Exploring public health nurses' acceptability of clinical assessment tools in a Norwegian child health centre.

BACKGROUND: Infants' symptoms of mental struggle are often diffuse and undifferentiated, and health services do not identify many infants at risk of poor development. However, primary health care is advantageous for early identification, given there are frequent consultations during the infant's first two years. Health policy encourages using evidence-based screening but use varies in primary health care. The Alarm Distress Baby Scale (ADBB) is an assessment tool targeting social withdrawal in infants 2-24 months of age. AIM: To explore contextual factors related to public health nurses' (PHNs) acceptability of clinical assessment tools in a Norwegian child health centre. METHODS: Prior to an upcoming ADBB training, we used focus group discussions with PHNs to explore their views on their professional role and practice and how this concurs with using assessment tools. FINDINGS: Thematic analysis resulted in the following themes: (1) A Role requiring Supporting the Parents and Safeguarding the Infant; (2) The Challenge of Interpreting Infant Expressions; and (3) Organisational Preconditions for Accepting New Methods. CONCLUSION: Our findings show that PHNs regard assessment tools as an aid to detect infants at risk, but that systematic use of such tools can hinder their ability to be flexible, egalitarian, and resource-focused. We also find that acceptability of assessment tools requires a system for continuous training and a well-established referral routine.

Associations Between Self-Rated Health and Mortality in the Norwegian Women and Cancer (NOWAC) Study.

Purpose: We investigated the association between self-rated health (SRH) and cancer incidence and SRH and all-cause mortality among Norwegian women. Population and Methods: We used data from 110,104 women in the Norwegian Women and Cancer (NOWAC) cohort aged 41-70 years at baseline. We used flexible parametric survival analysis with restricted cubic splines to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between SRH and mortality in the entire cohort. We employed the same method in a multistate design to assess associations between baseline SRH and 1) cancer incidence, and 2) all-cause mortality in subgroups of women who did and did not receive a cancer diagnosis during follow-up. Results: With very good SRH as reference category for all associations and median age at end of follow-up, lower SRH was associated with increased mortality (HRgood SRH 1.19, 95% CI 1.12-1.26) and HRpoor SRH 1.81, 95% CI 1.66-1.97). Lower SRH at baseline was associated with cancer incidence (HRgood SRH 1.14, 95% CI 1.08-1.20 and HRpoor SRH 1.44, 95% CI: 1.32-1.58). Poor baseline SRH was associated with increased mortality for women who received a cancer diagnosis (HRpoor SRH 1.20, 95% CI 1.04-1.39), and SRH showed a strong association with increased mortality for women who stayed cancer free (HRgood SRH 1.59, 95% CI 1.44-1.77 and HRpoor SRH 3.34, 95% CI 2.91-3.84). Conclusion: Lower SRH at baseline predicted increased cancer risk and all-cause mortality in middle-aged to older women. Poor SRH at baseline predicted all-cause mortality in women who later received a cancer diagnosis. Both good and poor SRH at baseline predicted all-cause mortality in women who stayed cancer-free, and the association was stronger for these women compared to both the entire cohort and to women who were subsequently diagnosed with cancer.

Post-traumatic stress disorder among heart disease patients: a clinical follow-up of individuals with myocardial infarction in the Tromsø Study.

BACKGROUND: Myocardial infarction is likely to be experienced as a life-threatening and potentially traumatic event. Approximately one-third of patients with myocardial infarction experience clinically significant symptoms of anxiety/depression. However, it is unclear how many of these patients experience these symptoms because of post-traumatic stress disorder (PTSD). We conducted a clinical screening of individuals with a confirmed myocardial infarction diagnosis. Our goal was to examine the prevalence of PTSD in myocardial infarction patients and study how PTSD symptoms were associated with exposure to potentially traumatic events. METHOD: This is epidemiological research with a cross-sectional design following up participants from the Tromsø Study with a confirmed diagnosis of myocardial infarction. We sent invitations to participants in the Tromsø Study with clinically significant self-reported anxiety or depression symptoms following myocardial infarction. A cross-sectional sample of N = 79 participants (61 men and 18 women) was collected. During an interview, participants completed the Stressful Life Events Screening Questionnaire and the PTSD checklist PCL-5. RESULTS: We found nine participants (11.6%) with probable PTSD. This was significantly higher than the postulated population prevalence in Norway (p < 0.015). We found no direct association between myocardial infarction as illness trauma and symptom levels (p = 0.123). However, we found a significant linear trend (p = 0.002), indicating that symptom severity increased proportionately as the number of post-traumatic events increased. CONCLUSION: PTSD prevalence in myocardial infarction patients was related to lifetime exposure to traumatic events, not the myocardial infarction event alone. More research is required to examine the interaction between myocardial infarction and PTSD. Clinicians should be aware that anxiety or depression symptoms after MI could be secondary symptoms of PTSD.

