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Megan S. Barker, Emily C. Gibson, and Gail A. Robinson
The term “acquired brain injury” refers to any type of brain damage that occurs after birth. Two main types of acquired brain injury are stroke and traumatic brain injury (TBI). A stroke occurs when there is a blockage or bleed in the vascular system of the brain, while a TBI results from an external force to the head. Older adults are at a higher risk of both stroke and TBI; thus, overall incidence is increasing as the proportion of older adults in the population is growing. Stroke and TBI result in immediate and long-term cognitive changes. Impairments in the domains of language, attention, memory, executive functions, perception, and social cognition have been documented following stroke and TBI. However, strokes tend to cause focal or selective cognitive disorders, while cognitive deficits following TBI are widespread and can be generalized. Individuals who have suffered a stroke or TBI may also experience psychosocial changes; for example, symptoms of depression and anxiety are common. Functional outcomes, including independence in activities, are varied and are associated with a range of factors including age, injury severity, cognitive disorders, and psychosocial factors. To achieve optimal outcomes for individuals following stroke and TBI, and to reduce the impact of the injury on everyday functioning, a multidisciplinary rehabilitation process is recommended.
Action regulation theory is a meta-theory on the regulation of goal-directed behavior. The theory explains how workers regulate their behavior through cognitive processes, including goal development and selection, internal and external orientation, planning, monitoring of execution, and feedback processing. Moreover, action regulation theory focuses on the links between these cognitive processes, behavior, the objective environment, and objective outcomes. The action regulation process occurs on multiple levels of action regulation, including the sensorimotor or skill level, the level of flexible action patterns, the intellectual or conscious level, and the meta-cognitive heuristic level. These levels range from unconscious and automatized control of actions to conscious thought, and from muscular action to thought processes. Action regulation at lower levels in this hierarchy is more situation specific and requires less cognitive effort than action regulation at higher levels.
Workers further develop action-oriented mental models that include long-term cognitive representations of input conditions, goals, plans, and expected and prescribed results of action, as well as knowledge about the boundary conditions of action and the transformation procedures that turn goals into expected results. The accuracy and level of detail of such action-oriented mental models is closely associated with the efficiency and effectiveness of action regulation. One of three foci can be in the foreground of action regulation: task, social context, or self. A task focus is most strongly associated with high efficiency and effectiveness of action regulation, because it links task-related goals with relevant plans, behavior, and feedback. Action regulation theory has been applied to understand several phenomena in the field of industrial, work, and organizational psychology, including proactive work behavior, work-related learning and error management, entrepreneurship, occupational strain and well-being, reciprocal influences between personality and work, innovation, teamwork, career development, and successful aging at work.
Kelsey E. Woods, Christina M. Danko, and Andrea Chronis-Tuscano
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention. ADHD is chronic, may persist into adulthood, and is associated with impairment in social and academic/work domains across the lifespan. Children and adolescents with ADHD often present with executive function deficits and emotion dysregulation, and these deficits may increase impairment and risk for co-occurring disorders. The etiology of ADHD is not yet understood, though research suggests that biological and environmental factors (e.g., family, community) contribute to its development and course. It should be noted that ADHD commonly co-occurs with additional psychiatric disorders, such as oppositional defiant disorder (ODD), conduct disorder (CD), and major depressive disorder.
Evidence-based assessment of ADHD requires information from multiple informants using multiple assessment methods to determine the presence of ADHD symptoms across settings and any co-occurring disorders. The evidence-based treatment options for ADHD are manifold. Pharmacotherapy for ADHD is common, although numerous behavioral interventions are also effective. Stimulant medications are commonly prescribed and are typically effective in ameliorating core ADHD symptoms. There is also evidence that the nonstimulant medication atomoxetine substantially decreases the symptoms of ADHD. Importantly, medication therapy works to reduce symptoms but typically does not alleviate the impairments associated with the disorder. Combined medication and behavioral interventions are more likely to reduce impairments and normalize behavior.
