Changes In Self-perception Research Articles

A Qualitative Study to Assess the Impact of Iatrogenic Trigeminal Nerve Injury.

To deepen knowledge of the impact of iatrogenic trigeminal nerve injury on dental patients. One-to-one semi-structured interviews and workshops were conducted with 12 patients who had incurred a nerve injury from dental treatment. Nerve injury was diagnosed by oral surgeons via a series of neurosensory tests. Interpretive phenomenologic analysis was used to analyze the narratives from the interviews. Key themes are presented and discussed. These include the personal impact for the patient (which includes a change in self-perception), the impact on relationships, the impact on oral health care, and adjustment to the injury over time. Patients also discussed a change in how they perceived their dentist and other health care professionals and highlighted factors they would like to change within the dental care system. Recommendations are made for clinical practice and future research.

The collaborative care project: A practice-based approach to interprofessional education in a primary healthcare setting in South Africa.

There is global evidence that primary healthcare (PHC) leads to improved health outcomes. In the South Africa PHC model, the PHC team identifies healthcare needs through community visits. For health professional students to learn this PHC model requires an immersed, interprofessional community experience. A select number of final year undergraduate health science students from Stellenbosch University, South Africa spend six weeks to one full year working at a rural clinical school with the focus on contextualised, transformative and interprofessional clinical training. The collaborative care project is one of the opportunities aimed at exposing students to contextual interprofessional training in a resource constrained community. Students are challenged to collaboratively find potential solutions to problems patients face using local resources, with the aim of improving patient outcomes and transforming students into collaborative change agents. Students, under the supervision of local community health workers, are tasked with conducting interprofessional home visits for discharged patients or patients identified by community members. Possible environmental, personal and health risk factors are identified and referrals made to existing community or state facilities for further management. The collaborative care project has resulted in improved patient identification, accessibility to available resources and referral. Students recognise the value of contextualised collaborative clinical training to shape them as clinicians. Challenges and successes are shared to encourage more practical, community based opportunities for collaborative care. Reciprocal teaching and learning take place and students express a change in self-perception, team identity and improved role clarification. This project creates an opportunity for students and community to improve their understanding of precipitating factors to illness, which are not often considered as routine health care and to find local solutions to problems identified.

Self-Assessments of Standardized Scalp Massages for Androgenic Alopecia: Survey Results.

IntroductionStandardized scalp massages (SSMs) improve hair thickness in nonbalding men, but their effects on androgenic alopecia (AGA) have not yet been evaluated. The objective of this study was to investigate the effect of SSMs on self-assessed AGA sufferers (SAGASs).MethodsBetween October 2016 and October 2017, 1899 SAGASs searching online for hair loss treatments beyond AGA management drugs accessed literature explaining SSMs as a potential therapy for AGA, then watched a demonstration video detailing twice-daily, 20-min SSMs segmented by three rotational scalp regions using hand-generated presses, pinches, and stretches. In December 2017, SAGASs were contacted once to participate in a retrospective survey study to assess SSM adherence and hair changes. Age, gender, hair loss region and gradient, diet, supplement and topical use, AGA management drug use, estimations for minutes daily and months of massaging, and self-perceived hair changes were reported. Some participants also submitted photosets documenting hair changes throughout SSM adherence.ResultsA total of 340 (17.9%) respondents completed the survey, and 327 (17.2%) reported attempting the SSMs. SSM participants reported a median daily massage effort of 11–20 min and mean adherence of 7.4 ± 6.6 months, with 68.9% reporting hair loss stabilization or regrowth. Estimated minutes daily, months, and total SSM effort (i.e., minutes daily × months) were positively associated with self-perceived hair changes. On average, perceived hair loss stabilization and regrowth occurred after 36.3 h of SSM effort. Results did not vary across age, gender, Norwood gradient, or concomitant supplement, topical, finasteride, minoxidil, or microneedling use. However, hair change improvements were marginally lower for participants reporting diffuse versus frontal/temporal or vertex thinning.ConclusionsWhile further research is warranted, these results align with previous findings and suggest the potential for SSMs to improve AGA.Electronic supplementary materialThe online version of this article (10.1007/s13555-019-0281-6) contains supplementary material, which is available to authorized users.

Social Determinants of Health Training in U.S. Primary Care Residency Programs: A Scoping Review.

