| 1. |
- Carvalho, Sérgio A., et al.
(author)
-
Cognitive fusion and depressive symptoms in women with chronic pain : A longitudinal growth curve modelling study over 12 months
- 2019
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 26:5, s. 616-625
-
Journal article (peer-reviewed)abstract
- This study aims to (a) explore individual differences in women with chronic pain (CP) in regard to pain intensity, functional impairment, cognitive fusion, and depressive symptoms and (b) longitudinally test whether cognitive fusion is a significant predictor of depression symptoms, while controlling for pain intensity and functional impairment, over a 12-month period. This study follows a longitudinal design and was conducted in a sample of 86 women with CP who responded to an online battery of questionnaires in three equally spaced assessment moments. In order to explore the growth trajectory of variables of interest, latent growth curve models were examined. Also, correlation analyses were conducted between demographic and illness-related variables and depressive symptoms, as well as between all variables in all assessment moments. Cognitive fusion and functional impairment (but not pain intensity) were significantly associated with baseline levels of depressive symptoms. Cognitive fusion significantly predicted the growth trajectory of depressive symptoms, whereas pain intensity and functional impairment did not. No demographic (age, marital status, education, socio-economic) nor illness-related variables (number of CP diagnoses, duration of CP, taking medication) were associated with depressive symptoms at any point. These results suggest that the trajectory of depressive symptoms in women with CP is not predicted by the intensity of pain nor pain-related functional impairment, but rather by the tendency to get entangled with internal experiences (e.g., thoughts, emotions, and physical sensations), which may or may not be related to pain-specific contents. Clinical implications are discussed.
|
|
| 2. |
- Carvalho, Sérgio A., et al.
(author)
-
Efficacy of an ACT and Compassion-Based eHealth Program for Self-Management of Chronic Pain (iACTwithPain) : Study Protocol for a Randomized Controlled Trial
- 2021
-
In: Frontiers in Psychology. - : Frontiers Media S.A.. - 1664-1078. ; 12
-
Journal article (peer-reviewed)abstract
- Background: Chronic pain (CP) has serious medical and social consequences and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving their quality of life is timely. Although acceptance and commitment therapy (ACT) is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates the change in disability and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a medical TAU group.Methods: The eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise eight weekly self-management sessions and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyze whether the iACTwithPain intervention will present superiority in improving CP's impact and related health markers over the two other conditions, this study will follow an RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-month follow-ups. The interventions' acceptability will also be assessed.Discussion: The iACTwithPain intervention is expected to improve CP patients' psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP.
|
|
| 3. |
- Carvalho, Sérgio A., et al.
(author)
-
Self-Compassion and Depressive Symptoms in Chronic Pain (CP) : A 1-Year Longitudinal Study
- 2020
-
In: Mindfulness. - : Springer. - 1868-8527 .- 1868-8535. ; 11:3, s. 709-719
-
Journal article (peer-reviewed)abstract
- Objectives: Self-compassion is associated with less depressive symptoms, better mental health outcomes, and less disability in chronic pain (CP). However, it remains longitudinally unexplored the role of self-compassion in CP. Also, although it acknowledged the conceptual overlapping between mindfulness and self-compassion, few studies have explored the role of self-compassion in CP while controlling for mindfulness in a longitudinal design.Methods: The current study conducts correlational and hierarchical linear regression analyses in a sample of 86 women with CP who completed an online battery of questionnaires that assess pain intensity, functional impairment, depressive symptoms, mindfulness, and self-compassion in three time points: baseline (T0), 6 months (T1), and 12 months (T2).Results: Results show that self-compassion (but not mindfulness) significantly predicts depressive symptoms at T1 and at T2 above and beyond depressive symptoms and functional impairment. Also, the interaction between functional impairment and self-compassion at T0 significantly predicts depressive symptoms at T1, but not at T2.Conclusions: These findings expand the current knowledge on the role of self-compassion in CP in showing that self-compassion is a significant predictor of later depressive symptoms in CP and suggesting its potential role in buffering the impact of functional impairment in future levels of depressive symptoms.
|
|
| 4. |
- Duarte, Cristiana, et al.
(author)
-
Body image and college women's quality of life : The importance of being self-compassionate
- 2015
-
In: Journal of Health Psychology. - : Sage Publications. - 1359-1053 .- 1461-7277. ; 20:6, s. 754-764
-
Journal article (peer-reviewed)abstract
- This study explored self-compassion as a mediator between body dissatisfaction, social comparison based on body image and quality of life in 662 female college students. Path analysis revealed that while controlling for body mass index, self-compassion mediated the impact of body dissatisfaction and unfavourable social comparisons on psychological quality of life. The path model accounted for 33per cent of psychological quality of life variance. Findings highlight the importance of self-compassion as a mechanism that may operate on the association between negative body image evaluations and young women's quality of life.
|
|
| 5. |
- Duarte, Cristiana, et al.
(author)
-
Normative body dissatisfaction and eating psychopathology in teenage girls : the impact of inflexible eating rules
- 2016
-
In: Eating and Weight Disorders. - : Springer. - 1124-4909 .- 1590-1262. ; 21:1, s. 41-48
-
Journal article (peer-reviewed)abstract
- Adolescence has been considered a critical time for the development of body image-related difficulties and disordered eating behaviours, especially in females. Although adherence to eating rules has been linked to disordered eating, literature has not yet explored how the inflexible subscription to those rules impacts on eating psychopathology. Therefore, the aim of the current study was to explore whether inflexible eating impacts on the relationships between weight and body image-related variables, and disordered eating.Participated in this study are 497 female adolescents from the community, aged between 14 and 18 years old, who completed self-report measures.Results revealed that the majority of the participants were dissatisfied with their weight and body shape. Moreover, 6.64 % of the participants demonstrated severe eating psychopathology. A path analysis revealed that BMI, body dissatisfaction and social comparisons based on physical appearance impact on disordered eating behaviours, through the mechanism of inflexible adherence to eating rules. This model explained 52 % of eating psychopathology's variance.Findings highlight the relevance of body image-related difficulties in adolescence and additionally they emphasise the importance of promoting more flexible attitudes towards eating in prevention and intervention programmes with female adolescents.
|
|
| 6. |
- Duarte, Cristiana, et al.
