Reduce Dementia Caregiver Grief with Mindfulness and Compassion

March 17, 2023March 17, 2023 psyjdc Leave a comment

By John M. de Castro, Ph.D.

“Grief is not as heavy as guilt, but it takes more away from you.” – Veronica Roth

Dementia is a progressive loss of mental function produced by degenerative diseases of the brain. Dementia patients require caregiving particularly in the later stages of the disease. Caregiving for dementia patients is a daunting intense experience that can go on for four to eight years with increasing responsibilities as the loved one deteriorates. This places tremendous psychological and financial stress on the caregiver. Hence, there is a need to care for caregivers. Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving.

In today’s Research News article “Effects of a compassion-based program on the grief experienced by caregivers of people suffering from dementia: a randomized controlled clinical trial.” (See summary below or view the full text of the study at: ) Jahani and colleagues recruited family caregivers of dementia patients and assigned them to either no treatment or do receive 5 weekly online sessions of mindfulness and compassion training. Before and after training the participants completed measures of grief.

They found that compared to baseline and the control group the participants who received mindfulness and compassion training had significantly lower levels of grief, personal sacrifice burden, heartfelt sadness and worry, worry and felt isolation, Hence, mindfulness and compassion training produced significant reductions in overall grief and all three fields of the grief experience in family caregivers of dementia patients.

“Many caregivers share that they often feel alone, isolated, and unappreciated. Mindfulness can offer renewed hope for finding support and value for your role as a caregiver…It is an approach that everyone can use. It can help slow you down some so you can make the best possible decisions for your care recipient. It also helps bring more balance and ease while navigating the caregiving journey.”― Nancy L. Kriseman

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Twitter @MindfulResearch

Study Summary

Jahani L, Abolhassani S, Babaee S, Omranifard V. Effects of a compassion-based program on the grief experienced by caregivers of people suffering from dementia: a randomized controlled clinical trial. BMC Nurs. 2022 Jul 25;21(1):198. doi: 10.1186/s12912-022-00980-5. PMID: 35879751; PMCID: PMC9316726.

Abstract

Background

Dementia is a syndrome that reduces the cognitive and functional abilities of the brain increasing the need for care. The caregivers of these patients are mostly their family members. The great care burden causes devastating effects on the health of family caregivers and the grief experienced by these family caregivers is considerable. This study was conducted to investigate the effects of a compassion-based program on the grief experienced by caregivers of people suffering from dementia.

Method

The present study was a randomized controlled clinical trial in which 70 family caregivers of people suffering from dementia were sampled through the block method and they were divided into experimental and control groups. The data collection tools included demographic information questionnaire and grief inventory that was completed before, a week and a month after the implementation of the compassion-based program in five sessions virtually by sending offline content to the experimental group. The obtained data were analyzed by SPSS 22 software using the repeated measures analysis of variance.

Results

The mean comparison of scores of the grief experienced in the experimental group between pretest and posttest and follow-up, unlike the control group, showed a significant difference (p < 0.001). The mean scores of the experimental and the control groups were significantly different in terms of experiencing mourning and all of its fields (p < 0.001). The mean comparison of post-test and follow-up showed that the effect of a compassion-based program at the follow-up stage has been mitigated.

Conclusions

According to the study results, the compassion-based program reduced the grief experienced by the family caregivers of people suffering from dementia. Nevertheless, the effect of a compassion-based program has been reduced over time. This program can be a good guide for providing society-oriented services to the health team.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9316726/

Psychedelic Drug Experiences Produce Long-Term Improvements in Psychological Well-Being

February 10, 2022 psyjdc Leave a comment

Psychedelic Drug Experiences Produce Long-Term Improvements in Psychological Well-Being

By John M. de Castro, Ph.D.

“Awe may be a critically important emotional experience during psychedelic treatment in generating compassion, empathy, and overall well-being” – Eve Ekman

Psychedelic substances such as peyote, mescaline, LSD, Bufotoxin, ayahuasca and psilocybin have been used almost since the beginning of recorded history to alter consciousness and produce spiritually meaningful experiences. People find these experiences extremely pleasant. eye opening, and even transformative. They often report that the experiences changed them forever. Psychedelics have also been found to be clinically useful as they markedly improve mood, increase energy and enthusiasm and greatly improve clinical depression. Even though the effects of psychedelic substances have been experienced and reported on for centuries, only very recently have these effects come under rigorous scientific scrutiny.

In today’s Research News article “Sustained, Multifaceted Improvements in Mental Well-Being Following Psychedelic Experiences in a Prospective Opportunity Sample.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277190/ ) Mans and colleagues recruited adults who were planning on having a psychedelic experience and had them complete a questionnaire before and after the experience and 2 weeks, 4 weeks, and 2 years after measuring well-being, depression, self-esteem, life orientation, emotional stability, meaning in life, acceptance, resilience, mindfulness, social connectedness, gratitude, spiritual transcendence, Spiritual and Religious Attitudes in Dealing with Illness, trust, and compassion and after the experience only Challenging Experience Questionnaire (CEQ), the Mystical Experience Questionnaire (MEQ), and the Emotional Breakthrough.

They found that in comparison to baseline after the psychedelic experiences there were significant improvements in all measures except spirituality that were maintained over follow-up. Factor analysis revealed three clusters of measures labelled as being well, staying well, and spirituality. They found that after the psychedelic experiences there were large significant improvements in being and staying well that were still present 2 years later.

It should be noted that there wasn’t a comparison, control, condition present and that the participants self-selected to engage in psychedelic experiences. Hence, a myriad of confounding alternative explanations for the findings abound, particularly participant expectancy effects (placebo effects). So, great caution must be exercised in drawing conclusions regarding the effects of psychedelic drugs. But placebo effects are generally transitory and don’t last over substantial periods of time and the present improvements lasted for at least 2 years, making it unlikely that confounding variable explanations are viable.