David M. Cadiz, Amy C. Pytlovany, and Donald M. Truxillo
The population is aging in most industrialized nations around the world, and this trend is anticipated to continue well into the future. This demographic shift impacts the workforce in that the average age of workers is increasing, and the workplace is becoming more age diverse, meaning different generations of employees are working side by side now more than ever before. Increasing age diversity can be problematic if misguided age-related attitudes, biases, and behaviors lead to ageism—the stigmatization of, and discrimination against, people based on age. Evidence of the impact of ageism in the workplace is being observed in increasing age-related discrimination claims as well as increased time for older people to find employment.
Workplace ageism manifests from cognitive, affective, and behavioral components. Age stereotypes are associated with the cognitive component, age-related prejudice is related to the affective component, and age discrimination is aligned with the behavioral component. There is an abundance of research identifying age-related stereotypes and it is thought that these stereotypes influence how workplace decisions are made. Age-related prejudice research indicates that older workers are generally viewed more negatively than younger workers which can result in lower performance appraisals or older workers’ receiving harsher consequences for lower performance. Finally, age-discrimination research has identified that older workers struggle to find employment, to receive training and development opportunities, and to advance their careers. Although the majority of research on workplace ageism has focused on older individuals, younger workers also face challenges related to their age and this is a line of research that needs further exploration. Nevertheless, the accumulating evidence supports claims that workplace ageism has wide-ranging effects on individuals, groups/teams, organizations, and society.
Victoria I. Michalowski, Denis Gerstorf, and Christiane A. Hoppmann
Aging does not occur in isolation, but often involves significant others such as spouses. Whether such dyadic associations involve gains or losses depends on a myriad of factors, including the time frame under consideration. What is beneficial in the short term may not be so in the long term, and vice versa. Similarly, what is beneficial for one partner may be costly for the other, or the couple unit over time. Daily dynamics between partners involving emotion processes, health behaviors, and collaborative cognition may accumulate over years to affect the longer-term physical and mental health outcomes of either partner or both partners across adulthood and into old age. Future research should move beyond an individual-focused approach to aging and consider the importance of and interactions among multiple time scales to better understand how, when, and why older spouses shape each other’s aging trajectories, both for better and for worse.
Lale M. Yaldiz, Franco Fraccaroli, and Donald M. Truxillo
The proportion of older people in the industrialized workforce is increasing owing to the aging of the baby-boom generation, improved health in industrialized countries, changing retirement laws, need for additional income by older workers, and entry of fewer younger people into the workforce in some countries. This “graying” trend of the workforce raises a number of issues such as the needs, motivation, job attitudes, and behaviors of older workers; how to manage age diversity issues at work; late career issues; and preparing the worker and the organization for retirement. Specifically, older worker issues as a research topic includes work-relevant changes taking place within individuals as they age (e.g., physical, cognitive, and personality changes); how older workers are affected by their physical and social environments; the sources of age stereotyping and discrimination and how to combat them; and how these factors affect outcomes such as older workers’ well-being, health, attitudes, motivation, performance, and desire to continue working.
Matthew P. Martens
Issues associated with athletics, alcohol abuse, and drug use continue to be salient aspects of popular culture. These issues include high-profile athletes experiencing public incidents as a direct or indirect result of alcohol and/or drug use, the role that performance-enhancing drugs play in impacting outcomes across a variety of professional and amateur contests, and the public-health effects alcohol abuse and drug use can have among athletes at all competitive levels. For some substances, like alcohol abuse, certain groups of athletes may be particularly at-risk relative to peers who are not athletes. For other substances, participating in athletics may serve as a protective factor. Unique considerations are associated with understanding alcohol abuse and drug use in sport. These include performance considerations (e.g., choosing to use or not use a certain substance due to concerns about its impact on athletic ability), the cultural context of different types of sporting environments that might facilitate or inhibit alcohol and/or drug use, and various internal personality characteristics and traits that may draw one toward both athletic activity and substance use. Fortunately, there are several effective strategies for preventing and reducing alcohol abuse and drug use, some of which have been tested specifically among athlete populations. If such strategies were widely disseminated, they would have the potential to make a significant impact on problems associated with alcohol abuse and drug use in sport and athletics.