Medical training has traditionally focused on the proximate determinants of disease, with little focus on how social conditions influence health. The authors conducted a scoping review of existing curricula to understand the current programs designed to teach primary care residents about the social determinants of health (SDH). In January and March 2017, the authors searched seven databases. Eligible articles focused on primary care residents, described a curriculum related to SDH, were published between January 2007 and January 2017, and were based in the United States. Of the initial 5,523 articles identified, 43 met study eligibility criteria. Most programs (29; 67%) were in internal medicine. Sixteen studies (37%) described the curriculum development process. Overall, 20 programs (47%) were short or one-time sessions, and 15 (35%) were longitudinal programs lasting at least 6 months. Thirty-two programs (74%) reported teaching SDH content using didactics, 22 (51%) incorporated experiential learning, and many programs (n = 38; 88%) employed both. Most studies reported satisfaction and/or self-perceived changes in knowledge or attitudes. The authors identified wide variation in curriculum development, implementation, and evaluation. They highlight curricula that considered community and resident needs, used conceptual frameworks or engaged multiple stakeholders to select content, used multiple delivery methods, and focused evaluation on changes in skills or behaviors. This review highlights the need not only for systematic, standardized approaches to developing and delivering SDH curricula but also for developing rigorous evaluation of the curricula, particularly effects on resident behavior.

Understanding the psychosocial impact of weight loss following bariatric surgery: a qualitative study

BackgroundBariatric surgery leads to changes in mental health, quality of life and social functioning, yet these outcomes differ among individuals. In this study, we explore patients’ psychosocial experiences following bariatric surgery and elucidate the individual-level factors that may drive variation in psychosocial outcomes.MethodsEleven semi-structured focus groups with Michigan Bariatric Surgery Collaborative (MBSC) patients (n = 77). Interviews were audio recorded, transcribed verbatim, and analyzed using a grounded theory approach. Data on participant demographic characteristics were abstracted from the MBSC clinical registry.ResultsMost focus group participants were female (89%), white (64%), and married (65%). We identified three major themes: (1) change in self-perception; (2) change in perception by others; and (3) change in relationships. Each theme includes 3 sub-themes, demonstrating a range of positive and negative psychosocial experiences. For example, weight loss led to increased self-confidence among many participants while others described a loss of self-identity. Some noted improved relationships with family or friends while others experienced worsening or even loss of relationships due to perceived jealousy.ConclusionWeight loss following bariatric surgery leads to complex changes in self-perception and inter-personal relationships, which may be proximal mediators of commonly assessed mental health outcomes such as depression. Individuals considering bariatric surgery may benefit from anticipatory guidance about these diverse experiences, and post-surgical longitudinal monitoring should include evaluation for adverse psychosocial events.

Changes in self-perception in patients treated with neurostimulating devices

BackgroundIn recent years, qualitative changes in self-perception have been reported in individual patients undergoing brain stimulation to treat their neurological disease. We here report a first systematic study addressing these unwanted treatment effects in a semiquantitative way. HypothesesHypothesis 1 (H1): Changes in self-perception can be detected and documented in patients following interventions with various neurostimulating devices using standardized assessment tools.Hypothesis 2 (H2): Central nervous-implanted neurostimulating devices (deep brain stimulation [DBS]) will have a greater impact on the patient's self-perception than “peripheral” implanted devices (implanted vagus nerve stimulation [iVNS]) and external devices (transcutaneous vagus nerve stimulation [tVNS] or transcutaneous electrical trigeminal nerve stimulation [eTNS]). MethodsApplication of a newly developed semiquantitative questionnaire (FST-questionnaire [Fragebogen zur Veränderung der Selbstwahrnehmung unter tiefer Hirnstimulation]: Questionnaire regarding changes in self-perception while treated with DBS) to systematically assess changes in self-perception in a single-center, cross-sectional pilot-study at the University Hospital Freiburg, Germany on 50 patients (44% male; age 50 years [range: 27–73 years]), undergoing neurostimulation (DBS, iVNS, tVNS, or eTNS) to treat Parkinson's disease or epilepsy. ResultsStandardized assessment detected alterations in self-perception in all treatment groups (H1 approved). This included rare self-alienating changes in self-perception. Unexpectedly, peripheral neurostimulation had similar effects as central stimulation techniques. ConclusionsProperly designed questionnaires – like the FST-questionnaire as standardized assessment tool – can detect changes in self-perception in patients during neurostimulatory treatment in a wide spectrum of brain stimulation techniques. This may provide a strategy to systematically identify the subgroup of patients liable to experience such problems during treatment already prior to treatment decisions.