The association of religious factors with mental health-service utilisation and satisfaction in a mixed Sámi and Norwegian adult population: Adopting the SAMINOR 2 Questionnaire Survey.

The Indigenous Sámi have poorer mental health than the majority population and fairly equal access to professional mental healthcare. Despite this condition, certain studies indicate that this group is underrepresented among the users of such services. Religion or spirituality (R/S) often influences mental health-service utilisation and satisfaction among other Indigenous peoples and ethnic minorities. Thus, this study examines the situation in Sámi-Norwegian areas. We utilised cross-sectional data from the population-based SAMINOR 2 Questionnaire Survey (2012; subsample n = 2,364; 71% non-Sámi) in mixed Sámi-Norwegian regions of Northern and Central Norway. We analysed the associations between R/S factors and past-year mental health-service utilisation and satisfaction among individuals reporting mental health problems, substance use, or addictive behaviours. Multivariable-adjusted regression models considering sociodemographic factors, including Sámi ethnicity, were applied. Religious attendance was significantly associated with infrequent past-year use of mental health services (OR = 0.77) and fewer mental health problems, indicating that the R/S fellowship may buffer mental distress and represent an alternative psychological support to professional services. R/S was not significantly associated with lifetime mental health-service satisfaction. We found no ethnic differences in service utilisation or satisfaction.

The effects of exceeding low-risk drinking thresholds on self-rated health and all-cause mortality in older adults: the Tromsø study 1994-2020.

BACKGROUND: Based on findings of increasing alcohol consumption in older adults, it is important to clarify the health consequences. Using data from the Tromsø study, we aimed to investigate the relationship between different levels of alcohol consumption in old adulthood and self-rated health trajectories and all-cause mortality. METHODS: This is an epidemiological study utilizing repeated measures from the Tromsø study cohort. It allows follow-up of participants from 1994 to 2020. A total of 24,590 observations of alcohol consumption were made in older adults aged 60-99 (53% women). PRIMARY OUTCOME MEASURES: Self-rated health (SRH) and all-cause mortality. SRH was reported when attending the Tromsø study. Time of death was retrieved from the Norwegian Cause of Death Registry. The follow-up time extended from the age of study entry to the age of death or end of follow-up on November 25, 2020. PREDICTOR: Average weekly alcohol consumption (non-drinker, < 100 g/week, ≥100 g/week). We fitted two-level logistic random effects models to examine how alcohol consumption was related to SRH, and Cox proportional hazards models to examine its relation to all-cause mortality. Both models were stratified by sex and adjusted for sociodemographic factors, pathology, biometrics, smoking and physical activity. In addition, all the confounders were examined for whether they moderate the relationship between alcohol and the health-related outcomes through interaction analyses. RESULTS: We found that women who consumed ≥100 g/week had better SRH than those who consumed < 100 g/week; OR 1.85 (1.46-2.34). This pattern was not found in men OR 1.18 (0.99-1.42). We identified an equal mortality risk in both women and men who exceeded 100 g/week compared with those who consumed less than 100 g/week; HR 0.95 (0.73-1.22) and HR 0.89 (0.77-1.03), respectively. CONCLUSIONS: There was no clear evidence of an independent negative effect on either self-rated health trajectories or all-cause mortality for exceeding an average of 100 g/week compared to lower drinking levels in this study with up to 25 years follow-up. However, some sex-specific risk factors in combination with the highest level of alcohol consumption led to adverse effects on self-rated health. In men it was the use of sleeping pills or tranquilisers and ≥ 20 years of smoking, in women it was physical illness and older age.

Leisure Time Physical Activities' Association With Cognition and Dementia: A 19 Years' Life Course Study.

