Miller Behavioral Style Scale Research Articles

The relationship between health sciences students' knowledge of cancer and behavioral styles

Objective: This study aimed to determine the relationship between knowledge of cancer and behavioral styles of health sciences faculty students registered at a state university. Method: The study is cross-sectional and descriptive. The study sample consisted of 1204 students at the Faculty of Health Sciences of a state university in Istanbul during the 2018-2019 fall semester. The Questionnaire Form and Miller Behavioral Style Scale (MBSS) were administered to the students. The data were evaluated using the SPSS package program in the computer environment. Results: The students’ mean age was 20.74±2.603. It was determined that at least one relative of 32.2% of the students had cancer, grandfathers mostly had cancer, and lung cancer was the most common cancer. A statistically significant difference was found upon examining the knowledge of cancer risks and early diagnosis methods of the students with and without a family history of cancer. The mean MBSS score was found to be 6.49±4.085 for students with a family history of cancer, and 5.97±4.092 for students without a family history of cancer. There was a significant difference when statistically comparing the mean MBSS scores of the students with and without a family history of cancer. Conclusion: Students with a family history of cancer were more knowledgeable about cancer risk factors and early diagnosis methods and applied early diagnosis methods such as mammography, clinical breast examination, and endoscopic examinations. Furthermore, the mean MBSS scores of students with a family history of cancer were higher than those without a family history of cancer.

Effects of pre-operative education tailored to information-seeking styles on pre-operative anxiety and depression among patients undergoing percutaneous coronary intervention: A randomized controlled trial

ObjectiveThis study aimed to evaluate the impact of pre-operative education tailored to percutaneous coronary intervention (PCI) patients’ information-seeking styles on pre-operative anxiety and depression. MethodsA single-blind randomized control trial was conducted. A total of 114 participants were recruited from the cardiology department in a tertiary hospital in Kunming, Southwest China from April to September 2020 and randomly allocated to the intervention group (n = 57) or control group (n = 57). All patients received oral pre-operative education as well as printed pre-operative education manuals and divided into monitors or blunters by the Chinese Version of the Monitoring Subscale of the Miller Behavioral Style Scale (C-MMBSS). The intervention group received pre-operative education tailored to information-seeking styles, while the control group received routine education. Anxiety and depression were measured at baseline and 1 h before the operation. Satisfaction with pre-operative education and length of stay were assessed at discharge. ResultsA total of 104 participants completed the study (52 participants in each group). Pre-operative education tailored to information-seeking styles was beneficial for reducing pre-operative anxiety (P < 0.01), reducing pre-operative depression (P < 0.01), and improving satisfaction with pre-operative education (P < 0.01) compared with routine education. There was no significant difference in length of stay between the intervention and control groups (P = 0.209). Conversely, pre-operative anxiety of patients was increased (P = 0.017) after pre-operative education in the control group. ConclusionThis study confirmed that pre-operative education tailored to information-seeking styles effectively reduces pre-operative anxiety and depression and improves satisfaction with preoperative education.

Cross-cultural adaptation, validity and reliability of the Chinese Version of Miller Behavioral Style Scale

