Educational Psychology Commons^™

Efficacy Of Patient Education And Duloxetine, Alone And In Combination, For Patients With Multisystem Functional Somatic Disorder: Study Protocol For The Edulox Trial, Cecilia Pihl Jespersen, Heidi Frølund Pedersen, Maria Kleinstäuber, Per Fink, Kaare Bro Wellnitz, Eva Ørnbøl, Andreas Schröder, Johanne Liv Agger, Lene Vase, Nanna Brix Finnerup, Lise Kirstine Gormsen

Psychology Faculty Publications

Background

Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment.

Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with not antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms …

Discussing Patient Emotions In Audiology: Provider Experiences With The Implementation Process Of Hearing Loss Psychological Inflexibility Screenings, Sydnee Grigsby, Karen Muñoz, Guadalupe G. San Miguel, Michael P. Twohig

Psychology Faculty Publications

Purpose: This study aimed to investigate barriers and facilitators experienced by clinical educators and graduate students when talking with patients about difficult emotions and thoughts related to their hearing.

Method: A longitudinal observational design was used, and an Implementation Research Logic Model guided the process. Five clinical educators and five graduate students participated in the study. Participants completed pre- and post-measures and attended individual debriefing sessions during the eight-month study period.

Results: Four themes emerged from the debriefing sessions: (1) learning process, (2) confidence (3) barriers, and (4) supervision. Participants described that the Acceptance and Action Questionnaire-Managing Child Hearing Loss …

Diminished Adolescent Social Well-Being During The Covid-19 Pandemic, Michael J. Furlong, Mei-Ki Chan, Erin Dowdy, Karen Nylund-Gibson

Psychology Faculty Publications

Managing the COVID-19 pandemic involved implementing public health policies that disrupted students' lives, creating conditions that substantially influenced their mental health and well-being. Subsequently, research focused don the mental health sequelae of increased depression and anxiety, but the possible impacts on adolescents' social well-being have been largely unexamined. Social well-being is essential to youth's overall mental health and can be diminished even without symptoms of depression and anxiety. This report explored heterogeneities in changes in adolescents' social well-being from pre-COVID-19 to post-restrictions using longitudinal data from adolescents attending middle and high schools in California (N = 1,299; 49.9% female). …

An Examination Of Psychological Flexibility As A Mediator Between Mental Health Concerns And Satisfaction With Life Among Autistic Adults, Ty B. Aller, Heather H. Kelley, Tyson S. Barrett, Benjamin Covington, Michael E. Levin, Maryellen Brunson Mcclain

Psychology Faculty Publications

Background: Experiencing mental health concerns (e.g., depression, anxiety, stress) can have negative effects on satisfaction with life (SWL) for autistic adults. Current mental health supports that may promote SWL do not effectively meet the needs of autistic adults, often due to deficits-based approaches. Methods: To begin addressing the gap in research surrounding mental health supports among autistic adults, we designed a preregistered longitudinal study that used structural equation modeling to assess 289 autistic adults from the Simons Powering Autism Research (SPARK) program to determine if progress toward ones values, a strengths-based component of psychological flexibility, is a potential …

Response To Commentary: The Framework For Systematic Reviews On Psychological Risk Factors For Persistent Somatic Symptoms And Related Syndromes And Disorders (Psy-Pss), Paul Hüsing, Abigail Smakowski, Bernd Löwe, Maria Kleinstäuber, Anne Toussaint, Meike C. Shedden-Mora

Psychology Faculty Publications

Persistent somatic symptoms (PSS) are common in all fields of medicine. Current classification systems for mental disorders in this field, i.e. Somatic Symptom Disorder (SSD; DSM-5) or Bodily Distress Disorder (BDD; ICD-11), now stress the relevance of psychological features associated with the physical complaints. It is well known that psychological criteria are among the relevant risk factors for the development and/or worsening of persistent physical symptoms, however, the selected diagnostic criteria remain subject to debate. Numerous psychological concepts have been studied and discussed in the scientific field. However, empirical evidence remains scattered, individual factors have not been reviewed systematically, and …

Increasing Transcultural Competence In Clinical Psychologists Through A Web-Based Training: Study Protocol For A Randomized Controlled Trial, Selina Studer, Maria Kleinstäuber, Ulrike Von Lersner, Cornelia Weise