It is interesting that spirituality was not affected as psychedelic drugs have been employed throughout history as a part of spiritual development. It is possible that the context of spiritual ceremony is essential for the effects of psychedelic drugs being interpreted as spiritual effects.

The results of the present study suggest that people who engage in psychedelic experiences have profound improvements in their well-being that are sustained for at least 2 years. The magnitude and duration of the effects may explain why psychedelics have such profound effects on people with mental illnesses producing relief of symptoms and appear to be safe and effective treatments for mental illnesses.

So, psychedelic drug experiences produce long-term improvements in psychological well-being.

“use of psychedelic substances in a naturalistic setting is associated with experiences of personal transformation, a sense of altered moral values, increased feelings of social connectedness, and a more positive mood.” – Matthias Forstmann

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Mans, K., Kettner, H., Erritzoe, D., Haijen, E., Kaelen, M., & Carhart-Harris, R. L. (2021). Sustained, Multifaceted Improvements in Mental Well-Being Following Psychedelic Experiences in a Prospective Opportunity Sample. Frontiers in psychiatry, 12, 647909. https://doi.org/10.3389/fpsyt.2021.647909

Abstract

In the last 15 years, psychedelic substances, such as LSD and psilocybin, have regained legitimacy in clinical research. In the general population as well as across various psychiatric populations, mental well-being has been found to significantly improve after a psychedelic experience. Mental well-being has large socioeconomic relevance, but it is a complex, multifaceted construct. In this naturalistic observational study, a comprehensive approach was taken to assessing well-being before and after a taking a psychedelic compound to induce a “psychedelic experience.” Fourteen measures of well-being related constructs were included in order to examine the breadth and specificity of change in well-being. This change was then analysed to examine clusters of measures changing together. Survey data was collected from volunteers that intended to take a psychedelic. Four key time points were analysed: 1 week before and 2 weeks, 4 weeks, and 2 years after the experience (N = 654, N = 315, N = 212, and N = 64, respectively). Change on the included measures was found to cluster into three factors which we labelled: 1) “Being well”, 2) “Staying well,” and 3) “Spirituality.” Repeated Measures Multivariate Analysis of Variance revealed all but the spirituality factor to be improved in the weeks following the psychedelic experience. Additional Mixed model analyses revealed selective increases in Being Well and Staying Well (but not Spirituality) that remained statistically significant up to 2 years post-experience, albeit with high attrition rates. Post-hoc examination suggested that attrition was not due to differential acute experiences or mental-health changes in those who dropped out vs. those who did not. These findings suggest that psychedelics can have a broad, robust and sustained positive impact on mental well-being in those that have a prior intention to use a psychedelic compound. Public policy implications are discussed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277190/

Reduce Burnout and Increase Resilience in Healthcare Workers with Mindfulness

February 1, 2022 psyjdc Leave a comment

Reduce Burnout and Increase Resilience in Healthcare Workers with Mindfulness

By John M. de Castro, Ph.D.

“Mindfulness practices and perspectives are profoundly beneficial at all levels of healthcare—from the personal to the professional to the patients.” – Mindful

Stress is epidemic in the western workplace with almost two thirds of workers reporting high levels of stress at work. In high stress occupations, like healthcare, burnout is all too prevalent. Burnout is the fatigue, cynicism, emotional exhaustion, sleep disruption, and professional inefficacy that comes with work-related stress. It is estimated that over 45% of healthcare workers experience burnout. It not only affects the healthcare providers personally, but also the patients, as it produces a loss of empathy and compassion. Burnout, in fact, it is a threat to the entire healthcare system. Currently, over a third of healthcare workers report that they are looking for a new job. Hence, burnout contributes to the shortage of doctors and nurses.

Preventing burnout has to be a priority. Unfortunately, it is beyond the ability of the individual to change the environment to reduce stress and prevent burnout. So, it is important that methods be found to reduce the individual’s responses to stress; to make the individual more resilient when high levels of stress occur. Contemplative practices have been shown to reduce the psychological and physiological responses to stress and improve well-being. Indeed, mindfulness has been shown to be helpful in treating and preventing burnout, increasing resilience, and improving sleep.

In today’s Research News article “A Novel Mindful-Compassion Art-Based Therapy for Reducing Burnout and Promoting Resilience Among Healthcare Workers: Findings From a Waitlist Randomized Control Trial.” (See summary below or view the full text of the study at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.744443/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1765474_a0P58000000G0YfEAK_Psycho_20211102_arts_A ) Ho and colleagues recruited frontline healthcare workers and randomly assigned them to either a wait-list control condition or to receive 6 weekly 3-hour sessions of Mindful-Compassion Art-based Therapy (MCAT). The treatment included meditation, lectures, and art therapy that was aimed at training “understanding, acceptance, and compassion for self and others to cultivate psychological resilience and shared meaning”. The participants were measured before and after training and 6 weeks later for mindfulness, burnout, resilience, emotion regulation, self-compassion, death attitude, and quality of life. Transcripts of group sharing sessions and artwork produced were also analyzed.

They found that in comparison to baseline and the wait-list control group after Mindful-Compassion Art-Based Therapy (MCAT) there were significant increases in emotion regulation, non-reactivity to intrusive thoughts, acceptance of death and significant reduction in mental exhaustion. At the 6-week follow-up, they found that the improvements in emotion regulation and mental exhaustion were maintained and the MCAT group also showed significant increases in mindfulness, self-compassion, interconnectedness to others, and quality of life. Analysis of the group discussions and artwork revealed that the training worked by reducing burnout, building resilience, nurturing compassion, and fostering collegial support among healthcare workers.

These results are encouraging and suggest that the mindfulness-based therapy was effective in improving the psychological health and well-being and reducing burnout of healthcare workers. Prior research by others reinforce these findings as it has been shown that mindfulness training produces increases in emotion regulation, self-compassion, interconnectedness, resilience, acceptance of death. and quality of life and reductions in burnout. Hence, the present findings along with previous research suggest that mindfulness training improves the psychological health and well-being of healthcare workers making them more resistant to professional fatigue and burnout. This suggests that mindfulness training should be recommended for frontline healthcare workers.