Introduction: Cognitive impairment is one of the main disabilities in dementia. Physical activity (PA) has been suggested as protective for dementia. However, the findings are disparate in studies, and the question of whether this is because of reverse causality is still open. We aimed to explore the association of PA with cognition in people who later developed dementia compared to those who did not. Method: Since 2001, 11,512 (55% women) participants over the age of 50 years had taken at least one cognitive test in the Tromsø Study. Of these, 1,123 (58% women) later developed dementia. The cases were extracted from hospital journals and entered into an endpoint registry. Leisure time PA (LTPA) was self-reported. Multilevel mixed-effects linear regression was used to address whether LTPA was associated with cognition, stratified by those later developing dementia, and dementia-free in a separate analysis. Results: Leisure time PA was associated with scores in cognitive tests that were 55% (z-score 0.14) higher in those who did not develop dementia. For those in a preclinical phase of dementia, there was no association with LTPA on global cognitive scores. However, in a multifactorial test on processing speed and memory, women had a positive association with processing speed and memory. Conclusion: Leisure time PA had a positive association with global cognition function only for those who did not develop dementia. In women who were developing dementia, LTPA had a positive association with processing speed and memory, while in men, there were no such associations.

Assessment of mental health trajectories before and after myocardial infarction, atrial fibrillation or stroke: analysis of a cohort study in Tromsø, Norway (Tromsø Study, 1994-2016).

OBJECTIVES: The increased survival rate of cardiovascular disease (CVD) implies a higher proportion of individuals who live with CVD. Using data from the Tromsø Study, we aimed to investigate mental health symptom trajectories before and after myocardial infarction, atrial fibrillation or stroke in a general population and to explore factors that contribute to the association. DESIGN: Cohort study. SETTING: Sample drawn from inhabitants of the municipality of Tromsø, Norway, who participated in the Tromsø Study (1994-2016). PARTICIPANTS: A total of 18 719 participants (52.3% women) were included, and of these 2098 (32.9% women) were diagnosed with myocardial infarction, 1896 (41.9% women) with atrial fibrillation and 1263 (42.9% women) with stroke. PRIMARY OUTCOME MEASURES: Mental health symptoms were assessed using the Hopkins Symptom Checklist-10 and the Conor Mental Health Index. RESULTS: The participants who were diagnosed with either myocardial infarction or stroke had a significant monotonous increase in mental health symptoms before myocardial infarction (p=0.029) and stroke (p=0.029) that intensified at the time of diagnosis. After the event, the study found a higher prevalence of mental health symptoms with a decline in symptom levels over time for myocardial infarction (p<0.001) and stroke (p=0.004), but not for atrial fibrillation (before: p=0.180, after: p=0.410). The risk of elevated mental health symptoms with myocardial infarction, atrial fibrillation and stroke was associated with sex (p<0.001), age (p<0.01), physical activity (p<0.001), diabetes (p<0.05) and other comorbidities (p<0.001). CONCLUSION: The study indicates that mental health problems among individuals with myocardial infarction, atrial fibrillation and stroke may have started to develop several years before the cardiovascular event and suggests that successful CVD rehabilitation may need to consider previous life factors. Future research is recommended to examine whether health promotion measures in a general population also create mental health resilience after a CVD event.

Religion and Health in Arctic Norway - the association of religious and spiritual factors with suicidal behaviour in a mixed Sámi and Norwegian adult population - The SAMINOR 2 Questionnaire Survey.

Given the higher suicide rates among the adult population in the northernmost part of Norway and some unfavourable psychosocial outcomes associated with the Laestadian revival movement in this region, it is reasonable to investigate the relationship between religiosity/spirituality and suicidal behaviour in this context. This study used cross-sectional data from the population-based SAMINOR 2 questionnaire survey (2012; n = 11,222; 66% non-Sámi; 22% Laestadian-affiliated; 27% response rate) in mixed Sámi-Norwegian areas of Mid and North Norway. We analysed the associations between religious/spiritual factors and lifetime suicidal ideation and attempts, age at the first attempt, motives, and number of attempts. Multivariable-adjusted regression models considering sociodemographics, Sámi background and self-ascription, and health-related risk factors were applied. Sámi and Laestadian affiliations were significantly associated with religious self-ascription, regular attendance, and Established Church membership. In a fully adjusted model, Laestadian family background was negatively associated with lifetime suicide attempts (OR = 0.66, 95% CI: 0.47-0.93) compared with other family circumstances, whereas regular religious participation was inversely associated with suicide ideation (OR = 0.74, 95% CI: 0.61-0.91) compared with non- or rare attendance. The findings suggest that Laestadianism and religious attendance contribute to less suicidal behaviour among adults in Sámi-Norwegian areas.