Psychology Faculty Publications

Background In mental health care, the number of patients with diverse cultural backgrounds is growing. Nevertheless, evaluated training programs for transcultural competence are missing. Barriers for engaging in transcultural therapy can be identified in patients as well as in therapists. Besides language barriers, clinical psychologists report insecurities, for example, fear of additional expenses when involving a language mediator, ethical concerns such as power imbalances, or fear of lack of knowledge or incorrect handling when working with patients from other cultures. Divergent values and concepts of disease, prejudices, and stereotyping are also among the issues discussed as barriers to optimal psychotherapy …

Reach, Adoption, And Maintenance Of Online Acceptance And Commitment Therapy At A University: An Implementation Case Study, Carter H. Davis, Korena Klimczak, Ty B. Aller, Michael P. Twohig, Michael E. Levin

Psychology Faculty Publications

College students are undergoing a mental health crisis and existing clinical resources at universities may be inadequate to meet their needs. One solution to this problem could be the use of self-guided, online programs for mental health that can be easily distributed to students. A persistent issue, however, is the transition from program development to implementation of a self-guided program at campus-wide scale. We describe, in a self-narrative format, the steps taken to translate an online program we developed based in acceptance and commitment therapy (ACT), called ACT Guide, from a research context to a campus-wide service at our university. …

Act-Enhanced Behavior Therapy For A Hispanic Adult With Trichotillomania: A Case Report, Marissa L. Donahue, Michael P. Twohig

Psychology Faculty Publications

Trichotillomania, also known as Hair-Pulling Disorder, is characterized by recurrent pulling out of one’s hair over brief episodes or sustained periods of time and results in hair loss. ACT-enhanced behavior therapy (A-EBT) has been shown to be an effective approach in the treatment of trichotillomania by promoting psychological flexibility around hair pulling urges and teaching stimulus control and habit reversal training. However, there is limited support of A-EBT for clients with an ethnic minority identity. This case report focuses on an adult, Hispanic female client, Luna (pseudonym), who received eight sessions of A-EBT for the treatment of trichotillomania. At post-treatment, …

Merging Acceptance And Commitment Therapy With Exposure Exercises To Treat Social Anxiety In A Teen, Caleb D. Farley, Michael P. Twohig

Psychology Faculty Publications

Social anxiety disorder (SAD) often develops during teenager years, and it is important to conceptualize developmentally appropriate interventions. Exposure therapy framed from a perspective of acceptance and commitment therapy (ACT) shows promise for decreasing pathology and increasing wellbeing. This case illustrates the process through which exposure therapy was integrated with ACT to elicit meaningful outcomes in a case of SAD with a 16-year-old female. Treatment outcomes assessed included engagement in values-based activities as well as assessments of depression, social anxiety, separation anxiety, generalized anxiety, experiential avoidance, and contextually targeted school-based wellbeing. Intervention centered on learning ACT principles through relatable metaphors …

Pediatric Hearing Aid Management: Experiences And Perspectives Of Spanish-Speaking Parents, Karen Muñoz, Diego Guillen, Carlos Muñoz, Michael P. Twohig

Psychology Faculty Publications

Purpose: The purpose of the study was twofold: (a) to explore hearing aid management experiences of Spanish-speaking parents who have young children using hearing aids and (b) to explore parents' access to the Internet and perceptions about remote audiology services.

Method: The study used a mixed methods design. Data were collected through a phone interview.

Results: Eleven mothers of children aged 14-60 months participated. Most of the children (9/11) had a bilateral hearing loss, and two had an additional disability. Three themes emerged for hearing aid management experiences: audiology services, routines, and emotional challenges/supports. Parents had variable levels of confidence …

Religion/Spirituality, Stress, And Resilience Among Sexual And Gender Minorities: The Religious/Spiritual Stress And Resilience Model, G. Tyler Lefevor, Chana Etengoff, Edward B. Davis, Samuel J. Skidmore, Eric M. Rodriguez, James S. Mcgraw, Sharon S. Rostosky