So, reduce burnout and increase resilience in healthcare workers with mindfulness.

“mindfulness-based stress reduction was associated with significant improvements in burnout scores and mental well-being for a broad range of healthcare providers.” – Matthew Goodman

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Ho AHY, Tan-Ho G, Ngo TA, Ong G, Chong PH, Dignadice D and Potash J (2021) A Novel Mindful-Compassion Art-Based Therapy for Reducing Burnout and Promoting Resilience Among Healthcare Workers: Findings From a Waitlist Randomized Control Trial. Front. Psychol. 12:744443. doi: 10.3389/fpsyg.2021.744443

Protecting the mental health of healthcare workers is an urgent global public health priority. Healthcare workers, especially those immersed in palliative care, are prone to burnout due to the intense emotions associated with end-of-life caregiving. This study examines the efficacy of a novel, multimodal, and group-based Mindful-Compassion Art-based Therapy (MCAT) that integrates reflective self-awareness with creative emotional expression for protecting healthcare workers’ mental health. A dual-arm open-label waitlist randomized controlled trial was conducted. A total of 56 healthcare workers were recruited from the largest homecare hospice in Singapore and randomized to the immediate-treatment condition of a standardized 6-week, 18-hours MCAT intervention (n=29), or the waitlist-control condition (n=27). Self-administered outcome measures on burnout, resilience, emotional regulation, self-compassion, death attitudes, and quality of life were collected at baseline, post-intervention/second-baseline at 6weeks, and follow-up/post-intervention at 12weeks. Results from mixed model ANOVAs reveal that treatment group participants experienced significant reduction in mental exhaustion, as well as significant improvements in overall emotional regulation, nonreactivity to intrusive thoughts, approach acceptance of death, and afterlife belief as compared to waitlist-control immediately after MCAT completion. Effect sizes of these impacts ranged from medium to large (η2=0.65 to 0.170). Results from one-way ANOVAs further reveal that the treatment gains of reduced mental exhaustion and increased emotional regulation were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe and describe one’s experiences, elevated overall self-compassion, greater mindful awareness, enhanced common humanity, and better quality of life. Effect sizes of these impacts were large (η2=0.128 to 0.298). These findings reflect the robust effectiveness and positive residual effects of MCAT for reducing burnout, building resilience, nurturing compassion, fostering collegial support, and promoting mental wellness among healthcare workers. The clinical model and applicability of MCAT in larger and more diverse caregiving contexts, such as family dementia care, are discussed.

https://www.frontiersin.org/articles/10.3389/fpsyg.2021.744443/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1765474_a0P58000000G0YfEAK_Psycho_20211102_arts_A

Improve Counselor Self-Efficacy and Reduce Compassion Fatigue with Mindfulness

January 21, 2022 psyjdc Leave a comment

Improve Counselor Self-Efficacy and Reduce Compassion Fatigue with Mindfulness

By John M. de Castro, Ph.D.

“mindfulness training may be beneficial as a prophylactic for stress and burnout for psychotherapists, counselors, and other mental health care workers.” – Tasha Felton

In occupations, like counseling, burnout is all too prevalent. Burnout is the fatigue, cynicism, emotional exhaustion, sleep disruption, and professional inefficacy that comes with work-related stress. It not only affects the counselors personally, but also the patients, as it produces a loss of empathy and compassion. Contemplative practices have been shown to reduce the psychological and physiological responses to stress. Indeed, mindfulness has been shown to be helpful in treating and preventing burnout, increasing resilience, and improving sleep. Mindfulness is also known to improve self-compassion, understanding one’s own suffering and self-efficacy, one’s belief in their ability to make things better. It is possible that this may be a key to understanding mindfulness’ effects on burnout.

In today’s Research News article “Self-Oriented Empathy and Compassion Fatigue: The Serial Mediation of Dispositional Mindfulness and Counselor’s Self-Efficacy.” (See summary below or view the full text of the study at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.613908/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1757290_a0P58000000G0YfEAK_Psycho_20211021_arts_A ) Zhang and colleagues recruited hotline psychological counselors online and had them complete a questionnaire measuring mindfulness, self-efficacy burnout, secondary traumatic stress, and empathy, including perspective taking, personal distress, fantasy, and empathic concern subscales.

They found that the higher the levels of empathy the higher the levels of burnout and secondary traumatic stress and the lower the levels of mindfulness and self-efficacy. The higher the levels of both mindfulness and self-efficacy the lower the levels of burnout and secondary traumatic stress while the higher the levels of mindfulness the higher the levels of self-efficacy. Linear structural modelling revealed that empathy was directly, positively, related to compassion fatigue and also indirectly related by being associated with self-efficacy which was in turn associated with lower compassion fatigue. Finally, empathy was also indirectly related to compassion fatigue by being negatively associated with mindfulness that was positively associated with self-efficacy which was in turn associated with lower compassion fatigue.

These findings are correlational. So, causation cannot be definitively established. But the associations are clear. Greater empathy is associated with greater compassion fatigue. In other words, an empathetic counselor is more likely to experience compassion fatigue which leads to burnout and secondary traumatic stress. These effects are mitigated, however, by the counselor’s empathy being associated with greater mindfulness and self-efficacy which work to lower compassion fatigue. This all leads to the suggestion that training in mindfulness may help prevent a counselor losing compassion and burning out. They may help prevent counselor burnout.

So, improve counselor self-efficacy and reduce compassion fatigue with mindfulness.

