DIVORCED PARTICIPANTS NEEDED
Participation is Free
Location: 524 9th Street
Wilmette, Il. 60091
Service Offered: Divorce Support Group Therapy
When: January 12 - March 16, 2010. Offered on Tuesday and Thursday evenings, 7-9 PM.
Men and women (18 years of age and older) who have been divorced for at least one month are needed for a study regarding the effectiveness of divorce support group treatment. The study consists of ten two-hour sessions with a focus on gaining insight into a person's experience with divorce and determining effective behaviors to manage their life situation. This study utilizes two different group therapy models which may be of benefit to those who participate.
For more information or to participate,
please contact:
Fr. Richard Jakubik – St. Francis Xavier Parish
524 Ninth St. Wilmette, IL. 60091
(847) 239-2326
richard.jakubik@yahoo.com
Saturday, September 26, 2009
Welcome Letter
Dear Participant,
My name is Fr. Richard Jakubik, a licensed clinical social worker. I am working toward completing my doctoral degree in clinical psychology at Argosy University. You are being contacted because you recently showed interest in participating in a Divorce Support Group study. This research study will contribute to the improvement of divorce support groups. I plan to ask forty-five people, eighteen years of age or older and who have been divorced for at least one month to participate in this research study. This study is sponsored by Argosy University.
I would like to invite you to meet with me for an individual appointment so that I can answer your questions you may have in regard to participating in this study. If you decide not to be in the study, I can provide you with referrals for individual counseling. If you decide to be in the study, you will be asked to fill out a demographic form, consent form and four questionnaires: a depression scale inventory; an anxiety scale inventory; a well-being inventory; and a physical symptoms inventory. This data will be collected to determine whether a person is right for this particular study. The testing is expected to take about one hour to complete. To keep this information confidential, the paperwork you fill out will be placed in a locked file cabinet. The researchers will enter this material into a computer that is password-protected. To protect confidentiality, your real name will not be used and a code number will be assigned. Your name or other identifying information will not be reported in any publication. The key linking your name to the data will be destroyed after the data analysis is complete, and all the data will be destroyed after five years.
If you are not selected, your demographic information, consent form, and testing material will be properly destroyed by the researcher and referrals will be given for other counseling services in the Chicago area. If you meet the criteria, you will be assigned to one of three study groups, two groups will receive treatment (two-hour group therapy sessions for ten weeks, a total of twenty hours of group therapy), and one group (the wait-list control group) will not receive treatment until after the study has been completed. If selected for the wait-list control group, you will complete three rounds of testing: at the beginning of the study; the end of the ten week support group; and three months after the support group sessions ended. After the three months and testing are completed, the wait-list control group will be offered ten-weeks of group, if so desired. Participants assigned to a therapy group will be exposed to ten, two-hour sessions with the therapist, a licensed clinical social worker.
You can feel free to contact me at 847-239-2326 or at richard.jakubik@yahoo.com for any research-related problems or questions regarding your rights. You may also direct problems or questions to the Institutional Review Board through the IRB Chair, Dr. David Van Dyke (dvandyke@argosy.edu) or through Dr. Leah Horvath (lhorvath@argosy.edu), the faculty advisor for this study at 312-777-7600.
Sincerely,
Fr. Richard Jakubik, LCSW
My name is Fr. Richard Jakubik, a licensed clinical social worker. I am working toward completing my doctoral degree in clinical psychology at Argosy University. You are being contacted because you recently showed interest in participating in a Divorce Support Group study. This research study will contribute to the improvement of divorce support groups. I plan to ask forty-five people, eighteen years of age or older and who have been divorced for at least one month to participate in this research study. This study is sponsored by Argosy University.
I would like to invite you to meet with me for an individual appointment so that I can answer your questions you may have in regard to participating in this study. If you decide not to be in the study, I can provide you with referrals for individual counseling. If you decide to be in the study, you will be asked to fill out a demographic form, consent form and four questionnaires: a depression scale inventory; an anxiety scale inventory; a well-being inventory; and a physical symptoms inventory. This data will be collected to determine whether a person is right for this particular study. The testing is expected to take about one hour to complete. To keep this information confidential, the paperwork you fill out will be placed in a locked file cabinet. The researchers will enter this material into a computer that is password-protected. To protect confidentiality, your real name will not be used and a code number will be assigned. Your name or other identifying information will not be reported in any publication. The key linking your name to the data will be destroyed after the data analysis is complete, and all the data will be destroyed after five years.
