The COVID-19 pandemic forced higher education institutions in Switzerland to move to distance learning, with certain limitations such as “Zoom fatigue” and a lack of interaction with peers and teachers. This has also impacted the development of interprofessional skills and key concepts such as professional acknowledgement, cooperation, and communication skills. This study was conducted using mixed methods, including performance assessment regarding examination notes, the 12-item General Health Questionnaire, and semi-structured interviews, to assess the impact of the pandemic on the performance of paramedic students and their psychological state. The results of the semi-structured interviews provided insight into the impact of the pandemic. The period of the COVID-19 pandemic appears to have had an impact on the psychological state of the paramedic students, most of whom were considered to be either at risk or in psychological distress. There may have been an effect on their theoretical knowledge performance, with pre-pandemic promotions performing better than pandemic promotions. In March 2020, the World Health Organization (WHO) announced that the coronavirus disease 2019 (COVID-19) outbreak could be characterized as a pandemic. In Switzerland, on March 13, 2020, the Federal Council declared an extraordinary situation and introduced more stringent measures, such as no complete lockdown . During The beneficial effects of the classroom courses are multiple. Positive peer influence, classroom cohesion, and student–teacher relationships are described as conditions for successful learning . EmpathyFor students and teachers, the perceived impact of COVID-19 on degree completion, perceived degree value, and future job prospects was a concern. In a previous study, medical students under lockdown reported feeling less prepared and felt that online teaching was less effective than face-to-face teaching . MoreoveDuring the curriculum, particular emphasis is normally placed on the development of interprofessional skills, as recommended by the Swiss Academy of Medical Sciences . InterprThe cancellation of a portion of hospital and pre-hospital internships also resulted in less exposure for students to clinical practice until the end of April 2020. In Swiss universities under lockdown, isolation in social networks, a lack of interaction and emotional support, and physical isolation were associated with negative mental health issues such as stress, anxiety, loneliness, and depressive symptoms. Depression significantly prejudices learning, especially for women and those without adequate social support ,14.The term “promotion,” which will be used widely through the manuscript, is used to describe a timespan corresponding to a year of study, e.g., the 2019 promotion corresponds to the class of second-year students passing their paediatric exam in 2019.A part of the students are commonly working as auxiliary staff in emergency medical services (EMS) from the second year of training, which can accumulate negative effects on learning, and expose them to aggravated psychological pressure, and even mental illness during the COVID-19 outbreak .In Switzerland, there has been no study of the COVID-19 pandemic’s impact in the specific setting of vocational education. The purpose of this study was to identify the effect of this period on learning and mental health in paramedic students.The main objective was to assess the impact of the lockdown and the learning adaptations during the COVID-19 pandemic on the promotions of paramedic students compared to pre-pandemic promotions regarding a specific exam performance.The secondary objective was to screen students from pandemic promotions for psychological disorders using the 12-item General Health Questionnaire (GHQ-12) and semi-structured interviews.The study was based on mixed methods. Three methods were used in this study: firstly, part one of the quantitative approach used the examination notes of the six last promotions to determine the students’ performance. Then, the GHQ-12 questionnaire was used to assess the psychological distress of the pandemic promotions. Finally, semi-structured interviews were conducted among some students from the pandemic promotions to explore the underlying reasons for the quantitative results.This study adheres to the STROBE  statement  File S1File S1. The primary outcome was the score obtained in a specific examination, i.e., the paediatric one. The exam questionnaires are regularly updated and renewed, making it impossible to compare between promotions. However, the paediatric exam has hardly changed over the last six years, justifying its use. Although they have several exams during their curriculum, it was therefore decided to only assess the 2nd year paediatric examination score. In Switzerland, there are several ways to calculate examination scores , the mosThe secondary outcomes were the scores of the GHQ-12 questionnaire, and the answers gathered through the semi-structured interviews.A clarification of responsibility was submitted to the local ethics committee . This study was considered to fall outside the scope of the Swiss legislation regulating research on human subjects, so the need for local ethics committee approval was waived (Req-2022-00361).For the primary outcome analysis, the setting was constituted of 118 students over six promotions . The choice of the number of promotions was based on the version of the examination, which has changed little over this period.For the GHQ-12, the study population consisted of 64 students in three grades  studying at the College of Higher Education in Prehospital Care in May 2021. They had 4 days to complete the questionnaire (between the 17 May 2021 and the 20 May 2021).For the qualitative part of the study, a convenience sample of six