“Mindfulness trains us to think about our thoughts as ‘just thoughts,’” including the thought that tragedies and outrage are part of life or that trying to effect change is hopeless. Part of desensitization and empathy fatigue is that “we become numb and disengaged, lacking in introspection and compassion for others,” Steven Lynn

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Zhang L, Ren Z, Jiang G, Hazer-Rau D, Zhao C, Shi C, Lai L and Yan Y (2021) Self-Oriented Empathy and Compassion Fatigue: The Serial Mediation of Dispositional Mindfulness and Counselor’s Self-Efficacy. Front. Psychol. 11:613908. doi: 10.3389/fpsyg.2020.613908

This study aimed to explore the association between self-oriented empathy and compassion fatigue, and examine the potential mediating roles of dispositional mindfulness and the counselor’s self-efficacy. A total of 712 hotline psychological counselors were recruited from the Mental Health Service Platform at Central China Normal University, Ministry of Education during the outbreak of Corona Virus Disease 2019, then were asked to complete the questionnaires measuring self-oriented empathy, compassion fatigue, dispositional mindfulness, and counselor’s self-efficacy. Structural equation modeling was utilized to analyze the possible associations and explore potential mediations. In addition to reporting confidence intervals (CI), we employed a new method named model-based constrained optimization procedure to test hypotheses of indirect effects. Results showed that self-oriented empathy was positively associated with compassion fatigue. Dispositional mindfulness and counselor’s self-efficacy independently and serially mediated the associations between self-oriented empathy and compassion fatigue. The findings of this study confirmed and complemented the etiological and the multi-factor model of compassion fatigue. Moreover, the results indicate that it is useful and necessary to add some training for increasing counselor’s self-efficacy in mindfulness-based interventions in order to decrease compassion fatigue.

https://www.frontiersin.org/articles/10.3389/fpsyg.2020.613908/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1757290_a0P58000000G0YfEAK_Psycho_20211021_arts_A

Reduce Loneliness with Mindfulness

June 19, 2021 psyjdc Leave a comment

Reduce Loneliness with Mindfulness

By John M. de Castro, Ph.D.

“The practice of mindfulness is an invitation to pay attention to the present moment with kindness and curiosity. This means dropping all of the judgments that we have about loneliness and acknowledging the way things are right now. It’s only from this gentle place of acceptance that loneliness can loosen its tight grip.” – Christi-an Slomka

Humans are social animals. We are generally happiest when we’re with family and friends. Conversely, being without close social contact makes us miserable. It’s the close relationship that is so important as we can be around people all day at work and still feel deep loneliness. These contacts are frequently superficial and do not satisfy our deepest need. It is sometimes said that we live in “the age of loneliness.” It is estimated that 20% of Americans suffer from persistent loneliness. This even when we are more connected than ever with the internet, text messaging, social media, etc. But these create the kinds of superficial contacts that we think should be satisfying, but are generally not. This has led to the counterintuitive findings that young adults, 18-34, have greater concerns with loneliness than the elderly.

The consequences of loneliness are dire. It has been estimated that being socially isolated increases mortality by 14%. Even worse, for people over 60, loneliness increases their risk of death by 45%. When a spouse loses a marital partner there’s a 30% increase in mortality in the 6-months following the death. Hence, loneliness is not only an uncomfortable and unhappy state, but it is also a threat to health and longevity. It is clear that this epidemic of loneliness needs to be addressed.

A potential antidote to loneliness is mindfulness which has been shown to reduce loneliness. In today’s Research News article “Can Mindfulness Help to Alleviate Loneliness? A Systematic Review and Meta-Analysis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947335/ ) Teoh and colleagues review, summarize and perform a meta-analysis of the published randomized controlled trials (RCTs) of the effectiveness of mindfulness to counteract loneliness. They identified 7 RCTs that included a total of 815 participants.

They report that the published randomized controlled trials (RCTs) found that mindfulness or compassion training of 8 weeks or longer produced significant reductions in loneliness. The reductions appeared to be larger in younger participants. The majority of the studies, however, used wait-list controls with no intervention while the mindfulness training occurred in group sessions. It is possible that meeting as a group was the reason for the decrease in loneliness rather than the mindfulness training. Obviously, more research is necessary with better active control conditions occurring in a group setting before definitive conclusions can be reached.

“Loneliness is on the rise, despite our interconnected world, but mindfulness training offers a practical intervention for anybody who wishes to decrease their feelings of loneliness and experience greater social connection.” – Christian Rigg

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Teoh, S. L., Letchumanan, V., & Lee, L. H. (2021). Can Mindfulness Help to Alleviate Loneliness? A Systematic Review and Meta-Analysis. Frontiers in psychology, 12, 633319. https://doi.org/10.3389/fpsyg.2021.633319

Abstract

Objective: Mindfulness-based intervention (MBI) has been proposed to alleviate loneliness and improve social connectedness. Several randomized controlled trials (RCTs) have been conducted to evaluate the effectiveness of MBI. This study aimed to critically evaluate and determine the effectiveness and safety of MBI in alleviating the feeling of loneliness.

Methods: We searched Medline, Embase, PsycInfo, Cochrane CENTRAL, and AMED for publications from inception to May 2020. We included RCTs with human subjects who were enrolled in MBI with loneliness as an outcome. The quality of evidence was assessed using Cochrane’s Risk of Bias (ROB) tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A random-effects model was used for meta-analysis.

Results: Out of 92 articles identified, eight studies involving 815 participants were included in this study. Most (7/8) trials conducted a minimum of 8 weeks of MBI. Most of the trials (5/8) used UCLA-Loneliness Scale. A pooled analysis combining three trials and compared with wait-list showed significant improvement in loneliness score reduction using the UCLA-R scale with MD of −6.33 [95% confidence interval (CI): −9.39, −3.26]. Subgroup analysis with only two Cognitively-Based Compassion Training (CBCT) trials also showed similar MD of −6.05 (95% CI: −9.53, 2.58). The overall quality of evidence (GRADE) was low.