Robert G. Jones
Based on current earth science findings, survival of our species will rely on better management of our relationships with the environmental system in which we reside. Accomplishing this requires the enlistment of a scientific understanding and management of our internal natural systems. Specifically, human urges that are oriented toward individual and small group well-being must be successfully managed to ensure species-level adaptation and survival. An essential first step for accomplishing this is to define a set of psychological criteria presumed to mediate the relationship between these individual urges and behavior at broader levels of analysis, and particularly organizational and community behaviors. Once criteria have been elaborated by key stakeholders, assessment and feedback processes common to major areas of applied psychology provide many options for intervention. This approach is at the heart of the applied psychology of sustainability that will be elaborated in this article. After defining the core problem and laying some foundational assumptions, an overview of this approach will be presented as a means to addressing the problem of using our psychological systems to manage our psychological systems’ effects on the environment.
Martin Turner and Marc Jones
Sport and stress are intertwined. Muhammad Ali once said, “I always felt pressure before a big fight, because what was happening was real.” As this quote attests, sport is real, unscripted, with the potential for psychological, and often physical, harm. The response to stress, commonly described as “flight or fight,” is an evolutionary adaptation to dangerous situations. It guides behavior and readies a person to respond, to fight, or flee. However, the stress response is not evoked solely in situations of mortal danger; it occurs in response to any situation with the potential for physical or psychological harm, such as sport. For example, the possibility of missing out on a life-changing gold-medal win in an Olympic Games, or losing an important competition that you were expected to win.
Stress in sport is often illustrated by the archetypal image of an athlete choking; snatching defeat from the jaws of victory. But stress can also help athletes perform well. Stress also plays a role in behavior away from the competition arena, influencing interactions with significant others, motivation and performance in training, and how athletes experience and manage injury and retirement from sport. In sport stress, the psychophysiological responses to stress are not just abstract theoretical concepts removed from the real world; they reflect the thoughts, feelings, and experiences of athletes.
It is important to understand the arousal response to stress in sport. Both theory and research suggest a connection between arousal and athletic performance. Recent approaches propose ideas about how the nature of arousal may differ depending on whether the athlete feels positively (as a challenge) or negatively (as a threat) about the stressor. The approach to seeing stress as a challenge supports a series of strategies that can be used to help control arousal in sport.
Aidan Moran and John Toner
We are constantly bombarded by information. Therefore, during every waking moment of our lives, we face decisions about which stimuli to prioritize and which ones to ignore. To complicate matters, the information that clamors for our attention includes not only events that occur in the world around us but also experiences that originate in the subjective domain of our own thoughts and feelings. The end result is that our minds can consciously attend to only a fraction of the rich kaleidoscope of information and experiences available to us from our senses, thoughts, memories, and imagination. Attentional processes such as “concentration,” or the ability to focus on the task at hand while ignoring distractions, are crucial for success in sport and other domains of skilled performance. To illustrate, Venus Williams, one of the greatest tennis players of all time, proclaimed that “for the players it is complete and pure focus. You don’t see anything or hear anything except the ball and what’s going on in your head.” For psychological scientists, concentration resembles a mental spotlight (like the head-mounted torch that miners and divers wear in dark environments) that illuminates targets located either in the external world around us or in the internal world of our subjective experiences. A major advantage of this spotlight metaphor is that it shows us that concentration is never “lost”—although it can be diverted to targets (whether in the external world or inside our heads) that are irrelevant to the task at hand. Research on attentional processes in sport and performance has been conducted in cognitive psychology (the study of how the mind works), cognitive sport psychology (the study of mental processes in athletes), and cognitive neuroscience (the study of how brain systems give rise to mental processes). From this research, advances have been made both in measuring attentional processes and in understanding their significance in sport and performance settings. For example, pupillometry, or the study of changes in pupil diameter as a function of cognitive processing, has been used as an objective index of attentional effort among skilled performers such as musicians and equestrian athletes. Next, research suggests that a heightened state of concentration (i.e., total absorption in the task at hand) is crucial to the genesis of “flow” states (i.e., rare and elusive moments when everything seems to come together for the performer) and optimal performance in athletes. More recently, studies have shown that brief mindfulness intervention programs, where people are trained to attend non-judgmentally to their own thoughts, feelings, and sensations, offer promise in the quest to enhance attentional skills in elite athletes. By contrast, anxiety has been shown to divert skilled performers’ attention to task-irrelevant information—sometimes triggering “choking” behavior or the sudden and significant deterioration of skilled performance. Finally, concentration strategies such as “trigger words” (i.e., the use of short, vivid, and positively phrased verbal reminders such as “this ball now”) are known to improve athletes’ ability to focus on a specific target or to execute skilled actions successfully.
