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A Psychologist's Response to the CaseStudy: Application of Theory andMeasurementAndrea L. Canada aa Department of Behavioral Sciences , Rush University MedicalCenter , Chicago, Illinois, USAPublished online: 29 Apr 2011.

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A Psychologist’s Response to the Case Study:Application of Theory and Measurement

ANDREA L. CANADADepartment of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA

This article represents a psychologist’s perspective on the case studyof Doris, a middle-aged woman with metastatic breast cancer whois initially referred to Chaplain Rhonda for assistance with deathanxiety. In the field of psychology, it has long been accepted thatgood clinical research is informed by theory. As such, ChaplainRhonda’s intervention with Doris will be examined through thelens of object relations theory. Specifically, we will see how Rhon-da’s relationship and interaction with Doris improves her imageof God and, by doing so, decreases her death anxiety. In psycho-logical research, it is also important to accurately measure theeffects or outcomes of clinical interventions. In this light, severalsuggestions are offered for the measurement of constructs relevantto the case of Doris, namely God image and death anxiety. Finally,a simple case study research design, applying the aforementionedtheory and measurement, is provided as a suggested starting pointfor research on the efficacy of chaplaincy interventions.

KEYWORDS case study, chaplaincy intervention, death anxiety,God image, object relations theory

INTRODUCTION

The quality of a given research project, including the case study, is determ-ined by a number of factors. One key factor is whether the hypotheses to betested are theory-driven. It has been said by many a professor, ‘‘All goodresearch is theory-driven,’’ meaning that one must find an existing theoreticalprinciple that can inform the research hypotheses and, thereby, help explain

Address correspondence to Andrea L. Canada, Ph.D., Department of Behavioral Sciences,Rush University Medical Center, 1653 West Congress Parkway, Chicago, Illinois 60612-3833,USA. E-mail: Andrea_L_Canada@rush.edu

Journal of Health Care Chaplaincy, 17:46–54, 2011Copyright # Taylor & Francis Group, LLCISSN: 0885-4726 print=1528-6916 onlineDOI: 10.1080/08854726.2011.559854

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the research findings (Bordens & Abbott, 2010). A hypothesis in the presentcase study might generally be phrased, ‘‘Chaplain Rhonda’s intervention willresult in positive outcomes for Doris.’’ In this paper, I propose a psychologicaltheory that, I believe, applies quite well to Chaplain Rhonda’s workwithDoris.

Another key factor in good research involves the accurate measurementof outcomes (Thorndike & Thorndike-Christ, 2009). Much of psychologicalresearch involves patient-reported outcomes; that is, patients are asked tocomplete paper-and-pencil questionnaires containing items that assess feel-ings or symptoms. Scores on the questionnaires are determined and statisticalanalyses are then applied to test the research hypotheses. In this paper, Ipropose several measures that, I believe, would be useful in assessing theoutcomes of Chaplain Rhonda’s intervention with Doris.

THEORY

Object Relations Theory

In their seminal work, Greenberg and Mitchell (1983) elegantly and compre-hensively synthesize the development and fruition of object relations theory.Object relations theory is rooted in classical psychoanalysis and shares withthat tradition many assumptions, including the view of the infant’s experi-ence as largely biological and universally sequenced. However, whereasclassical psychoanalysis is rooted in a drive=structural model, object relationstheory is founded in a relational=structural model. In other words, Freudviewed the role of ‘‘objects’’ (i.e., others) largely in relation to the dischargeof drive (sex or aggression): they may impede discharge, facilitate discharge, orfunction as its target. Object relations theorists have replaced the drive theorymodel with an essentially different conceptual framework in which relationswith others (not drives) constitute the ‘‘fundamental building blocks of mentallife’’ (Greenberg & Mitchell, 1983, p. 3). Other excellent texts describing objectrelations theory are also available (Hughes, 1989; Mitchell & Black, 1995;Ogden, 1993; Wachtel, 2008). The most well known theoreticians (and sug-gested readings) in this area include: Melanie Klein (Segal, 1988), D. W. Winni-cott (Davis &Wallbridge, 1981), andW. R. D. Fairbairn (Pereira & Scharff, 2002).

Object relations theory assumes the infant’s world involves the experi-ence of the body and self, the awareness of the existence of others as objects,and the knowledge of relations between the self and those others (hence,the term object relations). Interpersonal functioning is critically mediatedby the cognitive representations of particular people (object representations),the emotions attached to those representations, and understandings aboutthe relationship between the self and significant others. These impressionsand experiences are organized into ‘‘representational worlds’’ that arethen used as a guide to navigate through social relationships (Sandler &Rosenblatt, 1962).

