder: A Qualitative Study, Cami Weber Jan 2022

Rural Pregnant Women’S Experiences With Substance Use Disorder: A Qualitative Study, Cami Weber

Dissertations

Rural pregnant women with substance use disorder (SUD) are an understudied vulnerable population that often experiences poor pregnancy outcomes (Higgins et al., 2019; Jumah, 2016; Kramlich et al., 2018; Shaw et al., 2015). Despite the high prevalence and high burden associated with SUD, rural women are less likely than non-pregnant women to seek addiction treatment and complete an outpatient treatment program during pregnancy (Shaw et al., 2015). This study aimed to give voice to rural Missouri women with SUD. The research questions explored the life experiences and motivations for seeking treatment using a qualitative, descriptive research design with grounded theory …


Equine Assisted Psychotherapy: Implications For Treating Trauma, Kara L. Harrison Psy.D. Jan 2022

Equine Assisted Psychotherapy: Implications For Treating Trauma, Kara L. Harrison Psy.D.

Psychology Doctoral Specialization Projects

Trauma related symptoms and Posttraumatic Stress Disorder (PTSD) have been increasingly recognized for the key roles they occupy in mental health and overall individual well-being within both adult and childhood populations. They often represent significant barriers to the provision of mental healthcare within military populations and individuals diagnosed with serious mental illness (SMI). This original contribution to practice explores the significance of Equine Assisted Psychotherapy as a novel adjunctive approach to treating trauma. symptoms in adults and children. An extensive literature review examines current research and discussion on common definitions and nomenclature. It begins with discussion on the broader areas …


Mitigating Weight Stigma In The Medical System: Self-Compassion For Nursing Students, Ellen C. Joseph Jan 2022

Mitigating Weight Stigma In The Medical System: Self-Compassion For Nursing Students, Ellen C. Joseph

Electronic Theses and Dissertations

Weight stigma is a form of oppression that has been shown to have a detrimental impact on the well-being of people with higher weight. Healthcare providers are one of the most common sources of weight stigma, and their stigmatizing beliefs have been found to be associated with differential care for patients with “obesity”. The current study aimed to explore the feasibility of the loving-kindness meditation (LKM) as a brief intervention that reduces weight bias in nursing students by increasing self-compassion, positive, other-focused emotions, and cognitive flexibility, in order to improve compassionate care for patients with higher weight. Participants (189 nursing …


“If I Had Felt Comfortable Or Accepted, I Would Have Made More Progress”: A Phenomenological Investigation Into The Experiences Of Lgbtq+ Persons In Clinical Professional Counseling, Valerie Moreno-Tucker Jan 2022

“If I Had Felt Comfortable Or Accepted, I Would Have Made More Progress”: A Phenomenological Investigation Into The Experiences Of Lgbtq+ Persons In Clinical Professional Counseling, Valerie Moreno-Tucker

Graduate Research Theses & Dissertations

The counseling literature has indicated that LGBTQ+ persons have experienced fewer positive mental health outcomes than cisgender heterosexual persons. Professional counselors, despite their requirement to provide culturally sensitive counseling services for all communities, must learn how to better need the needs of LGBTQ+ persons and communities. This dissertation elevates LGBTQ+ persons’ voices by examining the experiences of LGBTQ+ persons in clinical professional counseling. Specifically, the IPA approach was utilized in analyzing data from six individuals who each participated in two interviews lasting 45-90 minutes each. This investigation found commonalities between each participant regarding both their helpful and unhelpful experiences in …


Mental Health Counselors’ Use Of Complementary And Alternative Approaches For Treating Individuals With Anxiety Disorders, Jane Rose Simmons Jan 2022

Mental Health Counselors’ Use Of Complementary And Alternative Approaches For Treating Individuals With Anxiety Disorders, Jane Rose Simmons

Walden Dissertations and Doctoral Studies

Anxiety disorders are one of the most prevalent mental health disorders worldwide. Traditional counseling approaches do not address the evolving needs of individuals with anxiety disorders, and information is scarce regarding counselors’ use of complementary and alternative approaches in treating anxiety disorders. The purpose of this quantitative survey study was to investigate whether counselors’ knowledge, perceptions, intentional practices, and openness predicted their use of complementary and alternative approaches in counseling individuals with anxiety disorders. The integrative mental health model for the conceptual framework guided this study. The research questions examined how five variables—spirituality, specialization, types of anxiety disorders treated, training, …


The Experience Of Providing Direct Care To Children Victims Of Boko Haram Insurgencies In Nigeria, Felicia Etuke Jan 2022

The Experience Of Providing Direct Care To Children Victims Of Boko Haram Insurgencies In Nigeria, Felicia Etuke