students was selected on a voluntary basis following these criteria: two per grade (during the first epidemic outbreak and the lockdown from 13 March to 27 April 2020), one of each main gender. The interviews were conducted between February 2022 and March 2022.No participant received any compensation.One hundred and eight participants were required to have a 90% chance of detecting, at the 5% level, a significant change in the examination note from 0.25 points in the pre-pandemic group compared to the pandemic group . A timeframe of six promotions  was selected because this was the period during which the examination remained the most unchanged. This timeframe represented 118 students’ examination performance. Given our sample size calculation, an adequate size could be achieved using this data. For the GHQ-12 outcome and to be as exhaustive as possible, the questionnaire was sent to a convenience sample containing all students from the pandemic promotions. No data exists on pre-pandemic promotions, and we did not want to recall them to limit memory biases.The General Health Questionnaire (GHQ) was developed in 1970 by David Goldberg and Paul Williams . The oriRespondents to this questionnaire should consider their current condition and the weeks leading up to it. There are 4 response modalities for the different items , e.g., “Better than usual,” “As usual,” “Less well than usual,” and “Much less well than usual.” There are several ways to account for the results. Before data collection, we decided to dichotomize the results, with the two first modalities corresponding to the absence of a problem (rated as 0) and the last two responses corresponding to the existence of suffering (rated as 1) ,23. WithThe prespecified thresholds were less than 2—mentally healthy, 2—at risk, and over 2—in psychological distress. The optimal threshold has been reported to range from 1/2 to 6/7, with the most common threshold being 2/3. If the goal of screening for psychiatric disorders in primary care is to help bridge treatment gaps, the recommended threshold is 1/2 point, where a score of 2 or above is ‘positive’ for those at risk of psychiatric disorders ,24.Semi-structured interviews were conducted by Lou Rauss (L.R.), a third-year female paramedic student without prior specific experience, for the purpose of her diploma thesis. She was studying at the College of Higher Education in Prehospital Care in Geneva, so she was also impacted by the pandemic. Prior to the study, a relationship was established with the participants, as they all attended the same college as her, particularly the third-year students who were in the same class. The participants were informed about the reasons underlying the study, and a written consent was gathered retrospectively. Content analysis was the methodological orientation stated to underpin the study. Saturation could not be determined as no exploratory factor analysis of the interview guide was conducted.A convenience sample of two students  was purposely selected by promotion for their willingness to take part in the study, their ability to express their feelings clearly, and to take an inside look. These students have all experienced semi-lockdown. The interviews were carried out twice face-to-face and the others by video conference. Notes were written during the interviews, lasting about 20 to 25 min, which were also audio recorded to allow further retranscription. No one, apart from the interviewer and the participant, attended the discussion. An interview guide , createdThe semi-structured interviews were based on a thematic analysis, according to Dejonckheere, M., and Vaughn, L.M. . The firOnce the interviews were done, L.R. transcribed them and sent them to F.O. and Loric Stuby for interpretation. The main themes were identified individually before the interpretation was brought together. Transcripts were not returned to participants for comment and/or correction. They were either not asked to provide feedback on the findings.t-test or the Mann–Whitney U test according to normality. Proportions were tested using Fisher’s exact test. Distribution was assessed graphically, and, in doubt, using the Shapiro-Wilk test. The examination note was treated as a continuous variable (unrounded). Missing data was treated as such. An univariable linear regression model was generated to assess the prediction of the examination scores based on the promotion. The objective was to compare the promotions between them, looking for “a promotion effect” that could affect the overall result. The quality of the model was assessed by checking the assumptions. Considering the rule proposed by Stevens . .As the canton of origin differs among groups , a sensip < 0.001), with an R2 of 0.19. The results by promotion are displayed in A simple linear regression was generated to predict the examination scores based on the promotion. A significant regression equation was found  = 5.13, p = 0.03).As the 2019 promotion was different from the others , a second sensitivity analysis was performed by reconducting the primary analysis with the exclusion of this promotion. The difference remained similar between groups after the exclusion of 2019′s promotion (pre-pandemic 4.92 (4.83 to 5.01) versus pandemic 4.75 (4.63 to 4.88), The GHQ-12 was sent to 64 students, of whom 52 (81.3%) answered. Their characteristics are displayed in The median ,  of the GHQ-12 was 2 , . The mean (SD) was 3.71 (3.12). The distribution is shown in Using the prespecified thresholds  were healthy, 11 (21.2%) were at risk, and 25 (48.1%) were in psychological distress.Six students were selected to participate in the semi-structured interviews. Their characteristics are reported in “feel useful.” A student reported that he “Could be useful and support the EMS,” another explained that he “Could