(author)
-
What makes dietary restraint problematic? Development and validation of the Inflexible Eating Questionnaire
- 2017
-
In: Appetite. - : Elsevier. - 0195-6663 .- 1095-8304. ; 114, s. 146-154
-
Journal article (peer-reviewed)abstract
- This study presents the Inflexible Eating Questionnaire (IEQ), which measures the inflexible adherence to subjective eating rules.The scale's structure and psychometric properties were examined in distinct samples from the general population comprising both men and women.IEQ presented an 11-item one-dimensional structure, revealed high internal consistency, construct and temporal stability, and discriminated eating psychopathology cases from non-cases. The IEQ presented significant associations with dietary restraint, eating psychopathology, body image inflexibility, general psychopathology symptoms, and decreased intuitive eating. IEQ was a significant moderator on the association between dietary restraint and eating psychopathology symptoms.Findings suggested that the IEQ is a valid and useful instrument with potential implications for research on psychological inflexibility in disordered eating.
|
|
| 7. |
- Ferreira, Cláudia, et al.
(author)
-
Getting entangled with body image : Development and validation of a new measure
- 2015
-
In: Psychology and Psychotherapy. - : John Wiley & Sons. - 1476-0835 .- 2044-8341. ; 88:3, s. 304-316
-
Journal article (peer-reviewed)abstract
- Objectives: Several studies have highlighted the role of cognitive fusion on human suffering and a wide range of psychopathological conditions. Namely, this process has been regarded as a core aspect in eating disorders. Nevertheless, the study of cognitive fusion on eating psychopathology is scarce and a measure that specifically concerns body image was still to be created. The present study aimed therefore at developing and validating such measure, the Cognitive Fusion Questionnaire - Body Image (CFQ-BI).Design and methods: The current study was conducted using different samples of both genders, collected in the general and student populations. The dimensionality of the CFQ-BI was tested through an exploratory factor analysis and a confirmatory factor analysis (CFA). The scale's internal reliability and other psychometric qualities were also analysed.Results: The CFQ-BI's final structure was one-dimensional and comprised 10 items that assess body image-related cognitive fusion. This final structure explained a total of 73.41% of the variance. The adequacy of the questionnaire was corroborated through a CFA which revealed that CFQ-BI presents good global and local adjustment values and goodness-of-fit indices. Results also showed that the CFQ-BI holds a very good internal consistency (=.96), convergent, divergent and temporal reliabilities, and is able to discriminate cases from non-cases of eating psychopathology.Conclusions: The CFQ-BI was thus established as a short, robust, and reliable measure of body image-related cognitive fusion. This new measure may correspond to a significant contribution to research and clinical practice in the field of body image and eating-related difficulties.
|
|
| 8. |
- Guiomar, Raquel, et al.
(author)
-
Usability Study of the iACTwithPain Platform : An Online Acceptance and Commitment Therapy and Compassion-Based Intervention for Chronic Pain
- 2022
-
In: Frontiers in Psychology. - : Frontiers Media S.A.. - 1664-1078. ; 13
-
Journal article (peer-reviewed)abstract
- Background: This pilot study aims to test the usability of the iACTwithPain platform, an online ACT-based intervention for people with chronic pain, to obtain information on which intervention and usability aspects need improvement and on expected retention rates.Methods: Seventy-three Portuguese women with chronic pain were invited to complete the first three sessions of the iACTwithPain intervention assess their quality, usefulness and the platform's usability. Twenty-one accepted the invitation. Additionally, eight healthcare professionals working with chronic medical conditions assessed the platform and the intervention from a practitioner's point of view.Results: This study presented a considerable attrition rate (71.43%) among chronic pain participants, with six completers. There were no significant differences in demographic or clinical variables between dropouts and completers except for completed education (participants who dropped out presented less education than completers). Reasons for dropout were related to difficult personal events occurring during the time of the intervention, lack of time, or having forgotten. There seemed to be an overall satisfaction with both the intervention, its contents and form of presentation of information, and the platform, concerning its design, appearance, and usability. Real image videos were preferred over animations or audio by chronic pain participants. Healthcare professionals emphasized the appealing and dynamic aspects of the animation format.Conclusion: This study informs the ongoing improvement of the iACTwithPain platform and provides valuable information on aspects researchers should consider while developing online psychological interventions for chronic pain. Further implications are discussed.
|
|
| 9. |
- Lucena-Santos, Paola, et al.
(author)
-
Cognitive Fusion Questionnaire—Body Image : Psychometric Properties and Its Incremental Power in the Prediction of Binge Eating Severity
- 2017
-
In: Journal of Psychology. - : Routledge. - 0022-3980 .- 1940-1019. ; 151:4, s. 379-392
-
Journal article (peer-reviewed)abstract
- Given the clinical usefulness of the CFQ-BI (Cognitive Fusion QuestionnaireBody Image; the only existing measure to assess the body-image-related cognitive fusion), the present study aimed to confirm its one-factor structure, to verify its measurement invariance between clinical and non-clinical samples, to analyze its internal consistency and sensitivity to detect differences between samples, as well as to explore the incremental and convergent validities of the CFQ-BI scores in Brazilian samples. This was a cross-sectional study, which was conducted in clinical (women with overweight or obesity in treatment for weight loss) and non-clinical samples (women from the general population). The one-factor structure was confirmed showing factorial measurement invariance across clinical and non-clinical samples. The CFQ-BI scores presented an excellent internal consistency, were able to discriminate clinical and non-clinical samples, and were positively associated with binge eating severity, general cognitive fusion, and psychological inflexibility. Furthermore, body-image-related cognitive fusion scores (CFQ-BI) presented incremental validity over a general measure of cognitive fusion in the prediction of binge eating symptoms. This study demonstrated that CFQ-BI is a short scale with reliable and robust scores in Brazilian samples, presenting incremental and convergent validities, measurement invariance, and sensitivity to detect differences between clinical and non-clinical groups of women, enabling comparative studies between them.
|
|
| 10. |
- Matos, Marcela, et al.