BackgroundHealth education basing on patients’ information-seeking styles can improve the effectiveness of health education and patients’ health outcomes. The Miller Behavioral Style Scale (MBSS) is widely used to identify individual’s information-seeking styles, but the Chinese version is lacking. The study aim was to translate and culturally adapt the MBSS into Chinese version and test the content validity, construct validity and internal consistency reliability of the Chinese version of MBSS (C-MBSS).MethodsThe forward-back-translation procedure was adopted in the translation of the MBSS. Content validity was assessed in a panel of experts. In a sample of 1343 individuals including patients, patients’ caregivers, university students, and medical staff, reliability and construct validity were assessed using Cronbach’s alpha coefficient and factor analysis. The measurement invariance across samples was tested using multigroup confirmatory factor analysis (MGCFA). Floor and ceiling effects were checked.ResultsThe C-MBSS achieved conceptual and semantic equivalence with the original scale. The item-level content validity index (I-CVI) of each item ranged from 0.78 to 1, and the averaging scale-level content validity index (S-CVI/ Ave) was 0.95. The exploratory factor analysis resulted in 2-factor assumption for each hypothetical threat-evoking scenario. Confirmatory factor analysis demonstrated a good fit between theoretical model and data, which provided confirmatory evidence for the second-order factor structure of 2-factor solution (Monitoring and Blunting). The Cronbach's alpha coefficients for the Monitoring and Blunting sub-scales of the C-MBSS were 0.75 and 0.62 respectively. MGCFA results supported the measurement invariance for the Monitoring sub-scale of the C-MBSS across samples. No floor or ceiling effects occurred.ConclusionsThis study indicates that the C-MBSS has good content and construct validity. The Monitoring sub-scale of the C-MBSS had acceptable internal consistency reliability while the Blunting sub-scale had unsatisfactory one, which suggest that the Monitoring sub-scale of the C-MBSS can be used to identify individuals’ information-seeking styles in Chinese contexts across different populations.

EFFECTIVENESS OF INFORMATION PAMPHLET REGARDING LIVER BIOPSY ON ANXIETY AMONG PATIENTS UNDERGOING LIVER BIOPSY

Background: Providing information to the patients before liver biopsy level of patient during procedure.To reduce the anxiety level, coping used as an procedure may decrease the level of anxiety and can improve tolerance alternatives. There are two types of coping present: Monitoring coping style- Individuals who seek information in response to stressful situation and Blunting coping style- Individuals who avoids informationin response to stressful situation. Methods: Convenient sampling was used to enroll 80 patients, randomly assigned to Experimental and Comparison group based on Randomized days using Hospital Anxiety and Depression-sub scale and Miller-Behavioral Style Scale. Results:Out of 40 subjects 24 were monitors and 16 were blunters in the Experimental group and in the Comparison group 25 were monitors and 15 were blunters. There was significant difference found between mean anxiety score of experimental group (6.9) and comparison group (9.03) at t value = 7.557 and p = 0.01. Anxiety of Monitors was significantly less in Experimental group as compared to Comparison group (p value 0.041) at 0.041. Conclusion:Information Pamphlet was found to be effective in decreasing the anxiety of patients undergoing Liver Biopsy.

Effects of monitoring versus blunting on the public's preferences for information in a hypothetical cancer diagnosis scenario.

Monitoring and blunting are coping styles that characterize how people respond when faced with personally threatening situations. High monitors tend to pay more attention to, scan for, and amplify threatening cues; high blunters tend to avoid information and seek distractions when faced with a threatening event. This study sought to investigate possible differential effects of monitoring and blunting coping styles on information preferences in a hypothetical cancer diagnosis scenario in the adult general public of Minnesota. In a survey administered at a large public venue (2016 Minnesota State Fair), participants were asked to imagine they carried a gene mutation and were diagnosed with colon cancer. They indicated their information preference [modified Cassileth Information Styles Questionnaire (MCISQ)], completed two coping style measures [Miller Behavioral Style Scale (MBSS) and Threatening Medical Situations Inventory (TMSI)], rated their perceived severity of colon cancer (low, moderate, high), and answered demographic questions. Eight hundred fifty-five individuals provided usable data. Participants classified as monitors on the TMSI had significantly higher MCISQ scores (i.e., preferred more information) than those classified as blunters (p=.004). Those scoring high on monitoring and low on blunting on the MBSS preferred significantly more information than those scoring high on both monitoring and blunting (p=.04). Linear regression analysis revealed being a monitor (TMSI), scoring high on monitoring (MBSS), rating colon cancer as more severe, and having a higher education level were significant positive predictors of MCISQ scores. Results suggest individual differences in coping style, perceived severity, and education level affect desire for information. Genetic counselors should consider these patient characteristics (e.g., asking patients about their information preferences) and tailor their approaches accordingly.

