scholarly journals Impact of COVID-19 lockdown measures on a cohort of eating disorders patients

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Paulo P. P. Machado ◽  
Ana Pinto-Bastos ◽  
Rita Ramos ◽  
Tânia F. Rodrigues ◽  
Elsa Louro ◽  
...  
Keyword(s):  
Emotion Regulation ◽  
Eating Disorder ◽  
Negative Impact ◽  
Self Report ◽  
Specialized Hospital ◽  
Impact Scale ◽  
Difficulties In Emotion Regulation ◽  
Clinical Impairment ◽  
Current Survey ◽  
The Impact

Abstract Background Lockdown implemented to prevent the COVID-19 spread resulted in marked changes in the lifestyle. The objective of the current study was to assess the impact of lockdown measures on a cohort of eating disorder (ED) patients being followed as part of an ongoing naturalistic treatment study. Methods Ninety-nine patients aged 18 or older, currently or previously, in treatment at a Portuguese specialized hospital unit were contacted by phone and invited to participate in the current survey. Fifty-nine agreed to be interviewed by phone, and 43 agreed to respond to a set of self-report measures of ED symptoms, emotion regulation difficulties, clinical impairment, negative urgency, and COVID-19 impact, during the week after the end of the lockdown period. Results Data showed that of the 26 patients currently in treatment: 8 remained unchanged (31%), 7 deteriorated (27%), and 11 reliably improved (42%). Of the 17 participants not currently in treatment: 3 deteriorated (18%), 9 remained unchanged (53%), and 5 (29%) improved after the lockdown period. The Coronavirus Impact Scale showed that most patients considered their routines moderately or extremely impacted, experienced stress related to coronavirus, and showed difficulty in maintaining physical exercise and feeding routines. Results suggest that higher impact of COVID-19 lockdown was significantly correlated with eating disorder symptoms and associated psychopathology, impulsivity, difficulties in emotion regulation and clinical impairment measured at post-lockdown. In addition, the impact of COVID-19 and lockdown measures on clinical impairment was mediated by difficulties in emotion regulation. Conclusions Findings suggest that some ED patients may experience worsening of their condition, especially if associated with difficulties in emotion regulation, and these difficulties might be exacerbated in the context of a stressful crisis and lockdown measures, highlighting the need for intervention strategies to mitigate its negative impact.

scholarly journals Ultra-processed foods and binge eating: A retrospective observational study

2020 ◽  
Author(s):  
Agnes Ayton ◽  
Ali Ibrahim ◽  
James Dugan ◽  
Eimar Galvin ◽  
Oliver Wroe-Wright
Keyword(s):  
Eating Disorder ◽  
Observational Study ◽  
Binge Eating ◽  
Clinical Sample ◽  
Self Report ◽  
Retrospective Observational Study ◽  
Processed Foods ◽  
Eating Behaviours ◽  
Male Patients ◽  
The Impact

OBJECTIVEThere is increasing evidence of the impact of ultra-processed foods on multiple metabolic and neurobiological pathways, including those involved in eating behaviours, both in animals and in humans. In this pilot study, we aimed to explore ultra-processed foods and their link with disordered eating in a clinical sample. METHODSThis was a single site, retrospective observational study in a specialist eating disorder service using self report on the electronic health records. Patients with a DSM-5 diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or binge eating disorder (BED) were randomly selected from the service database in Oxford from 2017 to 2019. The recently introduced NOVA classification was used to determine the degree of industrial food processing in each patient’s diet. Frequencies of ultra-processed foods were analysed for each diagnosis, at each mealtime and during episodes of bingeing.RESULTS71 female and 3 male patients were included in the study. 22 had AN, 25 BN and 26 had BED. Patients with AN reported consuming 55% NOVA-4 foods, as opposed to approximately 70% in BN and BED. Binge foods were 100% ultra-processed.DISCUSSIONFurther research into the metabolic and neurobiological effects of reducing ultra-processed food intake on bingeing behaviour is needed.

scholarly journals Effect of COVID-19 Lockdown on Patients with Multiple Sclerosis: an Italian Survey

