Application of well-being therapy to people with disability and chronic illness.

Rehabilitation Psychology 2016, Vol. 61, No. 1, 32– 43

© 2016 American Psychological Association 0090-5550/16/$12.00 http://dx.doi.org/10.1037/rep0000060

Application of Well-Being Therapy to People With Disability and Chronic Illness Barry Nierenberg, Gillian Mayersohn, Sophia Serpa, Alexia Holovatyk, Evan Smith, and Sarah Cooper

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Nova Southeastern University Purpose/Objective: Research data clearly indicate most people living with a disability return to premorbid levels of psychological functioning. However, some individuals living with a disability are vulnerable for the development of psychological disorders including depression, anxiety, and posttraumatic stress disorder. Rather than understanding this phenomenon of vulnerability solely as the presence of psychopathology, it can be understood from a positive psychology standpoint as a deficit of well-being. We extend this approach by demonstrating the links between the historic foundational principles of rehabilitation psychology and the relevant current research on psychology of well-being. The article then explores the implications of providing meaningful interventions that could improve the lives of persons living with disability and chronic illness. Results: Based on this view, well-being therapy is proposed as an intervention because it has proven efficacy in acting as a buffer against the development of some negative affective states. The assumptions and dimensions underlying this approach are shown to be relevant to both persons living with disability and to the foundational principles of rehabilitation psychology. A model for assisting people with disability in improving their well-being and decreasing negative aspects of their life by balancing factors relevant to well-being is discussed. Conclusions/ Implications: The authors conclude by exploring the benefits of engendering positive well-being versus the traditional focus on solely alleviating negative affective states.

Impact and Implications The current article adds to the literature by demonstrating how the foundational principles of rehabilitation psychology lead directly to the incorporation of some contemporary findings from positive psychology. Practice implications of the findings suggest a change in psychological interventions from “diagnose and treat” to “intercept and prevent.” As the paradigm shifts in rehabilitation psychology to a prevention model, it may reduce the frequency of mood disorders following acquired disability and may result in cost savings by reducing medical complications from nonadherence in self-care activities.

Keywords: psychosocial aspects of spinal cord injury, positive psychology, rehabilitation psychology, adaptation to disability, emotional factors

Social Psychology of Disability,” and the field can rightfully look back on a full and rich history since then. Part of this history includes some work that has not only endured but is now considered to be foundational to the field. From the start, a pattern that has characterized the field’s growth is its ability to utilize these principles to guide the process of incorporating current research findings and then using these data to improve interventions. Over time, however, these foundational principles have slowly moved to the background of our work and are now, in some circles, all but ignored (Weiten, Dunn, & Hammer, 2011). A fresh examination of where we came from could, and should, be informing new approaches and new understandings of people living with chronic illness and disability (Dunn, 2014). In this article we look back at the historic foundational principles of rehabilitation psychology and show the links to current research on the psychology of well-being and explore implications for providing meaningful interventions that could improve the lives of persons with disability and chronic illness. One place to start is Beatrice Wright’s classic 1983 work elucidating the 20 value-laden beliefs that continue to guide our field

It is not external events themselves that cause us distress, but the way in which we think about them, our interpretation of their significance. It is our attitudes and reactions that give us trouble. We cannot choose our external circumstances, but we can always choose how we respond to them. —Epictetus (AD 55–135)

Introduction Rehabilitation psychology (RP) is approaching 70 years since the publication of Lee Meyerson’s (1948) groundbreaking article “The

Barry Nierenberg, Gillian Mayersohn, Sophia Serpa, Alexia Holovatyk, Evan Smith, and Sarah Cooper, Center for Psychological Studies, Nova Southeastern University. Correspondence concerning this article should be addressed to Barry Nierenberg, PhD, ABPP, Nova Southeastern University, Center for Psychological Studies, 3301 College Avenue, Ft. Lauderdale, FL 33314. E-mail: [email protected] 32


WELL-BEING THERAPY, DISABILITY, AND CHRONIC ILLNESS

(Dunn, 2014). One important principle among those is the charge to constantly review and update these principles. It is instructive to briefly examine Wright’s original writing and reflect on where it can extend the effectiveness of our current work. As has been written elsewhere, the influence of Kurt Lewin’s impact on the 20 value-laden beliefs is evident (Dunn, 2014; Trieschmann, 1988). Let us take for example the second principle on the list (“The severity of a handicap can be increased or diminished by environmental conditions”; Wright, 1983). This represents an obvious use of Lewin’s (1943) construct of behavior being best understood as a product of the person– environment interaction. This principle has led to a recent reconceptualization of disability not as a characteristic of the person but as an outcome of each person’s interaction with the immediate environment (National Institute on Disability and Rehabilitation Research, 2013). To make this clear to people currently living without a disability, loss of electricity due to extreme weather may provide a useful analogy. People living an extended period under these conditions have learned how disabling life can be without modern conveniences dependent on electricity (e.g., climate control, refrigeration, lights). They are effectively disabled by environmental conditions. Wright’s (1983) Principle 3 states: “Issues of coping and adjusting to a disability cannot be validly considered without examining reality problems in the social and physical environment” And Principle 5 states: “The significance of a disability is affected by the person’s feelings about the self and his or her situation.” Together, these two principles imply it is not only what happens to the individual that is important but also how they understand it that moderates the behaviors and feelings that arise from it. This is captured by Lewin’s (1943) famous formula B ⫽ f(P, E), demonstrating the interrelationships between persons (P) and their environments (E). This formula represents the interaction that effectively determines individuals’ ability to manage situations associated with their disability. Wright’s (1983) Principles 1 and 7 lead directly to person-first thinking, where the person is seen first and not the particular disability. Specifically, they state “1. Every individual needs respect and encouragement; the presence of a disability, no matter how severe does not alter these fundamental rights” and “7. The client is seen not as an isolated individual but as a part of a larger group that includes other people, often the family.” When we place individuals first in our understanding, and our exploration of their living with a disability second, they take the foreground and the disability is then put in its place as being but one factor in their lives impacting their lifespace (Lewin, 1943), i.e., their idiosyncratic person– environment fit. In other words, no amount of disability erases a person’s assets. Another concept expanded upon in Wright’s 1983 book is the concept of coping versus succumbing (p. 195). Here she highlights the significant differences between (a) the instances where individuals demonstrate active coping by focusing on remaining strengths and viewing problems as surmountable and (b) times these same people passively succumb by focusing on losses and things they cannot change. The importance of coping and focusing on remaining strengths following an acquired disability goes back to at least Roberta Trieschmann’s (1978) article articulating the role for psychologists in a spinal cord injury (SCI) unit. Here she argued, “The clinical psychologist can play a significant role in the treatment of spinal injury as a behavioral consultant to the reha-