Conclusions: Mindfulness intervention with an average length of 8-week duration significantly improved the population’s loneliness level with no mental health issue. However, this evidence had a low GRADE level.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947335/

Improve Treatment Resistant Obsessive-Compulsive Disorder with Compassion-Focused Therapy

June 3, 2021 psyjdc Leave a comment

Improve Treatment Resistant Obsessive-Compulsive Disorder with Compassion-Focused Therapy

By John M. de Castro, Ph.D.

“A big part of learning to live with OCD is to incorporate self-compassion. Instead of avoiding your anxiety, self-compassion invites you to look at it with understanding and gentle curiosity. This approach allows you to see your pain exactly how it is without self-judgment or self-criticism.” – Nancy Larsen

Obsessive-Compulsive Disorder (OCD) sufferers have repetitive anxiety producing intrusive thoughts (obsessions) that result in repetitive behaviors to reduce the anxiety (compulsions). In a typical example of OCD, the individual is concerned about germs and is unable to control the anxiety that these thoughts produce. Their solution is to engage in ritualized behaviors, such as repetitive cleaning or hand washing that for a short time relieves the anxiety. The obsessions and compulsions can become so frequent that they become a dominant theme in their lives. Hence OCD drastically reduces the quality of life and happiness of the sufferer and those around them. About 2% of the population, 3.3 million people in the U.S., are affected at some time in their life.

Fortunately, Obsessive-Compulsive Disorder (OCD) can be treated and many respond to Cognitive Behavioral Therapy (CBT). But some do not. Mindfulness training has been shown to be effective in treating OCD. One understudied meditation technique is Compassion -Focused Therapy. It is designed to develop kindness and compassion to oneself and others. On the face of it learning self-compassion would seem to be useful in dealing with OCD. But there is little empirical evidence.

In today’s Research News article “Compassion-Focused Group Therapy for Treatment-Resistant OCD: Initial Evaluation Using a Multiple Baseline Design.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835278/ ) Petrocchi and colleagues recruited patients with Obsessive-Compulsive Disorder (OCD) who had received 6-months of Cognitive Behavioral Therapy (CBT) and still have significant residual OCD symptoms. They received 8 weekly 2-hour sessions of Compassion-Focused Therapy after varying periods of baseline (Multiple Baseline Research Design). The treatment consisted of training in meditation and visualization practices during sessions and at home. It is designed to replace self-criticism with self-compassion. Before and after training and 1 month later they were measured for OCD symptom severity, OCD symptom presence and distress, depression, fear of guilt, self-criticizing, self-attacking, self-reassuring, and self-compassion.

They found that the patients all had large improvements in Obsessive-Compulsive Disorder (OCD) symptoms that were maintained at the 1-month follow-up. They also found significant improvements in fear of guilt, self-criticism, and self-reassurance. In additions, there were less reliable improvements in depression and common humanity. Hence, Compassion-Focused Therapy improved the symptom of OCD in patients who didn’t respond to Cognitive Behavioral Therapy (CBT).

These are important preliminary findings that must be followed up with a large randomized controlled trial. But these results suggest that Compassion-Focused Therapy may be effective in treating Obsessive-Compulsive Disorder (OCD) symptoms in patients who do not respond to the gold standard treatment of Cognitive Behavioral Therapy (CBT). The results may suggest that CBT should incorporate Compassion-Focused training when being employed to treat OCD. This should be explored in future studies.

So, improve treatment resistant obsessive-compulsive disorder with compassion-focused therapy.

“people with OCD may feel better if they remind themselves that it is normal to worry, and that it is not their fault if their OCD symptoms get worse.” – Jessica Caporuscio

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Petrocchi, N., Cosentino, T., Pellegrini, V., Femia, G., D’Innocenzo, A., & Mancini, F. (2021). Compassion-Focused Group Therapy for Treatment-Resistant OCD: Initial Evaluation Using a Multiple Baseline Design. Frontiers in psychology, 11, 594277. https://doi.org/10.3389/fpsyg.2020.594277

Abstract

Obsessive–compulsive disorder (OCD) is a debilitating mental health disorder that can easily become a treatment-resistant condition. Although effective therapies exist, only about half of the patients seem to benefit from them when we consider treatment refusal, dropout rates, and residual symptoms. Thus, providing effective augmentation to standard therapies could improve existing treatments. Group compassion-focused interventions have shown promise for reducing depression, anxiety, and avoidance related to various clinical problems, but this approach has never been evaluated for OCD individuals. However, cultivating compassion for self and others seems crucial for OCD patients, given the accumulating research suggesting that fear of guilt, along with isolation and self-criticism, can strongly contribute to the development and maintenance of OCD. The primary aim of this pilot study was to evaluate the acceptability, tolerability, and effectiveness of an 8-week group compassion-focused intervention for reducing OCD symptoms, depression, fear of guilt and self-criticism, and increasing common humanity and compassionate self-reassuring skills in treatment-resistant OCD patients. Using a multiple baseline experimental design, the intervention was evaluated in a sample of OCD patients (N = 8) who had completed at least 6 months of CBT treatment for OCD, but who continued to suffer from significant symptoms. Participants were randomized to different baseline assessment lengths; they then received 8 weekly, 120-min group sessions of compassion-focused therapy for OCD (CFT-OCD), and then were tested again at post-treatment and at 1 month follow up. Despite the adverse external circumstances (post-treatment and follow-up data collection were carried out, respectively, at the beginning and in the middle of the Italian lockdown due to the COVID-19 pandemic), by the end of treatment, all participants demonstrated reliable decreases in OCD symptoms, and these improvements were maintained at 4-week follow-up for seven of eight participants. The intervention was also associated with improvements in fear of guilt, self-criticism, and self-reassurance, but less consistent improvements in depression and common humanity. Participants reported high levels of acceptability of and satisfaction with the intervention. Results suggest that the intervention may be beneficial as either a stand-alone treatment or as an augmentation to other treatments.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835278/

Further Improve Health Care Professionals’ Mental Health with Supplemental Mindfulness Training

May 6, 2021 psyjdc Leave a comment

Further Improve Health Care Professionals’ Mental Health with Supplemental Mindfulness Training

By John M. de Castro, Ph.D.