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As the infant develops, he=she can form either positive or negativerepresentations as self-as-object or other-as-object. If the child experiencesfairly consistent and supportive relationships with caregivers, he=she shouldinternalize generally healthy and stable internal representations of selfand relationships in general. However, should the child experience trauma,abuse, and=or inconsistent or emotionally disconnected caregiving, he=shemight internalize generally negative representations of the self-as-object orother-as-object (Beck, 2006).

Object Relations Theory and Image of God

As God is not directly observable to the child, the object representationof God is formed initially through relationships with others, suggestingthat God-representations are often built upon the pre-existing representa-tions of self and other (Beck, 2006). Some object relations theorists positthat the earliest foundations of the God image are associated with themother object representation (Rizutto, 1979); however, others suggestthat representations of God are more similar to a composite image ofboth parents (Birky & Ball, 1988). The foundation for one’s image ofGod is likely established in the earliest periods of life. According toRizutto, this God image is continually transformed and reshaped asnew experiences are brought into the internal representational world.McDargh (1986) writes:

Whether a given individual relates to a particular object representation ofGod with conscious belief, or unbelief, whether that representation isrepressed, rejected, embraced, or celebrated has everything to do withthe dynamic origins of that representation, its subsequent life history,and hence if and how it may be available to help the person sustain somesense of being a self-in-relationship (p. 256).

Results of qualitative studies suggest that a close and loving image ofGod is related to interpersonal styles that demonstrate empathy, affection,and acceptance toward others (Edwards, Goldberg, Hargrove, & Linamen,1979); conversely, psychopathology is inversely related to an image ofGod as close, loving, and kind (Brokaw & Edwards, 1994). Results of quan-titative studies investigating the relationship between object relations devel-opment and God image are similar. Studies have found that mature objectrelations are associated with the perception that God is more loving andemotionally close (Brokaw & Edwards, 1994; Hall & Edwards, 2002) andless distant, controlling, and wrathful (Brokaw & Edwards, 1994; Hall,Edwards, Brokaw, & Pike, 1998; Tisdale et al., 1997). Hall (2007) offers ahelpful discussion of the application of object relations theory to thepsychology of religion and spirituality.

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Doris’ Initial Image of God and Response

Object relations theory can help explain Doris’ negative view of God as shepresents to Chaplain Rhonda. In the transcripts of the case, Doris describesher parents as ‘‘distant and very protective.’’ She also stated that her mothertold her early and often that Doris was ‘‘not smart enough for college,’’ whichgave her the message that she would ‘‘never be good enough.’’ Doris’ Godimage was likely further impacted by her ‘‘very harsh and cruel’’ parochialteachers (‘‘mostly religious sisters’’) from the 1st grade.

In the transcripts, Doris is independently able to make the connectionbetween her early object relations and her God image development, as sheopenly admits to Chaplain Rhonda, ‘‘It sounds like my idea of God is reallylike my mother—punitive and withholding!’’ Doris further expresses herperception of God as a ‘‘stern, demanding, tyrant parent.’’

Doris was referred by her cancer center therapist to Ms. Cooper forassistance with death anxiety. Indeed, Doris expressed the fear that whenshe died God would not receive her into heaven because, ‘‘I haven’t donemuch for God or the Church, so why should God do anything for me?’’Again, it is likely that Doris’ view of God is an amalgamation of her seeminglyuncaring and rejecting parents, which was further damaged by her unforgiv-ing Catholic school teachers.

Doris’ Response to Ms. Cooper’s Intervention

Object relations theory puts the relationship between the Chaplain Rhonda andDoris at the center of the way of working. In short, Doris’ relationship with areligious representative, Chaplain Rhonda, can result in a sort of ‘‘correctingexperience’’ of Doris’ God image. Evidence of her God image shifting through-out the course of the intervention can be seen in Doris’ eventual requests forprayer, interest in seeing a Catholic priest (and subsequently expressing grati-tude for his spiritual interventions), and willingness to broach the topic offuneral arrangements. Through Chaplain Rhonda’s intervention, Doris ‘‘becamemore comfortable with the practice of prayer and felt more connected to Godwithout becoming more ‘religiously active.’ ’’ In the case transcripts, ChaplainRhonda explained, ‘‘Through our interactions and gradually developingrelationship of trust, Doris began to open herself to the possibility of a caringDivine Presence which transcended religious practice or dogma.’’ Once Doris’image of God was ‘‘repaired’’ through her relationship with Chaplain Rhonda,Doris became less anxious about and more accepting of her terminal condition.