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bilitation team, as a researcher into the rehabilitation process, as an evaluator of the psychological strengths and assets of the person with spinal injury, and as a therapist and counselor (original bold replaced with italics; Trieschmann, 1978, p. 217). As others have pointed out (Dunn, 2014; Dunn & Dougherty, 2005; Dunn, Uswatte, & Elliott, 2009), this focus upon one’s remaining personal assets lends itself to an exploration of what it takes to “live the good life with disability.” The relatively new field of positive psychology (PP) came into being as an attempt to address exactly this ancient philosophical question: “What does it mean to live the good life?” This question takes on added dimensions when we examine the implications of living with a disability and could be understood as a direct extension of RP’s original principles. Recent findings from PP give us a framework to understand the various answers for those living with a disabling condition (Dunn, 2014). How do we begin to enumerate our “assets” as a person with or without a disability? Before we go further, it is important to address a common misconception of PP. It is a misreading of this relatively new field to view PP simply as an iteration of “looking on the sunny side of the street” and “don’t worry, be happy.” Instead, the data from this approach suggest new perspectives can become available once we take a more-balanced look at current person– environment interactions. Within the PP framework, constructs such as optimism, hope, well-being, grit, and happiness are explored utilizing a variety of therapeutic techniques (e.g., mindfulness, acceptance, and commitment therapy). This approach argues that a morebalanced and comprehensive evaluation can lead to an increased appreciation for both the strengths remaining in each person’s “new normal” circumstances and the challenges and problems that were never asked for that remain frustratingly present. In this manner, rehabilitation professionals can have a more-realistic, balanced picture of the people they serve. Additionally, people living with chronic illness and disability can have a more-realistic picture of their present. In fact, there may be some basis for considering changing “coping versus succumbing” to “coping and succumbing.” People both cope and succumb throughout the course of a lifetime, and the word versus connotes “bad adjustment” and failure to cope. Taking this more-balanced approach leads one to see that succumbing is in reality neither “bad” nor a failure. In the body of this article we review how positive psychology approaches have been used for people with disabilities, present an overview of the development and structure of well-being therapy including a literature review, and then demonstrate how it could be applied to people with SCI. The article concludes with a discussion of the broader implications for utilizing these approaches more widely in RP as well as a cautionary note.

Positive Psychology (PP) Approaches to People With Disabilities (PWD) A review of the existing literature on PP approaches to PWD is somewhat hampered by fragmentation due to a lack of a universally accepted definition of which interventions are considered to be included in this category. An exhaustive review of the field is beyond the scope of this article; however, some reports in the literature nonetheless bear consideration to examine the data supporting this approach.


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One of the arguments for a PP approach to rehabilitation stated, “Positive psychology of rehabilitation should do more than just focus on treatment issues or adaptation to disability—it must capitalize on people’s psychosocial strengths to maintain or enhance psychological and physical well-being and to prevent pathology” (Dunn & Dougherty, 2005, p. 307). This clearly is resonant with the fourth value-laden principle: “The assets of the person must receive considerable attention in the rehabilitation effort.” One of the earliest explorations of PP in rehabilitation looked at psychological well-being (PWB) following amputation (Dunn, 1996) wherein researchers examined the beneficial effects of finding positive meaning in persons secondary to limb loss. Dunn (1996) hypothesized that finding meaning and being an optimist would be significantly predictive of lower levels of depressive symptoms and higher levels of self-esteem. Results of the study showed 77% of participants indicated something positive happened as a result of their amputation. The report concluded that given that dispositional optimism was a particularly strong predictor of both measures of PWB, rehabilitation professionals should consider helping patients to foster this sense of optimism during the rehabilitation phase. Additionally, heightened perceptions of control served to enhance individuals’ beliefs in personal autonomy and mastery over their physical condition and influence their activities during rehabilitation and beyond. The article concluded that rehabilitation professionals should find ways to promote a primary sense of perceived control by pointing out aspects of individuals’ behavior or environment that can be altered. One can view this study’s hypothesis and results as firmly rooted in Principle 5: “The significance of a disability is affected by the person’s feelings about the self and his or her situation.” Optimism has been linked to improved physical functioning and fewer physical symptoms in a study of rheumatoid arthritis patients (Fournier, de Ridder, & Bensing, 2002). Additionally, optimism has been linked to better psychosocial adjustment (Brenner, Melamed, & Panush, 1994) and higher levels of PWB in a longitudinal study of rheumatoid arthritis patients (Treharne, Lyons, Booth, & Kitas, 2007). There is also evidence in the literature that PWB plays a buffering role in coping with stress and has a favorable impact on disease course: A study by Mangelli, Gribbin, Büchi, Allard, and Sensky (2002) examined pain, disease activity, disability, depression, and anxiety in outpatients at a rheumatology clinic. They found lower levels of PWB in the clinical sample compared to an able-bodied community sample, and each of the well-being scales showed significant correlations, in the predicted direction, with both depression and anxiety. They argued that well-being levels should be able to help identify individuals who are more vulnerable to depression and that these individuals should then be targeted to receive some intervention. For people living with traumatic brain injury (TBI), a number of researchers have attempted to use PP constructs that are tied to foundational principles. A recent overview of PP approaches in brain injury (Evans, 2011, p. 118) argued one of the more significant impacts of brain injury on the individual is the decreased ability to experience the “engaged life” (Evans, 2011). Under some conditions, cognitive and/or physical impairments can reduce one’s personal autonomy, relationship satisfaction, ability to work or enjoy leisure activities, and cause an overall disruption in one’s sense of self and identity, thus impairing an individual’s sense of well-being. Evans (2011) further pointed out that PP potentially