“The therapeutic applications of mindfulness are considerable and its impact on clinical practice itself appears to be profound. Indeed, several commentators characterize mindfulness as inciting nothing short of a revolution in the way we conduct our mental lives both within the clinic and without.” – Matias P. Raski

Preventing the negative psychological consequences of stress in healthcare professionals has to be a priority. Contemplative practices have been shown to reduce the psychological and physiological responses to stress and improve well-being. Indeed, mindfulness has been shown to be helpful in treating and preventing burnout, increasing resilience, and improving sleep. Once mindfulness has been established it is not known if additional mindfulness training will produce greater benefits.

In today’s Research News article “The Interpersonal Mindfulness Program for Health Care Professionals: a Feasibility Study.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447696/ ) Bartels-Velthui and colleagues recruited health care professionals who had already received mindfulness training with either Mindfulness-Based Stress Reduction (MBSR) or Mindfulness-Based Cognitive Therapy (MBCT). The participants in the training group were further treated with an Interpersonal Mindfulness Course. This course was designed for participants who had already received mindfulness training to deepen mindful presence, empathy and compassion with other people. The course met for 9-weekly, 2.5-hour sessions combined with 45 to 60 minutes of daily home practice. All participants were measured before and after training for the feasibility and acceptability of the program, mindfulness, self-compassion, empathy, stress, and quality of life.

They found that the program was feasible as all participants completed the program and acceptable as 88% report the program to be highly relevant and would recommend it to others. They found that compared to baseline and the control group the participants who received the additional mindfulness training had significant improvements in self-compassion, empathy and compassion fatigue.

These are very interesting findings in that health care professionals who had already received mindfulness training had further increases in self-compassion, empathy and compassion fatigue when provided a program designed to improve mindfulness with other people. It is well known that mindfulness training improves self-compassion, empathy and compassion fatigue. These findings, though, suggests that these improvements can be strengthened with further training. In addition, the improvements were in characteristics that would tend to reduce health care professional burnout. The fact that the program emphasized being mindful of other people suggests that the health care workers would be have more empathy and understanding in treating their patients.

So, further improve health care professionals’ mental health with supplemental mindfulness training.

“mindfulness can result in decreased burnout and improved well-being. Mindfulness is a useful way of cultivating self-kindness and compassion, including by bringing increased awareness to and acceptance of those things that are beyond our control.” – Kate Fitzpatrick

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Bartels-Velthuis, A. A., van den Brink, E., Koster, F., & Hoenders, H. (2020). The Interpersonal Mindfulness Program for Health Care Professionals: a Feasibility Study. Mindfulness, 1–10. Advance online publication. https://doi.org/10.1007/s12671-020-01477-5

Abstract

Objectives

There are a number of mindfulness-based programs (MBPs) that have demonstrated effectiveness for patients and health care professionals. The Interpersonal Mindfulness Program (IMP) is a relatively new MBP, developed to teach those with prior mindfulness training to deepen their mindful presence, empathy and compassion in the interpersonal domain. The aim of the present study was to examine the feasibility of using the IMP with mental health care workers and assessing its effects on levels of mindfulness, self-compassion, empathy, stress and professional quality of life when compared with the control group participants.

Methods

The IMP training consisted of nine weekly 2.5-h sessions and daily home practice (45–60 min). Twenty-five participants (mean age, 51.4 years) with mindfulness experience participated in the training. Twenty-two individuals in the control group (mean age, 47.5 years) were recruited from those who had followed a mindfulness training before. Feasibility of the IMP was assessed in the training participants in six domains. All study participants completed self-report questionnaires before and after the training.

Results

The IMP training was considered highly acceptable and very useful. The training had a significant positive effect on self-compassion, empathy and compassion fatigue, but no effect on mindfulness, stress and compassion satisfaction. Five participants reported some mild adverse reactions.

Conclusions

The IMP training appears feasible for health care professionals and seems to induce some positive effects. A few mild adverse effects were reported. Further research on the effectiveness and possible mechanisms of change of the IMP training in larger samples is needed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447696/

More Attentive Mother-Child Interactions are Associated with Mindfulness

April 23, 2021 psyjdc Leave a comment

More Attentive Mother-Child Interactions are Associated with Mindfulness

By John M. de Castro, Ph.D.

“Mindful parenting means that you bring your conscious attention to what’s happening, instead of getting hijacked by your emotions. Mindfulness is about letting go of guilt and shame about the past and focusing on right now. It’s about accepting whatever is going on, rather than trying to change it or ignore it.” – Jill Ceder

Raising children, parenting, is very rewarding. But it can also be challenging. Children test parents frequently. They test the boundaries of their freedom and the depth of parental love. They demand attention and seem to especially when parental attention is needed elsewhere. They don’t always conform to parental dictates or aspirations for their behavior. The challenges of parenting require that the parents be able to deal with stress, to regulate their own emotions, and to be sensitive and attentive their child. These skills are exactly those that are developed in mindfulness training. It improves the psychological and physiological responses to stress. It improves emotion regulation. It improves the ability to maintain attention and focus in the face of high levels of distraction.

Mindful parenting involves the parents having emotional awareness of themselves and compassion for the child and having the skills to pay full attention to the child in the present moment, to accept parenting non-judgmentally and be emotionally non-reactive to the child. Mindful parenting has been shown to have positive benefits for both the parents and the children. Hence, it is important to study the effects of the mother’s mindfulness on their interactions with their infants.

In today’s Research News article “Does Mothers’ Self-Reported Mindful Parenting Relate to the Observed Quality of Parenting Behavior and Mother-Child Interaction?” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652703/ ) Potharst and colleagues recruited mothers with infants (0 to 24 months of age) and toddlers (24 to 48 months of age). The mothers completed measures of mindful parenting and were observed with their infants and toddlers for maternal sensitivity and acceptance. The mother’s speech while interacting with the child was categorized and mind related comments assessed and the mothers gaze during the interaction recorded.