(author)
-
Cultivating the Compassionate Self : an Exploration of the Mechanisms of Change in Compassionate Mind Training
- 2022
-
In: Mindfulness. - : Springer Science and Business Media LLC. - 1868-8527 .- 1868-8535. ; :13, s. 66-79
-
Journal article (peer-reviewed)abstract
- Objectives: The current study aimed to examine the mechanisms of change that mediate the impact of a compassionate mind training (CMT) intervention, in particular, whether changes in compassion, fears of compassion and heart rate variability (HRV) would mediate the effects of a brief CMT intervention on psychological vulnerability factors, mental health indicators and positive affect. Methods: Using a longitudinal design, general population participants were randomly assigned to one of the two conditions: compassionate mind training (n = 56) and wait list control (n = 37). Participants in the CMT condition attended a psychoeducation session and practiced a set of core CMT exercises for 2 weeks. Self-report measures of compassion, fears of compassion, self-criticism, shame, depression, stress and positive affect were completed, and HRV was assessed at pre- and post-intervention. Results: Mediation analyses revealed that increases in compassion for self and from others and reductions in fears of compassion for self, for others and from others mediated the effects of CMT on self-criticism and shame. In depression and stress, compassion for the self and from others and fears of compassion for the self emerged as significant mediators. Compassion for the self and from others and fears of compassion for self and from others significantly mediated the effect of CMT in safe affect. Compassion for the self, fears of compassion for self and for others and HRV mediated changes in relaxed affect. Conclusions: Cultivating a compassionate mind/self-identity through the core components of CMT may stimulate vagal regulatory activity and positively impact one’s ability to experience and be open to compassion, and thus promote emotion regulation, well-being and mental health.
|
|
| 11. |
- Nogueira, Maria Rita, et al.
(author)
-
Design and Usability of an E-Health Mobile Application
- 2020
-
In: Design, User Experience, and Usability. Case Studies in Public and Personal Interactive Systems. - Cham : Springer. - 9783030497569 - 9783030497576 ; , s. 314-328
-
Conference paper (peer-reviewed)abstract
- Health applications have increasingly been used to improve physical, mental and social well-being. Chronic pain (CP) is defined as pain that lasts for a period of three months and causes sporadic or constant discomfort. In Portugal, the treatments for this type of pain are almost exclusively pharmacological and with known limited effects. Endowing patients with self-management skills, will help them cope with pain in a more effective way. Psychological treatments (e.g. mindfulness-based interventions) may play a relevant role here, because they intervene on a cognitive, emotional and behavioural level, which in turn helps the chronic pain patient to deal with pain-related disorders and suffering. The current availability of connected and powerful smartphones and tablets creates an opportunity to propose alternative pain management solutions that may be used immediately when pain appears, which has been the argument that favoured the pharmacological solutions. For this we propose a mobile application that guides patients on the mindfulness practice and to self-manage the sensed pain. Learning to gradually adequate pain management may have several advantages such as: reduced the number of consultation visits and consequent waiting lists; increased cost-effectiveness; self-management of chronic pain at the patient’s pace and according to their needs; extend access to the treatment to patients that reside in low density regions. Being an alternative to traditional treatment, the proposed treatment will be under the guidance of qualified health professionals that will supervise treatment sessions and perform the required assessments. By promoting patients’ self-management, the control and monitoring of the chronic pain condition is expected to improve greatly, which in turn may prevent the aggravation of the clinical condition. This research and the mobile application are being developed in a collaboration between the Centre for Research in Neuropsychology and Cognitive Behavioral Intervention of the University of Coimbra and the Institute of Systems and Robotics.
|
|
| 12. |
|
|
| 13. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Acceptability and preliminary test of efficacy of the Mind programme in women with breast cancer : An acceptance, mindfulness, and compassion-based intervention
- 2020
-
In: Journal of Contextual Behavioral Science. - : Elsevier. - 2212-1447. ; 15, s. 162-171
-
Journal article (peer-reviewed)abstract
- Although there is some evidence on the efficacy of mindfulness-based interventions in improving health and psychological outcomes in women with breast cancer, further research is needed to understand these findings' clinical significance. Furthermore, Acceptance and Commitment Therapy (ACT) intervention studies on breast cancer are scarce, and no compassion-based intervention has been tested for cancer patients. Given the complementarily and compatibility of mindfulness practice, ACT, and Compassion Focused Therapy, the current study combined these approaches to develop an integrative intervention specifically adapted to cancer patients, the Mind programme. Participants were recruited at the Radiotherapy Service of the Coimbra University Hospital (CHUC) and were assigned to one of two groups: the experimental group (Treatment As Usual + Mind Programme (8 weekly sessions and homework assignments) - n = 15) and the control group (Treatment As Usual - n = 17). There was a 100% retention on the experimental group, during the intervention. The effect size for psychological health (g = 0.79) was particularly noteworthy, suggesting that the intervention presented benefits that are comparable to mindfulness only-based interventions. The experimental group also improved on physical health (g = 0.16), quality of social relationships (g = 0.42), depression symptoms (g = - 0.42), and stress (g = - 0.32). Participants reported it was important for them to take part in the programme, and that it improved the way they deal with difficulties. Results indicate that the Mind programme may be a useful complement to the medical treatment of breast cancer and support the combination of acceptance, mindfulness, and compassion-based components in this context. Having an accessible and integrative psychological programme for people with cancer may significantly help improving quality of life and mental health in this population. Further implications are discussed.
|
|
| 14. |
- Trindade, Inês A., 1990-, et al.