offers a framework for conceptualizing changes in mental health (positive and negative) following brain injury. However, he stressed the fact that to date little research has been done in this area. In the first recorded trial of PP interventions for individuals with acquired brain injury, researchers utilized two types of PP interventions: (1) a gratitude journal and (2) a “signature strengths” intervention (Andrewes, Walker & O’Neill, 2014). For the latter, individuals identified their key strengths via Peterson and Seligman’s (2004) Value in Action Inventory of Strengths and were encouraged to find a new way to use these every day for a week. Andrewes et al.’s (2014) stated goal here was for individuals to be more easily guided toward a more-realistic, positive sense of identity. The authors reported that individuals who received the PP intervention scored higher on a happiness index following the intervention and at the end of the 12-week program when compared to baseline and control group scores. However, no differences were found between groups on a self-concept score. It should be noted here the authors did not link their work to the foundational principles, thereby missing an opportunity to give their study more grounding in accepted RP theory. Another group looking at people with acquired brain injury— Bertisch, Rath, Long, Ashman, and Rashid (2014)—represents one of the first explorations of the relationships between PP constructs (character strengths, resilience, and positive mood) and rehabilitationrelated variables (perceptions of functional ability postinjury and beliefs about treatment) at several time points (baseline, 6 months follow-up, and longitudinally). They found that measures of character strengths and resilience were associated with rehabilitationrelated variables within the baseline set and the follow-up set as well as longitudinally. They concluded that their “preliminary findings support relationships between character strengths, resilience, and positive mood states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment success and quality of life outcomes in rehabilitation medicine settings” (Bertisch et al., 2014, p. 585).

Development and Structure of Well-Being Therapy (WBT) As indicated earlier, an exhaustive review of the field is beyond the scope of this article. However, one way to begin exploring an integration of some PP approaches is to look at well-articulated factors that have been proven to be an integral part of “living the good life.” A number of researchers in this area have argued that in the English language, the word happiness is utilized correctly in numerous nonrelated situations and is too ambiguous and vague a concept to be effectively utilized, so they have argued it should be replaced by the term well-being (Ryff, 1989; Seligman, 2011). With over 25 years of data behind the study of well-being, an examination of the ideas of Carol Ryff is warranted. In Ryff’s 1989 article exploring the theoretical aspects of well-being, she outlined six key dimensions of wellbeing. These are enumerated in Table 1. Along with her colleagues, Ryff developed a structured, selfreport instrument to measure these dimensions, and subsequent factor analysis supported this dimensional structure (Ryff, 1989). The original instrument was initially completed by 321 men and women. The test–retest reliability coefficients for the 20-item scale over a 6-week period on a subsample of respondents (n ⫽ 117)


Table 1 Ryff’s Well-Being Factors Factor Self-Acceptance Purpose in Life Personal Growth


Positive Relations With Others Environmental Mastery Autonomy

Definition The capacity to see and accept one’s strengths and weaknesses Having goals and objectives that give life meaning and direction Feeling that personal talents and potential are being realized over time Having close, valued connections with significant others Being able to manage the demands of everyday life Having the strength to follow personal convictions, even if they go against conventional wisdom

Note. Adapted from “Happiness Is Everything, or Is It? Explorations on the Meaning of Psychological Well-Being,” by C. D. Ryff, 1989, Journal of Personality and Social Psychology, 57, p. 1069. Copyright 1989 by the American Psychological Association.

were all between .81 and .85. Ryff’s Psychological Well-Being Scale additionally showed good validity on the basis of analyses of overlap with other instruments and the distinctness of factors (Ryff, 1989). One of the more intriguing findings was an almost perfect inverse relationship between positive and negative affective states (Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998). Fava and his colleagues (1998) explored the relatively high depression relapse rates that are repeatedly documented in the literature (Hooley & Teasdale, 1989; Teasdale et al., 2000). Given the finding of a strong inverse relationship between positive and negative affective states, he hypothesized that the relapse rate may be a function of a deficit in well-being rather than the presence of depressive states. Utilizing Ryff’s (1989) instrument, he compared the well-being of individuals who had been treated successfully for their depression with psychopharmacological agents and therapy to a group of individuals who did not meet criteria for pathology as defined by theDiagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000). Both groups ostensibly did not qualify for a DSM–IV–TR diagnosis; however, he found that the group of previously depressed individuals had 40% less well-being than did their “normal” counterparts. This led to the question of whether previously depressed individuals could improve their well-being and the extent to which this would affect their relapse rates. Utilizing cognitive– behavioral techniques, researchers taught them to increase these factors over eight sessions, 30 –50 min long, occurring every other week. Fava, Ruini, Rafanelli, et al. (2004) found participants’ well-being increased and depression significantly decreased in the pre- and posttest design. Concerning relapse rates, he retested the original group 6 years later, hypothesizing the therapeutic effects of the intervention would persist over time (Fava, Ruini, Rafanelli, et al., 2004). His group persisted on elevated levels of well-being, even after a lengthy time, with only a 40% depression relapse rate. A similar intervention for anxiety yielded equally strong results. In considering the application of this concept to PWD, we could use SCI as an example. We know from the literature that individuals who experience an SCI are at a greater risk of developing

