The primary taste cortex consists of the insula and operculum. Previous work has indicated that neurons in the primary taste cortex respond solely to sensory input from taste receptors and lingual somatosensory receptors. Using functional magnetic resonance imaging, we show here that expectancy modulates these neural responses in humans. When subjects were led to believe that a highly aversive bitter taste would be less distasteful than it actually was, they reported it to be less aversive than when they had accurate information about the taste and, moreover, the primary taste cortex was less strongly activated. In addition, the activation of the right insula and operculum tracked online ratings of the aversiveness for each taste. Such expectancy-driven modulation of primary sensory cortex may affect perceptions of external events.
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Objective: Few studies have evaluated moderators of mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs). We tested whether baseline patterns of scores for SUD symptom severity and depression and anxiety symptoms moderated the efficacy of MBRP. Method: We used a latent class moderation approach with data from a randomized trial of MBRP compared to cognitive–behavioral relapse prevention and treatment as usual (TAU; Bowen et al., 2014; N = 286, 71.8% male, 48.4% non-White, mean age = 38.44 years, SD = 10.92) and a randomized trial comparing MBRP to TAU (Bowen et al., 2009; N = 168, 63.7% male, 44.6% non-White, mean age = 40.45, SD = .28). Indicators for the latent class models were measures of SUD severity (Severity of Dependence Scale and Short Inventory of Problems), depression symptoms (Beck Depression Inventory), and anxiety symptoms (Beck Anxiety Inventory). Results: In both trials, 3 latent classes provided the best fit: a high–high class characterized by high SUD severity and depression and anxiety symptoms, a high–low class characterized by high SUD severity and low depression and anxiety symptoms, and a low–low class characterized by low SUD severity and depression and anxiety symptoms. In both trials, we found significant latent Class × Treatment interaction effects: There were significant and large effects of MBRP on substance use outcomes in the high–high and high–low classes, but no MBRP effect in the low–low class. Conclusion: MBRP may be an optimal treatment for preventing relapse among clients with severe levels of SUD symptoms and depression and anxiety symptoms, as well as clients with only severe SUD symptoms.
This research was supported by a grant from the National Institute on Drug Abuse: R21 DA010562 (Marlatt, PI). The authors would like to acknowledge Dr. G. Alan Marlatt for his guidance and support, Katie Witkiewitz for her editorial consultation, and the Mindfulness‐Based Relapse Prevention clinical and research teams for their dedication to this project.
Research on the development of theory of mind (ToM), the understanding of people in relation to mental states and emotions, has been a vibrant area of cognitive development research. Because the dominant focus has been addressing when children acquire a ToM, researchers have concentrated their efforts on studying the emergence of psychological understanding during infancy and early childhood. Here, the benchmark test has been the false-belief task, the awareness that the mind can misrepresent reality. While understanding false belief is a critical milestone achieved by the age of 4 or 5, children make further advances in their knowledge about mental states and emotions during middle childhood and beyond. Thus, a comprehensive understanding of children's sociocognitive abilities in older age groups is necessary to understand more fully the course of ToM development. The aim of this review is to outline continued development in ToM during middle childhood. In particular, we focus on children's understanding of interpretation—that different minds can construct different interpretations of the same reality. Additionally, we consider children's growing understanding of how mental states (thoughts, emotions, decisions) derive from personal experiences, cohere across time, and interconnect (e.g., thoughts shape emotions). We close with a discussion of the surprising paucity of studies investigating individual differences in ToM beyond age 6. Our hope is that this chapter will invigorate empirical interest in moving the pendulum toward the opposite research direction—toward exploring strengths, limitations, variability, and persistent errors in developing theories of mind across the life span.