Creativity, emotional intelligence and coping style in intellectually gifted adults

Although recently there has been a growing interest in gifted adults, the differences between intellectually gifted and nongifted adults in creativity, emotional intelligence and coping style have not yet been deeply studied. In this study, 23 intellectually gifted and 18 intellectually nongifted adults completed the Alternative Uses Task (AUT), the Bar-On Emotional Quotient Inventory (EQ-i), and the Miller Behavioural Style Scale (MBSS). Results indicated that intellectually gifted adults scored higher in the AUT and the blunting subscale of the MBSS than intellectually nongifted adults. However, they showed comparable scores on the EQ-i and the monitoring subscale of the MBSS. This study investigates the characteristics of intellectually gifted adults to adequately support their needs.

Dementia-related anxiety and coping styles associated with suicidal ideation

Objective: Dementia-related anxiety is associated with general anxiety and depression, which are risk factors for suicidal ideation. Consequently, dementia-related anxiety may be associated with suicidal ideation. When faced with a negative event (e.g. developing dementia), individuals primarily employ monitoring or blunting styles of coping. The present study investigated whether dementia-related anxiety and coping styles were associated with suicidal ideation in adults and whether coping styles moderated the relation between dementia-related anxiety and suicidal ideation.Methods: Online Mturk participants (n = 330) completed the Miller Behavioral Style Scale, Dementia Worry Scale, and Patient Health Questionnaire-9. Suicidal ideation was assessed with the Patient Health Questionnaire.Results: Dementia-related anxiety and monitor/blunter coping styles were independently associated with suicidal ideation in a multiple logistic regression; coping styles did not moderate the relation between dementia-related anxiety and suicidal ideation.Discussion: Greater dementia-related anxiety and less use of monitoring coping style were associated with suicidal ideation. Interventions to decrease suicide risk may benefit from taking into account individual differences in dementia-related anxiety and coping styles.

Use of information sources regarding medicine side effects among the general population: a cross-sectional survey.

To determine the use and perceived value of different information sources that patients may use to support identification of medicine side effects; to explore associations between coping styles and use of information sources. Side effects from medicines can have considerable negative impact on peoples' daily lives. As a result of an ageing UK population and attendant multi-morbidity, an increasing number of medicines are being prescribed for patients, leading to increased risk of unintended side effects. A cross-sectional survey of patients who use medicine, recruited from community pharmacies. The survey sought views on attributes of various information sources, their predicted and actual use, incorporating a shortened Side Effects Coping Questionnaire (SECope) scale and the abbreviated Miller Behavioural Style Scale (MBSS). Of 935 questionnaires distributed, 230 (25.0%) were returned, 61.3% from females; 44.7% were retired and 84.6% used at least one medicine regularly. 69.6% had experienced a side effect, resulting in 57.5% of these stopping the medicine. Patient information leaflets (PILs) and GPs were both predicted and actually most widely used sources, despite GPs being judged as relatively less accessible and PILs less trustworthy, particularly by regular medicine users. Pharmacists, considered both easy to access and trustworthy, were used by few in practice, while the internet was considered easy to access, but less trustworthy and was also little used. SECope sub-scales for non-adherence and information seeking showed positive associations with stopping a medicine and seeking information from a health professional. More high monitors than low monitors stopped a medicine themselves, but there were no differences in use of information sources. Information seeking following a side effect is a common strategy, potentially predicted by the SECope, but not the MBSS. Limited GP accessibility could contribute to high internet use. Further research could determine how the trustworthiness of PILs can be improved.