2021 ◽  
pp. 1-7
Author(s):  
Marta Altieri ◽  
◽  
Mariangela Fratino ◽  
Flavia Pauri ◽  
Antonella Conte ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Family Caregiving ◽  
Social Life ◽  
Negative Impact ◽  
Self Report ◽  
Psychological Status ◽  
Control Group ◽  
Clinical Effects ◽  
Future Expectations ◽  
The Impact

Background: Italy was one of the first affected countries by coronavirus disease 2019 (COVID-19) pandemic. Public health measures like quarantine or national lockdown were adopted, with negative psychological and clinical effects on patients with chronic diseases. To investigate the impact of lockdown on patients with multiple sclerosis (MS), we developed a 36 items self-report questionnaire. Methods: Questionnaires were emailed to 120 patients with MS and 100 with chronic migraine (CM) as a control group, matched for age, sex, and education. The questionnaire was divided into five domains, evaluating concerns about 1) MS and therapy during COVID-19 pandemic, 2) personal and family caregiving, 3) working activities, 4) general and disease-related emotions during the lockdown, 5) future expectations concerning health status, social life, and working activity. Results: patients with MS had higher scores than those with CM in domains 4 and 5, investigating respectively general and disease-related emotions and future expectations (p= 0.05 and 0.02 respectively). About half of the patients with MS expressed some concern about the need to continue their therapy during the pandemic compared to people with CM (p= 0.0002). Conclusions: Covid-19 pandemic had a more negative impact on psychological status of patients with MS compared with those with CM

scholarly journals Emotion regulation group skills training: a pilot study of an add-on treatment for eating disorders in a clinical setting

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Kristina Holmqvist Larsson ◽  
Anna Lowén ◽  
Linda Hellerstedt ◽  
Linn Bergcrona ◽  
Mimmi Salerud ◽  
...  
Keyword(s):  
Eating Disorders ◽  
Emotion Regulation ◽  
Eating Disorder ◽  
Pilot Study ◽  
Clinical Setting ◽  
Skills Training ◽  
Adjunctive Treatment ◽  
Paired Samples ◽  
Clinical Impairment ◽  
Group Skills

Abstract Background Emotion regulation difficulties appear to play a role in the development and maintenance of several eating disorders. This pilot study aimed at examining whether a short add-on group skills training in emotion regulation for young adults with different eating disorders was feasible in a psychiatric clinical setting. We also investigated if the treatment increased knowledge of emotions, and decreased self-reported difficulties with emotion regulation, alexithymia, symptoms of eating disorder, anxiety and depression, as well as clinical impairment. Methods Six skills training groups were piloted with a total of 29 participants (M = 21.41 years, SD = 1.92). The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired samples t-test was used to compare differences between before-and-after measures. Results The primary outcomes measures difficulties in emotion regulation (p <  0.001) and alexithymia (p <  0.001) showed significant improvement after treatment. The total eating disorder score (p = 0.009) was also significantly reduced, as was clinical impairment (p <  0.001). Acceptance/valued direction, identifying primary emotions and learning about secondary emotions was rated as especially helpful. Conclusions This preliminary pilot study showed that group training targeting emotion regulation skills was feasible and appreciated by participants, as well as being potentially promising as an adjunctive treatment for different eating disorders. Further controlled studies are needed. Trial registration The study was retrospectively registered NCT04148014 on October 30th 2019.

Shame traumatic memories and body image shame in Binge Eating Disorder: Can memories of warmth and safeness buffer this link?

2017 ◽  
Vol 41 (S1) ◽  
pp. S549-S549
Author(s):  
C. Duarte ◽  
J. Pinto-Gouveia
Keyword(s):  
Body Image ◽  
Eating Disorder ◽  
Binge Eating ◽  
Binge Eating Disorder ◽  
Self Report ◽  
Childhood And Adolescence ◽  
Moderator Effect ◽  
Traumatic Memories ◽  
Emotional Memories ◽  
The Impact