A prospective study on the effect of self-reported health and leisure time physical activity on mortality among an ageing population: results from the Tromsø study.

BACKGROUND: The prevailing Western ideal of ageing in place, with the option to stay at home as one ages, has led to the development of physical activity guidelines for people of advanced age to increase their quality of life and promote their functional abilities. This study investigates the effect of self-reported health and physical activity on mortality and examines how levels of age-specific physical activity affect self-reported health trajectories in an ageing cohort. METHODS: The sample cohort of the population-based Tromsø Study consists of 24,309 participants aged 25-97 years at baseline. This study involved a survival analysis from 1994 to 2015 and included those who completed two or more surveys (n = 12,241) between 1994 and 2008. The purpose was to examine the relationship between physical activity and self-reported health throughout life using a random coefficient model analysis. RESULTS: Being sedentary was associated with an increased risk of mortality in the ageing cohort. Subjects who reported neither light physical activity nor hard physical activity had a 57% (OR 1.57, 1.07-2.31) increased risk of all-cause death. Both hard (OR 2.77, 2.35-3.26) and light (OR 1.52, 1.32-1.76) physical activity were positively associated with self-reported health. The effect was age dependent. Vigorous physical activity was most beneficial for individuals younger than 40 years old, while moderate physical activity levels prolonged the period in which good self-reported health was likely. CONCLUSIONS: Poor self-reported health and being sedentary were independently associated with an increased risk of mortality in the participants. Furthermore, physical activity prolonged the period of good self-reported health among older adults in two ways: physical activity habits from early adulthood and onwards were beneficial to self-reported health at an advanced age, and self-reported health was dependent on engagement in moderate intensity physical activity after approximately 65 years of age.

Use of a simple form to facilitate communication on long-term consequences of treatment in sarcoma survivors.

BACKGROUND: To report on our experience using a simple optional form to facilitate communication on late effects between the patients and the oncologists during outpatient follow-up and to detail on the spectrum of challenges reported by sarcoma survivors. METHODS: The form was presented for the patients to complete before their consultation and covered topics related to late effects and unmet needs that the patient wished to discuss with the medical personnel. Logistic regression analysis examined how the distribution of the topics varied with age, gender, diagnosis and type of treatment received. RESULTS: The form was manageable in a busy outpatient clinic. Of the 265 patients that received the form, 236 (89%) returned it. Patients in a palliative setting and those with other diagnosis than bone sarcoma (BS) and soft-tissue sarcoma (STS) were excluded for subsequent analyses. The final study-cohort comprised 160 patients, 54 (34%) with BS and 106 (66%) with STS. Among these, 140 (88%) had late-effect topics they wanted to discuss with their oncologist. Fatigue was raised by 39% of the patients, pain by 29% and impaired mobility by 23%. BS patients raised fatigue more often (P < 0.005) than those with STS. Patients who had undergone multimodal treatment with chemotherapy raised fatigue more frequently (P < 0.001) than those who had only undergone surgery, radiotherapy or both. CONCLUSIONS: A simple form on the long-term consequences of sarcoma treatment achieved a high response rate, was feasible to use in an outpatient clinic and facilitated communication on these issues. Fatigue was the most frequent topic raised and it was raised significantly more often in patients who had undergone chemotherapy.

Community treatment orders - what are the views of decision makers?

BACKGROUND: Community treatment orders (CTOs) are being increasingly used in Western countries. The scheme implies that mental health patients can live outside a hospital, but still be subject to coercive care to ensure compliance with their treatment. There is limited knowledge of how the scheme is practised. AIMS: To gain knowledge of how decision makers weigh and evaluate various considerations when making decisions on CTOs. METHOD: Qualitative in-depth interviews with decision makers responsible for CTOs in Norway. RESULTS: Decision makers viewed CTOs as a useful scheme to ensure control, continuity and follow-up care in the treatment of outpatients with a history of poor treatment motivation. They had varied interest in and knowledge of the patient's life situation and how the scheme affects the patient's everyday life. Little attention was devoted to patient experiences of formal and informal coercion. CONCLUSION: When deciding on CTOs, decision makers should pay more attention to the negative consequences that patients may experience. In many cases, decision makers are probably not aware of these coercive factors.