(author)
-
An 18-month study of the effects of IBD symptomatology and emotion regulation on depressed mood
- 2017
-
In: International Journal of Colorectal Disease. - : Springer. - 0179-1958 .- 1432-1262. ; 32:5, s. 651-660
-
Journal article (peer-reviewed)abstract
- Depressive symptomatology in IBD patients is known to predict disease activity, which, in turn, can increase depressive symptoms in perpetuating a cycle between depression and IBD symptomatology. The mechanisms that contribute to the relationship between disease activity and depressive symptoms are not clearly investigated yet. Since emotion regulation has been considered particularly relevant to define the impact of adverse experiences on different outcomes, the current study aimed to examine the longitudinal influence of two maladaptive emotion regulation processes, cognitive fusion and brooding, on the association between disease activity and depressed mood.This study was conducted over an 18-month period, using a sample of 116 IBD patients that completed self-report validated measures in three different waves. Correlation analyses and cross-lagged panel models were performed.The main result from this study discovered that the experience of IBD symptomatology at baseline, although positively linked to the manifestation of depressed mood 18 months later (r = 0.25; p < 0.01), does not directly predict depressive symptoms. This relationship is rather indirect, as it is explained by the engagement in cognitive fusion (p = 0.028) and brooding (p = 0.017). These maladaptive emotion regulation processes, that were revealed to be consistent over time, link IBD symptoms with subsequent depressed mood.These findings indicate that clinicians should be aware of the emotion regulation processes patients tend to use to handle difficult experiences. The inclusion of psychological assessments and interventions in the healthcare of IBD patients should be seriously considered. Further implications are discussed.
|
|
| 15. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Assessment of Chronic Illness-Related Cognitive Fusion : Preliminary Development and Validation of a New Scale with an IBD Sample
- 2018
-
In: Journal of clinical psychology in medical settings. - : Springer. - 1068-9583 .- 1573-3572. ; 25:4, s. 356-366
-
Journal article (peer-reviewed)abstract
- Although research recognizes the advantages of creating specific content measures, no specific measure of chronic illness-related cognitive fusion had been developed to date. The current study presents the development and validation of the Cognitive Fusion Questionnaire-Chronic Illness (CFQ-CI) in a sample of inflammatory bowel disease (IBD) patients and the analysis of the role of this construct in the psychological health of those patients. Results indicated that the 7-item CFQ-CI was a unidimensional measure of cognitive fusion in patients with chronic illnesses, and that scores had adequate/good internal consistency and construct, convergent, and discriminant validity. This study also showed that chronic illness-related cognitive fusion as assessed by the CFQ-CI acted as a mediator in the association between both IBD-related symptoms and shame with quality of life. The development of the CFQ-CI may thus contribute to a better understanding of the mechanisms influencing functional outcomes in chronic illness.
|
|
| 16. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Chronic illness-related cognitive fusion explains the impact of body dissatisfaction and shame on depression symptoms in breast cancer patients
- 2018
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 25:6, s. 886-893
-
Journal article (peer-reviewed)abstract
- Breast cancer is linked to psychological distress and mood disorders that are in turn associated with higher psychological dysfunction and decreased breast cancer survival. It is considered that psychological health in breast cancer is considerably affected by body image impairment, which in turn seems to be highly associated with shame. However, the impact of these variables on mental health may not be direct. The current study aimed to explore a comprehensive model regarding the role of chronic illness-related cognitive fusion in the relationship of body image dissatisfaction and chronic illness-related shame with depression symptoms. The sample was composed of 75 women with nonmetastatic breast cancer, recruited in a Radiotherapy Service in central Portugal. The conducted path model presented an excellent fit and accounted for 59% of the variance of depressive symptomatology. Further, it demonstrated that body image dissatisfaction's impact on depressed mood is significantly explained by the mechanisms of chronic illness-related shame and chronic illness-related cognitive fusion. It was also revealed that chronic illness-related cognitive fusion additionally mediated the impact of chronic illness-related shame on depression. These findings are suggestive of the importance of body image and chronic illness shame in the determination of breast cancer patients' depression symptoms and also the central role of chronic illness-related cognitive fusion in these relationships. Therefore, the implementation of acceptance and defusion-based psychotherapeutic interventions to improve mental health in cancer patients seems to be of great importance.
|
|
| 17. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Chronic Illness-Related Shame : Development of a New Scale and Novel Approach for IBD Patients' Depressive Symptomatology
- 2017
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 24:1, s. 255-263
-
Journal article (peer-reviewed)abstract
- The aims of the present study were to develop and validate a scale specifically focused on shame feelings derived from chronic illness-related experiences, the Chronic Illness-related Shame Scale (CISS) and to fill a gap in literature and analyse the role of this construct in the association between inflammatory bowel disease (IBD) symptomatology and depressed mood. This study comprised two samples: a sample of 161 IBD patients and a mixed sample of 65 chronic patients that reported medical data and completed self-report measures. The CISS's unidimensional seven-item structure was evaluated through confirmatory factor analyses. These analyses revealed good to excellent global and local adjustments in both samples. Results also showed that the CISS presents excellent internal consistencies and convergent, concurrent and divergent validity, being a valid, short and robust scale. Furthermore, the present study explored through path analyses, the role of CISS and self-judgement in the relationship between IBD symptomatology and depressed mood. Results showed that, although the level of IBD symptomatology directly predicted patients' depressive symptoms, the majority of this effect was mediated by CISS and self-judgement. Possible explanations for these findings are discussed in more detail in the succeeding text. The present study seems to highlight the pertinence of developing IBD patients' self-compassionate abilities to adaptively deal with symptomatology and related shame feelings. It thus may represent an avenue for the development of compassionate-based interventions for IBD patients and for the conduction of future studies exploring the shame phenomenon in other chronic illnesses.