IntroductionGrowing research show that body image-related shame plays a particularly important role in the vulnerability to and persistence of Binge eating symptoms. Also, shame experiences from childhood and adolescence were found to function as traumatic memories and are significantly associated with eating psychopathology. Nonetheless, little is known about the effect of shame traumatic memories in Binge Eating Disorder (BED), and whether early positive emotional memories of warmth and safeness may buffer against the impact of shame memories on body image shame.AimsThis study examined the moderator effect of positive emotional memories on the association between shame traumatic memories and current body image shame in women diagnosed with BED.MethodsParticipants (N = 109) were assessed through the eating disorder examination and the shame experiences interview, and answered to self-report measures assessing the traumatic features of a key shame memory, positive emotional memories s and body image shame.ResultsBody image-related experiences were most frequently recalled as significant shame memories. Positive emotional memories were negatively associated with shame traumatic memories and body image shame, and had a significant moderator effect on the association between shame traumatic memories and current body image shame.ConclusionsThis study was the first to demonstrate that early shame experiences may contribute for BED patients’ shame based on their body image. Data suggest that the access to memories of early feelings of affiliation and safeness may be key to tone down negative affect. These findings have important implications for the conceptualization and treatment of BED.Disclosure of interestThe authors have not supplied their declaration of competing interest.

scholarly journals Emotion Regulation Difficulties And Psychopathology In Bariatric Surgery Candidates

2021 ◽  
Author(s):  
Rachel Strimas
Keyword(s):  
Quality Of Life ◽  
Bariatric Surgery ◽  
Emotion Regulation ◽  
Eating Disorder ◽  
Psychiatric Disorder ◽  
Difficulties In Emotion Regulation ◽  
Current Axis ◽  
Axis I ◽  
A Current

Evidence suggests high rates of psychiatric disorders in bariatric surgery candidates (e.g., Kalarchian et al., 2007; Mitchell et al., in press), although no rigorous studies have examined the prevalence in a Canadian sample. As such, the first purpose of this study was to assess the prevalence of Axis I disorders, and associations with quality of life, in a sample of consecutively referred bariatric surgery candidates at the Toronto Western Hospital Bariatric Surgery Program. In light of emerging evidence linking emotion regulation difficulties with diverse psychiatric symptoms, the second purpose of this study was to examine whether emotion regulation difficulties were common or specific determinants of mood, anxiety, and eating psychodiagnostic categories, as such information would help inform interventions. Three hundred and twenty-one bariatric surgery candidates (80.1% female; M age = 44.37 years) were assessed using a structured psychodiagnostic interview and completed questionnaires of health-related quality of life and emotion regulation difficulties. Results indicated that 54.5% of patients met DSM-IV-TR criteria for a lifetime psychiatric diagnosis and 18.4% met criteria for a current psychiatric disorder. Major depressive disorder was the most common lifetime psychiatric disorder and binge eating disorder was the most prevalent current psychiatric disorder. Compared to patients without a current Axis I disorder, participants diagnosed with a current Axis I disorder reported significantly worse functioning on most mental and physical health domains (p’s < .01). Overall, a series of regression analyses revealed that difficulties regulating emotions accounted for unique variance in current mood and anxiety disorder status (p’s < .001). Difficulties in emotion regulation were not significantly associated with current eating disorder status after Bonferroni correction. Taken together, these results confirm the high rates of psychiatric disorders in a Canadian sample of bariatric surgery candidates and provide evidence for associated functional health impairment. The data also add to the growing body of literature demonstrating emotion regulation difficulties across psychodiagnostic categories and are consistent with suggestions that psychosocial interventions for bariatric patients might benefit from directly targeting difficulties in emotion regulation. Further study of these associations is needed to replicate these findings and elucidate how difficulties in emotion regulation interact with psychopathology to affect patients’ post-operative outcomes.

scholarly journals Педагогічний супровід метакогнітивного моніторингу навчальної діяльності студентів

2019 ◽  
Vol 9 (1) ◽  
pp. 82-88
Author(s):  
Марія Августюк
Keyword(s):  
University Students ◽  
Negative Impact ◽  
Cognitive Activity ◽  
Cognitive Strategies ◽  
Self Report ◽  
Learning Activity ◽  
Metacognitive Monitoring ◽  
Study Program ◽  
Illusion Of Knowing ◽  
The Impact