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psychological disorders. Migliorini, Tonge, and Taleporo (2008) found that individuals with an SCI have higher prevalence rates of depression (37%), anxiety (30%), and posttraumatic stress disorder (PTSD; 8.4%) when compared to a control group. Furthermore, additional studies have found that the prevalence of depression within this population ranges between 10% and 60% (Bombardier, Richards, Krause, Tulsky, & Tate, 2004; Elliott & Frank, 1996; Kalpakjian & Albright, 2006). Pollard and Kennedy (2007) showed that these symptoms of depression appear to remain stable over an extended period of time. Importantly, the researchers found that coping strategies 12 weeks postinjury predicted approximately one third of the variance in depression at Year 10. Before exploring the possible application of WBT to people with SCI, an examination of WBT is in order. WBT is a structured, directive, and problem-oriented model based upon an educational model. Self-observation is emphasized through the use of a structured diary and patient–therapist interactions (Emmelkamp, 1974; Fava, Ruini, Rafanelli, et al., 2004). WBT, as conceptualized by Fava, Ruini, Rafanelli, et al. (2004), is a short-term psychotherapeutic strategy that extends over eight to 12 sessions, each 30 –50 min long, which may occur either weekly or biweekly. Although the standard format of WBT is outlined as eight sessions, the number of sessions may vary according to the patient’s needs and collaboration with other therapies. For example, if the patient has already undergone a course of traditional, symptom-oriented cognitive– behavioral therapy (CBT) and, therefore, is familiar with the concepts of the homework and the diary, the number of sessions needed may be decreased. Fava’s (1998) model of WBT is based upon Carol Ryff’s conceptualization of PWB (Ryff, 1989). This model was selected on the basis of its easy applicability to clinical populations (i.e., residual phase of affective disorders, recurrent depression, generalized anxiety disorder) as well as its 25-year history of good reliability and validity (Fava, Mangelli, & Ruini, 2001; Fava & Tomba, 2009; Rafanelli et al., 2002). Within Ryff’s (1989) model of PWB, the therapist’s goal is to assist the patient in moving from an impaired to an optimal level within Ryff’s six dimensions of PWB. Rather than obtaining the highest possible levels in all dimensions, patients are encouraged to obtain balanced functioning (see Table 2). Optimal-balanced well-being varies from patient to patient, according to factors such as personality traits, social rules, and cultural and social contexts (Ryff & Singer, 2008).

WBT Session Development Initial sessions. The beginning sessions of WBT focus upon identifying episodes of well-being and putting them into a situational context, no matter how short the episodes were. Patients report episodes of well-being on a scale of 0 –100 (with 0 being absence and 100 being the most intense well-being) in a structured diary. The initial phase usually extends over a couple of sessions; yet, its duration is dependent upon factors that impact any of the homework assignments, including issues of resistance and noncompliance. Intermediate sessions. After patients properly recognize instances of well-being, they transition to the next phase of treatment, which involved the identification of thoughts and beliefs that lead to the premature interruption of their well-being. This phase is crucial because it allows the therapist to determine which areas

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Table 2 Modifications of Psychological Well-Being Following Well-Being Therapy or Other Positive Interventions


Ryff psychological well-being factorsa

Low level

Balanced-functional level

Environmental Mastery

Has difficulties managing everyday affairs Feels unable to change or improve surrounding context Is unaware of surrounding opportunities Lacks sense of control over external world

Autonomy

Is concerned about the expectations and evaluations of others Relies on judgments of others to make important decisions Conforms to social pressures to think and act in certain ways

Self-Acceptance

Feels dissatisfied with self Is disappointed with what has occurred in past life Is troubled about certain personal qualities Wishes to be different from what he or she is Lacks a sense of meaning in life Has few goals or aims Lacks sense of direction Does not see purpose in past life Has no outlooks or beliefs that give life meaning

Possesses a positive attitude toward the self Acknowledges and accepts multiple aspects of self, including good and bad qualities Feels positive about past life

Has few close, trusting relationships with others Finds it difficult to be warm, open, and concerned about others Is isolated and frustrated in interpersonal relationships Is not willing to make compromises to sustain important ties with others Has a sense of personal stagnation Lacks a sense of improvement or expansion over time Feels bored and uninterested with life Feels unable to develop new attitudes or behaviors

Has warm, satisfying, and trusting relationships with others Is concerned about the welfare of others Is capable of strong empathy, affection, and intimacy Understands give and take of human relationships Has a feeling of continued development Sees self as growing and expanding Is open to new experiences Has a sense of realizing his or her potential Sees improvement in self and behavior over time Is changing in ways that reflect more self-knowledge and effectiveness

Purpose in Life

Positive Relations With Others

Personal Growth

Has a sense of mastery and competence in managing the environment Controls complex array of external activities Makes effective use of surrounding opportunities Able to create or choose contexts suitable to personal needs and values Is self-determining and independent Is able to resist social pressures to think and act in certain ways Regulates behavior from within Evaluates self by personal standards

Has goals in life and a sense of directedness Feels there is a meaning to the present and past life Holds beliefs that give life purpose Has aims and objectives for living

Excess level Is unable to savor positive emotions and hedonic pleasure Is unable to relax

Is unable to get along with other people, to work in a team, and to learn from others Spends time and energy fighting for opinions and rights Relies only on self to solve problems Unable to ask for advice or help Has narcissistic and egocentric traits Has difficulty admitting own mistakes and rigidity

Has obsessional passions Is unable to admit failures Manifests persistence and rigidity Is unable to change perspective and goals Finds excessive hope paralyzing and hampers facing negativity and failures Feels pain and distress of others due to exaggerated empathy Sacrifices own needs and well-being for others due to exaggerated altruism May mask low self-esteem and sense of worth through extreme forgiveness and gratefulness Is unable to process negativity Forgets or does not give enough emphasis to past negative experiences Cultivates benign illusions that do not fit with reality Sets unrealistic standards for overcoming adversities

Note. Adapted from “Role of Well-Being Therapy in Achieving a Balanced and Individualized Path to Optimal Functioning”, by C. Ruini and G. A. Fava, 2012, Clinical Psychology & Psychotherapy, 19, pp. 294 –295. Copyright 2012 by John Wiley & Sons, LTD. a From Ryff (1989).

of well-being are not impacted by irrational or automatic thoughts in addition to those that are saturated with them. The focus of this phase is on self-monitoring for moments and feelings of wellbeing. Notably, the therapist refrains from suggesting any technical or conceptual alternatives, unless patients have achieved a satisfactory degree of self-observation. This phase may extend over two or three sessions depending on the patients’ motivation and ability.