|
|
| 18. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Clarity of Personal Values and Committed Action : Development of a Shorter Engaged Living Scale
- 2016
-
In: Journal of Psychopathology and Behavioral Assessment. - : Springer. - 0882-2689 .- 1573-3505. ; 38:2, s. 258-265
-
Journal article (peer-reviewed)abstract
- The Engaged Living Scale (ELS) is a measure of the process of engaged living, defined by Acceptance and Commitment Therapy as the evaluation and performance of valued life activities. This 16-item measure was recently created and has been validated in middle-aged and chronic pain samples. The aim of the present study was to validate the ELS-16 in a young-adult sample and additionally to develop a shorter ELS. This study was conducted using different samples of Portuguese young-adult college students. The dimensionality of the ELS-16 (which was translated to Portuguese from the original Dutch) was tested through a CFA. The adequacy of the shorter ELS (ELS-9) was also tested through a CFA. The scales' internal reliability and other psychometric qualities were additionally analysed. Results from the CFA suggested that the model benefits from the establishment of correlations between pairs of error terms of items with similar contents. These results led to the decision to shorten the measure by excluding the item of each pair with the lowest communalities. The ELS-9 was then created and its CFA results revealed good to excellent adjustment values and goodness-of-fit indices. Results also showed that the ELS-16 and the ELS-9 present adequate to good psychometric properties. The present study thus shows that these instruments seem to be reliable measures of engaged living and to perform adequately in young-adult college students, with the ELS-9 being a new contribution to health research and allowing faster administrations.
|
|
| 19. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Developments on committed action : Validity of the CAQ-8 and analysis of committed action's role in depressive symptomatology in breast cancer patients and healthy individuals
- 2018
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 25:1, s. e42-e50
-
Journal article (peer-reviewed)abstract
- Committed action, a process of acceptance and commitment therapy's psychological flexibility model, is considered an understudied construct that currently can only be measured by one instrument, the Committed Action Questionnaire (CAQ-8). This study aims at analysing the psychometric properties of the CAQ-8 in healthy individuals and breast cancer patients. This study also aims to explore the specific meditational role of committed action in the well-established relationship between experiential avoidance and depression symptoms. The healthy sample comprised 294 adults from the general population, and the breast cancer samples comprised 82 participants. Both groups completed the validated self-report measures. CAQ-8's robustness was examined through validity analyses, confirmatory factor analyses, and multigroup analysis. The meditational model was conducted using structural equation modelling. The CAQ-8 presented good internal consistency and construct, convergent, concurrent, and divergent validity in both samples. Further, the CAQ-8 showed incremental validity over a measure of engaged living. Findings also demonstrated measurement invariance between healthy individuals and breast cancer patients. Regarding the conducted meditational model that was also invariant between the two analysed groups, it was demonstrated that part of the effect that experiential avoidance holds on depressive symptomatology is explained by committed action. This study suggests that the CAQ-8 is adequate for use in healthy and cancer populations. Moreover, it provides novel, empirical support regarding the links between committed action, experiential avoidance, and depressed mood, being also the first investigation to particularly study committed action in a cancer population. Implications for theory and practice are discussed.
|
|
| 20. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain : A Systematic Review and Meta-Analysis
- 2021
-
In: Journal of Pain. - : Elsevier. - 1526-5900 .- 1528-8447. ; 22:11, s. 1328-1342
-
Research review (peer-reviewed)abstract
- Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at followup. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias.Perspective: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.
|
|
| 21. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Further validation of the cognitive fusion questionnaire – chronic illness (CFQ-CI) in different health condition samples
- 2020
-
In: Journal of Contextual Behavioral Science. - : Elsevier. - 2212-1447. ; 16, s. 45-48
-
Journal article (peer-reviewed)abstract
- CFQ-CI was previously developed and preliminarily validated in a study with a single online-recruited inflammatory bowel disease (IBD) sample. The current study presents a further validation of CFQ-CI in four different samples of patients with chronic health conditions: a sample of 82 women with breast cancer, an online-recruited mixed sample of 100 people with cancer, a sample of 69 people with IBD, and an online-recruited mixed chronic illness sample of 93 participants. Confirmatory Factor Analyses, multi-group, reliability, and differences analyses were conducted.Results indicated that the scale is a robust unidimensional 7-item measure of chronic illness-related cognitivefusion, with excellent reliability and structural validity across the four studied samples and in both paper-penciland online-based collection methods. Measurement invariance was not established across the samples, suggesting that CFQ-CI does not appear tofunction equivalently across different illness diagnoses.This study confirms CFQ-CI as a robust, adequate, and simple measure of chronic illness-related cognitive fusion that can be used in different behavioural medicine research and clinical contexts. As the scale does not seem to present measurement invariance, comparing scores between different illness groups is not recommended.
|
|
| 22. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Gender differences in inflammatory bowel disease : Explaining body image dissatisfaction
- 2019
-
In: Journal of Health Psychology. - : Sage Publications. - 1359-1053 .- 1461-7277. ; 24:7, s. 847-856
-
Journal article (peer-reviewed)abstract
- The aim of this study was to examine the role of body image problems in the context of inflammatory bowel disease and to explore gender differences in these associations. A sample of inflammatory bowel disease patients (60 males and 140 females) was collected. Findings from a multi-group analysis show that inflammatory bowel disease symptomatology may impact on body image in both male and female patients through the effect of body-image-related cognitive fusion. Body image difficulties in the context of inflammatory bowel disease should not be a neglected dimension in research aiming at understanding the psychosocial effects of inflammatory bowel disease and by health professionals working with these patients.
