The Potential for Using a Shortened Version of the Everyday Discrimination Scale in Population Research with Young Adults: A Construct Validation Investigation.

Discrimination is associated with numerous psychological health outcomes over the life course. The nine-item Everyday Discrimination Scale (EDS) is one of the most widely used measures of discrimination; however, this nine-item measure may not be feasible in large-scale population health surveys where a shortened discrimination measure would be advantageous. The current study examined the construct validity of a combined two-item discrimination measure adapted from the EDS by Add Health (N = 14,839) as compared to the full nine-item EDS and a two-item EDS scale (parallel to the adapted combined measure) used in the National Survey of American Life (NSAL; N = 1,111) and National Latino and Asian American Study (NLAAS) studies (N = 1,055). Results identified convergence among the EDS scales, with high item-total correlations, convergent validity, and criterion validity for psychological outcomes, thus providing evidence for the construct validity of the two-item combined scale. Taken together, the findings provide support for using this reduced scale in studies where the full EDS scale is not available.

The importance of education for understanding variability of dementia onset in the United States.

BACKGROUND: Greater levels of education are associated with lower risk of dementia, but less is known about how education is also associated with the compression of dementia incidence. OBJECTIVE: We extend the literature on morbidity compression by evaluating whether increased levels of education are associated with greater dementia compression. We evaluate these patterns across race and gender groups. METHODS: We use the Health and Retirement Study (2000-2016), a nationally representative longitudinal study of older adults in the United States. To evaluate the onset and compression of dementia across education groups, we examine the age-specific distribution of dementia events, identifying the modal age of onset and the standard deviation above the mode (a measure of compression). RESULTS: While the modal age of onset is around 85 years among adults with a college degree, the modal age for adults with less than a high school education occurs before age 65 - at least a 20-year difference. The standard deviation of dementia onset is about three times greater for adults with less than a high school education compared to adults with a college degree. Patterns were consistent across race and gender groups. CONCLUSION: This research highlights the variability of dementia experiences in the older population by documenting differences in longevity without dementia and compression of dementia onset among more educated adults and less educated adults. CONTRIBUTION: We incorporate conceptual insights from the life span variability and compression literature to better understand education-dementia disparities in both the postponement and uncertainty of dementia onset in the US population.

Dynamic Changes in the Association Between Education and Health in the United States.

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

Coping Strategy Enhancement for Auditory Verbal Hallucinations Within Routine Clinical Practice.

ABSTRACT: Auditory verbal hallucinations (AVH) are often multiple distressing experiences. Emerging evidence suggests that interventions informed by the principles of cognitive behavioral therapy, such as brief Cognitive Strategy Enhancement (brief-CSE), can reduce the distress related to AVH. The benefits of brief-CSE have been demonstrated for English-speaking patients. This uncontrolled pilot study, conducted in routine clinical practice, evaluated the benefits of brief-CSE within a group of French-speaking AVH hearers. Thirty-two patients were offered the brief-CSE intervention. Self-administered questionnaires were completed pre-post intervention. A significant reduction was observed in AVH distress, with a large effect size, and for more than half of the patients, this reduction was clinically meaningful. AVH severity and anxiety also decreased significantly. This study demonstrates that brief-CSE can be implemented in non-English-speaking routine clinical practice and can reduce several aspects of AVH subjective experience. There is a need to confirm these findings in a larger sample.

Relating Therapy for Distressing Voices in the Context of Anorexia Nervosa: A Case Series.

ABSTRACT: Voice hearing experiences are commonly reported by patients with anorexia nervosa (AN) and are associated with negative outcomes. The "eating disorder voice" (EDV) can be understood within relational frameworks. Relating therapy (RT) has offered encouraging outcomes when targeted at voice hearing experiences transdiagnostically but has not been evaluated in the context of AN. This study aimed to offer a preliminary and mixed methods exploration of RT for the EDV. RT was delivered to three participants with a diagnosis of AN who were distressed by an EDV. Weight, negative impact of voices, and eating disorder cognitions were assessed at baseline, posttherapy and at brief follow-up. Participant experiences were explored through exit interviews. Therapy was completed by all participants. Weight gain was reported by two participants and maintained at brief follow-up. Positive changes were not reported on other measures. Qualitative data were suggestive of positive experiences that facilitated assertive responding.

A systematic review and thematic synthesis of qualitative literature on personal recovery and voice hearing.