Final sessions. Monitoring the course of episodes of wellbeing permits the therapist to identify specific impairments across the well-being dimensions as described in Ryff’s (1989) conceptual framework. At times, an additional source of information may be provided via the administration of Ryff’s (1989) Psychological Well-Being Scale self-rating inventory. The six dimensions of PWB are introduced to the patients progressively, as long as the material in the patient’s diary lends itself to it. For example, if a



patient discloses struggles with independence, the therapist could explain that autonomy consists of having an internal locus of control, independence, and self-determination or that personal growth consists of being open to new experiences and considering the self as expanding over time. The therapist then engages in cognitive therapy techniques by discussing cognitive distortions and introducing alternative interpretations to the patient’s thinking errors. The factor that differentiates WBT from other standard cognitive therapies is that the primary focus of WBT is upon instances of emotional well-being rather than psychological distress. Additionally, the goal in WBT is the promotion of PWB as defined by Ryff (1989), as opposed to the goal of standard cognitive therapy, which is upon the reduction of psychological distress through one’s ability to control and/or contrast automatic thoughts. WBT is conceptualized as a specific strategy within the broad continuum of self-therapies because it shares similar techniques to other cognitive modalities (Fava, 2000). Last, WBT “refrains from explaining from the onset to the patient its rationale and strategies, but relies on his/her progressive appraisals of positive self” (Fava & Ruini, 2003, p. 54). For example, it may help the individual who struggles with anxiety to view anxiety as an unavoidable element of everyday life, which can be “counteracted by a progressive increase in environmental mastery and self-acceptance” (Fava & Ruini, 2003, p. 54). The current iteration of WBT is firmly rooted in a CBT approach (Fava, Ruini, & Rafanelli, 2004). Other foundations could logically be applied if assumptions inherent in utilizing this cognitive focus are not met. For example, in the case of people with SCI, the nature of their difficulties may not lie in “dysfunctional core beliefs” but may alternatively lie in assumptions inherent in their perception of living with their “new normal” postinjury status. Here it would be possible to use an acceptance and commitment therapy (ACT) approach connecting Ryff’s (1989) factors to related values that each person’s behaviors are supporting or blocking. ACT has been defined as a functional contextual therapy approach based on Relational Frame Theory which views human psychological problems dominantly as problems of psychological inflexibility fostered by cognitive fusion and experiential avoidance. In the context of a therapeutic relationship, ACT brings direct contingencies and indirect verbal processes to bear on the experiential establishment of greater psychological flexibility primarily through acceptance, defusion, establishment of a transcendent sense of self, contact with the present moment, values, and building larger and larger patterns of committed action linked to those values. (Bach & Moran, 2008)

Developed by Hayes, Levin, Plumb-Vilardaga, Villatte, and Pistorello, 2013, ACT is built on empirically based principles utilizing mindfulness and behaviorally based principles to undermine unhelpful language processes and increase psychological flexibility. Within the framework of ACT the following assumptions are made: (1) Pain in life is inevitable and (2) feelings of joy and sadness are two sides of the same coin (Hayes et al., 2013). In keeping with the examination of what it means to live the good life, Russ Harris stated, “The aim of ACT is to create a rich, full, meaningful life while accepting the pain that inevitably goes with it” (Harris, 2009, p. 2). Although ACT is similar to CBT because

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it also developed from behaviorism (Hayes et al., 2013), it posits that neither the thought nor the emotional responses can be either controlled or made to go away and, therefore, places emphasis upon on the person’s attempts to control the emotional consequences of the thought rather than attempts to control the thought itself, as in CBT. Ultimately, ACT seeks to generate psychological flexibility via behavioral activation upon the basis of an individual’s values.

Literature Review of Well-Being Therapy Although gradually increasing, the body of empirical literature examining the utilization of WBT for all populations is limited. Likewise, the literature related to the efficacy of WBT for rehabilitation populations, such as SCI, is even scarcer. However, given that the literature has demonstrated WBT is associated with positive effects for depression, affective disorders, anxiety, and psychosomatic medicine, a review of the existing literature on efficacy is warranted. Studies utilizing WBT were identified through four major database searches: PubMed, PsycINFO, ERIC, and Social Science Citation Index, as well as Google Scholar (http://scholar.google.com). Keywords included throughout the search were as follows: WBT, PWB, Ryff’s PWB, and WBT. Compiled manuscripts were reviewed to determine whether they used Ryff’s definition of PWB and/or explicitly used Ryff’s Psychological Well-Being Scale as an outcome measure. Because there are several definitions of well-being within the field of PP, we chose the aforementioned criteria in order to maintain consistency across the studies reviewed. PWB as defined by Carol Ryff was chosen due to the comprehensive nature of the foundations that formed the basis of her established and well-validated measure. For the purposes of this review, any study, including dissertations, for which the full-text was available was included. A total of 11 articles met criteria for inclusion. Fava et al. (2005) used WBT to increase the length of remission in individuals with generalized anxiety disorder. Participants received either eight sessions of standard CBT or the sequential administration of four sessions of CBT followed by four sessions of WBT (CBT-WBT). The two groups were compared posttreatment, and results revealed a significant advantage for the CBT-WBT intervention. Additionally, a significantly higher degree of improvement across all of the PWB scales was evidenced among the CBT-WBT participants. Fava et al. (2005) hypothesized that changes in well-being may impact the balance of positive and negative affect that characterizes anxiety disorders, thus leading to an increased level of well-being. The data from this study are in “keeping with the complexity of the balance of positive and negative effects in health and disease, the emerging models of positive mental health, and the clinical needs of sustained recovery in patients with mood and anxiety disorders” (Fava et al., 2005, p. 30). Moeenizadeh and Salagame (2010) randomly assigned patients diagnosed with depression to either CBT or WBT in an effort to evaluate treatment efficacy related to improvement in well-being and reduction of depressive symptoms among these patients. Although pre- and posttreatment comparisons demonstrated that both patients treated with CBT and those treated with WBT endorsed significant symptom reduction, results indicated those in the WBT condition experienced greater relief of depressive symptomatol-