|
|
| 23. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Going beyond social support : Fear of receiving compassion from others predicts depression symptoms in breast cancer patients
- 2018
-
In: Journal of psychosocial oncology. - : Routledge. - 0734-7332 .- 1540-7586. ; 36:4, s. 520-528
-
Journal article (peer-reviewed)abstract
- Background: Recent studies have highlighted the importance of being able to receive compassion and affiliative signals from others. The main aim of the present study was to explore whether social support and fear of receiving compassion from others are predictors of depression symptoms in a sample of breast cancer patients.Methods: The sample included 86 female patients with non-metastatic breast cancer. Participants were recruited at a Radiotherapy Service in central Portugal and completed validated self-report instruments. Multiple regression analysis were conducted to examine the predictive effects of clinical (cancer stage, comorbidities) and demographic variables (age, education), social support, and fear of receiving compassion from others on depressive symptoms.Results: Fear of receiving compassion from others was the only significant predictor of the model, with a positive effect on depression symptomatology ( = 0.44; p < 0.001). These results suggest that the amount of supportive social contacts and networks may not be as important as cancer patients' ability to receive compassion from others.Conclusions: This is the first study to focus on fear of receiving compassion from others in cancer patients and seems to be a significant contribution for the study of the social factors that may be associated with depression in breast cancer. Psychological screening interviews in breast cancer, besides assessing patients' level of depression and social support, ought to also evaluate the ability to receive empathy and emotional help and support from other people.
|
|
| 24. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Inflammatory bowel disease : The harmful mechanism of experiential avoidance for patients' quality of life
- 2016
-
In: Journal of Health Psychology. - : Sage Publications. - 1359-1053 .- 1461-7277. ; 21:12, s. 2882-2892
-
Journal article (peer-reviewed)abstract
- This study aimed to test the effects of inflammatory bowel disease symptomatology and associated medical complications on physical and psychological quality of life and to explore whether these relationships are mediated by experiential avoidance. A total of 200 inflammatory bowel disease patients reported demographic and medical data and completed self-report instruments. Results revealed that the tested model presented an excellent fit, explaining 51 per cent of physical quality of life and 53 per cent of psychological quality of life. Inflammatory bowel disease-associated complications directly impacted on physical quality of life, and experiential avoidance significantly mediated the relationships between inflammatory bowel disease symptomatology and physical and psychological quality of life. These results highlight the importance of implementing psychological interventions for inflammatory bowel disease patients.
|
|
| 25. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Measuring structural model invariance across internet-recruited and hospital-recruited IBD patients : Experiential avoidance’s effect on psychopathological symptoms
- 2021
-
In: Current Psychology. - : Springer. - 1046-1310 .- 1936-4733. ; 40:7, s. 3459-3466
-
Journal article (peer-reviewed)abstract
- Research has questioned whether it is feasible to assess psychosocial variables through web-based recruitment methods. Previous literature on IBD focused exclusively on testing differences on psychosocial scores and did not test the invariance between types of recruitment on the relationships between variables. The aim of the present study is thus to analyse structural invariance between internet-recruited and hospital-recruited groups of IBD patients on a mediation model with theoretical basis on previous studies (experiential avoidance as possible mediator of the association between IBD symptomatology and psychopathology). The internet sample included 137 IBD patients recruited through a patients association, and the hospital sample comprised 66 IBD patients. Structural equation modelling was used; a multiple-group comparison was conducted to examine model invariance between samples. Although the internet sample presented higher levels of experiential avoidance and psychopathological symptoms compared to the hospital sample, the relationships between these variables were invariant across groups. Experiential avoidance partially mediated the impact of IBD symptomatology on levels of stress, anxiety, and depression symptoms in a similar way for online respondents and hospital-recruited patients. This is a new finding that argues for the validity of web-based research methods.
|
|
| 26. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Roles of body image-related experiential avoidance and uncommitted living in the link between body image and women’s quality of life
- 2018
-
In: Women & health. - : Routledge. - 0363-0242 .- 1541-0331. ; 58:1, s. 38-50
-
Journal article (peer-reviewed)abstract
- The current study aimed to test whether the associations of body mass index, body image discrepancy, and social comparison based on physical appearance with women's psychological quality of life (QoL) would be explained by the mechanisms of body image-related experiential avoidance and patterns of uncommitted living. The sample was collected from October 2014 to March 2015 and included 737 female college students (aged between 18 and 25 years) who completed validated self-report measures. Results demonstrated that the final path model explained 43% of psychological QoL and revealed an excellent fit. Body image-related experiential avoidance had a meditational role in the association between body image discrepancy and psychological QoL. Further, the link between social comparison based on physical appearance and psychological QoL was partially mediated by body image-related experiential avoidance and uncommitted living. These findings indicate that the key mechanisms of the relationship between body image and young women's QoL were those related to maladaptive emotion regulation. It thus seems that interventions aiming to promote mental health in this population should promote acceptance of internal experiences related to physical appearance (e.g., sensations, thoughts, or emotions) and the engagement in behaviors committed to life values.
|
|
| 27. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Shame and emotion regulation in inflammatory bowel disease : Effects on psychosocial functioning
- 2020
-
In: Journal of Health Psychology. - : Sage Publications. - 1359-1053 .- 1461-7277. ; 25:4, s. 511-521
-
Journal article (peer-reviewed)abstract
- Although patients with inflammatory bowel disease seem to be prone to high levels of shame, the mechanisms behind the impact of chronic illness-related shame on patients' functioning have not been explored yet. This study aims to address these gaps using a sample of 161 patients with inflammatory bowel disease who completed self-report measures on an online survey. The results from path analyses showed that chronic illness-related shame presented direct and indirect effects on psychological health (R-2 = .66) and social relationships (R-2 = .46). The indirect effects were mediated by experiential avoidance and uncommitted living. Possible explanations to these findings and clinical implications are discussed.
|
|
| 28. |
- Trindade, Inês A., 1990-, et al.