BACKGROUND: Personal recovery literature has been influential in the conceptualization of emotional distress and service provision. While personal recovery in psychosis has been well-studied, voice hearing literature has not been reviewed to elucidate recovery processes. METHOD: Five databases were systematically searched to identify relevant qualitative recovery literature. Twelve eligible studies were included in this review, and an appraisal tool was applied to assess quality. Thematic synthesis was used to examine the results. RESULTS: Three superordinate themes were found relating to 'Recovery Phases', 'Recovery Facilitators' and 'Barriers to Recovery'. Papers included descriptions of finding voices distressing initially yet moving towards integrating and accepting voices. Searching for meaning versus seeking distance from voices were pivotal processes to recovery pathways. Enabling and disrupting recovery experiences are discussed within a proposed model. CONCLUSIONS: Recovery in voice hearing is an individual and potentially ongoing process. Future research should seek to examine recovery factors in voice hearing longitudinally and add further evidence to the supportive role services can play in recovery and voice hearing.

Voice Hearing in Borderline Personality Disorder Across Perceptual, Subjective, and Neural Dimensions.

BACKGROUND: Auditory verbal hallucinations (AVH) commonly occur in the context of borderline personality disorder (BPD) yet remain poorly understood. AVH are often perceived by patients with BPD as originating from inside the head and hence viewed clinically as "pseudohallucinations," but they nevertheless have a detrimental impact on well-being. METHODS: The current study characterized perceptual, subjective, and neural expressions of AVH by using an auditory detection task, experience sampling and questionnaires, and functional neuroimaging, respectively. RESULTS: Perceptually, reported AVH correlated with a bias for reporting the presence of a voice in white noise. Subjectively, questionnaire measures indicated that AVH were significantly distressing and persecutory. In addition, AVH intensity, but not perceived origin (i.e., inside vs outside the head), was associated with greater concurrent anxiety. Neurally, fMRI of BPD participants demonstrated that, relative to imagining or listening to voices, periods of reported AVH induced greater blood oxygenation level-dependent activity in anterior cingulate and bilateral temporal cortices (regional substrates for language processing). AVH symptom severity was associated with weaker functional connectivity between anterior cingulate and bilateral insular cortices. CONCLUSION: In summary, our results indicate that AVH in participants with BPD are (1) underpinned by aberrant perceptual-cognitive mechanisms for signal detection, (2) experienced subjectively as persecutory and distressing, and (3) associated with distinct patterns of neural activity that inform proximal mechanistic understanding. Our findings are like analogous observations in patients with schizophrenia and validate the clinical significance of the AVH experience in BPD, often dismissed as "pseudohallucinations." These highlight a need to reconsider this experience as a treatment priority.

Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model.

BACKGROUND: Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life. METHOD: Thirty-one outpatients with frequent voices completed a smartphone-based ESM questionnaire 10 times a day over 9 days, assessing voice-related distress; resistance and compliance responses to voices; voice characteristics (intensity and negative content); appraisals of voice dominance, uncontrollability and intrusiveness. RESULTS: In line with predictions, behavioural responses were associated with voice appraisals (dominance and uncontrollability), but not voice characteristics. Greater resistance and compliance were reported in moments of increased voice distress, but these associations did not persist after controlling for concurrent voice appraisals and characteristics. Voice distress was predicted by appraisals, and, unexpectedly, also by voice characteristics. As predicted, compliance and resistance were related to increases in distress at subsequent timepoints, whilst antecedent voice appraisals and characteristics had no such effect. Compliance, but not resistance, additionally predicted subsequent increases in voice uncontrollability. In both cases, the reverse models showed no association, indicating directional effects of responses on subsequent distress, and of compliance on uncontrollability appraisals. CONCLUSIONS: These results provide support for the cognitive model by suggesting that momentary behavioural and emotional responses to voices are associated with concurrent negative voice appraisals. Findings suggest that behavioural responses may be driven by voice appraisals, rather than directly by distress, and may in turn maintain voice appraisals and associated distress during the course of daily life.

Brief coping strategy enhancement for the treatment of distressing voices in the context of borderline personality disorder: A comparison with outcomes in the context of psychosis.