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ogy. The authors concluded WBT effectively decreased the cognitive-affective and somatic-vegetative factors. Furthermore, those who completed the WBT intervention demonstrated a significant increase in PWB compared to the CBT group, and this improvement in PWB was inversely related to the experience of depressive symptomatology. The authors suggested that treating depressive symptoms of well-being with WBT could be more effective than CBT, because all patients who took part in eight sessions of WBT group improved their close relationships, optimism, happiness, innocence, success, and socialization with others when compared to the CBT group. A substantial body of evidence has indicated the influences of well-being on vulnerability to disease (Mangelli et al., 2002; Ryff & Singer, 1998) and quality of life (Fava & Sonino, 2000; Ryff & Singer, 2000). Increased well-being may buffer or prevent possible feelings of demoralization and loss that can be present in individuals with chronic diseases. As a result, increased well-being may improve individual coping abilities and offer more balance to times of succumbing. WBT may yield clinical benefits/improvements in quality of life, coping style, and social support for individuals with chronic and life-threatening illnesses (Emmelkamp & Van Oppen, 1993). Additionally, there is evidence that well-being can act as a mitigating factor in coping with stress and has a positive impact on disease course (Fava, 1992; Fava, 1996; Ryff & Singer, 1998); it also has some positive effects on the immunological and endocrine systems (Fava & Sonino, 2000). Further clinical examples in the literature include anxiety and hope in the course of medical disorders (HeszenNiejodek, Gottschalk, & Januszek, 1999), the relationship between life satisfaction and cardiac variables (Majani et al., 1999), and the role of optimism and coping style in transplantation outcomes (Stilley, Miller, Manzetti, Marino, & Keenan, 1999). Mangelli et al. (2002) further investigated the findings mentioned in the studies previously, along with the evidence that cognitive therapy for individuals with rheumatoid arthritis led to positive changes (Sharpe et al., 2001). They studied pain, disease activity, disability, depression, and anxiety among outpatients at a rheumatology clinic. Results indicated lower levels of well-being within the participants compared to those individuals in the community sample from the study performed by Ryff, Lee, Essex, and Schmutte in 1994. This discrepancy appeared across all of the six dimensions; however, it was most prominent within the domains of personal growth and purpose in life. Also, there were significant inverse bivariate correlations between depression or anxiety and each of the PWB subscale scores. Notably, these correlations were stronger for depression than anxiety. Environmental mastery and self-acceptance evidenced the strongest negative correlations with depression. Reduced level of autonomy was associated with anxiety, whereas low levels of positive relations with others was associated with depression (Mangelli et al., 2002). Findings from this study (Mangelli et al., 2002) need to be replicated because they have valuable implications for treatment of not only rheumatoid arthritis but also other chronic illnesses. Another study examining well-being in individuals with a chronic medical condition was conducted by Cosci, Pennato, Bernini, and Berrocal (2011). The authors investigated whether well-being predicted negative affect in patients with fibromyalgia. Participants included 48 females with fibromyalgia and 48 matched-age controls. Results indicated the participants living

with fibromyalgia had significantly higher scores on depression, functional impairment, and pain than did controls. Purpose in life and positive relationships were found to be significant predictors of functional impairment among fibromyalgia patients. The authors concluded from their data that having higher levels of purpose in life and positive relationships prevents diminished daily functioning, which in turn prevents depression. Moreover, having an optimal level of self-acceptance prevents anxiety, thereby protecting the individual from depression. The biopsychosocial model of fibromyalgia suggests stress has a possible etiology in the disorder and that stress-related factors, such as anxiety, can perpetuate symptoms and disability (Van Houdenhove & Egle, 2004). The results of this study suggested that certain dimensions of well-being might protect individuals living with fibromyalgia from the effects of the adversity on ill-being. Cosci et al. (2011) suggested that WBT might be useful for individuals with fibromyalgia, given that the intervention works on strengthening the dimensions of well-being. The aforementioned could diminish anxiety levels, enhance daily functioning, and, ultimately, prevent depression. We argue that given these reports, the use of WBT within populations of individuals living with chronic illnesses and/or disability should be effective and could lead to positive treatment outcomes.

The Case for Clinical Application of WBT: People With SCI Individuals with a SCI who experience depression are likely to experience longer hospitalizations, increased pain, decreased functional improvement, higher rates of pressure ulcers, and higher financial expenditures, as well as decreased self-efficacy and diminished quality of life (Elliott & Frank, 1996; Fann et al., 2011; Middleton et al., 2007). Depression among this population can be considered a comorbid complication as opposed to an adaptive process in adjustment (Elliott & Kennedy, 2004). Living with depression can severely impact a person’s quality of life, mobility, and family functioning (Elliott & Frank, 1996). Active self-care can significantly reduce the occurrence of pressure ulcers, skin injuries, and urinary tract infections; however, sustaining a self-care regimen if one is suffering from depression is more difficult. Applying WBT to this population can lead to an alternative way of understanding why some individuals mainly succumb to their acquired disabilities whereas others are more able to balance this by also coping effectively at times. Ryff and Singer (1996) suggested that under some circumstances, it is actually the absence of well-being that leads to individuals’ being vulnerable to potential future hardships. If true, they argued then the route to morepositive and enduring adaptation lies not entirely in eliminating the negative but instead in building the positive. From another standpoint, this can be understood as a logical extension of the foundational RP principles of (1) no amount of physical disability erases a person’s assets and (2) individuals able to cope tend to balance a focus on their old and newly found strengths, whereas those who mostly succumb tend to mainly be aware of their losses (Trieschmann, 1988). Just such an approach focused on understanding positive coping is demonstrated by the work of Hammell (2004), who



examined quality of life among people with SCI and enumerated factors that significantly contribute to quality of life. Emergent themes found within Hammell’s interviews were as follows: autonomy, meaningful use of time, “doing and being” (p. 610), relationships, belonging, support and reciprocity, refocusing values, the need to have something to wake up for, ability to explore new opportunities, and the need to envision future time engaged in meaningful activities. It is interesting that without referencing Ryff’s work, upon examination, one can see Hammell’s themes are quite similar to and significantly reflect Ryff’s six factors (see Table 3). The RP literature reveals added support for applying Ryff’s PWB formulation to SCI. As can be seen in Table 3, each of her factors has been found to apply to persons with SCI well-being,

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lending further credence to utilizing this construct. By assessing each individual according to Ryff’s Psychological Well-Being Scale, greater clarity could be gained regarding in which domain individuals may benefit from an increase in well-being. It is an empirical question whether achieving an optimal level of well-being as defined by Ryff will help individuals with SCI live a purposeful, engaged, independent, and meaningful life. However, using a well-being framework is consistent with previous research findings on positive adaptation following SCI. By assessing an individual on Ryff’s six factors, one could identify areas in need of improvement. Then it would be possible to intervene in each of these identified areas by using Fava’s CBT approach to increasing well-being, moving individuals toward a morebalanced, functional level. This would effectively replace tradi-

Table 3 Ryff’s Subjective Well-Being Factors and Corresponding Support in Spinal Cord Injury (SCI) Literature Ryff’s well-being factorsa

Related factors in persons with SCI

Environmental Mastery

Physical environment: Challenges with physical access, urban infrastructure, and the availability and accessibility of transportation. Economic environment: Cost of health care for individuals with SCI. Political/legal environment: Difficulties surrounding accessibility to resources such as medical assistance, transportation, and insurance. Social environment: Negative impact on those with SCI and the associated stigma, fewer social connections (Hammell, 2007).