(author)
-
The effects of body image impairment on the quality of life of non-operated Portuguese female IBD patients
- 2017
-
In: Quality of Life Research. - : Springer. - 0962-9343 .- 1573-2649. ; 26:2, s. 429-436
-
Journal article (peer-reviewed)abstract
- Inflammatory bowel diseases (IBD) and their treatment are known to negatively impact on patients' body image, especially female patients. However, although there are broad evidences of body image impairment in female IBD patients, its negative impact on the quality of life (QoL) of non-operated women is not clearly and specifically studied. The aim of the current study was therefore to analyse, in a sample of non-operated female IBD patients, the factors that contribute to body image impairment and its impact on QoL.Ninety-six non-operated women (39.7 % with CD and 60.3 % with UC), aged between 18 and 40 years old, completed an online survey with validated self-report measures, which included the Body Image Scale and the WHO Brief Quality of Life Assessment Scale.Negative body image was correlated with lower psychological and physical QoL and increased corticosteroids use, associated medical complications, body mass index (BMI), and IBD symptomatology. Regression analyses revealed that BMI and IBD symptomatology significantly predicted body image impairment. Furthermore, results from path analyses indicated that BMI and IBD symptomatology's effect on psychological and physical QoL was mediated through the negative effects of body image impairment. This model explained 31 % of psychological QoL and 41 % of physical QoL.These findings suggest that non-operated female patients are subject to pervasive and harmful effects of body image impairment on psychological and physical functioning. Therefore, psychological interventions aiming to target body dissatisfaction should be implemented in the health care of IBD, independently of patients' operative status.
|
|
| 29. |
- Trindade, Inês A., 1990-, et al.
(author)
-
The impact of illness-related shame on psychological health and social relationships : Testing a mediational model in students with chronic illness
- 2018
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 25:3, s. 408-414
-
Journal article (peer-reviewed)abstract
- This study explores the impact of illness-related shame on the quality of social relationships and psychological health in chronic patients. We aimed to examine the roles of fear of receiving compassion from others and experiential avoidance as potential mediators of this relationship. Although some studies have demonstrated the negative impact of chronic illness-related shame on psychological functioning, the mechanisms that may underlie this link remain understudied. The sample was comprised by 115 college students, which had been diagnosed with at least 1 chronic illness. Participants completed self-report measures on an online platform. This study's design was cross-sectional. A path analysis was conducted using structural equation modelling. Results showed that the impact of illness-related shame on both psychological health (R-2=.45) and the quality of social relationships (R-2=.33) was fully accounted by fear of compassion from others and experiential avoidance. This model revealed an excellent fit. Fear of receiving compassion from others was the main mediator of the illness-related shame link with the quality of social relationships (=-.22). The main mediator of the association between shame-related chronic illness and psychological health was experiential avoidance (=-.21).This study shed light on possible psychological mechanisms linking feelings of shame associated with having a chronic condition and impaired social relationships and mental health. On one hand, resisting feelings of compassion and care from others and, on the other hand, avoiding difficult internal experiences and situations that might trigger them seem to underlie the impact of shame on psychological and social functioning in chronic patients.
|
|
| 30. |
- Trindade, Inês A., 1990-, et al.
(author)
-
The influence of self-criticism on depression symptoms among ambulatory patients with inflammatory bowel disease
- 2019
-
In: Clinical Psychology and Psychotherapy. - : John Wiley & Sons. - 1063-3995 .- 1099-0879. ; 26:6, s. 743-750
-
Journal article (peer-reviewed)abstract
- Considering that self-criticism is an important process in the development and maintenance of depression, and taking into account the stigma associated with inflammatory bowel disease (IBD), the present study aimed to analyse whether self-criticism exacerbates the relationships of depression symptoms with IBD symptomatology and chronic illness-related shame. The sample included 53 ambulatory IBD patients (66% females) with ages from 18 to 65. Moderation analyses were conducted using structural equation modelling. Self-criticism exacerbated the associations of depression with IBD symptoms (b = 0.01; standard error [SE] = 0.00; Z = 3.73; P < .001) and illness shame (b = 0.02; SE = 0.01; Z = 2.40; P = .016). For the same level of IBD symptomatology or chronic illness-related shame, those individuals who present more feelings of inadequacy towards the self, experience more symptoms of depression. This exacerbation effect is stronger when IBD symptomatology and chronic illness-related shame are more intense. A high self-critical IBD patient may view the illness and/or symptomatology as a flaw or error that should be self-corrected. Physicians and other health professionals should be attentive to these pathological mechanisms and should attempt to alleviate them. It may be beneficial to refer high self-critical patients to psychological care.
|
|
| 31. |
- Trindade, Inês A., 1990-, et al.
(author)
-
The longitudinal effects of emotion regulation on physical and psychological health : A latent growth analysis exploring the role of cognitive fusion in inflammatory bowel disease
- 2018
-
In: British Journal of Health Psychology. - : John Wiley & Sons. - 1359-107X .- 2044-8287. ; 23:1, s. 171-185
-
Journal article (peer-reviewed)abstract
- Objective: This study thus aims to test differences between patients with inflammatory bowel disease (IBD) regarding IBD symptomatology, cognitive fusion, and psychological and physical health, as well as to explore whether the maladaptive emotion regulation process of cognitive fusion longitudinally impacts on the baseline and evolution of these outcomes over a period of 18months.Design and methods: Participants include 116 IBD patients with a mean age of 36.76 (SD=11.39) of both genders (69.83% females) that completed the self-report measures of interest in three different times, equally spaced 9months apart, over a period of 18months. Latent growth curve models were conducted using structural equationmodelling to estimate the growth trajectory of the variables in study.Results: Inflammatory bowel disease symptomatology and cognitive fusion's levels were negatively associated with psychological health and physical health's baseline levels. Furthermore, IBD symptomatology did not influence the growth of psychological health, while cognitive fusion did (=.30, p=.007). The same result was found for physical health (=.26, p=.024). These findings indicate that individuals with higher levels of cognitive fusion present lower levels of psychological health and physical health that tend to further decrease over the time through the effects of this maladaptive emotion regulation process.Conclusions: This study implies that it is of crucial importance to include psychotherapeutic interventions in the health care of patients with IBD. If successful, these interventions could represent decreases in the cost of IBD treatment and in the use of drugs with adverse side effects, in addition to improving patients' mental health and quality of life. Further implications for clinical and research work are discussed.
|
|
| 32. |
- Trindade, Inês A., 1990-, et al.