Lukas J. Wolf, Geoff Haddock, and Greg Maio
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Psychology. Please check back later for the full article.
Attitudes refer to our summary evaluations of people, groups, ideas, and other objects, indicating whether we like or dislike them. The study of attitudes takes a central position in social psychology. Since attitudes were described as the most distinctive and indispensable concept in social psychology more than 80 years ago, decades of extensive research have studied attitudes. This research has revealed how attitudes shape our perceptions and behavior.
One of the key aspects of attitudes is their affective, cognitive, and behavioral content. That is, an attitude may associate an attitude object with affective or emotional reactions, cognitions or knowledge, beliefs, and thoughts, and intentions or past actions. The attitude itself may also have a simple (e.g., positive or negative) structure or a more conflicted, ambivalent (e.g., simultaneously positive and negative) structure, and it may serve different psychological functions (e.g., simplification of knowledge, value expression). In more recent decades, scientists have focused on developing diverse techniques to measure attitudes. On the whole, research has shown that attitudes are moderately predictive of future behavior and that the strength of this link depends on diverse factors, such as how strongly the attitude is held, individuals’ personality, and the environmental context. Overall, the long history of research on attitudes has shown considerable theoretical and practical relevance.
Ye In (Jane) Hwang and Julian Trollor
Autism spectrum disorder (ASD), or autism, is a neurodevelopmental disorder that is typically recognized and diagnosed in childhood. There is no established biological marker for autism; rather, the diagnosis is made based on observation of behavioral traits, including (a) persistent deficits in social interaction and communication, and (b) restricted, repetitive patterns of behavior, interests, or activities. Because autism is a spectrum disorder, autistic individuals are a highly heterogeneous group and differ widely in the presentation and severity of their symptoms. The established prevalence of ASD is approximately 1% of the population.
Information about autism in adulthood is limited; most of the literature examines childhood and adolescence. While the term “later life” has traditionally been associated with those over the age of 65, a dire lack of understanding exists for those on the autism spectrum beyond early adulthood.
Individuals remain on the spectrum into later life, though some mild improvements in symptoms are observed over time. Autistic adults experience high levels of physical and mental health comorbidities. Rates of participation in employment and education are also lower than that of the general population. Quality of life is reportedly poorer for autistic adults than for nonautistic peers, though this is not affected by age. More robust studies of the health, well-being, and needs of autistic adults are needed, especially qualitative investigations of adulthood and aging and longitudinal studies of development over the lifespan.
Amanda L. Rebar
Much of our sport and physical activity behavior is regulated by processes occurring outside of conscious awareness. In contrast, most sport and physical activity research focuses on processes that are easily accessible by conscious introspection. More and more, however, research is demonstrating that automatic regulation is instrumental to our understanding of how to get people to maintain a physically active lifestyle and how to get the most out of people’s sports performance potential. Automatic regulation is the influence on our thoughts and actions that result from the mental network of associations we use to make sense of the world around us. Habits are automatic associations of cues with behavioral responses. Automatic evaluations are automatic associations of cues as being good or bad. Automatic schemas are automatic associations of cues with actual or ideal self-identity. These processes have been assessed with implicit measures by making indirect inferences from self-report or response latency tasks. Emerging research demonstrates that automatic associations influence sport performance and physical activity behavior, but further work is still needed to establish which type of automatic regulation is responsible for these influences and how automatic regulation and reflective processes interact to impact movement.
Anne Josephine Dutt, Hans-Werner Wahl, and Manfred Diehl
The term Awareness of Aging (AoA) incorporates all aspects of individuals’ perceptions, behavioral experiences, and subjective interpretations related to their process of growing older. In this regard, AoA goes beyond objective descriptions of the aging process, such as calendar age or biological age. Commonly used AoA constructs referring to the ongoing experience of the aging process encompass concepts such as subjective age, attitudes toward one’s own aging, self-perceptions of aging, and awareness of age-related change. AoA also incorporates elements that are more pre-conscious in nature, such as age stereotypes and culturally held notions about the aging process. Despite their theoretically broad common foundation, AoA constructs differ according to their specific frames of reference, such as whether and how they take into account the multidimensionality and multi-directionality of development. Examining the existing body of empirical work identifies several antecedents of AoA, such as sociodemographic “background” variables, physical health and physical functioning, cognition, psychological well-being and mental health, psychological variables (e.g., personality, anxiety), and life events. In general, more positive manifestations on these variables are accompanied by a more positive perception and evaluation of the aging process. Moreover, AoA is longitudinally linked to important developmental outcomes, such as health, cognition, subjective well-being, and mortality. Overall, the study of AoA has developed as a promising area of psychological aging research that has grown in its conceptual and empirical rigor during recent years.