What is the impact of underweight on self-reported health trajectories and mortality rates: a cohort study.

BACKGROUND: Utilizing a cohort study design combining a survey approach with repeated physical examinations, we examined the independent effects of BMI on mortality and self-reported health (SRH) and whether these independent effects change as people grow older. METHODS: The Tromsø Study consists of six surveys conducted in the municipality of Tromsø, Norway, with large representative samples of a general population. In total, 31,985 subjects participated in at least one of the four surveys administered between 1986 and 2008. Outcomes of interest were SRH and all-cause mortality. RESULTS: Overweight and underweight subjects reported significantly lower levels of SRH, but age affected the thinnest subjects more than all others. The SRH trajectory of underweight subjects at age 25 was slightly above the other categories (0.08), but it fell to -.30 below the reference category at age 90. For obese subjects, the difference was -0.15 below the reference category at age 25 and -0.18 below at age 90. This implies that even though a low BMI was slightly beneficial at a young age, it represented an increasing risk with age that crossed the reference curve at age 38 and even crossed the obese trajectory at age 67 in the full fitted model. The proportional hazard ratio for those who were underweight was 1.69 (95% CI: 1.38-2.06) for all-cause death as compared to 1.12 (95% CI: 1.02-1.23) for obese subjects. CONCLUSION: BMI affected SRH and all-cause mortality independently from comorbidity, mental health, health-related behaviors and other biological risk factors. Being underweight was associated with excess mortality as compared to all others, and age affected the thinnest subjects more than all others. Weight increase was beneficial for mortality but not for SRH among the underweight. The rapid decline of SRH with increasing age suggests that particular attention should be paid to underweight after 38 years of age.

Visual methods in health dialogues: A qualitative study of public health nurse practice in schools.

AIMS: We aimed to explore how using visual methods might improve or complicate the dynamics of the health dialogue between public health nurses (PHNs) and school pupils. This was done from the perspective of PHNs, specifically examining how they understood their role and practice as a PHN and the application of visual methods in this practice. BACKGROUND: The health dialogue is a method used by PHNs in school nursing in Norway. In this practice, there can be communicative barriers between pupils and PHNs. Investigating how PHNs understand their professional practice can lead to ways of addressing these communicative barriers, which can affect pupil satisfaction and achievement of health-related behaviours in the school context. Specifically, the use of visual methods by PHNs may address these communicative barriers. DESIGN: The research design was qualitative, using focus groups combined with visual methods. METHODS: We conducted focus group interviews using a semi-structured discussion guide and visual methods with five groups of PHNs (n = 31) working in northern Norwegian school health services. The data were collected during January and February 2016. Discussions were audio recorded, transcribed and coded into themes and sub-themes using systematic text condensation and drawings were analysed using interpretive engagement, a method of visual analysis. FINDINGS: Drawings and focus group discussions showed that PHNs perceived their professional practice as primarily a relational praxis. The PHNs used a variety of visual methods as part of the health dialogue with school pupils. This active use of visualization worked to build and strengthen relations when words were inadequate and served to enhance the flexible and relational practice employed by the PHNs. CONCLUSIONS: PHNs used different kinds of visualization methods to establish relations with school pupils, especially when verbalization by the pupils was difficult. PHNs were aware of both the benefits and challenges of using visualization with school pupils in health education. We recommend the use of visual methods in schools because they are useful for PHNs, other health professionals and teachers working with children and young people in developing relations, particularly where verbal communication may be a challenge.

Ageing and mental health: changes in self-reported health due to physical illness and mental health status with consecutive cross-sectional analyses.