(author)
-
Ulcerative Colitis Symptomatology and Depression : The Exacerbator Role of Maladaptive Psychological Processes
- 2015
-
In: Digestive Diseases and Sciences. - : Springer. - 0163-2116 .- 1573-2568. ; 60:12, s. 3756-3763
-
Journal article (peer-reviewed)abstract
- Several studies have indicated that depressive symptomatology plays a pertinent role in the clinical recurrences of ulcerative colitis (UC). Due to the self-perpetuating cycle between UC symptomatology and depressive mood, it is considered that more investment should be given to the study of factors that influence depressive symptomatology in UC patients.This study aimed therefore at analyzing the exacerbator effect of maladaptive psychological strategies, such as cognitive fusion and brooding, on the relationship between UC symptomatology and depressive symptoms.The sample of the current study included 84 Portuguese patients with UC that completed an Internet-based survey (comprising demographic and medical questions, and self-report measures of depression, cognitive fusion, and brooding).Results showed that UC symptomatology explained 21 % of depression severity's variance. In addition, a significant interaction between UC symptomatology and cognitive fusion was found and explained 50 % of depressive symptoms' severity. A similar interaction was revealed between UC symptomatology and brooding, which accounted for 42 % of depression's variance. These findings demonstrated that, for the same level of UC symptomatology, those participants who revealed more cognitive fusion or more brooding presented significant higher levels of depression.The present study revealed cognitive fusion and brooding as moderators that exacerbate the impact of UC symptomatology on reported levels of depression. Psychological interventions that focus on the promotion of adaptive emotion regulation strategies to deal with adverse and stressful events should therefore be developed and implemented in UC patients' health care.
|
|
| 33. |
- Trindade, Ines, PhD, 1990-
(author)
-
Emotion regulation and chronic illness : The roles of acceptance, mindfulness and compassion in physical and mental health
- 2018
-
Doctoral thesis (other academic/artistic)abstract
- Introduction: Chronic illness is an increasingly predominant problem among the world population which vastly impacts on physical and mental health, quality of life and social functioning. Although chronic illnesses merit a long-term and complex response which would be ideally delivered by a multidisciplinary team of health professionals, most of the current healthcare for chronic illnesses still focus on acute episodes of illness. The third wave of cognitive and behavioural approaches on psychological problems, in particular mindfulness, Acceptance and Commitment Therapy, and evolutionary and compassion-based approaches have presented promising perspectives on behavioural medicine. Nevertheless, the efficacy of third wave interventions in improving well-being and mental health in chronic illness, although promising, is not yet clear. This doctoral dissertation aimed to contribute to a greater understanding of the psychological mechanisms that influence the vulnerability and persistence of psychological, social, and physical impairment in chronic illness. The role of verbal and emotion regulation processes aligned with third wave approaches’ conceptualizations of psychological problems in the comprehension of psychosocial and physical problems in chronic illness was thus explored in this dissertation. With this information, this thesis also aimed to develop, apply and test the efficacy of a new integrative acceptance, mindfulness, and compassion-based intervention for cancer.Methods: This dissertation includes 18 empirical studies with cross-sectional and longitudinal designs, including the development and test of efficacy of the MIND programme for cancer patients. The majority of these studies were conducted in samples of inflammatory bowel disease patients and breast cancer patients. Some studies also included individuals from the general population, as well as mixed samples of chronic patients. Generally, participants were recruited via internet or from hospital outpatient units. Data was collected through self-report measures and, in some specific studies, from medical records.Results: Overall, the studies revealed that: i) The Engaged Living Scale and its new shorter version (ELS-9), and the Committed Action Questionnaire are valid measures of engaged living and committed action for the Portuguese population. ii) The new chronic illness-specific measures – the Chronic Illness-related Shame Scale (CISS) and the Cognitive Fusion Questionnaire - Chronic Illness (CFQ-CI) – are robust and valid instruments that enable the assessment of chronic illness-related shame and chronic illness-related cognitive fusion, respectively. iii) The studied verbal and emotion regulation processes (cognitive fusion,experiential avoidance, self-criticism, fear of compassion from others, and lack of committed action) seem to be more important to the comprehension of psychosocial problems in chronic illness than physical symptomatology and contextual variables, and seem to mediate the effects of these variables, as well as the effects of chronic illness shame and body image dissatisfaction, on psychological, social, and physical health outcomes. Cognitive fusion and experiential avoidance in particular were identified as fundamental causal processes in the determination of the level of psychological health and perceived physical health in chronic patients. iv) The integration of acceptance, mindfulness, and compassion-based approaches in chronic illness seems to be feasible. The MIND programme for cancer patients presented a seemingly increased efficacy on the improvement of psychological health in relation to other mindfulness-based interventions in the context of breast cancer. Preliminary results suggested that the programme is a feasible, useful, accessible and cost-effective complement to the treatment of breast cancer.Conclusions: This dissertation clarifies the role of verbal and emotion regulation processes in chronic illness, presenting particularly innovative data in inflammatory bowel disease. The findings give support to the pertinence of acceptance, mindfulness, and compassion-based approaches, as well as their complementary integration, in behavioural medicine. The findings were integrated in a new transdiagnostic model for the comprehension of psychosocial and physical impairment in chronic illness. This dissertation provides new opportunities for future research, especially regarding the application of the MIND programme in other chronic illness populations.
|
|
| 34. |
|
|