The Aftermath of Shelter: Abused Arab Women in Israel

Shelters for battered women play a major role in combating abuse against women. Extensive research has dealt with various aspects of shelters, including professional and ideological perceptions and the women’s experiences. However, scarce research exists on women’s coping following shelter-stay, especially research on the meaning of shelter-stay for women from collectivist societies. In the present study, we focused on how Arab women who had lived in a shelter coped after returning to the community to begin independent lives. In the Arab society in Israel, Arab women who live in shelters are perceived as violating a cultural norm. In-depth qualitative interviews were conducted with 12 Arab women aged between 25 and 42, who had stayed in a shelter for Arab women for at least six months.The major themes that emerged from the interviews revealed changes in perception of self and of social environment, including a self-transformation from weakness to strength, from perceiving themselves as devoid of rights to the development of an identity of entitlement. Through their release from weakening cultural systems, they were transformed from familial and societal victims to empowered beings, and moved from negative gender self-awareness to an empowered gender self-perception. These changes helped the interviewees to cope with stresses and to live independently. The findings are conceptualized in the discussion using relational-cultural theory.

Subjective Cognitive Decline and APOE ɛ4: A Systematic Review.

Individuals with subjective cognitive decline (SCD) report self-perceived declines in cognitive function but perform within normal limits on standardized tests. However, for some, these self-perceived changes may herald eventual decline to Alzheimer's disease (AD). In light of this, the relationship between SCD and APOE ɛ4, a known genetic risk factor for AD, has garnered interest; however, no systematic review of this literature exists. The current review (n = 36 articles) examined the prevalence of APOE ɛ4 in SCD samples relative to healthy and objectively impaired samples, and summarized APOE ɛ4-related risk of conversion from SCD to AD. Univariate ANOVA indicated that APOE ɛ4 frequency was comparable between healthy control and SCD samples, yet significantly higher in objectively impaired samples (i.e., MCI, AD) relative to either of these groups. Narrative review provided mixed evidence linking coincident APOE ɛ4-positive genotype and SCD to structural neuropathology. Though there was little evidence to suggest that APOE ɛ4 predisposes individuals to developing SCD, both APOE ɛ4 and SCD were found to confer individual and multiplicative risk of conversion to objective cognitive impairment. Combined, it is likely that a relationship between APOE ɛ4, SCD, and AD exists, though its exact nature remains undetermined. A clearer understanding of these relationships is hindered by a lack of standardization in SCD classification and a dearth of longitudinal outcome research. Wide-scale adoption of genetic screening for dementia risk in persons with SCD is considered premature at this time. Ethical considerations and clinical implications of genetic testing for dementia risk are discussed.

Distinguishing change in self-perception by Self-Figure Drawings in Subjects Who Underwent Different Breast Cancer Treatments

Distinguishing change in self-perception by Self-Figure Drawings in Subjects Who Underwent Different Breast Cancer Treatments

Doing Time Wisely: The Social and Personal Benefits of Higher Education in Prison

Much of the research on postsecondary education effects on incarcerated individuals has focused on men. However, given the increased rates of women’s imprisonment over the past 40 years, scholars should examine the impact of higher education in prison on women. In this qualitative study, the authors assess the social and personal benefits of participating in a college behind bars program delivered in a women’s prison. Data gathered with both program participants and faculty suggest that students in the program experienced a reduction in criminogenic attitudes and behaviors as well as positive changes in self-perception.

The Fountain of Health: effective health promotion knowledge transfer in individual primary care and group community-based formats.

Assess the effectiveness of FoH KT delivered in individual and group-based formats. Pre- and post-intervention quality assurance survey of FoH KT. Interventions occurred in Nova Scotia, Canada. Adults over age 50 years without pre-existing dementia were targeted. A total of 92 participants received FoH KT in individualized (n = 41) and group-based (n = 51) formats. FoH KT (e.g. sharing evidence, lifestyle coaching, and goal setting) using a range of KT supports (e.g. FoH website, paper materials) was delivered to (1) individual patients by primary care clinicians and (2) community-based groups by lay leaders. The main outcome measure was participant pre- and post-quality assurance self-reports. Improvements were found in participant awareness of FoH, knowledge of evidence-based mental health promotion initiatives, and in application of this information in daily life in both individual and group-based settings. Improvements in participant knowledge about epigenetic factors that impact health and confidence with health behavior goal setting were reported in both contexts. Changes in self-perceptions of aging scores reached significance in the group intervention. FoH KT produced short-term positive self-reported changes in participants in both individual and group formats. Larger control studies with long-term follow up are needed to better assess effects of both individual and group formats of FoH KT and longer term impacts on health behaviors and outcomes.