BACKGROUND: Voice hearing in the context of Borderline Personality Disorder (BPD) has traditionally been regarded as transient and an experience that lacks legitimacy. Consequently, there are no evidence-based treatments for the voices reported by BPD patients. Contrary to the traditional view, there is a growing literature suggesting that voice hearing in the context of BPD can be an enduring and distressing experience which shares similarities with voice hearing in the context of psychosis. Given these similarities, the aim of this study was to explore whether brief Coping Strategy Enhancement developed in the context of psychosis can be used to treat distressing voice hearing in the context of BPD. METHOD: This was a service evaluation carried out in a specialist NHS service delivering psychological therapies for distressing voices. Patients with either a BPD (n = 46) or a psychosis diagnosis (n = 125) received four sessions of Coping Strategy Enhancement (CSE). The primary outcome was voice-related distress. The pre-post outcomes for BPD patients were explored and compared with those achieved by the psychosis patients. RESULTS: Both the BPD and psychosis groups experienced a significant reduction in voice-related distress after CSE compared with baseline. The interaction between diagnosis group and time was small and statistically non-significant. CONCLUSION: These findings suggest a brief CSE intervention developed in the context of psychosis can be an effective starting point in the treatment of distressing voice hearing in the context of BPD. Such interventions have the potential to be integrated into broader BPD treatment programmes for those who hear voices.

A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality disorder.

BACKGROUND: The presence of auditory verbal hallucinations (AVHs) does not currently feature in the main diagnostic criteria for borderline personality disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVHs which constitute a significant risk factor for suicide plans and attempts, and hospitalization. AIM: This study addressed questions about the validity and phenomenology of AVHs in the context of BPD. The longer-term aim is to facilitate the development and translation of treatment approaches to address the unmet need of this population. METHOD: This was a cross-sectional study, combining phenomenological and psychological assessments administered in person and online. We explored the experiences of 48 patients with a diagnosis of BPD who were hearing AVHs. RESULTS: Participants gave 'consistent' reports on the measure of AVH phenomenology, suggesting that these experiences were legitimate. Similar to AVHs in a psychosis context, AVHs were experienced as distressing and appraised as persecutory. AVHs were found to be weakly associated with BPD symptoms. AVHs were also rated highly as a treatment priority by the majority of participants. CONCLUSION: The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psychological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs in the context of psychosis.

Pilot evaluation of a brief training video aimed at reducing mental health stigma amongst emergency first responders (the ENHANcE II study).

BACKGROUND: First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first responders. AIMS: The aim of the present study was to evaluate a brief training video aimed at reducing mental health stigma amongst first responders. METHODS: First responders watched a training video based on the cognitive behavioural model of mental health stigma, and involved contributions from people with lived experience, and first responders. Measures of mental health stigma were collected before and after viewing the training. RESULTS: The training video produced small but significant improvements in mental health stigma, and these effects did not differ between police and ambulance staff. We were unable to determine what psychological constructs mediated this change in stigma. The feedback on the training video was generally positive, but also indicated some key areas for future development. CONCLUSIONS: The present study provides encouraging evidence that levels of mental health stigma can be improved using a resource-light training intervention.

US State Disparities in Life Expectancy, Disability-Free Life Expectancy, and Disabled Life Expectancy Among Adults Aged 25 to 89 Years.

Objectives. To estimate total life expectancy (TLE), disability-free life expectancy (DFLE), and disabled life expectancy (DLE) by US state for women and men aged 25 to 89 years and examine the cross-state patterns.Methods. We used data from the 2013-2017 American Community Survey and the 2017 US Mortality Database to calculate state-specific TLE, DFLE, and DLE by gender for US adults and hypothetical worst- and best-case scenarios.Results. For men and women, DFLEs and DLEs varied widely by state. Among women, DFLE ranged from 45.8 years in West Virginia to 52.5 years in Hawaii, a 6.7-year gap. Men had a similar range. The gap in DLEs across states was 2.4 years for women and 1.6 years for men. The correlation among DFLE, DLE, and TLE was particularly strong in southern states. The South is doubly disadvantaged: residents have shorter lives and spend a greater proportion of those lives with disability.Conclusions. The stark variation in DFLE and DLE across states highlights the large health inequalities present today across the United States, which have significant implications for individuals' well-being and US states' financial costs and medical care burden.

A service evaluation of a group mindfulness-based intervention for distressing voices: how do findings from a randomized controlled trial compare with routine clinical practice?