Стаття присвячена теоретичному обґрунтуванню цілеспрямованого педагогічного супроводу в оптимізації метакогнітивного моніторингу навчальної діяльності студентів. Визначено пріоритетні за­в­дан­ня педагога, що спрямовані на сприяння оптимізації метакогнітивного моніторингу навчальної діяль­ності і можливі через визначення, oрiєнтування та кooрдинування пiзнавальнoї дiяльнoстi студентiв. Так, ви­кладач пoвинен звертати увагу на рiвень рoзвитку oсoбистiсних, кoгнiтивних та метакoгнiтивних харак­теристик студентiв; зважати на викoристoвуванi для перевiрки пoтoчнoгo та пiдсумкoвoгo кoнт­рoлю знань студентiв характеристики iнфoрмацiї та завдань (з метoю запoбiгання виникненню iлюзiї знання); враховувати особливості прояву ілюзії знання в метакогнітивних судженнях; враховувати ефекти склад­ності/легкості запам’ятовування, впливу емоційного забарвлення та цікавості інформації, впливу поперед­ніх навчальних успіхів; враховувати специфіку психологічних механізмів, що лежать в основі різних видів метакогнтивного моніторингу; сприяти метакогнітивному моніторингу студентів через зворотний зв’язок, самозвіт щодо розвитку відчуття істинності власного знання тощо. Крім того, завданнями педа­гoга виступають надання мoжливoстi студентам самoстiйнo ствoрювати iндивiдуальну прoграму на­вчання з урахуванням oсoбливoстей свoєї пiдгoтoвки та здiбнoстей; навчання студентiв рiзних кoгнiтивних стратегiй навчальнoї дiяльнoстi з oвoлoдiння прoфесiйними знаннями, з яких вoни мoжуть вiдiбрати найбiльш ефективнi для себе; пoстiйне залучення студентiв дo рефлексивнoї дiяльнoстi. Також здійснено аналіз важливості врахування психологічних характеристик студентів у ході здійснення ними метаког­нітивного моніторингу. Зокрема, підкреслено важливість стимулювання навчальної мотивації студентів, формування у них адекватної самооцінки, розвитку високих показників рефлексивності, метакогнітивних обізнаності, знань та активності, здатності до самостійного оцінювання своєї діяльності та її резуль­татів. Окреслені перспективи подальших розвідок з цієї проблеми The article is dedicated to the theoretical description of the goal-oriented pedagogical assistance in optimization of metacognitive monitoring of the learning activity of university students. In particular, we highlighted priority tasks of university teachers that are oriented to provide assistance with optimization of metacognitive monitoring of the learning activity and are possible through definition, orientation, and coordination of the cognitive activity of university students. Thus, the pedagogical tasks are to provide students with the opportunity to create a self-study program taking into account their own learning backgrounds and interests; training students for different cognitive strategies of the learning activity in the sphere of professional knowledge, from which they are able to choose the most effective ones for themselves; constant involvement of students in reflexive activities. Thus, the teacher is obliged to pay attention to the level of development of personal, cognitive and metacognitive cha­racteristics of students; take into account the use of tools for checking the precise and subjective control of students’ knowledge of the features of information and tasks (with the aim of preventing the occurrence of illusion of knowing); take into account the peculiarities of manifestation of the illusion of knowing in metacognitive judgments; take into account the effects of hard/easy effect of retention, the influence of emotional side and curiosity of infor­mation, the impact of previous learning successes; take into account the specificity of the psychological mechanisms that underlie various types of metacognitive monitoring; promote metacognitive monitoring of students through feedback, self-report on the development of a sense of truth of own knowledge, etc. In addition, an analysis of the importance of psychological characteristics in students’ judgments of metacognitive monitoring was carried out. Among the most important characteristics, student motivation, academic achievements, feedback, and self-regu­lation are the characteristics aimed to provide better understanding of the nature of metacognitive monitoring effectiveness and can help in the annihilation of the negative impact of the illusion of knowing. In particular, the importance of stimulating students’ learning motivation, forming of their adequate self-esteem, development of high indicators of reflectivity, metacognitive awareness, knowledge and activity, ability to independently evaluate their activity and its results is emphasized. The prospects for further researches on this problem are outlined

scholarly journals Emotion regulation difficulties in anorexia nervosa: associations with improvements in eating psychopathology

2021 ◽  
Author(s):  
Marsha Rowsell ◽  
Danielle E. MacDonald ◽  
Jacqueline C. Carter
Keyword(s):  
Emotion Regulation ◽  
Anorexia Nervosa ◽  
Eating Disorder ◽  
Intensive Treatment ◽  
Self Report ◽  
Eating Psychopathology ◽  
Eating Disorder Symptoms ◽  
Core Deficit ◽  
Eating Disorder Psychopathology ◽  
Regulation Strategies