MEASUREMENT

When conducting research, it is important to keep in mind that results willonly be as good as the measures (e.g., questionnaires) of the outcomes. As

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such, much thought should be given to choosing them. It is helpful, afteridentifying a specific outcome of interest, to evaluate any number of avail-able measures of that outcome and, then, use the measure with items thatbest capture this outcome in the context of the research study (Thorndike& Thorndike-Christ, 2009). Every measure should have an accompanyingmanual or original report that describes the quality of the measure or its basicpsychometric properties (e.g., reliability, validity; Anastasi & Urbina, 1997).Reliability refers to the consistency of scores obtained by the same personswhen reexamined with the same test on different occasions, with differentsets of equivalent items, or under other variable examining conditions.(A commonly-accepted rule of thumb is that a Cronbach’s a of 0.6–0.7indicates acceptable reliability, and 0.8 or higher indicates good reliability.)Validity refers to the degree to which a questionnaire measures what itpurports to measure.

A hypothesis about Doris’ case might be as follows: Chaplain Rhonda’sintervention will result in Doris having a more ‘‘mature’’ God image and lessdeath anxiety. As such, good measures of God Image and of death anxietywould be essential to test this hypothesis. After searching available measures,the following instruments are presented as examples that could be applied tothe case study of Doris.

Image of God

The Cancer and Deity Questionnaire (CDQ; Bowman, Beitman, Palesh,Perez, & Koopman, 2009) is a 12-item measure assessing perceived relationswith God after a cancer diagnosis. It was developed based on object relationstheory and measures benevolent and abandoning God representations. TheCDQ Benevolence scale demonstrates excellent internal consistency,Cronbach’s a of 0.97, and the Abandonment scale showed good internal con-sistency, Cronbach’s a of 0.80. The CDQ shows good convergent validity withthe Styles of Religious Coping Scales (SRCS; Pargament et al., 1992) and gooddiscriminant validity with the Spiritual Well-Being Scale (SWBS; Ellison, 1983).

The Spiritual Assessment Inventory (SAI; Hall & Edwards, 2002) consistsof 54 self-report items developed to measure relationship with God from anobject relations perspective. The SAI yields scores on 6 subscales with goodestimates of internal consistency (Cronbach’s a): Awareness (0.95), Instability(0.84), Grandiosity (0.73), Realistic Acceptance (0.83), Disappointment(0.90), and Impression Management (0.77). Construct validity of the SAIwas supported by correlations of its subscales with the SWBS (Ellison,1983), the Intrinsic=Extrinsic – Revised (Gorsuch & McPherson, 1989), theBell Object Relations Inventory (Bell, Billington, & Becker, 1986),the Defenses Styles Questionnaire (Andrews, Singh, & Bond, 1993), andthe Narcissistic Personality Inventory (Emmons, 1984, 1987; Raskin & Terry,1988).

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Death Anxiety

The Revised Collett-Lester Fear of Death and Dying Scale (Lester, 1994)contains 32-items assessing fear of death and dying of both self and other.Cronbach’s a were quite good at 0.91, 0.89, 0.72, and 0.87, respectively,for Fear of Death of Self, Fear of Dying of Self, Fear of Death of Others,and Fear of Dying of Others. Construct validity was supported by correlationswith the Maudsley Personality Inventory (Jensen, 1958).

The Death Anxiety Scale (DAS; Templer, 1970) is a 15-item, two-pointscale (true or false), self-report instrument that measures death anxiety.The DAS has good test–retest reliability, 0.83, and acceptable consistency,Cronbach’s a, 0.73. The Revised Death Anxiety Scale (Thorson & Powell,1984), consisting of 25 true-false items, demonstrated good reliability witha Cronbach’s a of 0.80.

CONCLUSION

In order to test the hypothesis, Chaplain Rhonda’s intervention will result inDoris having a more positive God image and less death anxiety, a researchermight ask Doris to complete measures of these outcomes prior to meetingwith Chaplain Rhonda (pre-test) and then again after the full interventionis delivered (post-test). (See Figure 1 for a suggested design.) Based on Doris’presentation and the hypothesis, it is likely that Doris will have a negativeGod image and a high level of death anxiety at pre-test. At post-test, follow-ing a given number of meetings with Chaplain Rhonda, Doris will likely havea more positive image of God and a lower level of death anxiety. Whether ornot the changes in Doris’ scores on God image and death anxiety are signifi-cant can be determined statistically.

Of course, the case study has a number of limitations. In the case ofDoris, for example, how do we know the changes in her scores on Godimage and death anxiety are due specifically to Chaplain Rhonda’s

FIGURE 1 Suggested research design.

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intervention and not simply the passage of time? The answer to this type ofquestion can be answered using more sophisticated research methodology,but, as chaplaincy research is in its infancy, the case study is an excellentstarting point. (The sciences of psychiatry and psychology were foundedon the case study.) Once similar case studies are well-represented in theliterature, chaplains can begin to identify the ‘‘active ingredients’’ (i.e., whatspecifically they are doing that is resulting in positive patient outcomes) intheir interventions, and further test the efficacy of their efforts using morecomplex research designs (e.g., the randomized clinical trial).

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