If you are not selected, your demographic information, consent form, and testing material will be properly destroyed by the researcher and referrals will be given for other counseling services in the Chicago area. If you meet the criteria, you will be assigned to one of three study groups, two groups will receive treatment (two-hour group therapy sessions for ten weeks, a total of twenty hours of group therapy), and one group (the wait-list control group) will not receive treatment until after the study has been completed. If selected for the wait-list control group, you will complete three rounds of testing: at the beginning of the study; the end of the ten week support group; and three months after the support group sessions ended. After the three months and testing are completed, the wait-list control group will be offered ten-weeks of group, if so desired. Participants assigned to a therapy group will be exposed to ten, two-hour sessions with the therapist, a licensed clinical social worker.
You can feel free to contact me at 847-239-2326 or at richard.jakubik@yahoo.com for any research-related problems or questions regarding your rights. You may also direct problems or questions to the Institutional Review Board through the IRB Chair, Dr. David Van Dyke (dvandyke@argosy.edu) or through Dr. Leah Horvath (lhorvath@argosy.edu), the faculty advisor for this study at 312-777-7600.
Sincerely,
Fr. Richard Jakubik, LCSW
Consent Form
CONSENT FORM FOR ALL THREE GROUPS OF THERAPY
Research Project: Divorced Supportive Therapy
I have been asked to participate in a research study about supportive group therapy for the divorced population. I was selected to be a possible participant because I am divorced. Forty-five people have been asked to participate in this study. The purpose of this study is to determine whether a certain therapy technique is an effective treatment for divorced people who have symptoms of anxiety and depression. If I agree to be in this study, I will be asked to fill out a brief demographic form and complete four questionnaires,i.e., a depression scale inventory, an anxiety scale inventory, a well-being inventory, and a physical symptoms inventory.
I will fill out the four questionnaires three times, at the beginning of the study, the end of group therapy, and three months after the sessions ended. Each of these questionnaires will take approximately 15-20 minutes of my time to complete. I understand that I will be assigned to one of three study groups: two groups will receive treatment (two-hour group therapy sessions for ten weeks, a total of twenty hours of group therapy) and one group will not receive treatment until after the study has been completed. If selected for the wait-list control group, participants will complete three rounds of testing: at the beginning of the study; the end of the ten week support group; and three months after the support group sessions ended. After the three months and testing are completed, the wait-list control group will be offered ten-weeks of group therapy or individual therapy, if so desired. The sessions will be a private-closed group and will be held at the Psychological Services Center at Argosy University, Chicago.
The risks associated with this study are that I may become uncomfortable answering the questions on the demographic form and filling out the depression and anxiety inventory forms. Being part of the group therapy process may cause me to become emotionally upset. Except for my time and inconvenience, there are no other risks to me from participating in this study. The benefits of participation may include an increase in overall sense of well being and the receipt of free counseling services. It is possible that there will be no benefit to me for participating in this study. I will not receive any payment or monetary compensation for participating in this study.
Limits to honoring confidentiality specifically include: if the therapist comes to believe that I am threatening serious harm to another person, he is required to try to protect that person. He may have to tell the person and the police, or perhaps try to have me put in a hospital. If I seriously threaten or act in a way that is very likely to harm myself, he may have to seek to hospitalize me, or call on my family members or others who can help protect me. If such a situation does come up, the therapist will fully discuss the situation with me before he does anything, unless there is a very strong reason not to do do. In an emergency where my life or health is in danger, and he cannot get my consent, he may give another professional some information to protect my life. The therapist will try to get my permission first, and he will discuss this with me as soon as possible afterwards. If the therapist believes or suspects that I am abusing a child, an elderly person, or a disabled person, he must file a report with DCFS, the state agency. To “abuse” means to neglect, hurt, or sexually molest another person. The therapist does not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. In any of these situations, the therapist would reveal only the information that is needed to protect me or the other person.
This study is confidential and my name will not be on any of the documents. A code number will be used to protect my identity. Data will be kept in the investigator’s locked office. My name or other identifying information will not be reported in any publication. The key linking my name to the data will be destroyed after the data analysis is complete, and all the data will be destroyed after five years. The records of this study will be kept private. No identifiers linking me to the study will be included in any sort of report that might be published. My decision whether or not to participate in the study will not affect my current or future relationship with Argosy University.
If I decide to participate, I am free to refuse to answer any of the questions that may make me uncomfortable. I can withdraw at any time without my relations with the university, job, benefits, etc., being affected. I can contact Richard Jakubik at 847-239-2326 or at richard.jakubik@yahoo.com. I understand that this research study has been reviewed and certified by the Institutional Review Board, Argosy University - Chicago. For research-related problems or questions regarding participants' rights, I can contact the Institutional Review Board through the IRB Chair, Dr. David Van Dyke (dvandyke@argosy.edu), or through Dr. Leah Horvath (lhorvath@argosy.edu), the faculty advisor for this study, at 312-777-7600. I have read and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study. I have been given a copy of this consent form. By signing this document, I consent to participate in the study.