Psychology Faculty Publications

Although many sexual and gender minorities (SGMs) consider themselves religious or spiritual, the impact of this religiousness or spirituality (RS) on their health is poorly understood. We introduce the religious/spiritual stress and resilience model (RSSR) to provide a robust framework for understanding the variegated ways that RS influences the health of SGMs. The RSSR bridges existing theorizing on minority stress, structural stigma, and RS-health pathways to articulate the circumstances under which SGMs likely experience RS as health promoting or health damaging. The RSSR makes five key propositions: (a) Minority stress and resilience processes influence health; (b) RS influences general resilience …

Choosing Act Or Cbt: A Preliminary Test Of Incorporating Client Preferences For Depression Treatment With College Students, Carter H. Davis, Michael P. Twohig, Michael Levin

Psychology Faculty Publications

Background

Depression is a significant concern among college students, who suffer at higher rates and with greater severity than the general population. Online self-help could reduce the burden currently placed on college counseling centers, and programs based in cognitive behavioral therapies (CBTs) have a strong evidence base. However, online CBTs for depression often suffer from low adherence rates. An understudied method for improving adherence in this population is offering students a choice between various CBTs.

Methods

We conducted a randomized trial with 142 students with high levels of depression, with a subset of participants randomly receiving either traditional cognitive behavioral …

Differential Effects Of Mindful Breathing And Loving Kindness Meditations: A Component Analysis Study, Sarah J. Bolognino, Tyler L. Renshaw, Mary L. Phan

Psychology Faculty Publications

Objective: Mindful breathing meditation (MBM) and loving-kindness meditation (LKM) are common components of effective mindfulness-based interventions (MBIs). This study examined the differential effects of MBM and LKM on purported therapeutic process variables and mental health outcomes via component analysis.

Method: The research design was a randomized controlled trial with four conditions: MBM, LKM, combined (MBM + LKM), and a relaxation control. All conditions consisted of 10-min. audio-recorded guided meditations that were self-implemented over the course of two weeks. Participants were college undergraduates (N = 52).

Results: Findings indicated statistically significant and very large main effects of time, regardless of …

Girls Are Good At Stem: Opening Minds And Providing Evidence Reduce Boys' Stereotyping Of Girls' Stem Ability, Emily N. Cyr, Kathryn M. Kroeper, Hilary B. Bergsieker, Tara C. Dennehy, Christine Logel, Jennifer R. Steele, Rita A. Knasel, W. Tyler Hartwig, Priscilla Shum, Stephanie L. Reeves, Odilia Dys-Steenbergen, Amrit Litt, Christopher Lok, Taylor Ballinger, Haemi Nam, Crystal Tse, Amanda L. Forest, Mark Zanna, Sheryl Staub-French, Mary Wells, Toni Schmader, Stephen C. Wright, Steven J. Spencer

Psychology Faculty Publications

Girls and women face persistent negative stereotyping within STEM (science, technology, engineering, mathematics). This field intervention was designed to improve boys' perceptions of girls' STEM ability. Boys (N = 667; mostly White and East Asian) aged 9-15 years in Canadian STEM summer camps (2017-2019) had an intervention or control conversation with trained camp staff. The intervention was a multi-stage persuasive appeal: a values affirmation, an illustration of girls' ability in STEM, a personalized anecdote, and reflection. Control participants discussed general camp experiences. Boys who received the intervention (vs. control) had more positive perceptions of girls' STEM ability, d = 0.23, …

The Impact Of Covid-19 Pandemic Experiences On College Drinking Via Mental Distress: Cross-Sectional Mediation Moderated By Race, Abby L. Braitman, Rachel Ayala Guzman, Megan Strowger, Jennifer L. Shipley, Douglas J. Glenn, Emily Junkin, Alina Whiteside, Cathy Lau-Barraco

Psychology Faculty Publications

Background: The COVID-19 pandemic has been linked to stress, anxiety, and depression among college students, with heightened distress tied to greater drinking for some individuals. Emerging research suggests that these associations may differ across race, but few studies use adequate samples to examine this, particularly among college students, an at-risk population for both heavy drinking and mental distress. Specifically, pandemic-related stressors and mental distress may be higher among Black students than White students. The current study examined: (1) whether mental distress cross-sectionally mediates the association between pandemic-specific stressors and drinking and (2) whether race (Black or White) moderates these associations. …