They found that the higher the levels of mindful parenting the higher the levels of compassion for the child. They also found that the higher the levels of mindful listening with full attention the higher the levels of non-attuned mind related comments. Finally, they found that the higher the levels of mindful parenting, the higher the levels of mother’s gave upon the child’s face during interacting with the child.

These results are interesting but correlational, so caution must be exercised in concluding causation. The results do suggest that the mother’s levels of mindful parenting are related to their levels of compassion for the child and how the mothers interact with the child. In particular mindful parenting appears to be related to the amount of attention the mother provides the child. These better interactions between mother and child might predict better psychological well-being of the children are they grow. It will be interesting in the future to investigate whether training in mindful parenting will produce improvements in mother’s interactions with their children.

So, more attentive mother-child interactions are associated with mindfulness.

“Mindfulness is also a potent tool for parents, especially when they’re feeling challenged by a child’s attitudes or behavior, and it’s easier to achieve than most people realize.” – Donna Matthews

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Potharst, E. S., Leyland, A., Colonnesi, C., Veringa, I. K., Salvadori, E. A., Jakschik, M., Bögels, S. M., & Zeegers, M. (2020). Does Mothers’ Self-Reported Mindful Parenting Relate to the Observed Quality of Parenting Behavior and Mother-Child Interaction?. Mindfulness, 1–13. Advance online publication. https://doi.org/10.1007/s12671-020-01533-0

Abstract

Objectives

Growing academic interest in mindful parenting (MP) requires a reliable and valid measure for use in research and clinical setting. Because MP concerns the way parents relate to, and nurture, their children, it is important to evaluate the associations between self-reported MP and observed parenting and parent-child interaction measures.

Methods

Seventy-three mothers who experience difficulties with their young children aged 0–48 months admitted for a Mindful with your baby/toddler training (63% in a mental health care and 27% in a preventative context) were included. Mothers completed the Interpersonal Mindfulness in Parenting scale (IM-P) and video-observations of parent-child interactions were coded for maternal sensitivity, acceptance, mind-mindedness, and emotional communication (EC).

Results

The IM-P total score was positively associated only with mothers’ gaze to the child (EC). IM-P subscale Listening with Full Attention negatively predicted non-attuned mind-mindedness, Compassion with the Child positively predicted maternal sensitivity and positive facial expression (EC), and Emotional Awareness of Self positively predicted mothers’ gaze to the child (EC) and dyadic synchrony of positive affect (EC).

Conclusions

The current study provides support for the hypothesis that the IM-P total score is predictive of maternal actual attention for the child during a face-to-face interaction. When the IM-P is administered with the aim to gain understanding of different aspects of parenting behavior and the parent-child interaction, it is important not only to employ the IM-P total score but also to incorporate the individual IM-P subscales, as meaningful associations between IM-P subscales and observed parenting and parent-child interactions were found.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652703/

Mindfulness is Associated with Non-Judging and Positive Emotions which Improve Emotional Health

February 25, 2021 psyjdc Leave a comment

Mindfulness is Associated with Non-Judging and Positive Emotions which Improve Emotional Health

By John M. de Castro, Ph.D.

“Almost any approach for cultivating care for others needs to start with paying attention. The beginning of cultivating compassion and concern, or doing something for the benefit of others, is first noticing what something or someone means to you.” – Erika Rosenberg

Over the last several decades, research and anecdotal experiences have accumulated an impressive evidential case that the development of mindfulness has positive benefits for the individual’s mental, physical, and spiritual life. One way that mindfulness may be producing its benefits is by improving emotion regulation so that mindful people are better able to experience yet control their responses to emotions. This then improves mental health.

Mindfulness, though, is not a unitary concept. It has been segregated into five facets; observing, describing, acting with awareness, non-judgement, and non-reactivity. People differ and an individual can be high or low on any of these facets and any combination of facets. It is not known what pattern of mindfulness facets are most predictive of good mental health. So, it is important to investigate the interrelationships of mindfulness, compassion, and emotions with negative states such as of anxiety, depression, perceived stress, and negative emotions.

In today’s Research News article “Network Analysis of Mindfulness Facets, Affect, Compassion, and Distress.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689647/ ) Medvedev and colleagues recruited college students and also mailed questionnaires to the general population (response rate 12%). They had them complete measures of anxiety, depression, perceived stress, positive and negative emotions, compassion, and mindfulness, including observing, describing, acting with awareness, non-judgement, and non-reactivity facets. These data were subjected to a network analysis.

They found two major clusters of variables. The maladaptive factors of anxiety, depression, perceived stress, and negative emotions were highly associated and strongly clustered into a tight node. The adaptive factors of positive emotions, compassion, and mindfulness, including observing, describing, acting with awareness, non-judgement, and non-reactivity facets were also clustered but not as tightly into a second node. Examining which variables were the primary bridge between the two nodes revealed that the mindfulness facet of non-judging of internal experience and positive emotions were by far the strongest negative bridges. Compassion was associated with the maladaptive node by a strong connection with positive emotions that were negatively associated with the maladaptive node.

These results are correlative and as such caution must be exercised in reaching causal connections. But mindfulness and its facets have been shown in previous research to reduce anxiety, depression, perceived stress, and negative emotions. So, the associations observed in the present study likely represent causal connections. Nonetheless, the present findings suggest that mindfulness and compassion work to reduce maladaptive emotions through non-judging of internal experience and positive emotions. That is, they increase these bridging factors and thereby reduce the maladaptive emotions.