A Qualitative Investigation of the Self-Perceived Health Behavior Changes in Seniors After Their Transitions Into a Retirement Home.

It is important for seniors to engage in positive health behaviors to reduce the incidence of health-related consequences associated with aging. The purpose of this research study was to examine self-perceived changes in physical activity, nutrition, and alcohol consumption behaviors of seniors living in a retirement home through consideration of previous behaviors and self-perceptions of behavior changes. A qualitative research design was used for this study. Semistructured one-on-one interviews were conducted with 9 Canadian women living in a retirement home. Two key themes, each with 3 subthemes, highlighted the various factors that influenced changes in health behaviors. The 2 themes consisted of (a) aging and adapting and (b) the transition: give a little to gain a lot. Participants' insights revealed the importance of maintaining a positive attitude, the influence of the social environment on health behaviors, and the nutritional sacrifices of retirement living. Future research should investigate ways in which nurses can assist seniors in enhancing health behaviors throughout transitions into retirement homes.

One-step intraoperative radiotherapy optimizes conservative treatment of breast cancer with advantages in quality of life and work resumption

BackgroundIntraoperative radiotherapy (IORT) could be not-inferior to external beam radiotherapy (EBRT) in selected patients, but toxicities, self-perception of body image, quality of life, and resumption of work or daily activities have been poorly explored. The aim of the present study was to compare these outcomes between EBRT, IORT full-dose (IORT-f) and IORT boost (IORT-b). Methods443 consecutive patients, candidates for breast-conserving surgery, were included: EBRT was performed in 220 patients (49.7%), IORT-f in 140 patients (31.6%), and IORT-b in 83 patients (18.7%). Radiotherapy-related toxicities were registered. Patients were evaluated at 6 months for Body Image after Breast Cancer Questionnaire (BIBCQ) to assess possible changes in self-perception of body image and limitations. A second questionnaire explored the impact of EBRT, IORT-f and IORT-b on resumption of work and normal daily activities. ResultsEBRT had a higher risk of breast fibrosis and retraction (OR 3.58, 95% CI 1.024–12.526, p = 0.046) and breast edema (OR 6, 95% CI 2.077–17.335, p = 0.001) compared to IORT-f, but a lower risk of seroma compared to IORT-b (OR 0.36, 95% CI 0.166–0.785, p = 0.01). The BIBCQ scores showed a better outcome in arm concerns with IORT-f (−3.3) vs. IORT-b (−1.3, p = 0.002) and EBRT (−1.7, p = 0.006), although biased by the lower rate in axillary dissections. Return to daily activities occurred after 70.6 days with EBRT vs. 41 days with IORT-f (p < 0.0001) and 53.3 days with IORT-b (p = 0.07), without any effect of age or axillary dissection. ConclusionIORT could reduce adverse effects, allowing faster resumption of job and houseworks.

Photovoice and empowerment: evaluating the transformative potential of a participatory action research project

BackgroundPhotovoice is a visual research methodology with the intention to foster social change. Photovoice has been used to investigate change in empowerment in vulnerable communities, However, the individual experience of participants involved in Photovoice projects is seldom scrutinized. Our aim was to explore and describe the individual experiences of the female individuals who participated in a previous Photovoice project. We analyzed a change in the women’s empowerment in terms of: 1) gain in knowledge and skills, 2) change in self-perception, and 3) access to and use of resources.MethodsThis qualitative study took place in the low-income District of Villaverde (Madrid, Spain), from January-June 2016. We conducted 10 semi-structured interviews with the female residents who had participated in the previous Photovoice project. We also collected field notes. We analyzed these data through a direct qualitative content analysis. The three outlined dimensions of empowerment provided guidance for the analysis of the results.ResultsWe found positive changes in the three dimensions of empowerment: 1) participants acquired new knowledge and developed critical awareness of their community; 2) the social recognition participants received transformed their self-perception; and 3) the project allowed them to expand their social networks and to build new links with different actors (research partners, local decision makers, media and the wider public).ConclusionsPhotovoice projects entail the opportunity for empowering participants. Future research using Photovoice should assess the influence it has on participants’ empowerment changes and how to sustain these individual and social changes.