Temporal Expectations In Delay Of Gratification, Jeremy M. Haynes, Mariah E. Willis-Moore, D. Perez, Devanio J. Cousins, Amy L. Odum

Psychology Faculty Publications

We examined how temporal expectations influence preference reversals in a delay of gratification task for rats based on a hypothesis of Rachlin (2000), who suggested that preference for a larger-later reward may shift in favor of a smaller-immediate reward as a result of changes in when that larger reward is expected. To explore Rachlin’s hypothesis, we pre-exposed two groups of rats to the delays associated with a larger-later reinforcer from a delay of gratification task. One group experienced the delays as a function of their choices in an intertemporal choice task and the other group experienced delays yoked from the …

“I Just Wanted Support”: Examining How Lds Clergy May Effectively Minister To Sexual And Gender Minority Congregants, Samuel J. Skidmore, G. Tyler Lefevor, Adlyn M. Perez-Figueroa, Kristen A. Gonzalez

Psychology Faculty Publications

This study explored why members of the Church of Jesus Christ of Latter-day Saints (LDS) who identify as sexual or gender minorities (SGM) speak with clergy regarding their SGM identities, as well as what LDS SGMs find helpful and unhelpful in these conversations. A sample of 25 current or former LDS SGMs participated in semi-structured interviews, which were analyzed using thematic analysis. Participants reported six overarching reasons for talking with clergy, including church procedures, seeking guidance, seeking emotional comfort, seeking repentance, seeking openness, and other people’s initiation. Participants reported several ways clergy were helpful, including empathic listening, openness, and affirmative …

Unpacking The Internalized Homonegativity–Health Relationship: How The Measurement Of Ih And Health Matter And The Contribution Of Religiousness, G. Tyler Lefevor, Eric R. Larsen, Rachel M. Golightly, Maddie Landrum

Psychology Faculty Publications

Internalized homonegativity (IH) is widely recognized to negatively influence the health of lesbian, gay, bisexual, and queer/questioning (LGBQ +) individuals. It is not clear, however, the role that religiousness may play in the relationship between IH and health or how differing conceptualizations of IH or health may influence this relationship. We conducted a multi-level meta-analysis of 151 effect sizes from 68 studies to examine the relationship between IH and health as well as what may moderate this relationship. Results suggested that IH was consistently and negatively related to health (r = − .28). Analyses suggest that IH was most …

“I Come Out Because I Love You”: Positive Coming Out Experiences Among Latter-Day Saint Sexual And Gender Minorities, Samuel J. Skidmore, G. Tyler Lefevor, Adlyn M. Perez-Figueroa

Psychology Faculty Publications

Background:

Coming out conversations are pivotal and stressful experiences for sexual and gender minorities (SGMs). Coming out can lead to more affirmation, safety, confidence, and improved relationships. However, adverse coming out experiences can lead to damaged relationships and ostracization, which may be more likely in conservative religious contexts.

Purpose:

The purpose of the current study was to explore what leads to positive coming out experiences for SGM members of the Church of Jesus Christ of Latter-day Saints.

Method:

A sample of 25 current or former Latter-day Saint (LDS) SGMs participated in semi-structured interviews, which were analyzed using thematic analysis.

Results: …

Does Internalized Stigma Change The Way That Religiousness Relates To Depression For People With Minoritized Sexualities?, G. Tyler Lefevor, Chana Etengoff, Samuel J. Skidmore

Psychology Faculty Publications

Drawing on minority stress and intersectionality theories, we examine whether the relationship between religiousness and depression among people with marginalized sexualities changes as a function of their experience of internalized stigma. Analyses of a sample of 260 people with marginalized sexualities suggested that the relationship between religiousness and depression was moderated by internalized homonegativity. Simple slopes analyses revealed that when people with marginalized sexualities reported higher degrees of internalized homonegativity, the relationship between religiousness and depression was positive. Conversely, when people with marginalized sexualities reported lower degrees of internalized homonegativity, religiousness was negatively related to depression. Dismantling analyses using subscales …

Sexual Complexity: A Comparison Between Men And Women In A Sexual Minority Sample Of Members Of The Church Of Jesus Christ Of Latter-Day Saints, William S. Bradshaw, John P. Dehlin, Renee V. Galliher