Non-judging of internal experience involves taking a neutral attitude toward one’s own experience. Accepting one’s internal experiences appears to be the key to reducing anxiety, depression, perceived stress, and negative emotions. In other words, if a thought arises that predicts a future negative event it does not evoke anxiety or depression if that thought is not judged, just allowed to happen. The adaptive characteristics also appear to improve one’s emotional state producing greater positive feelings. This also appears to be an antidote to negative feelings. So, mindfulness and compassion increase positive emotions that act to counteract negative feelings.

So, mindfulness is associated with non-judging and positive emotions which improve emotional health.

“The beauty of self-compassion is that instead of replacing negative feelings with positive ones, new positive emotions are generated by embracing the negative ones. The positive emotions of care and connectedness are felt alongside our painful feelings. When we have compassion for ourselves, sunshine and shadow are experienced simultaneously.” – Kristin Neff

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Medvedev, O. N., Cervin, M., Barcaccia, B., Siegert, R. J., Roemer, A., & Krägeloh, C. U. (2020). Network Analysis of Mindfulness Facets, Affect, Compassion, and Distress. Mindfulness, 1–12. Advance online publication. https://doi.org/10.1007/s12671-020-01555-8

Abstract

Objectives

Mindfulness, positive affect, and compassion may protect against psychological distress but there is lack of understanding about the ways in which these factors are linked to mental health. Network analysis is a statistical method used to investigate complex associations among constructs in a single network and is particularly suitable for this purpose. The aim of this study was to explore how mindfulness facets, affect, and compassion were linked to psychological distress using network analysis.

Methods

The sample (n = 400) included equal numbers from general and student populations who completed measures of five mindfulness facets, compassion, positive and negative affect, depression, anxiety, and stress. Network analysis was used to explore the direct associations between these variables.

Results

Compassion was directly related to positive affect, which in turn was strongly and inversely related to depression and positively related to the observing and describing facets of mindfulness. The non-judgment facet of mindfulness was strongly and inversely related to negative affect, anxiety, and depression, while non-reactivity and acting with awareness were inversely associated with stress and anxiety, respectively. Strong associations were found between all distress variables.

Conclusions

The present network analysis highlights the strong link between compassion and positive affect and suggests that observing and describing the world through the lens of compassion may enhance resilience to depression. Taking a non-judging and non-reacting stance toward internal experience while acting with awareness may protect against psychological distress. Applicability of these findings can be examined in experimental studies aiming to prevent distress and enhance psychological well-being.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689647/

Brief Guided Meditations Improve Empathy

September 25, 2020 psyjdc Leave a comment

Brief Guided Meditations Improve Empathy

By John M. de Castro, Ph.D.

“Empathy is the understanding and sharing of someone else’s feelings. It’s not to be confused with compassion, which is a feeling of concern for others that we feel we need to act on. Empathy goes that step further; by putting yourself in the place of someone else, you are appreciating how they feel, even if they’re experiencing something you’ve never encountered.” – Mindfulness Works

Humans are social animals. This is a great asset for the species as the effort of the individual is amplified by cooperation. In primitive times, this cooperation was essential for survival. But in modern times it is also essential, not for survival but rather for making a living and for the happiness of the individual. Mindfulness has been found to increase prosocial emotions such as compassion, and empathy and prosocial behaviors such as altruism.

It is not clear, however, exactly how meditation training improves empathy. Is it due to increased mindfulness or perhaps by the suggestion embedded in the measurements to be mindful of others. In today’s Research News article “How does brief guided mindfulness meditation enhance empathic concern in novice meditators?: A pilot test of the suggestion hypothesis vs. the mindfulness hypothesis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352088/) Miyahara and colleagues performed 2 studies of the effects of meditation on empathy.

In study 1 they recruited meditation naïve college students and randomly assigned them to listen to and practice brief (8 minute) recorded guided meditations of either breath following and body scan or compassion meditation. They were measured before and after the meditation for mindfulness, compassionate love, helping intention and empathy. They found that both meditations significantly increased all of the measures with no significant differences between meditation types. Study 2 was very similar to study 1 except there we no recorded guided meditations. They found that there were no significant changes in any of the measures from the first to the second measurement.

These results demonstrate that brief mindfulness meditations, regardless of whether they are breath and body meditations or compassion meditation produce increases in empathy and prosocial intentions in college students. The effects were not due to repeated measures. Hence, the suggestions for empathy and prosocial intentions embedded in the measurement instruments were not responsible for the changes, thus eliminating this alternative explanation for the effects. These results, then, suggest that it is improvements in mindfulness that result from brief meditation that are responsible for increased empathy.

So, brief guided meditations improve empathy.

“Mindfulness and empathy are linked through their shared relationship with stress. While mindfulness decreases stress, stress weakens empathy.” – Matthew Brensilver

CMCS – Center for Mindfulness and Contemplative Studies

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Study Summary

Miyahara, M., Wilson, R., Pocock, T., Kano, T., & Fukuhara, H. (2020). How does brief guided mindfulness meditation enhance empathic concern in novice meditators?: A pilot test of the suggestion hypothesis vs. the mindfulness hypothesis. Current Psychology (New Brunswick, N.j.), 1–12. Advance online publication. https://doi.org/10.1007/s12144-020-00881-3

Abstract

Despite the widespread popularity of mindfulness meditation for its various benefits, the mechanism underlying the meditation process has rarely been explored. Here, we present two preliminary studies designed to test alternative hypotheses: whether the effect of brief guided mindfulness meditation on empathic concern arises from verbal suggestion (suggestion hypothesis) or as a byproduct of an induced mindfulness state (mindfulness hypothesis). Study 1 was a pilot randomized control trial of sitting (breath-and-body) meditation vs. compassion meditation that provided preliminary support for the mindfulness hypothesis. Study 2 was set up to rule out the possibility that the meditation effects observed in Study 1 were the effects of repeated measures. An inactive control group of participants underwent the repeated measures of empathic concern with no meditation in between. The pre-post comparison demonstrated no significant changes in the measures. Thus, the results of two studies supported the mindfulness hypothesis. Limitations of the present study and future research directions are discussed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352088/