The experience of aversion is shaped by multiple physiological and psychological factors including one's expectations. Recent work has shown that expectancy manipulation can alter perceptions of aversive events and concomitant brain activation. Accruing evidence indicates a primary role of altered expectancies in the placebo effect. Here, we probed the mechanism by which expectation attenuates sensory taste transmission by examining how brain areas activated by misleading information during an expectancy period modulate insula and amygdala activation to a highly aversive bitter taste. In a rapid event-related fMRI design, we showed that activations in the rostral anterior cingulate cortex (rACC), orbitofrontal cortex (OFC), and dorsolateral prefrontal cortex to a misleading cue that the taste would be mildly aversive predicted decreases in insula and amygdala activation to the highly aversive taste. OFC and rACC activation to the misleading cue were also associated with less aversive ratings of that taste. Additional analyses revealed consistent results demonstrating functional connectivity among the OFC, rACC, and insula. Altering expectancies of upcoming aversive events are shown here to depend on robust functional associations among brain regions implicated in prior work on the placebo effect.
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Mindfulness meditation yields beneficial effects on the processing of emotions. However, it is still unclear whether the focus of attention during meditation influences these effects. In the present study we aimed at comparing the effects of breathing meditation and emotion-focused meditation on the immediate and delayed processing of negative and positive emotions. The study included 65 adult novice meditators who were exposed to positively and negatively valenced film clips. Participants were randomly assigned to three conditions. While watching the films at t1, they were asked to mindfully focus on their breath (condition 1), on emotions (condition 2), or on nothing in particular (condition 3). Ten minutes later at t2, comparable film clips were shown but all participants watched them without taking up a mindful attitude. Dependent measures were emotional states at t1 and t2. Participants of both meditation conditions particularly showed a more preferable delayed emotional reaction to negative stimuli than participants of the control condition. Breathing meditation and emotion-focused meditation may constitute effective emotion regulation strategies to deal with negatively valenced emotional states.
This study investigated the effects of a school-based anxiety prevention and intervention social emotional learning (SEL) program (i.e., FRIENDS for Life) on anxiety symptoms and the frequency of episodes of victimization due to bullying in an experimental intervention study of elementary aged school children. Standardized assessments were administered in ten school classrooms in an Independent school district (e.g., nonsecular) to Grade 4 children (N = 205), and were used to assess self-reported levels of frequency of victimization episodes, and anxiety symptoms. Classrooms were randomly assigned to either the intervention (i.e., FRIENDS for Life SEL program) or a waitlist control group. Student self-report assessments were collected on two
The term cognition refers to unconscious mechanisms in the mind that bring about representations. Social cognition may be defined as any cognitive process that involves other people. These processes can be involved in social interactions at a group level or on a one-to-one basis. This chapter identifies the scope of social cognition and recent research on the mechanisms of social cognition and its component processes in the brain. The study of social cognition uses the same measures as any other area of cognitive science. Some measures are especially helpful in the study of communication and emotion. These include: autonomic responses, brain activity, neuronal activity, scalp electrical impulses, cerebral blood flow, and non-verbal behavior. Mechanisms of social cognition are thought to be crucial for reading faces, detecting eye gaze, recognizing emotional expressions, perceiving biological motion, and detecting goal-directed actions and agents. This chapter further discusses how pathology affects social cognition. It also poses some burning questions from interactions in everyday life.
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This descriptive, cross-sectional survey was conducted in inpatient nursing units and outpatient clinics in a cancer center in the midwestern United States. The sample of 153 healthcare providers included RNs, medical assistants, and radiology technicians. The fourth revision of the 30-item Professional Quality of Life (ProQOL R-IV) scale was used for measuring compassion fatigue, compassion satisfaction, and burnout. A series of cross tab analyses examined the relationship between participant demographics and three ProQOL R-IV subscales. The study sample scored similarly on compassion satisfaction and burnout when compared with participants who used the ProQOL R-IV in previous studies. Value exists in analyzing the prevalence of burnout and compassion fatigue among oncology healthcare providers. Understanding the needs of distinct demographic groups offers valuable direction for intervention program development. Applying internal evidence in the design of a relevant stress-reduction program will better equip healthcare providers to recognize and manage compassion fatigue and burnout.