Psychology Faculty Publications

We report here some of the results from an online survey of 1612 LGBTQ members and former members of the Church of Jesus Christ of Latter-day Saints (CJCLDS, Mormon). The data permitted an exploration of diversity—individual similarities and differences within and between the sexes. Men and women were compared with respect to sexual identity self-labeling and behavior (i.e., identity development, disclosure, activity), orientation change efforts, marital relationships, and psychosocial health—these variables in the context of their religious lives. More women than men self-identified in the bisexual range of the sexual attraction continuum. Both men and women had engaged in extensive …

"He Just Wanted Me To Do What Was Best For Me": Latter-Day Saint Clergy's Counsel To Sexual And Gender Minorities And Its Impact, G. Tyler Lefevor, Adlyn M. Perez-Figueroa, Samuel J. Skidmore, Kirsten A. Gonzalez

Psychology Faculty Publications

The purpose of this study was to understand counsel given to sexual and gender minority individuals by clergy in the Church of Jesus Christ of Latter-day Saints (CJCLDS), the impact of that counsel, and individuals’ perceptions of meetings with clergy. Twenty-five current and former members of the CJCLDS who identify as sexual and gender minorities (SGM) participated in 30–60 min semi-structured interviews focused on their interactions with clergy in the CJCLDS. Participants reported receiving various forms of counsel, including encouragement to adhere to church doctrine, counsel focused on self-acceptance, messages that clergy would support congregants’ agency and self-determination, counsel focused …

Religious Sexual Minorities, Belongingness, And Suicide Risk: Does It Matter Where Belongingness Comes From?, Samuel J. Skidmore, G. Tyler Lefevor, Rachel M. Golightly, Eric R. Larsen

Psychology Faculty Publications

Sexual minorities (SMs) experience a unique set of stressors as a result of their minority status that can lead to adverse mental health outcomes, including increased suicidal ideation (SI). A sense of belongingness—particularly in sexual minority communities—has been shown to buffer these outcomes. It is less clear, however, how belongingness in communities that hold heteronormative values may relate to SI. The present study fills this gap through an analysis of data from 602 SM members of the Church of Jesus Christ of Latter-day Saints (CJCLDS; “Mormon” church). We examine how minority stressors and religiousness are related to SI for SMs …

Testing Delay Of Gratification In Rats Using A Within-Session Increasing-Delay Task, Jeremy M. Haynes, Amy L. Odum

Psychology Faculty Publications

In delay discounting, preference reversals refer to shifts in preference from a larger-later reward to a smaller-sooner reward. Steep hyperbolic discounting predicts a preference reversal when a smaller-sooner and larger-later reward both become temporally proximal; prior research is consistent with this prediction. Hyperbolic discounting does not predict a preference reversal, however, after an individual chooses a larger-later reward over a smaller-immediate reward; prior research is inconsistent with this prediction. We sought to replicate and extend these findings using a delay of gratification task in rats. The task included a defection response which allowed rats to reverse their preference after choosing …

Reinforced Behavioral Variability In The Valproate Rat Model Of Autism Spectrum Disorder, Ann Galizio, Amy L. Odum

Psychology Faculty Publications

Individuals diagnosed with autism spectrum disorder (ASD) tend to display restricted, repetitive behaviors and deficits in social interaction. Rats exposed to valproate (VPA) in utero have been shown to model symptoms of ASD. In previous research, VPA rats engaged in less social interaction and more repetitive responding than controls. The purpose of the present study was to further investigate behavioral variability in the VPA rat model of ASD by testing VPA and control rats in a reinforced-behavioral-variability operant task. In this procedure, rats emitted sequences of lever presses, some of which produced food. During baseline, food was delivered probabilistically, and …

Acceptance And Commitment Therapy For Obsessive Compulsive Disorder In A Brazilian Context: Treatment Of Three Cases, Luana D. Laurito, Carla Pereira Loureiro, Livi Faro, Rafaela Venâncio Dias, Bianca Torres, Maria Eduarda Moreira-De-Oliveira, Samara Dos Santos-Ribeiro, Gabriela B. De Menezes, Leonardo F. Fontenelle, Carter H. Davis, Michael P. Twohig