Signature of Participant: _________________________ Date: ___________
Signature of Investigator:_________________________ Date: ___________
Research Project: Divorced Supportive Therapy
I have been asked to participate in a research study about supportive group therapy for the divorced population. I was selected to be a possible participant because I am divorced. Forty-five people have been asked to participate in this study. The purpose of this study is to determine whether a certain therapy technique is an effective treatment for divorced people who have symptoms of anxiety and depression. If I agree to be in this study, I will be asked to fill out a brief demographic form and complete four questionnaires,i.e., a depression scale inventory, an anxiety scale inventory, a well-being inventory, and a physical symptoms inventory.
I will fill out the four questionnaires three times, at the beginning of the study, the end of group therapy, and three months after the sessions ended. Each of these questionnaires will take approximately 15-20 minutes of my time to complete. I understand that I will be assigned to one of three study groups: two groups will receive treatment (two-hour group therapy sessions for ten weeks, a total of twenty hours of group therapy) and one group will not receive treatment until after the study has been completed. If selected for the wait-list control group, participants will complete three rounds of testing: at the beginning of the study; the end of the ten week support group; and three months after the support group sessions ended. After the three months and testing are completed, the wait-list control group will be offered ten-weeks of group therapy or individual therapy, if so desired. The sessions will be a private-closed group and will be held at the Psychological Services Center at Argosy University, Chicago.
The risks associated with this study are that I may become uncomfortable answering the questions on the demographic form and filling out the depression and anxiety inventory forms. Being part of the group therapy process may cause me to become emotionally upset. Except for my time and inconvenience, there are no other risks to me from participating in this study. The benefits of participation may include an increase in overall sense of well being and the receipt of free counseling services. It is possible that there will be no benefit to me for participating in this study. I will not receive any payment or monetary compensation for participating in this study.
Limits to honoring confidentiality specifically include: if the therapist comes to believe that I am threatening serious harm to another person, he is required to try to protect that person. He may have to tell the person and the police, or perhaps try to have me put in a hospital. If I seriously threaten or act in a way that is very likely to harm myself, he may have to seek to hospitalize me, or call on my family members or others who can help protect me. If such a situation does come up, the therapist will fully discuss the situation with me before he does anything, unless there is a very strong reason not to do do. In an emergency where my life or health is in danger, and he cannot get my consent, he may give another professional some information to protect my life. The therapist will try to get my permission first, and he will discuss this with me as soon as possible afterwards. If the therapist believes or suspects that I am abusing a child, an elderly person, or a disabled person, he must file a report with DCFS, the state agency. To “abuse” means to neglect, hurt, or sexually molest another person. The therapist does not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. In any of these situations, the therapist would reveal only the information that is needed to protect me or the other person.
This study is confidential and my name will not be on any of the documents. A code number will be used to protect my identity. Data will be kept in the investigator’s locked office. My name or other identifying information will not be reported in any publication. The key linking my name to the data will be destroyed after the data analysis is complete, and all the data will be destroyed after five years. The records of this study will be kept private. No identifiers linking me to the study will be included in any sort of report that might be published. My decision whether or not to participate in the study will not affect my current or future relationship with Argosy University.
If I decide to participate, I am free to refuse to answer any of the questions that may make me uncomfortable. I can withdraw at any time without my relations with the university, job, benefits, etc., being affected. I can contact Richard Jakubik at 847-239-2326 or at richard.jakubik@yahoo.com. I understand that this research study has been reviewed and certified by the Institutional Review Board, Argosy University - Chicago. For research-related problems or questions regarding participants' rights, I can contact the Institutional Review Board through the IRB Chair, Dr. David Van Dyke (dvandyke@argosy.edu), or through Dr. Leah Horvath (lhorvath@argosy.edu), the faculty advisor for this study, at 312-777-7600. I have read and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study. I have been given a copy of this consent form. By signing this document, I consent to participate in the study.
Signature of Participant: _________________________ Date: ___________
Signature of Investigator:_________________________ Date: ___________
Demographic Questionnaire
Demographics Questionnaire:
Name: ________________________________________
Date: ________________
01. Age: ____________
02. Gender: ____________
03. Which of the following best describes your race?
__ American Indian
__ Asian or Pacific Islander
__ African American
__ Caucasian
__ Other (please specify):_________________________
__ Prefer not to answer
04. Which of the following best describes your national origin or ancestry (check all that apply)?
__ Puerto Rican __ Chicano
__ Cuban __ Other Latin American
__ Mexican/Mexicano __ Other Spanish
__ Mexican American __ None of the above
05. What is the highest grade or year of regular school that you completed?
__ Never attended
__ Elementary School
__ Some High School
__ High School Diploma/GED
__ Some College
__ College Degree
__ Some Graduate or Professional School
__ Graduate or Professional Degree
06. I have been divorced for ___________?
__ less than one year
__ two to three years
__ four to five years
__ six to seven years
__ over eight years
07. Which of the following best describes your total combined household income
during the past 12 months?