Resilience: a structuring force

The destabilizing power of a traumatic experience has been widely discussed in many studies; however, on the other hand, many studies in psychological literature show a different view of this experience. This study addresses the positive meaning and the transforming power of an event, which, although devastating, reveals to the subject skills, unknown until now. Referring to recent longitudinal studies (Cimino, S., Sinesi, S., Monniello, G., (2012); Cimino, S., Monniello, G., Cerniglia, L., Ballarotto G. (2013) it is proposed to highlight how it is an usual position which is generated in order to deal with the pain. In these studies, the traumatic event taken into account concerns parental loss in children and adolescents (development age) in the attempt to explore, by the use of specific instruments such as Symptom Checklist – 90 – R, (Derogatis, 1994); Eating Attitude Test-40 (Garner and Garfinkel, 1979) and Adolescent Dissociative Experiences Scale (Armstrong et al., 1997), the multiple aspects of the subjective answer to the traumatic event. In addition, a more systemic review is given to the different measures of resilience, such as: dispositional measures (Miller Behavioral Style Scale, Miller, 1987) and situational ones (Ways of Coping Questionnaire, Lazarus and Folkman, 1984); and also, to the psychotherapeutic processes intended as an element to promote the increment of such capacity with a particular reference to the cognitive-behavioral and systemic-relational model. Finally, special attention is given to the protective value of a secure attachment, together with the ability for mentalization, considered as aspects capable of strengthening some important cognitive-emotional self regulation abilities and, therefore, promoting the development of resilient behavior. In conclusion, the many aims of this study are: to provide a right definition of resilience, to try analysing and fixing solutions about the main theoretical controversies over this matter; moreover, this study tries to highlight all those factors that contribute to influence resilient behaviours and to identify strategies and procedures that can facilitate or hinder their execution.

Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU

ObjectiveThe Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience.MethodsParticipants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual’s ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU.ResultsThree hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile.ConclusionDistinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.

Medication-related Self-management Behaviors among Arthritis Patients: Does Attentional Coping Style Matter?

Objective: The aim of this study was to investigate the relationship between the attentional coping styles (monitoring and blunting) of rheumatoid arthritis (RA) and osteoarthritis (OA) patients and: (a) receipt of medication information; (b) receipt of conflicting medication information; (c) ambiguity aversion; (d) medication-related discussions with doctors and spouse/partners; and (e) medication adherence.Method: A sample of 328 adults with a self-reported diagnosis of arthritis (RA n=159; OA n=149) completed an Internet-based survey. Coping style was assessed using the validated short version of the Miller Behavioral Style Scale. Measures related to aspects of medication information receipt and discussion and validated measures of ambiguity aversion and medication adherence (Vasculitis Self-Management Survey) were collected. Pearson correlation coefficients, ANOVA, independent samples t-tests and multiple regression models were used to assess associations between coping style and the other variables of interest.Results: Arthritis patients in our sample were more likely to be high monitors (50%) than high blunters (36%). Among RA patients, increased information-receipt was significantly associated with decreased monitoring (b = -1.06, p = .001). Among OA patients, increased information-receipt was significantly associated with increased blunting (b = .60, p = .02).Conclusion: In our sample of patients with arthritis, attentional coping style is not in accordance with the characteristic patterns outlined in the acute and chronic disease coping literature.

Cognitive Coping Style and the Effectiveness of Distraction or Sensation-Focused Instructions in Chronic Pain Patients.

AimThis study set out to investigate whether cognitive coping strategies that match participants’ preferred coping style effectively reduce pain intensity and situational anxiety in a population of people with chronic pain.MethodChronic pain patients (N = 43) completed questionnaires on coping style, pain intensity, self-efficacy, and situational/trait anxiety. Participants were classified as Monitors (n = 16) or Blunters (n = 19) based on their Miller Behavioural Style Scale score. Participants were then provided with an audiotaped intervention in which they were instructed to focus on pain sensations or to engage in a distraction task and then to rate the pain intensity and their anxiety during and after the attentional focus and distraction conditions. The two interventions were each completed by all participants, having been presented in counterbalanced order.ResultsFindings revealed that Monitors’ level of anxiety decreased following a congruent (i.e., sensation-focused) intervention. No effects were obtained in terms of perceived pain. For blunters, however, their perceived levels of anxiety and pain did not attenuate following a congruent, distraction-focused intervention.ConclusionAmong persons experiencing chronic pain, tailoring coping strategies to match an individual’s preferred coping style–in particular, those with a high level of monitoring–may enhance the benefit of psychological approaches to management of anxiety.