Psychology Faculty Publications

Previous research indicates that a combination of Acceptance and Commitment Therapy (ACT) and Exposure and Response Prevention (ERP) is an effective treatment for obsessive-compulsive disorder (OCD). However, there are no studies to date of ACT for OCD in Latin American populations. Because socio-cultural context influences OCD symptomatology, it is worth adapting and testing ACT for OCD in such cultures. Three patients seeking treatment for OCD at a public health center in Rio De Janeiro, Brazil were treated with 16 sessions of ACT and ERP. All participants showed decreased OCD scores from baseline to post-treatment that remained lower at follow-up, suggesting …

The “How” Of Exposures: Examining The Relationship Between Exposure Parameters And Outcomes In Obsessive-Compulsive Disorder, Clarissa W. Ong, Julie M. Peterson, Carina L. Terry, Jennifer Krafft, Jennifer L. Barney, Jonathan S. Abramowitz, Michael P. Twohig

Psychology Faculty Publications

Exposure and response prevention (ERP) is the most empirically supported treatment for obsessive-compulsive disorder (OCD). However, details on how to effectively conduct ERP are lacking. The current study aimed to identify exposure parameters associated with better subsequent outcomes in ERP for OCD. We analyzed data from 271 therapy sessions across 46 participants in a randomized controlled trial comparing traditional ERP and ERP conducted from an acceptance and commitment therapy framework (ACT + ERP). Multilevel model results indicated that experiential delivery of acceptance/tolerance practice was associated with higher exposure homework adherence, lower psychological inflexibility, and less OCD symptom severity (except contamination) …

Experiential Avoidance In Depression, Anxiety, Obsessive-Compulsive Related, And Posttraumatic Stress Disorders: A Comprehensive Systematic Review And Meta-Analysis, Mehdi Akbari, Mohammad Seydavi, Zahra S. Hosseini, Jennifer Krafft, Michael E. Levin

Psychology Faculty Publications

Although numerous studies on experiential avoidance and its relationship to psychopathology have been conducted, systematic summaries of this research are lacking. The current systematic review and meta-analysis evaluated the transdiagnostic role of experiential avoidance across depression, anxiety and related disorders (obsessive-compulsive and related disorders [OCRDs] and post-traumatic stress disorder [PTSD]) as well as potential moderators of these relations. A total of 441 eligible studies including 135,347 participants (66.16% female, mean age = 31.53) and 899 effect-sizes were summarized. Results indicated a moderate-to-large association of experiential avoidance with anxiety (r = .506) and depressive symptoms (r = .562), major …

Enabling Resilient Educational Support Network During Covid-19 Pandemic For Undergraduate And Second Career Seeking Students, Phillip Dillulio, Oleksandr Kravchenko, Konstantin Cigularov

Psychology Faculty Publications

During times of local and national quarantine due to the COVID-19 pandemic, universities had to close campuses and expediently convert operations and services from face-to-face to virtual learning environments, including virtual classrooms, learning communities, offices, and meeting/advising rooms. Many engineering faculty and students experienced personal, technical, and psychosocial challenges associated with this dramatically altered reality, which may have significant and unprecedented effects on their personal and academic lives. The current study presents results from a needs assessment survey examining the perceptions of 157 engineering students majoring in mechanical and aerospace engineering about the strengths and challenges exhibited by their professors/instructors …

An Open Trial Of Acceptance And Commitment Therapy With Exposure And Response Prevention In An Intensive Outpatient Setting For Adults With Ocd, L. K. Capel, P. Zurita-Ona, C. Muller, Michael P. Twohig

Psychology Faculty Publications

Intensive outpatient (IOP) treatment settings for adults with obsessive-compulsive disorder (OCD) are common, but data on their effectiveness is limited. The effectiveness of IOP treatment for adults with OCD using combined Acceptance and Commitment Therapy (ACT) and Exposure and Response Prevention (ERP) was studied with eight adults. The intervention was 15 hours per week for three weeks. Measures were collected at pre-treatment, one-week, two-weeks, post-treatment, and at one-month follow-up. At the end of treatment, all participants were in the mild range of OCD symptom severity with a mean symptom decrease of 58%. Psychological inflexibility, depression, anxiety and stress significantly decreased …