still be active, [...] I had a chance to work in an EMS because our internships were all cancelled.”We noted that all the students interviewed experienced the semi-lockdown more or less well. In fact, students who were professionally involved in a service during this period experienced it better. They could “It was a very stressful time because my mom is immunosuppressed. I was potentially a vector. I had to move and live with my best friend.” Fear was present in some of them, linked to their relatives, and in others, to a lack of knowledge and information about the virus. Anxiety was a feeling expressed by all students. A student reported that “you are permanently anxious and then you can’t get into your classes or anything.” One student said she was “Worried about becoming incompetent” in her future occupation as a paramedic. Contrary to expectations sadness was not noted. Anger and joy were expressed by some students. Anger was expressed by doubting the college. “It was when we were told by email that they had announced to the services that they were closing the internships. I think that was the first time I started to doubt the college.”The students’ testimonies reported very different feelings. Stress was present in all the students, either because of concern about the disease or about the future of the curriculum. For one of them, who worked in an EMS, the stress was caused by the fear of infecting his loved ones. He explains that “You close yourself up, tummy ache [...]”; and another said: “I was moving less, I gained quite a bit of weight and that stressed me a lot too [...]”.Some students reported somatic manifestations of their anxiety, and stress. One student said: “you isolate yourself, you don’t want to see people anymore” and “you get away from everyone.” Despite this loneliness, they all lived in shared apartments or with their parents.Most students felt lonely during this period. First-year students who have not been assigned to a workplace feel lonelier. According to one student, “lost the pleasure to go out and see people, drink beers.” This was despite a large network of friends for most students. One student said, “You get away from everyone a bit.”They expressed a kind of after-effect of semi-lockdown like a lack of motivation to go out. This was illustrated by the words of the student, who In most interviews, students said that distance learning was difficult. The presence of difficulties in the learning of some students did not favour a good adherence to distance learning, especially videoconferences.Very hard to follow the lessons, to concentrate [...]. Always distracted at home.”; “Because of the video conferencing, it was very difficult to concentrate.”; “Very hard [...]. And in videoconferencing even more so, being all alone in my room in front of my screen, I could not concentrate at all.”; “I have too many distractions at home.”; “It’s hard to stay focused, your attention quickly wanders.”; “You can’t ask all the questions you want.”; “As long as you are at home, it is not conducive to learning. I had a quiet environment but even so, I had plenty of distractions.”Nearly all students described home as a quiet place. However, home was not a good place to learn since there was a lot of entertainment: ““human presence” was expressed by all students during distance learning courses as well as in a working environment: “I missed the interactions the most, because they are very difficult in video conferencing.”; “And also the contact with the other students, to see them at breaks, to discuss with them.”; “Because of the lack of interaction, I had less concentration, it was harder to follow a class and pay attention.”; “Usually, when we were in class and I did not understand, I often had the opportunity to ask the question in a low voice to a classmate who answered me in two words, and allowed me to stay focused.”; “What I missed the most was the exchange, it’s still different from face-to-face, the exchange with your classmates, where you can ask questions.”The lack of interaction and It was very complicated with connection problems, computer problems, sound problems. [...] with much less interaction between people.”A student also mentioned logistical issues: “There was quite a bit of support.” Only one of the students appreciated the learning by videoconference; he had previous experience with distance learning. All the interviewed students appreciated the e-learning and the recorded lectures, which allowed them to work at their own pace. One student explained that “the only good thing is the recorded lectures that you can listen to again.”Furthermore, half of the students were able to find, through their families, help with learning. However, all the students were able to find help from a classmate. “Personally, paediatrics remains a stress that I do not have in the other branches. The only thing I missed was paediatrics, and I feel like that’s where it comes from, even though paediatrics is still something that is very stressful for everyone.”