Exploring the relationship between patients' information preference style and knowledge acquisition process in a computerized patient decision aid randomized controlled trial.

BackgroundWe have shown in a randomized controlled trial that a computerized patient decision aid (P-DA) improves medical knowledge and reduces decisional conflict, in early stage papillary thyroid cancer patients considering adjuvant radioactive iodine treatment. Our objectives were to examine the relationship between participants’ baseline information preference style and the following: 1) quantity of detailed information obtained within the P-DA, and 2) medical knowledge.MethodsWe randomized participants to exposure to a one-time viewing of a computerized P-DA (with usual care) or usual care alone. In pre-planned secondary analyses, we examined the relationship between information preference style (Miller Behavioural Style Scale, including respective monitoring [information seeking preference] and blunting [information avoidance preference] subscale scores) and the following: 1) the quantity of detailed information obtained from the P-DA (number of supplemental information clicks), and 2) medical knowledge. Spearman correlation values were calculated to quantify relationships, in the entire study population and respective study arms.ResultsIn the 37 P-DA users, high monitoring information preference was moderately positively correlated with higher frequency of detailed information acquisition in the P-DA (r = 0.414, p = 0.011). The monitoring subscale score weakly correlated with increased medical knowledge in the entire study population (r = 0.268, p = 0.021, N = 74), but not in the respective study arms. There were no significant associations with the blunting subscale score.ConclusionsIndividual variability in information preferences may affect the process of information acquisition from computerized P-DA’s. More research is needed to understand how individual information preferences may impact medical knowledge acquisition and decision-making.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-015-0168-0) contains supplementary material, which is available to authorized users.

The effect of monitoring 'processing style' on post-surgical neuropathic pain in women with breast cancer.

Pain is a commonly reported symptom following surgery that is more likely to occur in individuals psychologically distressed prior to surgery. Monitoring processing style, a cognitive tendency to focus on health-related threats, has been associated with increased reporting of somatic symptoms, but no studies have specifically addressed the link between this cognitive style and pain. This prospective clinical study aimed to investigate whether monitoring processing style predicted post-surgical pain in women undergoing breast surgery, controlling for pre-surgical psychological distress. Women scheduled to undergo breast cancer surgery (N = 106) completed pre-surgical assessments of monitoring processing style (Miller Behavioral Style Scale) and psychological distress (Depression Anxiety Stress Scales-21). Demographic and medical characteristics were documented. Self-reported neuropathic pain (Neuropathic Pain Scale) was assessed at 3 months post surgery. Post-surgical neuropathic pain levels were low to moderate (M = 19.3, SD = 21.1). Higher pre-surgical monitoring processing style scores significantly predicted higher post-surgical neuropathic pain (β = 0.23, p = 0.023), over and above psychological stress (β = 0.22, p = 0.020) and age (β = -0.25, p = 0.011). Pre-surgical monitoring processing style was an independent predictor of post-surgical neuropathic pain, even when accounting for pre-surgical psychological distress. Since the reduction of post-surgical pain is a key goal of healthcare, efforts should be made prior to breast cancer surgery to counsel and support individuals with high monitoring processing styles irrespective of their level of distress.

MBSS（Miller Behavioral Style Scale）日本語版の信頼性及び妥当性の検討

MBSS（Miller Behavioral Style Scale）日本語版の信頼性及び妥当性の検討

Employment pathways and work‐related issues in head and neck cancer survivors

In this exploratory study, employment and psychological factors were investigated in head and neck cancer survivors with survivorship of ≥2 years. Fifty-five head and neck cancer survivors ≤60 years old completed a survey including subscales from the Functional Assessment of Cancer Therapy (FACT) instrument, the Miller Behavioral Style Scale, the General Perceived Self-Efficacy Scale, the Patient Health Questionnaire-9 (PHQ-9), and the Hornheider-Fragebogen short version (HFB) measuring the need for psychological interventions. Exploratory analyses of associations to the employment status were performed. The rate of employed patients dropped from three-fourths of patients before diagnosis to one-third at an average of 66.8 months after diagnosis. Current unemployment was associated with harder physical work before cancer diagnosis, surgical treatment, and current risky alcohol consumption. Unemployed survivors reported decreased FACT functional and social well-being and higher PHQ depression scores. Psychosocial variables were significantly related to employment. Further research is needed to examine these relationships.