Lizbeth Benson and Nilam Ram
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Psychology. Please check back later for the full article.
In ecological sciences, biodiversity is the dispersion of organisms across species and is used to describe the complexity of systems where species interact with each other and the environment. Typically, higher biodiversity is indicative of health and resilience of the ecosystem because each species performs functional roles, which means the ecosystem has greater capability to respond, maintain function, resist damage, and recover quickly from perturbations or disruptions. In behavioral sciences, diversity-type constructs and metrics are being used to describe a broad range of psychological, social, behavioral, physical and environmental phenomena. Emodiversity, for instance, is the dispersion of an individual’s emotion experiences across emotion types (e.g., happy, anger, sad). Although not always explicitly labeled as such, many core propositions in lifespan developmental theory—such as differentiation, dedifferentiation, and integration—imply intraindividual change in diversity and/or interindividual differences in diversity. The relevance of diversity to a broad range of phenomena and the utility of biodiversity metrics for quantifying dispersion across categories in multivariate and/or repeated measures data suggests further use of biodiversity conceptualizations and methods in studies of lifespan development.
Thomas M. Hess, Erica L. O'Brien, and Claire M. Growney
Blood pressure is a frequently used measure in studies of adult development and aging, serving as a biomarker for health, physiological reactivity, and task engagement. Importantly, it has helped elucidate the influence of cardiovascular health on behavioral aspects of the aging process, with research demonstrating the negative effect of chronic high blood pressure on various aspects of cognitive functioning in later life. An important implication of such research is that much of what is considered part and parcel of getting older may actually be reflective of changes in health as opposed to normative aging processes. Research has also demonstrated that situational spikes in blood pressure to emotional stressors (i.e., reactivity) also have implications for health in later life. Although research is still somewhat limited, individual differences in personal traits and living circumstances have been found to moderate the strength of reactive responses, providing promise for the identification of factors that might ameliorate the effects of age-related changes in physiology that lead to normative increases in reactivity. Finally, blood pressure has also been successfully used to assess engagement levels. In this context, recent work on aging has focused on the utility of blood pressure as a reliable indicator of both (a) the costs associated with cognitive engagement and (b) the extent to which variation in these costs might predict both between-individual and age-related normative variation in participation in cognitively demanding—but potentially beneficial—activities. This chapter elaborates on these three approaches and summarizes major research findings along with methodological and interpretational issues.
Leslee A. Fisher and Lars Dzikus
Bullying is a growing problem in sport and performance settings. Bullying falls under the umbrella of “athlete maltreatment,” which includes any form of harm and all relationships where harm could occur in sport and performance. Specifically, bullying is defined as repeated hostile and deliberate behavior from one person (the perpetrator) to another (the target) with the intent to harm or threaten harm to the target; it is marked by an imbalance of power. Often, after extreme bullying, the target feels terrorized.
Athlete maltreatment in sport and performance has been categorized into one of two forms: relational maltreatment and nonrelational maltreatment. Bullying is a relational problem. In particular, sport and performance bullying can occur from coach to player, parent to player, or player to player, and often takes the form of (1) making unreasonable performance demands of the target, (2) repeated threats to restrict or remove the target’s privileges or opportunities, (3) screaming or yelling directed at the target that is unwarranted, (4) repeated and continual criticism of the target’s abilities, (5) discounting or denying the target’s accomplishments, (6) blaming the target for his or her mistakes, (7) threats of and/or actual physical violence toward the target, and (8) social media or e-mail messages with threats or insults toward the target.