Background Difficulties with emotion regulation have been established as a core deficit in anorexia nervosa (AN). However, limited research has evaluated whether weight gain is associated with improvements in emotion regulation difficulties in AN and whether improvements in emotion regulation are associated with reductions in eating disorder psychopathology. The aims of this study were threefold: 1) to examine the nature and extent of emotion regulation difficulties in AN; 2) to determine whether these difficulties improved during intensive treatment for the eating disorder; and 3) to study whether improvements in emotion regulation were associated with improvements in eating disorder psychopathology. Method The participants were 108 patients who met DSM-IV-TR criteria for AN and were admitted to a specialized intensive treatment program. Self-report measures of eating disorder symptoms and difficulties with emotion regulation were administered at admission to and discharge from the program. Results Patients with the binge-purge subtype of AN reported greater difficulties with impulse control when upset and more limited access to emotion regulation strategies when experiencing negative emotions than those with the restricting subtype. Among those who completed treatment and became weight restored, improvements in emotion regulation difficulties were observed. Greater pre-to-post treatment improvements in emotional clarity and engagement in goal directed behaviours when upset were associated with greater reductions in eating disorder psychopathology during treatment. Conclusions These findings add to growing evidence suggesting that eating disorder symptoms may be related to emotion regulation difficulties in AN and that integrating strategies to address emotion regulation deficits may be important to improving treatment outcome in AN.

scholarly journals Examining emotion regulation in binge-eating disorder

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Anna Walenda ◽  
Barbara Kostecka ◽  
Philip S. Santangelo ◽  
Katarzyna Kucharska
Keyword(s):  
Emotion Regulation ◽  
Eating Disorder ◽  
Depressive Symptoms ◽  
Binge Eating ◽  
Binge Eating Disorder ◽  
Emotional Regulation ◽  
Emotion Regulation Strategies ◽  
Self Blame ◽  
Difficulties In Emotion Regulation ◽  
Regulation Strategies

Abstract Background Inefficient mechanisms of emotional regulation appear essential in understanding the development and maintenance of binge-eating disorder (BED). Previous research focused mainly on a very limited emotion regulation strategies in BED, such as rumination, suppression, and positive reappraisal. Therefore, the aim of the study was to assess a wider range of emotional regulation strategies (i.e. acceptance, refocusing on planning, positive refocusing, positive reappraisal, putting into perspective, self-blame, other-blame, rumination, and catastrophizing), as well as associations between those strategies and binge-eating-related beliefs (negative, positive, and permissive), and clinical variables (eating disorders symptoms, both anxiety, depressive symptoms, and alexithymia). Methods Women diagnosed with BED (n = 35) according to the DSM-5 criteria and healthy women (n = 41) aged 22–60 years were assessed using: the Eating Attitudes Test-26, the Eating Beliefs Questionnaire-18, the Hospital Anxiety and Depression Scale, the Toronto Alexithymia Scale-20, the Cognitive Emotion Regulation Questionnaire, and the Difficulties in Emotion Regulation Scale. Statistical analyses included: Student t - tests or Mann–Whitney U tests for testing group differences between BED and HC group, and Pearson’s r coefficient or Spearman’s rho for exploring associations between the emotion regulation difficulties and strategies, and clinical variables and binge-eating-related beliefs in both groups. Results The BED group presented with a significantly higher level of emotion regulation difficulties such as: nonacceptance of emotional responses, lack of emotional clarity, difficulties engaging in goal-directed behavior, impulse control difficulties, and limited access to emotion regulation strategies compared to the healthy controls. Moreover, patients with BED were significantly more likely to use maladaptive strategies (rumination and self-blame) and less likely to use adaptive strategies (positive refocusing and putting into perspective). In the clinical group, various difficulties in emotion regulation difficulties occurred to be positively correlated with the level of alexithymia, and anxiety and depressive symptoms. Regarding emotion regulation strategies, self-blame and catastrophizing were positively related to anxiety symptoms, but solely catastrophizing was related to the severity of eating disorder psychopathology. Conclusions Our results indicate an essential and still insufficiently understood role of emotional dysregulation in BED. An especially important construct in this context seems to be alexithymia, which was strongly related to the majority of emotion regulation difficulties. Therefore, it might be beneficial to pay special attention to this construct when planning therapeutic interventions, as well as to the maladaptive emotion regulation strategies self-blame and catastrophizing, which were significantly related to BED psychopathology.