Education to Improve Dementia Care: Impact of a Structured Clinical Reasoning Approach.

Dementia often goes undiagnosed. A workshop was developed to provide primary care clinicians with a structured clinical reasoning approach to dementia diagnosis and brain map tool to differentiate type of dementia. The purpose of this study was to examine the impact of this approach on self-perceived changes in knowledge, confidence, and ability to assess and manage memory problems and on self-reported application of learning to clinical practice. Participants of 20 workshops (N=392) were invited to complete a reaction survey and of these, participants of 12 consecutive workshops (N=242) were invited to complete a 3-month follow-up survey to assess application of new learning to clinical practice and challenges experienced in doing so. In total, 355 reaction and 108 follow-up surveys were completed. Mean ratings of usefulness reflected that participants considered the clinical reasoning approach and brain map very useful to learning and knowledge transfer. At follow-up, the majority of respondents reported they were more confident (79%) and better able to assess (79%) persons with cognitive impairment and more confident (88%) and better able to manage (86%) persons with cognitive impairment. A number of practice changes and challenges were identified. These results add to a growing literature on strategies to improve dementia care with effective continuing medical education. A structured clinical reasoning approach to cognitive impairment is effective in improving confidence and ability to assess and manage patients with cognitive impairment, although participants continue to experience challenges in managing this complex condition.

Feeling the sound – short-term effect of a vibroacoustic music intervention on well-being and subjectively assessed warmth distribution in cancer patients—A randomized controlled trial

ObjectivesSo far, the effects of vibroacoustic music therapy in cancer patients are unknown. However, used in anthroposophic medicine, it could be an approach to enhance well-being.The goal of this study was to evaluate the immediate effects of a sound-bed music intervention with respect to the subjective well-being as well as body warmth and pain. Patients and methodsWe treated 48 cancer patients with 10 min of sound-bed intervention in a cross-over design. Primary outcome was the total sum of the Basler Mood Questionnaire (BMQ), secondary outcomes were subscales of the BMQ and questions addressing body warmth and pain. The EORTC-QLQ C30 was used as baseline assessment for quality of life (QOL). ResultsPatients had lower QOL values than the EORTC reference samples (p < .001, d = 0.90). The primary outcome increased after music (p < .001, d = 0.47), no changes were seen in the control condition (p = .73, d = 0.04), the time by condition interaction was significant (p < .05). Secondary outcomes: Increase after music for the BMQ subscales inner balance (p < .001, d = 0.73), vitality (p < .001, d = 0.51) and vigilance (p < .001, d = 0.37) as well as for the additional questions satisfaction (p < .001, d = 0.43), current mood (p < .001, d = 0.43), body warmth (p < .05, d = 0.44) and warmth distribution (p < .01, d = 0.49). No significant changes were seen in pain levels and social extroversion. ConclusionSound-bed intervention improved momentary well-being and caused self-perceived physiological changes associated with relaxation beyond the benefits of simple resting time (control condition). Thus, it might be a promising approach to improve well-being in cancer patients.

Making space for a new role – gender differences in identity changes in couples transitioning to parenthood

Changes in life roles reflect the process of reorganization of identity, which is an important component of adaptation during transition to parenthood. During this family transition gender differences are significant. Despite the fact that in Western societies women and men are encouraged to share family and work responsibilities, female self-concept is more strongly associated with motherhood, whereas men still highly value the role of a breadwinner. Therefore, relative perceived and desired salience, and directly assessed importance of main life roles (a spouse, a worker and a parent) before and after the birth of the child were examined. One hundred and eighty-seven couples participated in the study. The perceived (relative and directly assessed), and relative desired salience of a parental role increased after the child’s birth in both genders. Women valued the parent role higher than men who deemed the worker role more salient to their identity after the child’s birth. Spouse identity seemed to be created in the couple itself as both partners assessed it similarly. Inclusion of couples and repeated measurement of all variables allowed for the analysis of complex changes in self-perceptions in transitions to motherhood and fatherhood.