Walden Dissertations and Doctoral Studies

The insurgency of terrorism leaves lasting economic, social, academics, spiritual, religious, and psychological effects, but often children’s psychological welfare is neglected in the aftermath of terrorist attacks. Boko Haram’s presence in Nigeria has left many children orphaned, displaced, and impoverished. Thus, there is a need to highlight the importance of the role that care providers play in securing the psychological health of the child victims of Boko Haram insurgency. This qualitative, phenomenological study explored the experiences of care providers to the child victims of Boko Haram insurgency in Nigeria. Compassion fatigue theory was used as a theoretical framework for the …


Moral Distress Experienced By Behavioral Health Clinicians Who Have Worked With Maternal, Opioid-Using Clients, Jill Lee-Hubble Jan 2022

Moral Distress Experienced By Behavioral Health Clinicians Who Have Worked With Maternal, Opioid-Using Clients, Jill Lee-Hubble

Walden Dissertations and Doctoral Studies

Moral distress (MD) is a concept that has been well studied in nursing and other medical fields as a precursor to provider burnout. Understanding how MD impacts behavioral health (BH) clinicians provides insights for counselor educators and supervisors to identify clinical situations that often lead to MD. This qualitative phenomenological study explored how MD was experienced by five BH clinicians who have worked in residential and hospital settings providing counseling to maternal, opioid-using clients. Interpretive phenomenological analysis (IPA) informed the research methodology and data analysis. Substance use during pregnancy is highly stigmatized in society; thus, a feminist conceptualization was integrated …


Experiences Of Maritally Satisfied Black American Couples Serving In Law Enforcement, Amanda Davis-Buie Jan 2022

Experiences Of Maritally Satisfied Black American Couples Serving In Law Enforcement, Amanda Davis-Buie

Walden Dissertations and Doctoral Studies

The purpose of this hermeneutic phenomenological study was to explore the lived experiences of maritally satisfied Black American couples when at least one partner is serving in law enforcement. Members of law enforcement, Black American couples, and members of the counseling profession can gain knowledge from the answering of the research question. A family strengths perspective was used to provide a framework to study the phenomenon of marital satisfaction from a positive perspective. Six Black American couples, who are satisfied in their marriage and employed in law enforcement for a period of a least 6 months during their marriage, participated …


Stress, Resiliency, And Burnout Among Leaders In The Counseling Profession, Adriana Bovee Jan 2022

Stress, Resiliency, And Burnout Among Leaders In The Counseling Profession, Adriana Bovee

Walden Dissertations and Doctoral Studies

Leaders in the counseling profession face many demands. The purpose of this quantitative regression analysis study was to determine if there was a predictive relationship between the independent variables of stress and resiliency and dependent variables of burnout, emotional exhaustion, depersonalization, and personal accomplishment among leaders in the counseling profession. Transformational leadership theory and resilience theory were applied as the theoretical framework of this study. A cross-sectional data collection method was used, and data were collected through anonymous online surveys from a purposive sample of 75 counseling leaders. Data analyses methods included descriptive statistics and multiple linear regressions. Results indicated …


Educating Providers About Integrated Treatment For Individuals With Co-Occurring Disorders, Ihuarulam Chidiebere Okoroji Jan 2022

Educating Providers About Integrated Treatment For Individuals With Co-Occurring Disorders, Ihuarulam Chidiebere Okoroji

Walden Dissertations and Doctoral Studies

AbstractThe problem identified by this staff education project was the providers’ lack of knowledge on integrated treatment for individuals with co-occurring disorders (CODs). Integrated treatment is the gold standard for working with individuals with CODs. Providers knowledge gap and barriers were addressed by educating them on integrated treatments. This project used the analysis, design, development, implementation, and evaluation (ADDIE) model in planning, implementation, and evaluation. The participants were 20 providers in a residential addiction treatment facility which include one physician, three nurse practitioners, eight counselors, one registered nurse, and seven licensed practical nurses. This project used a pretest to determine …


The Sustained Effects Of Mindfulness-Based Interventions On Distress Symptoms In Female Breast Cancer Patients, Candace K. Sprouse Jan 2022

The Sustained Effects Of Mindfulness-Based Interventions On Distress Symptoms In Female Breast Cancer Patients, Candace K. Sprouse

Walden Dissertations and Doctoral Studies

The purpose of this study was to illuminate the magnitude and prevalence of distress symptoms among female breast cancer patients and help identify best social work practices for treating distress symptoms in cancer patients. Using the social cognitive model of restorative well-being, the sustained effects of mindfulness-based interventions on distress symptoms female breast cancer patients experienced were examined in this study. Grounded in social cognitive theory, this model facilitated understanding of the recovery of well-being after an emotional setback. This quantitative experimental study included analysis of secondary data with pre- and post testing with multiple follow ups to measure the …