___ $0-$14,999
___ $15,000-$34,999
___ $35,000-$54,999
___ $55,000-$84,999
___ $85,000 to 129,999
___ $130,000 or more
___ Decline to answer
08. What is your religious affiliation?
__ Protestant Christian
__ Roman Catholic
__ Evangelical Christian
__ Jewish
__ Muslim
__ Hindu
__ Buddhist
__ Other _________________________
09. How many years were you married?
__ (1-5)
__ (6-10)
__ (11-15)
__ (16-20)
__ (21-25)
__ (26-30)
__ (31 +)
10. To what do you attribute your marital discord? Check as many as apply.
__ Infidelity
__ Communication
__ Disagreement about child-rearing
__ Sexual Incompatibility/Dysfunction
__ Substance Use/Abuse
__ Work/Career Difficulties
__ Financial Difficulties
__ Mental Illness
__ Other
11. Are you currently living with your former spouse?
__ Yes
__ No
12. How many children do you have? _____________
13. If applicable, what are their ages? __________________________________
14. Did you receive marital counseling?
__ Yes Number of sessions? ______.
__ No
15. Did you receive individual counseling regarding your marital problems?
__ Yes Number of sessions? _______.
__ No
16. Did you receive group counseling regarding your marital problems?
__ Yes How many sessions? ______.
__ No
17. Please list any medications you may have taken before the marital problems.
_______________________________
_______________________________
18. Please list any medications you may have taken post marital problems.
______________________________
______________________________
19. If you are taking psychological medications, for how long?
__ 1-3 months
__ 4-6 months
__ 1 yr or more
20. Are you currently being treated by a physician for any physical illness?
__ Yes
__ No
Name: ________________________________________
Date: ________________
01. Age: ____________
02. Gender: ____________
03. Which of the following best describes your race?
__ American Indian
__ Asian or Pacific Islander
__ African American
__ Caucasian
__ Other (please specify):_________________________
__ Prefer not to answer
04. Which of the following best describes your national origin or ancestry (check all that apply)?
__ Puerto Rican __ Chicano
__ Cuban __ Other Latin American
__ Mexican/Mexicano __ Other Spanish
__ Mexican American __ None of the above
05. What is the highest grade or year of regular school that you completed?
__ Never attended
__ Elementary School
__ Some High School
__ High School Diploma/GED
__ Some College
__ College Degree
__ Some Graduate or Professional School
__ Graduate or Professional Degree
06. I have been divorced for ___________?
__ less than one year
__ two to three years
__ four to five years
__ six to seven years
__ over eight years
07. Which of the following best describes your total combined household income
during the past 12 months?
___ $0-$14,999
___ $15,000-$34,999
___ $35,000-$54,999
___ $55,000-$84,999
___ $85,000 to 129,999
___ $130,000 or more
___ Decline to answer
08. What is your religious affiliation?
__ Protestant Christian
__ Roman Catholic
__ Evangelical Christian
__ Jewish
__ Muslim
__ Hindu
__ Buddhist
__ Other _________________________
09. How many years were you married?
__ (1-5)
__ (6-10)
__ (11-15)
__ (16-20)
__ (21-25)
__ (26-30)
__ (31 +)
10. To what do you attribute your marital discord? Check as many as apply.
__ Infidelity
__ Communication
__ Disagreement about child-rearing
__ Sexual Incompatibility/Dysfunction
__ Substance Use/Abuse
__ Work/Career Difficulties
__ Financial Difficulties
__ Mental Illness
__ Other
11. Are you currently living with your former spouse?
__ Yes
__ No
12. How many children do you have? _____________
13. If applicable, what are their ages? __________________________________
14. Did you receive marital counseling?
__ Yes Number of sessions? ______.
__ No
15. Did you receive individual counseling regarding your marital problems?
__ Yes Number of sessions? _______.
__ No
16. Did you receive group counseling regarding your marital problems?
__ Yes How many sessions? ______.
__ No
17. Please list any medications you may have taken before the marital problems.
_______________________________
_______________________________
18. Please list any medications you may have taken post marital problems.
______________________________
______________________________
19. If you are taking psychological medications, for how long?
__ 1-3 months
__ 4-6 months
__ 1 yr or more
20. Are you currently being treated by a physician for any physical illness?
__ Yes
__ No
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