The practice of yoga in transnational contexts, from North America to Europe to India, has been linked with what has come to be known as the Green movement for environmentally sustainable living. Both this Green movement and the yoga practices that are being mobilized on its behalf are closely connected to the construction of a transnational cosmopolitan middle class that defines itself through particular understandings of health, well-being, and environmentalism. In this paper, we discuss the utility of yoga for both promoting an ecological worldview as well as for linking personal health and well-being with a broader understanding of planetary health; our analysis also highlights the current commercialization of both yoga and the more general health and ecology arenas. In order to do this, we provide both a discursive analysis of web and print media representations of these topics, and also explore the meanings of yoga through ethnographic data collected in a variety of locations between 1992 and 2010. These data were collected among yoga practitioners associated with the training initiated by three major figures in the history of twentieth century yoga, Swami Sivananda, T. Krishnamacharya, and Sri. K. Patabhi Jois. By combining ethnographic research with an examination of text and images, we explore how personal practice and planetary health are linked through the minds, bodies, discourses, and transcultural flows of the yoga world’s diverse members.
The practice of yoga in transnational contexts, from North America to Europe to India, has been linked with what has come to be known as the Green movement for environmentally sustainable living. Both this Green movement and the yoga practices that are being mobilized on its behalf are closely connected to the construction of a transnational cosmopolitan middle class that defines itself through particular understandings of health, well-being, and environmentalism. In this paper, we discuss the utility of yoga for both promoting an ecological worldview as well as for linking personal health and well-being with a broader understanding of planetary health; our analysis also highlights the current commercialization of both yoga and the more general health and ecology arenas. In order to do this, we provide both a discursive analysis of web and print media representations of these topics, and also explore the meanings of yoga through ethnographic data collected in a variety of locations between 1992 and 2010. These data were collected among yoga practitioners associated with the training initiated by three major figures in the history of twentieth century yoga, Swami Sivananda, T. Krishnamacharya, and Sri. K. Patabhi Jois. By combining ethnographic research with an examination of text and images, we explore how personal practice and planetary health are linked through the minds, bodies, discourses, and transcultural flows of the yoga world’s diverse members.
The 21st-century has seen a rapid expansion of interest in contemplative pedagogy across institutions of higher education, not to mention K-12 education. Even as contemplative pedagogy can be found everywhere from courses on law to language, it has a more complex relationship with religious studies. Although the fiction of pure objectivity has receded in intellectual inquiry more broadly, many religious studies departments defend themselves from critics on all sides by presenting themselves as engaged in the “scientific study of religion” (religionswissenschaft). Promoting contemplative practice in the classroom can risk crossing the line into proselytizing, as well as into the culturally imperialist decontextualization and appropriation of others’ traditions, leaving some religious studies scholars wary of first-person approaches to learning that are based on practices associated with particular religions.
This study examines the agreement across informant pairs of teachers, parents, and students regarding the students' social-emotional learning (SEL) competencies. Two student subsamples representative of the social skills improvement system (SSIS) SEL edition rating forms national standardization sample were examined: first, 168 students (3rd to 12th grades) with ratings by three informants (a teacher, a parent, and the student him/herself) and a second group of 164 students who had ratings by two raters in a similar role--two parents or two teachers. To assess interrater agreements, two methods were employed: calculation of q correlations among pairs of raters and effect size indices to capture the extant rater pairs differed in their assessments of social-emotional skills. The empirical results indicated that pairs of different types of informants exhibited greater than chance levels of agreement as indexed by significant interrater correlations; teacher-parent informants showed higher correlations than teacher-student or parent-student pairs across all SEL competency domains assessed, and pairs of similar informants exhibited significantly higher correlations than pairs of dissimilar informants. Study limitations are identified and future research needs outlined.