Autonomy

Autonomy has been linked to the opportunity to live in the community, to direct one’s own personal care, to make decisions, and to act on choices. Factors that can influence one’s autonomy are the ability to have a job or continue engaging in daily functions such as driving and also the level and type of injury. This research suggests that autonomy is linked with a higher quality of life and is a key factor of assessment and goal of treatment for individuals with SCI. Similar to self-efficacy. Scivoletto, Petrelli, Di Lucente, and Castellano (1997) examined factors linked with anxiety and depression in individuals with SCI and found that rates were significantly associated with a lack of autonomy. Hammell (2004) identified autonomy as being essential for attaining quality in living.

Self-Acceptance

Problems associated with the self and the perception of a “disabled” body can have a significant impact upon the lives of many people with SCI (Hammell, 2007). Redefining disability and changing their own subjective experience of disability has led participants to a gradual rediscovery of self and provided them with an avenue by which a personal interpretation of disability could be made, not in terms of inadequacy or limitations but in terms of personal potential and self-confidence (Carpenter, 1994). Emotional adjustment, particularly selfperception and self-acceptance, is considered one of the more crucial indicators of achievement of rehabilitation goals (Ben-Sira, 1981; Cohen & Lazarus, 1983; Oliver, Zarb, Silver, & Salisbury, 1988; Trieschmann, 1988; Zola, 1982).

Purpose in Life

Research findings indicate that purpose in life is a powerful predictor of adjustment after SCI, mediating the effects of personality variables and locus of control. (Thompson, Coker, Krause, & Henry, 2003; Dunn, 1994). To demonstrate the link between purpose in life and psychological well-being, Crewe (1997) examined narratives of people’s lives with long-term SCI and found that individuals who identified a purpose in life and found meaning from their injury adapted well compared to those who did not report a purpose in life.

Positive Relations With Others

Previous research has found that traumatic spinal cord injury can lead to disrupted social relationships (Kleiber, Brock, Lee, Dattilo, & Caldwell, 1995). The research supports the significance of the need for warm, trusting, understanding social relationships that correlate with overall psychological well-being. Factors and priorities differ from the those of the general population (i.e., accomplishments such as achieving sitting balance and wheelchair-to-toilet transfers) and contribute to a sense of separation from the “real world,” which alienates them from their personal life and social context (Cogswell, 1983).

Personal Growth

Hammell (2007), who examined factors of quality of life and adjustment to SCI, found that those who adjusted well to SCI perceived their growth process as a continuity of their personal life biography, focusing on capability and competence rather than inadequacy and limitation. These individuals viewed themselves as able, not disabled, acknowledging that they are the same person preinjury but just have more challenges, such as difficulty getting around and different body functioning. Leisure activities such as good acts (e.g., volunteering) or good habits (e.g., regular exercise) can contribute to posttraumatic growth by providing opportunities to discover unique abilities and hidden potential, build companionship and meaningful relationships, make sense of traumatic experience and finding meaning in everyday life, and generate positive emotions. This is also consistent with Crewe’s (1997) findings.

a

From Ryff (1989).

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tional clinical psychology’s psychopathology paradigm focusing solely on alleviating negative affective states.


Less attention has been devoted to the understanding of individuals who adapt successfully to SCI and the factors that facilitate successful adaptation . . . It is important to understand how individuals successfully adapt as it could provide the basis for developing interventions for bolstering or establishing skills, attitudes, or beliefs that facilitate positive outcomes after the onset of disability. (Kortte, Gilbert, Gorman, & Wegener, 2010, p. 40)

Contemporary approaches within the field of RP are refocusing on the foundational principles that recognize that no amount of physical disability erases one’s assets as a person and that disability is a product of the person– environment interactions. This is diametrically opposed to viewing the patient as “victims of cruel fate, objects of prejudice or pity, or simply health-preoccupied, passive recipients of medical care” (Dunn et al., 2009, p. 652). Rather than concentrating on the loss a person has experienced, the trend is to sharpen the focus on the positive aspects of a person’s life. Similarly, well-being places attention on the positive aspects of the self and, therefore, gives people with SCI autonomy and power over their recovery process. One of the many goals of a rehabilitation psychologist is to help individuals with a disability attain the highest possible level of wellbeing. By utilizing PP interventions such as a model of WBT, it may be possible to effectively increase well-being and decrease instances of depression and other psychological disorders such as anxiety or PTSD among individuals with a chronic illness or disability. Finally, it is expected that individuals who are able to achieve optimal wellbeing across the six dimensions identified by Ryff (1989) may expend more effort in the rehabilitation process, which could in turn decrease future hospitalizations, decrease instances of depression and other psychological disorders, and improve coping and adjustment to the disability. Individuals with increased well-being may make more functional improvements after rehabilitation, have decreased hospitalizations, and have decreased secondary complications. This of course is an empirical question that begs to be answered with data, given the current search for ways to prevent disease and increase health. The overarching goal of using WBT is not only to lower instances of psychopathology in people with chronic illness or disability but also to improve their quality of life, increase well-being, and decrease future rehospitalizations. As mentioned previously, adjusting to living with a disability can be challenging. As Roberta Trieschmann (1988) stated in discussing the personal dimension of living with an SCI, “people with SCI are a fairly heterogeneous group but they have one thing in common: the disability penalizes them and reduces their freedoms” (pp. 4 –5). It seems possible that by engendering the positive aspects of one’s life and focusing on the different areas of well-being, we could assist PWD to increase their well-being and possibly prevent the development or relapse of a psychological condition such as depression, PTSD, or anxiety. The use of this intervention could, and we argue should, be expanded to other rehabilitation diagnoses such as limb loss, orthopedic conditions, mild brain injuries, and chronic illnesses. The efficacy of this approach in other diagnoses needs further study; however, data in our current literature do suggest that WBT could lead to a significant improvement in quality of life and well-being in a rehabilitation population.