BACKGROUND: Person-based cognitive therapy (PBCT) was developed as a treatment for psychosis. The effectiveness of group PBCT was examined in the Mindfulness for Voices (M4V) randomized controlled trial and generated promising results. Group PBCT was implemented as a trans-diagnostic treatment for distressing voices within the Sussex Voices Clinic (SVC), a specialist secondary care mental health service. AIM: To conduct a service evaluation of engagement, outcomes and cost of group PBCT within SVC, and to compare engagement and outcomes from routine practice with the M4V trial. Secondary aims were to explore predictors of levels of engagement and change in group PBCT. METHOD: Service level data from 95 SVC patients were evaluated. Descriptive statistics, hypothesis tests and linear regression models were used. The primary clinical outcome was voice-related distress. Engagement levels and pre-post effect sizes were estimated; associated predictors were explored. RESULTS: Fifty-nine per cent of patients completed group PBCT within SVC, compared with 72% within M4V. Completers within SVC had lower baseline depression scores compared with non-completers. There were significant improvements in voice-related distress (Cohen's d = -0.47; p = 0.001), subjective recovery (Cohen's d = 0.35; p = 0.001) and depression (Cohen's d = -0.20; p = 0.044); these outcomes were comparable to M4V. Higher baseline subjective recovery and lower depression both predicted improvement in voice-related distress. Therapy within SVC cost an average of £214 per patient. CONCLUSION: PBCT groups can be delivered trans-diagnostically in routine clinical practice. Engagement was lower when compared with an RCT, but outcomes were comparable. The low level of resources involved suggests that group PBCT can offer value for money.

US State Policies, Politics, and Life Expectancy.

Policy Points Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy. Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries. CONTEXT: Life expectancy in the United States has increased little in previous decades, declined in recent years, and become more unequal across US states. Those trends were accompanied by substantial changes in the US policy environment, particularly at the state level. State policies affect nearly every aspect of people's lives, including economic well-being, social relationships, education, housing, lifestyles, and access to medical care. This study examines the extent to which the state policy environment may have contributed to the troubling trends in US life expectancy. METHODS: We merged annual data on life expectancy for US states from 1970 to 2014 with annual data on 18 state-level policy domains such as tobacco, environment, tax, and labor. Using the 45 years of data and controlling for differences in the characteristics of states and their populations, we modeled the association between state policies and life expectancy, and assessed how changes in those policies may have contributed to trends in US life expectancy from 1970 through 2014. FINDINGS: Results show that changes in life expectancy during 1970-2014 were associated with changes in state policies on a conservative-liberal continuum, where more liberal policies expand economic regulations and protect marginalized groups. States that implemented more conservative policies were more likely to experience a reduction in life expectancy. We estimated that the shallow upward trend in US life expectancy from 2010 to 2014 would have been 25% steeper for women and 13% steeper for men had state policies not changed as they did. We also estimated that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies. CONCLUSIONS: Understanding and reversing the troubling trends and growing inequalities in US life expectancy requires attention to US state policy contexts, their dynamic changes in recent decades, and the forces behind those changes. Changes in US political and policy contexts since the 1970s may undergird the deterioration of Americans' health and longevity.

Demographic predictors of wellbeing in Carers of people with psychosis: secondary analysis of trial data.

BACKGROUND: Carers of people with psychosis are at a greater risk of physical and mental health problems compared to the general population. Yet, not all carers will experience a decline in health. This predicament has provided the rationale for research studies exploring what factors predict poor wellbeing in carers of people with psychosis. Our study builds on previous research by testing the predictive value of demographic variables on carer wellbeing within a single regression model. METHODS: To achieve this aim, we conducted secondary analysis on two trial data sets that were merged and recoded for the purposes of this study. RESULTS: Contrary to our hypotheses, only carer gender and age predicted carer wellbeing; with lower levels of carer wellbeing being associated with being female or younger (aged under 50). However, the final regression model explained only 11% of the total variance. CONCLUSIONS: Suggestions for future research are discussed in light of the limitations inherent in secondary analysis studies. Further research is needed where sample sizes are sufficient to explore the interactive and additive impact of other predictor variables.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

Association Between Educational Attainment and Causes of Death Among White and Black US Adults, 2010-2017.