Sport and performance organizations should develop and implement antibullying policies. Six potential steps toward policy development and implementation include: (1) defining bullying behaviors, (2) referring to existing “best-practice” bullying policies, (3) specifically outlining the reporting of bullying incidents, (4) outlining clearly investigation and disciplinary actions to be taken, (5) outlining specific assistance for bullying targets, and (6) including prevention and training procedures. In the meantime, coaches as well as parents and players can recognize that they are role models for everyone with whom they come into contact in sport and performance settings. Coaches, parents, and players can also accept responsibility for creating a respectful and safe sport and performance environment, have a pre-season meeting to discuss antibullying policy, foster open and honest communication, accept critical feedback, not engage or allow bullying behavior themselves, create acceptable boundaries between themselves and others, and teach players to trust their instincts when things do not feel right. More advanced bullying prevention and training procedures can then take place.
Robert C. Eklund and J.D. Defreese
Athlete burnout is a cognitive-affective syndrome characterized by perceptions of emotional and physical exhaustion, reduced accomplishment, and devaluation of sport. A variety of theoretical conceptualizations are utilized to understand athlete burnout, including stress-based models, theories of identity, control and commitment, and motivational models. Extant research has highlighted myriad antecedents of athlete burnout including higher levels of psychological stress and amotivation and lower levels of social support and psychological need (i.e., autonomy, competence, relatedness) satisfaction. Continued longitudinal research efforts are necessary to confirm the directionality and magnitude of these associations. Moreover, theoretically focused intervention strategies may provide opportunities for prevention and treatment of burnout symptoms via athlete-focused stress-management and cognitive reframing approaches as well as environment-focused strategies targeting training loads and enhancement of athlete psychological need satisfaction. Moving forward, efforts to integrate research and practice to improve burnout recognition, prevention, and intervention in athlete populations likely necessitate collaboration among researchers and clinicians.
Benjamin T. Mast and Diana DiGasbarro
Clinicians conduct capacity evaluations to determine an older adult’s ability to make and execute a decision within key domains of functioning. Questions of capacity often arise when an older adult experiences a decline in cognitive functioning due to Alzheimer’s disease, stroke, or severe psychiatric illness, for example. Capacity is related to legal competency, and a lack of capacity may be proved by providing evidence that an older adult is unable to understand the act or decision in question; appreciate the context and consequences of the decision or act; reason about the potential harms and benefits; or express a choice. Capacity is domain-specific, time-specific, and decision-specific. Domains include financial capacity, medical treatment and research consent capacity, driving capacity, sexual consent capacity, and voting capacity. Each capacity domain encompasses activities that may vary in complexity or risk, and thus require different levels of capacity. For example, within the medical treatment consent capacity domain, an older adult may lack the capacity to consent to a complicated and risky surgical procedure while retaining the capacity to consent to a routine blood draw. Clinicians determine capacity by using a combination of tools including capacity assessment instruments, task-specific functional evaluations, interviews with the patient and family members, measures of cognitive functioning, and consideration of social, physical, and mental health factors. Extensive research has been conducted to determine the reliability and validity of a variety of capacity assessment instruments for many domains. These instruments generally assess the patient’s responses to vignettes pertaining to the domain in question, information gleaned from structured and semi-structured interviews, functional ability, or a combination of these methods. Although there is still need for more research, especially in emerging domains, capacity assessments help to protect vulnerable older adults from harm while allowing them to retain the highest possible level of autonomy.
Caring for an older adult who needs help or supervision is in many cases associated with mental and physical health issues, especially if the care recipient has dementia, although positive consequences associated with caregiving have also been reported. Several theoretical models have shown the relevance of psychological variables for understanding variations in the stress process associated with caregiving and how interventions may benefit from psychological techniques and procedures.
Since the 1990s it has been witnessed an increment in the number of studies aimed at analyzing caregiver health and developing and testing interventions for decreasing caregiver distress. Several examples of interventions for helping caregivers are considered empirically supported, including interventions for ethnically and culturally diverse caregivers, with psychotherapeutic and psychoeducational interventions showing strong effect sizes. However, efforts are still needed to maintain the results of the interventions in the long term and to make the interventions accessible (e.g., through technological resources) to a large number of caregivers who, because of time-pressure issues associated with caregiving or a lack of support, are not benefiting from them. Making these interventions available in routine healthcare settings would help a large population in need that presents with high levels of psychological suffering.