OBJECTIVES: It is known that self-reported health (SRH) declines with increasing age and that comorbidity increases with age. We wished to examine how age transfers its effect to SRH through comorbid disease and mental illness and whether these processes remained stable from 1994 until 2008. The hypothesis is that ageing and/or the increased age-related burden of pathology explains the declining SRH. SETTING: The Tromsø Study (TS) is a cohort study using a survey approach with repeated physical examinations. It was conducted in the municipality of Tromsø, Norway, from 1974 to 2008. PARTICIPANTS: A total of 21 199 women and 19 229 men participated. PRIMARY AND SECONDARY OUTCOME MEASURES: SRH is the outcome of interest. We calculated and compared the effect sizes of age, comorbidity and mental health symptoms using multimediator analysis based on OLS regression. RESULTS: Ageing had a negative impact on SRH, but the total effect of age decreased from 1994 to 2007. We assessed the direct effect of age and then the proportion of indirect age-related effects through physical illness and mental health symptoms on the total effect. The direct effect of age represented 79.3% of the total effect in 1994 and decreased to 58.8% in 2007. Physical illness emerged as an increasingly important factor and increased its influence from 15.7% to 41.2% of the total effect. Age alone had a protective effect on mental health symptoms and this increased (2.5% to 17.3%), but we found a stronger association between mental health symptoms and physical disease in the later waves of the study (increasing from 3.7% to 14.8%). CONCLUSIONS: The results suggest that the effect on SRH of mental health symptoms caused by physical illness is an increasing public health problem. Treatment and care for specific medical conditions must therefore focus more strongly on how these conditions affect the patient's mental health and address these concerns accordingly.

"I Do Not Really Belong Out There Anymore": Sense of Being and Belonging Among People With Medically Unexplained Long-Term Fatigue.

In this article, we explore relations between health, being, belonging and place through an interpretive thematic analysis of autobiographic text and photographs about the everyday lives of 10 women and men living with medically unexplained long-term fatigue in Norway. While interpreting their place-related illness experiences, we ask: How do they experience their being in the world, where do they experience a sense of belonging/not belonging, and why do places become places of belonging/not belonging? The participants describe experiences of (a) being socially detached and alienated, (b) being imprisoned, (c) being spectators who observe the world, and (d) senses of belonging. They describe senses of being and belonging/not belonging as closely attached to physical and symbolic aspects of places in which they reside, and they wistfully reflect on the question of "why." The study illustrates the influence of experienced place-material as well as immaterial-on health and illness.

Health Impact Index. Development and Validation of a Method for Classifying Comorbid Disease Measured against Self-Reported Health.

The objective of this study was to develop a method of classifying comorbid conditions that accounts for both the severity and joint effects of the diseases. The Tromsø Study is a cohort study with a longitudinal design utilizing a survey approach with physical examinations in the Tromsø municipality from 1974 to 2008, where in total 40051 subjects participated. We used Tromsø 4 as reference population and the Norwegian Institute of Public Health (FHI) panel as validation population. Ordinal regression was used to assess the effect of comorbid disease on Self-Reported Health (SRH). The model is controlled for interaction between diseases, mental health, age, and gender. The health impact index estimated levels of SRH. The comparison of predicted and observed SRH showed no significant differences. Spearman's correlation showed that increasing levels of comorbidity were related to lower levels of SRH (RS = -0.36, p <.001). The Charlson Comorbidity Index(CCI) was also associated with SRH (r = -.25, p <.001). When focusing on only individuals with a comorbid disease, the relation between SRH and the Health Impact Index (HII) was strengthened (r = -.42, p <.001), while the association between SRH and CCI was attenuated (r = -.14, p <.001). CCI was designed to control for comorbid conditions when survival/mortality is the outcome of interest but is inaccurate when the outcome is SRH. We conclude that HII should be used when SRH is not available, and well-being or quality of survival/life is the outcome of interest.

Attuned understanding and psychotic suffering: a qualitative study of health-care professionals' experiences in communicating and interacting with patients.

This study was initiated to examine how experiences with mental illness are perceived by health-care workers, and how insight affects assessment of their perspective and involvement. Lack of insight gives rise to problems concerning communication: if we expect what the person says and does not to have any meaning, how then can we establish a relationship based on understanding? This study was based on in-depth interviews with 11 mental health-care workers. Participants were recruited from a variety of institutions and professional backgrounds. The following topics were discussed with the participants: lack of insight, awareness of illness, and coping strategies, as well as how these factors affected treatment, cooperation, and participation. The participants describe attuned understanding as an other-oriented process, involving sensitivity to many aspects of the person's situation. Understanding is sought and is established through emotional, human contact, and practical interaction, and ends with new articulated understanding. The results suggest that the process described here can be viewed as other-oriented understanding, and not merely sympathy. It is an interdependent process of imagining oneself in the other's place, and depends on awareness of the nature of this process and on sensitivity to the person's expressions.