Prevalence and Behavioral Styles of Fear of Flying

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), fear of flying is a specific situational phobia, but it has a heterogeneous character because it can be influenced by many other fears. Attention toward (monitoring) or away from (blunting) threatening information is influenced by people’s control of voluntary attention. In our online questionnaire study, 9,166 subjects (age 17–70 years) were selected for participation. The Flight Anxiety Modality (FAM) questionnaire and Miller Behavioral Style Scale (MBSS) were used to measure fear of flying and behavioral style. Also, demographic information was collected. Women reported a higher FAM sum score than men, as predicted. Participants who scored higher on the MBSS were found to have also scored higher on the FAM. Participants who had never flown before scored higher on the FAM than participants who had flown before. In this sample, monitoring can be associated with an increase in fear of flying. Future research should focus on gaining a more multicultural picture of fear of flying.

Patients with Cancer and their Relatives Beliefs, Information Needs and Information-Seeking Behavior about Cancer and Treatment

To identify cancer patient and relatives beliefs, information needs, information-seeking behavior and information sources about cancer and treatment. This research was conducted at two hospitals of a university. Data was collected via questionnaires and the Turkish version of the Miller Behavioral Style Scale (MBSS) to assess information-seeking behavior. The sample included 82 patients and 54 relatives. Patients were receiving treatment mostly for breast, gynecologic, lung cancer and leukemia/ lymphoma. All of them indicated that they want to be informed by a doctor about their diagnosis and treatment first. Other information sources were internet, media and nurses. The majority of the patients and half of their relatives agreed that "cancer is curable and preventable disease". Only 2.5% of patients agreed with the statement "I don't want to get information about disease which disturbs me". According the data obtained from MBSS; the mean patients MBSS score (6.41±3.2) was higher than their relatives (5.46±3.1). Respondents with higher education and younger age indicated more information-seeking behavior. Patients and their relatives differ in some of their information-seeking behavior. Patients beliefs and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. Healthcare professionals need to assess and be sensitive to the information-seeking behavior of cancer patients and their relatives.

Understanding integrated care pathways in palliative care – context, approaches, outcomes

BackgroundPolicy and evidence based guidelines have aided in identifying a greater need for advanced palliative care services. However, there is still evidence of individuals dying undignified deaths with little pain...

Informational Coping Style and Depressive Symptoms in Family Decision Makers

Overwhelmed family decision makers of chronically critically ill patients must comprehend vital information to make complex treatment decisions that are consistent with patients' preferences. Exploration of informational coping styles of family decision makers may yield evidence for tailored communication practices supporting the psychological and informational needs of family decision makers. To describe patterns in the demographic characteristics and informational coping styles of family decision makers; to assess differences in informational satisfaction, role stress, and depressive symptoms between family decision makers classified as monitors and as blunters; and to describe the predictive associations between informational coping styles, informational satisfaction, and role stress on depressive symptoms in family decision makers. A secondary data analysis of 210 family decision makers of cognitively impaired patients who required 3 days or more of mechanical ventilation. On enrollment, decision makers completed the abbreviated Miller Behavioral Style Scale to assess informational coping styles, the Critical Care Family Satisfaction Survey's informational subscale to assess informational satisfaction, a single-item measure of role stress, and the Center for Epidemiological Studies Depression scale to assess depressive symptoms. No associations emerged between demographic characteristics and informational coping styles of family decision makers. Monitors had higher depression scores than did blunters. Both information coping style and informational satisfaction influenced depressive symptoms; however, role stress was the most significant predictor. Family decision makers classified as monitors were at higher risk for depression than were those who seem to avoid information. Targeting monitors with additional psychological and informational support may mitigate their psychological impairment.