Patient satisfaction and oral health-related quality of life 10–15 years after orthodontic-surgical treatment of mandibular prognathism

This study investigated 36 patients at 10–15 years after they had undergone mandibular setback surgery by intraoral vertical ramus osteotomy (IVRO) and subsequent intermaxillary fixation for 6 weeks. The patients completed a 37-item structured questionnaire to evaluate patient satisfaction and possible long-term effects of the treatment. Visual analogue scales were used to measure self-perceived changes in seven items concerning oral function and appearance. Oral health-related quality of life was assessed using the Oral Impacts on Daily Performance (OIDP) index. The main reasons for seeking treatment were to improve chewing function and appearance. The treatment had resulted in significant improvements regarding chewing function, appearance, bullying, and self-confidence in social settings (all P<0.05). All patients were either very satisfied (61%) or reasonably satisfied (39%) with the treatment result. The mean OIDP frequency score was 8.49 on a scale from 8 to 40. Seventy-four percent of the patients reported no oral impacts on quality of life. In conclusion, 10–15 years after combined orthodontic and IVRO surgical treatment of mandibular prognathism, the patients were satisfied, and oral health-related quality of life was reported to be good.

Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life

BackgroundAn early observation after chest wall correction is direct inspection from the PE patient of their “new” thorax. Changes in self-perception may give raise to other psychological adaptations. The aim of this study was to evaluate the early changes in the fields of self-esteem, body image and QoL.MethodsProspective observational longitudinal multicenter cohort study. Self-esteem, emotional limitations and general health were assessed using the Child Health Questionnaire (CHQ) in patients under 18 and the World Health Organization Quality of Life Questionnaire-bref (WHOQOL-bref) was used for body image, psychological domain and overall QoL in patients over 16 years of age. Measurements were taken before surgery (T1) and 6 weeks (T2), and 6 months thereafter (T3).ResultsScores on post-operative self-esteem were significantly higher compared with scores pre-operatively (p < 0.007). Also body image, psychological domain and emotional limitations showed significant improvement, respectively p < 0.001, p < 0.001, and p < 0.016. Significant improvement in the first three components was mainly achieved in the first 6 weeks post-operative. In emotional limitation, however, the largest change was between 6 weeks and 6 months. Overall quality of life in the WHOQOL-bref and general health domain in the CHQ showed no significant improvement in relation to the pre-operative scores.ConclusionPost-operative PE patients after Nuss procedure showed an improved body image, increased self-esteem and increased psychological resilience in the first 6 months, with the most marked change in the first 6 weeks. Also emotional limitations changed significantly over time. The changes were not large enough to influence general QoL or general health significantly.

“I Smoke Like This to Suppress These Issues That Are Flaws of My Character”: Challenges and Facilitators of Cessation Among Smokers With Bipolar Disorder

ABSTRACTObjective: Smokers with bipolar disorder (BD) have low rates of successful quitting, yet no prior studies have evaluated the process of quitting among these smokers in the context of a current quit attempt. To facilitate development of more effective interventions, we conducted a qualitative exploration of challenges and facilitators of quitting in an intervention study for smokers with BD. Methods: Participants were adult daily smokers with BD (n = 10) who completed a 10-week smoking cessation intervention consisting of Acceptance and Commitment Therapy (ACT) and nicotine patch. We administered semistructured interviews focused on the quitting process at the end of treatment and used inductive content analysis to extract themes. Results: Emergent themes representing challenges of quitting included social impediments, lack of awareness, avoidance, maladaptive beliefs, ambivalence, benefits of smoking, and difficulties with nicotine replacement. Themes representing change facilitators included positive treatment effects (ACT-specific, nonspecific, and nicotine patch-related), coping behaviors, reasons to quit, changes in self-perception, and social benefits. Conclusions: Results suggest a need for assistance with obtaining social support and handling social impediments, interrupting the automaticity of smoking, expanding the behavioral repertoire to handle aversive internal states that tend to be avoided by smoking, preventing maladaptive beliefs from interfering with quitting, taking meaningful action toward change while experiencing ambivalence, either replacing the benefits of smoking or accepting their loss, and troubleshooting difficulties with nicotine replacement. Findings regarding facilitators of quitting supported previous quantitative findings that the ACT intervention impacted theory-based targets and highlighted the importance of the counseling relationship.