<p>Objective: A strong relation between negative affect and craving has been demonstrated in laboratory and clinical studies, with depressive symptomatology showing particularly strong links to craving and substance abuse relapse. Mindfulness-based relapse prevention (MBRP), shown to be efficacious for reduction of substance use, uses mindfulness-based practices to teach alternative responses to emotional discomfort and lessen the conditioned response of craving in the presence of depressive symptoms. The goal in the current study was to examine the relation between measures of depressive symptoms, craving, and substance use following MBRP. Method: Individuals with substance use disorders (N = 168; mean age 40.45 years, SD = 10.28; 36.3% female; 46.4% non-White) were recruited after intensive stabilization, then randomly assigned to either 8 weekly sessions of MBRP or a treatment-as-usual control group. Approximately 73% of the sample was retained at the final 4-month follow-up assessment. Results: Results confirmed a moderated-mediation effect, whereby craving mediated the relation between depressive symptoms (Beck Depression Inventory) and substance use (Timeline Follow-Back) among the treatment-as-usual group but not among MBRP participants. MBRP attenuated the relation between postintervention depressive symptoms and craving (Penn Alcohol Craving Scale) 2 months following the intervention (ƒ² = .21). This moderation effect predicted substance use 4 months following the intervention (ƒ² = .18). Conclusion: MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in postintervention substance use among the MBRP group. Although results are preliminary, the current study provides evidence for the value of incorporating mindfulness practice into substance abuse treatment and identifies a potential mechanism of change following MBRP.</p>
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OBJECTIVE:A strong relation between negative affect and craving has been demonstrated in laboratory and clinical studies, with depressive symptomatology showing particularly strong links to craving and substance abuse relapse. Mindfulness-based relapse prevention (MBRP), shown to be efficacious for reduction of substance use, uses mindfulness-based practices to teach alternative responses to emotional discomfort and lessen the conditioned response of craving in the presence of depressive symptoms. The goal in the current study was to examine the relation between measures of depressive symptoms, craving, and substance use following MBRP.
METHOD:
Individuals with substance use disorders (N = 168; mean age 40.45 years, SD = 10.28; 36.3% female; 46.4% non-White) were recruited after intensive stabilization, then randomly assigned to either 8 weekly sessions of MBRP or a treatment-as-usual control group. Approximately 73% of the sample was retained at the final 4-month follow-up assessment.
RESULTS:
Results confirmed a moderated-mediation effect, whereby craving mediated the relation between depressive symptoms (Beck Depression Inventory) and substance use (Timeline Follow-Back) among the treatment-as-usual group but not among MBRP participants. MBRP attenuated the relation between postintervention depressive symptoms and craving (Penn Alcohol Craving Scale) 2 months following the intervention (f(2) = .21). This moderation effect predicted substance use 4 months following the intervention (f(2) = .18).
CONCLUSION:
MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in postintervention substance use among the MBRP group. Although results are preliminary, the current study provides evidence for the value of incorporating mindfulness practice into substance abuse treatment and identifies a potential mechanism of change following MBRP.
BACKGROUND:Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial.
OBJECTIVES:
To establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT's acceptability and mechanism of action.
DESIGN:
Single-blind, parallel, individual randomised controlled trial.
SETTING:
UK general practices.
PARTICIPANTS:
Adult patients with a diagnosis of recurrent depression and who were taking m-ADM.
INTERVENTIONS:
Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT's acceptability and mechanism of action.
MAIN OUTCOMES MEASURES:
The primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities.
RESULTS:
In total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation.
CONCLUSIONS:
There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group.
BACKGROUND:Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial.
OBJECTIVES:
To establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT's acceptability and mechanism of action.
DESIGN:
Single-blind, parallel, individual randomised controlled trial.
SETTING:
UK general practices.
PARTICIPANTS:
Adult patients with a diagnosis of recurrent depression and who were taking m-ADM.
INTERVENTIONS:
Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT's acceptability and mechanism of action.
MAIN OUTCOMES MEASURES:
The primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities.
RESULTS:
In total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation.
CONCLUSIONS:
There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group.
TRIAL REGISTRATION:
Current Controlled Trials ISRCTN26666654.
FUNDING:
This project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full in Health Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.
BackgroundMindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness or cost-effectiveness for young people. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of a mindfulness training (MT) programme to enhance mental health, wellbeing and social-emotional behavioural functioning in adolescence.
Methods/design
To address this aim, the design will be a superiority, cluster randomised controlled, parallel-group trial in which schools offering social and emotional provision in line with good practice (Formby et al., Personal, Social, Health and Economic (PSHE) Education: A mapping study of the prevalent models of delivery and their effectiveness, 2010; OFSTED, Not Yet Good Enough: Personal, Social, Health and Economic Education in schools, 2013) will be randomised to either continue this provision (control) or include MT in this provision (intervention). The study will recruit and randomise 76 schools (clusters) and 5700 school students aged 12 to 14 years, followed up for 2 years.
Discussion
The study will contribute to establishing if MT is an effective and cost-effective approach to promoting mental health in adolescence.
This study investigated the effects of a brief meditation intervention on perceived stress, mindfulness, and sleep quality for college freshmen who have aged out of foster care. Thirty-six youth who had aged out of foster care and enrolled at a large midwestern 4-year university (n = 16 experimental group, n = 20 control group) participated in a study in which they were assessed three times on the dependent variables. Students also participated in a focus group after the intervention ended. Four sessions of the brief mindfulness intervention resulted in significant short-term reductions in stress levels and increases in sleep quality. Finding effective personal interventions to increase chances for college success for students with histories in foster care can also offer potential insight toward the development of educational models and resources for other vulnerable college student populations.
This study investigated the effects of a brief meditation intervention on perceived stress, mindfulness, and sleep quality for college freshmen who have aged out of foster care. Thirty-six youth who had aged out of foster care and enrolled at a large midwestern 4-year university (n = 16 experimental group, n = 20 control group) participated in a study in which they were assessed three times on the dependent variables. Students also participated in a focus group after the intervention ended. Four sessions of the brief mindfulness intervention resulted in significant short-term reductions in stress levels and increases in sleep quality. Finding effective personal interventions to increase chances for college success for students with histories in foster care can also offer potential insight toward the development of educational models and resources for other vulnerable college student populations.
BACKGROUND:Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness among young people.
AIMS:
To assess the acceptability and efficacy of a schools-based universal mindfulness intervention to enhance mental health and well-being.
METHOD:
A total of 522 young people aged 12-16 in 12 secondary schools either participated in the Mindfulness in Schools Programme (intervention) or took part in the usual school curriculum (control).
RESULTS:
Rates of acceptability were high. Relative to the controls, and after adjusting for baseline imbalances, children who participated in the intervention reported fewer depressive symptoms post-treatment (P = 0.004) and at follow-up (P = 0.005) and lower stress (P = 0.05) and greater well-being (P = 0.05) at follow-up. The degree to which students in the intervention group practised the mindfulness skills was associated with better well-being (P<0.001) and less stress (P = 0.03) at 3-month follow-up.
CONCLUSIONS:
The findings provide promising evidence of the programme's acceptability and efficacy.
Few empirical studies have explored the associations between formal and informal mindfulness home practice and outcome in Mindfulness-based Cognitive Therapy (MBCT). In this study ninety-nine participants randomised to MBCT in a multi-centre randomised controlled trial completed self-reported ratings of home practice over 7 treatment weeks. Recurrence of Major Depression was assessed immediately after treatment, and at 3, 6, 9, and 12-months post-treatment. Results identified a significant association between mean daily duration of formal home practice and outcome and additionally indicated that participants who reported that they engaged in formal home practice on at least 3 days a week during the treatment phase were almost half as likely to relapse as those who reported fewer days of formal practice. These associations were independent of the potentially confounding variable of participant-rated treatment plausibility. The current study identified no significant association between informal home practice and outcome, although this may relate to the inherent difficulties in quantifying informal home mindfulness practice. These findings have important implications for clinicians discussing mindfulness-based interventions with their participants, in particular in relation to MBCT, where the amount of participant engagement in home practice appears to have a significant positive impact on outcome.
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