Utilizing PP approaches such as WBT may prove to be an effective intervention to help improve quality of life and increase well-being, coping, and adjustment to disability. There are unanswered questions that need to be addressed such as optimal timing for implementation of an intervention to be maximally effective. Should WBT be used as a sequential treatment to evidence-based interventions to address psychopathology such as CBT, as a stand-alone treatment, or in combination with other psychotherapeutic approaches? Additionally, it is essential to identify during which phase of recovery and adjustment this intervention would be most appropriate: inpatient acute, postacute, or postdischarge? More specifically, the question remains as to whether these interventions should be used as a prevention method, as an intervention in the active phase of psychological disorders, or as a relapse-prevention treatment. For example, do groups receiving WBT shortly after injury experience lesser rates of depression than do those who do not? One can infer from the current literature that individually, for example, people living with SCI tend to do well. However, as a cohort, this population psychologically fares worse than do their counterparts living without an SCI. If this group does prove to benefit significantly with WBT, this intervention could be implemented as part of routine care for acute patients with SCI to circumvent a host of negative consequences associated with depression. In speaking with board members of an SCI support group in Miami, Florida, all of whom are living with SCI, they agreed this form of prophylactic intervention may be most useful in the immediate outpatient phase of treatment, when patients must return home to deal with the hassles of everyday life without the support of their inpatient care team. This transition phase, from full-time support from a medical care team to caring for oneself at home, can be lonely and emotionally traumatic for patients with a new SCI. In sum, this vulnerable period wherein patients have time to process their experience without the social support network that is built into an inpatient setting may be the most optimal time to implement a well-being intervention. Again, research must be done to corroborate this hypothesis. It remains an empirical question as to the optimal timing for WBT. Is there a critical time period for WBT effectiveness? Can it be useful for people years after their injury? Does it serve a protective function in individuals not experiencing a deficit in their well-being levels? Additionally, data are necessary to address the issue of potential efficacy (or lack thereof) for individuals not showing an impairment in their well-being levels. Further studies could help clarify the optimal period to implement this type of intervention. Moreover, further studies are required to assess the efficacy of these approaches in combination with an antidepressant or anxiolytic medication. PP is not a one-size-fits-all solution for increasing well-being and quality of life, and therefore, the use of customized treatment is encouraged (e.g., taking into account the areas of well-being that are below optimal level to the specific individual). This leads to another empirical question, namely are differing variants of WBT necessary for different conditions? In what ways, if any, should WBT for people with amputations differ from WBT for individuals living with TBI? Examining the six dimensions as described by Ryff’s model of PWB within people with chronic conditions could lead to a moreindividualized treatment and, potentially, to a more-efficacious treatment. To use one example, the financial costs associated with living with SCI are high. Without taking into account the wage loss, fringe



benefits, and productivity after having an SCI, the annual estimated costs are $730,000 for individuals with paraplegia who were 25 years old at the age of injury and are as high as $2.185 million for individuals with tetraplegia who were 25 years old at the age of injury (National Spinal Cord Injury Statistical Center [NSCISC], 2002). Additionally, individuals with an SCI have decreased employment rates. One year postinjury, only 12% of people with SCI are employed, and 20 years postinjury only approximately 33% of individuals are employed (NSCISC, 2013). All of these factors can significantly contribute to decreased well-being and higher incidents of psychopathology such as depression and anxiety. It is an empirical question as to what degree, if any, these adverse outcomes could be affected by a WBT intervention. Research data investigating psychological contributions to preventing or mitigating both financial and emotional costs associated with preventable complications would be both timely and welcome additions to current health care debates. If the data warrant inclusion, PP interventions such as WBT could become a standard aspect of medical care instead of an elective add-on. Ryff and Singer (1996) posited that the treatment of psychopathology that focuses exclusively on the alleviation of negative symptoms leaves people vulnerable to future relapses. However, focusing on bolstering one’s positive attributes may serve to create a buffer against future adversities. In a preventative model, building a “wall” of positive psychological defenses has the potential to prepare individuals to weather the emotional pitfalls of coping with the substantial life change that accompanies a physical disability or chronic illness. Reconnecting people with the values and goals that are most dear to them (regardless of physical disability), giving people the means to shore up their cognitive skill set to achieve those goals, teaching self-compassion, and creating a feeling of connectedness with others are a few examples of the building blocks that PP uses to build positive psychological defenses. One should not assume that the alleviation of negative symptoms in itself will result in an increase in well-being. In fact, facilitating the growth of positive factors may work through an entirely separate mechanism (Ryff & Singer, 2006). In the same vein, it should not be assumed that the bolstering of positive affect will remove negative affect throughout the active phase of an illness. At present, there is no evidence to suggest that interventions such as WBT can effectively be used independently from standard treatments such as CBT or pharmacotherapy; therefore, more research must be conducted before WBT is used independently or even in conjunction with standard care during the active phase of an illness.

A Caveat Dunn et al. (2009) issued the following caveat, however: “Resiliency and growth should be encouraged, not required” (p. 658). A positive psychology approach, they argued, must not be forced upon people living with chronic illness or disability, because there is no correct way to respond. The authors pointed out that among some well-intentioned researchers and therapists there still exists a sizable cohort who believe people with acquired physical disabilities need to “properly mourn their loss of function” and that any failure to properly grieve for loss of a premorbid self is seen as psychological denial or another defensive reaction. However, as Trieschmann (1988, p. 69) pointed out, this “requirement of mourning” is rooted in the assump-

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tion that a display of depression is necessary for “healthy adjustment,” and it endures despite data showing quite the opposite. It is important to keep in mind that individuals cope in their own way, which is generally syntonic with how they have dealt with adversity previously, on the basis of their individual differences.

Conclusion There is power in revisiting the underlying foundational principles of our past and looking at how they can inform our present and future functioning. Clearly the basic ideas put forth by Lewin, Meyerson, Wright, and Treischmann that underlie our field lead logically to the examination of some approaches within the realm of positive psychology and especially the data-based approaches of researchers such as Carole Ryff and Giovanni Fava. Once examined, ideas like wellbeing therapy come to the foreground, and data need to be collected on whether this logical extension of our some of our foundational principles can be effective in assisting those people living with chronic illness and disability.

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Received March 13, 2015 Revision received September 3, 2015 Accepted September 8, 2015 䡲

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