scholarly journals Cognitive and affective empathy relate differentially to emotion regulation

2021 ◽  
Author(s):  
Nicholas M Thompson ◽  
Carien M. van Reekum ◽  
Bhismadev Chakrabarti
Keyword(s):  
Emotion Regulation ◽  
Emotion Dysregulation ◽  
Cognitive Empathy ◽  
Self Report ◽  
Affective Empathy ◽  
Interference Effects ◽  
Emotional Interference ◽  
Difficulties In Emotion Regulation ◽  
Component Processes ◽  
The Relationship

The constructs of empathy (i.e. understanding/sharing another’s emotion) and emotion regulation (i.e. the processes by which one manages emotions) have largely been studied in relative isolation of one another. To better understand the interrelationships between their various component processes, this manuscript reports two studies that examined the relationship between empathy and emotion regulation using a combination of self-report and task measures. In study 1 (N=137), trait cognitive and affective empathy were found to share divergent relationships with self-reported emotion dysregulation. Emotion dysregulation was negatively related to cognitive empathy but showed no relationship with affective empathy. In the second study (N=92), the magnitude of emotion interference effects (i.e. the extent to which inhibitory control was impacted by emotional relative to neutral stimuli) in variants of a Go/NoGo and Stroop task were used as proxy measures of implicit emotion regulation abilities. Trait cognitive and affective empathy were found to share different relationships with both task metrics. Higher affective empathy was associated with increased emotional interference in the Emotional Go/NoGo; no such relationship was observed for trait cognitive empathy. In the Emotional Stroop, higher cognitive empathy was associated with reduced emotional interference, but no such relationship was observed for affective empathy. Together, these studies demonstrate that greater cognitive empathy was broadly associated with improved emotion regulation abilities, while greater affective empathy was typically associated with increased difficulties with emotion regulation. This finding points to the need for assessing the different components of empathy in psychopathological conditions marked by difficulties in emotion regulation.

scholarly journals “It is the only constant in what feels like a completely upside down and scary world”: Living with an Eating Disorder during COVID-19 and the importance of perceived control for recovery and relapse.

2021 ◽  
Author(s):  
Dawn Branley-Bell ◽  
Catherine V. Talbot
Keyword(s):  
Eating Disorders ◽  
Eating Disorder ◽  
Perceived Control ◽  
Online Survey ◽  
Negative Impact ◽  
Significant Risk ◽  
Study Data ◽  
External Control ◽  
Time Points ◽  
The Impact

Background: The COVID-19 pandemic has had a profound, negative impact on the lives and wellbeing of the population, and it can raise additional challenges for individuals with eating disorders. During early stages of the UK lockdown, individuals reported disruptions to many aspects of their lives, including reduced feelings of control and serious concerns over the impact of the pandemic on eating disorder symptoms and/or recovery. This study compares data from two time points to explore the ongoing impacts of the pandemic on this population. Method: A mixed-methods online survey was developed for the purpose of this study. Data was collected at the two key time points: First, soon after the start of the first UK lockdown (April 2020) and second, as the first lockdown restrictions began to be lifted (June 2020). The sample consisted of 58 individuals currently experiencing, or in recovery from, an eating disorder. Participants were aged between 16-65 years; 57 identified as female, and 1 male. Results: Higher perceptions of general, external control were associated with recovery between the time points. Individuals who experienced less perceived control reported a tendency to rely upon eating disorder behaviours as an auxiliary coping mechanism, i.e., diminished external control was directed inwards and replaced with controlling their own behaviour. Conclusions: Perceived control is a significant factor in eating disorder recovery. As a result of the pandemic’s negative impact upon peoples’ sense of control, individuals with eating disorders are at significant risk of detrimental impacts on their recovery and wellbeing. The results have implications for future treatments based on strengthening individuals’ perceptions of control to promote recovery.

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