Importance: There are substantial and increasing educational differences in US adult life expectancy. To reduce social inequalities in mortality, it is important to understand how specific causes of death have contributed to increasing educational differences in adult life expectancy in recent years. Objective: To estimate the relationship of specific causes of death with increasing educational differences in adult life expectancy from 2010 to 2017. Design, Setting, and Participants: Serial cross-sectional study of 4 690 729 deaths recorded in the US National Vital Statistics System in 2010 and 2017. Exposures: Sex, race/ethnicity, and educational attainment. Main Outcomes and Measures: Life expectancy at age 25 years and years of life lost between ages 25 and 84 years by cause of death. Results: The analysis included a total of 2 211 633 deaths in 2010 and 2 479 096 deaths in 2017. Between 2010 and 2017, life expectancy at age 25 significantly declined among white and black non-Hispanic US residents from an expected age at death of 79.34 to 79.15 years (difference, -0.18 [95% CI, -0.23 to -0.14]). Greater decreases were observed among persons with a high school degree or less (white men: -1.05 years [95% CI, -1.15 to -0.94], white women: -1.14 years [95% CI, -1.24 to -1.04], and black men: -0.30 years [95% CI, -0.56 to -0.04]). White adults with some college education but no 4-year college degree experienced similar declines in life expectancy (men: -0.89 years [95% CI, -1.07 to -0.73], women: -0.59 years [95% CI, -0.77 to -0.42]). In contrast, life expectancy at age 25 significantly increased among the college-educated (white men: 0.58 years [95% CI, 0.42 to 0.73], white women: 0.78 years [95% CI, 0.57 to 1.00], and black women: 1.70 years [95% CI, 0.91 to 2.53]). The difference between high- and low-education groups increased from 2010 to 2017, largely because life-years lost to drug use increased among those with a high school degree or less (white men: 0.93 years [95% CI, 0.90 to 0.96], white women: 0.50 years [95% CI, 0.47 to 0.52], black men: 0.75 years [95% CI, 0.71 to 0.79], and black women: 0.28 years [95% CI, 0.25 to 0.31]). Conclusions and Relevance: In this serial cross-sectional study, estimated life expectancy at age 25 years declined overall between 2010 and 2017; however, it declined among persons without a 4-year college degree and increased among college-educated persons. Much of the increasing educational differences in years of life lost may be related to deaths attributed to drug use.

Evaluating the "C" and "B" in brief cognitive behaviour therapy for distressing voices in routine clinical practice in an uncontrolled study.

Brief and single-symptom forms of cognitive behaviour therapy (CBT) for distressing voices may increase access to evidence-based psychological therapy and transcend diagnostic barriers. The current study evaluated the "C" and "B" in CBT for distressing voices in a transdiagnostic voices clinic. The B module (component of therapy) sought to enhance coping with voices, and the C module evaluated the accuracy of negative beliefs about the self and voices. The aims of the study were to investigate (a) whether modules B and/or C led to significant and clinically meaningful improvements on the primary outcome of voice-related distress, and (b) if changes in beliefs about self and voices (proposed change mechanisms) underpinned changes in voice distress across module C. Each module consisted of four sessions, individually tailored yet manualized, and designed with ease of staff training and delivery in mind. Assessment measures were administered at baseline (T1), post-module B (T2), and post-module C (T3). The results (N = 62) showed statistically significant medium-sized pre- and post-effects for voice-related distress from T1 to T2 and from T2 to T3, with large effects from T1 to T3. Just over half of the clients reported clinically meaningful improvements from T1 to T3. Neither beliefs about self nor voices were found to mediate improvements in voice distress during module C. The findings from this study suggest that both the B and C in CBT for voices can contribute to positive outcomes within routine clinical practice.

Black/white differences in mortality among veteran and non-veteran males.

U.S. military veterans are a large and racially heterogeneous population. There are reasons to expect that racial disparities in mortality among veterans are smaller than those for non-veterans. For example, blacks are favorably selected into the military, receive relatively equitable treatment within the military, and after service accrue higher socioeconomic status and receive health and other benefits after service. Using the 1997-2009 National Health Interview Survey (N = 99,063) with Linked Mortality Files through the end of 2011 (13,691 deaths), we fit Cox proportional hazard models to estimate whether racial disparities in the risk of death are smaller for veterans than for non-veterans. We find that black/white disparities in mortality are smaller for veterans than for non-veterans, and that this is explained by the elevated socioeconomic resources of black veterans relative to black non-veterans. Leveraging birth cohort differences in military periods, we document that the smaller disparities are concentrated among All-Volunteer era veterans.

Building a Grounded Theory of Engagement in Mindfulness-Based Group Therapy for Distressing Voices.

Mindfulness-based group therapy shows promise as a treatment for distressing voice hearing. However, fostering engagement in groups can be challenging, and no theory of engagement in group therapy for distressing voices exists to guide practice or research. This study employed Grounded Theory Method to build a theory of engagement in mindfulness-based groups for distressing voices. Ten service-users and three therapists were interviewed about their experiences of such groups. The model that emerged involves a recursive process of investing in change and continually evaluating its usefulness and safety. Barriers to engagement were often overcome, but sometimes compromised perceived safety, leading to dropout. For others, group participation led to rewards, some of which were integrated beyond group termination. Group engagement can be encouraged by establishing universality around voice hearing early, reducing uncertainty, sharing difficulties with mindfulness practices, and mapping group progress to create a cohering sense of collaboration on therapy tasks.