.All students were impacted by the reduction in the number of training hours during the semi-lockdown period. Only the first-year students were able to do their prehospital internship. The internships of the second- and third-year students were cancelled, and many of the practical exercises were removed. The latter did not have their internship in specific fields such as anaesthesia or paediatrics. The consequences of this absence of about 2 months were felt. One student illustrated this with these words: “I am comfortable with COVID-19 management but I am not comfortable with management of complications of childbirth, or major events.” The development of certain specific skills also seems to have been impacted: “I think if I had been able to do my anaesthesiology internship I would be even more comfortable than I am now with ventilation and medication.” For the third-year students, the return to the internship never took place, and they immediately attended their final exams.Students were unanimous in their view that the pandemic has had an impact on the development of their practical skills. However, they did not notice a difference in their new occupation. Third-year students described their lack of skills in the areas where the internship was cancelled: “: “When it was a whole week of videoconferencing, I was demotivated”; “It takes twice as much work because you have to redo all the courses because it is very difficult to follow.”Motivation was a challenge for all students. For some, videoconferencing courses required more work“It’s not very motivating to get up and listen to someone you don’t interact with…”For others, the fact of being alone in front of a screen and not being able to interact was demotivating: “Motivation has changed, because non-diversified interventions during two months of internship is complicated.”One student also mentioned the absence of diversity in prehospital care: However, none of them had any doubts about their motivation to continue the curriculum.“I was very worried that we would graduate with less competence as the others.”A student has questioned herself about her level: Many people in the professional community criticized the management of the exams, and said that the exam was poorly administered by the college and that many students should not have passed because they did not have the skills.” However, two years after graduation, those who were third-year students during the first lockdown did not feel that the pandemic had changed the value of their degree.The title of paramedic for students who graduated in July 2021 has been criticized by some graduated paramedics due to their lack of practicum as well as the way they passed their final exam: ““Puzzles, embroidery, knitting, video games, activities that kept my mind busy.”; “I tried to do sports at home and keep a balance between physical activity, and work for college.”The coping strategies applied by the students were all different, they did activities to entertain themselves: “I moved in with my best friend, I think it helped me keep a balance.”; or to stay informed: “I got informed by reading studies, and by being confronted with the disease.”; “I have made inquiries about the disease, and what was going on. I think that was the best way to fight the fear of the unknown.”They also tried to socialize themselves: “We had to set ourselves deadlines [...]. I made a schedule for the rest of the lockdown [...].” For some, coping strategies in themselves seemed difficult to live: “You run away to something else, you do activities where you escape. Sports, series, or stuff like that. It is not about reducing stress but forgetting about it.”One student mentioned the need to have a frame: “I could be useful and support the EMS and when we were in confinement we could work a lot, and that’s cool”; “As soon as the lockdown started, I very quickly started working in EMS so I did not feel isolated at all at any point. I could still be active. I had a chance to work in an ambulance because our internships were all cancelled.” “I was working in an EMS, I always felt invested”. “Working in an ambulance service saved my degree.” In these students, two reported to being stressed by working in EMS: “It was a very stressful time because my mom is immunosuppressed. I was potentially a vector. I had to move and live with my best friend.” “I was afraid at the beginning of the pandemic. But once we had more explanation about the virus, that I could be confronted with the disease, with the protective gear...it was okay... it reduced my fear a lot...”Most students reported working in an EMS. Their testimonies highlight the positive aspect of being active in the field during this period: The COVID-19 outbreak impacts scholar performance with a mean score (95% CI), pre-pandemic 4.99 out of 6 points (4.91 to 5.07) versus pandemic 4.75 out of 6 points (4.63 to 4.88)] in these specific exams. This is relevant because it represents one grade difference  . The effect of the COVID-19 pandemic on student performance could be related to many factors.The shift to online distance learning in vocational education could be beneficial. Typically, the curriculum includes more than 50% hands-on skills labs and simulations. However, due to the outbreak, emergency adaptations from blended learning to 100% online courses must have been made. Effective online courses need to be adjusted and pedagogical concepts should be designed and developed explicitly for e-learning . It was very complicated with connection problems, computer problems, sound problems,” demonstrating the difficulties of implementing a 100% online program. Internet connection problems are a common barrier to effective online courses . As high“When it was a whole week of videoconferencing, I was demotivated,” and “It’s not very motivating to get up and listen to someone you don’t interact with.” Low motivation seems to have occurred in at least these two students. The motivational aspect has an impact, with boredom having a negative impact and motivation having a positive impact . Two stu“Always distracted at home.”; “When video conferencing, it was very difficult to concentrate.”Family distractions and concentrating difficulties are frequent barriers to effective learning . In our “you escape into something else; you do activities where you escape. […] watch series, things like that.” This could impact learning, a scholar’s results, and their psychological state in different ways. Higher levels of screen time were associated with a variety of health harms for children and young people, with evidence for adiposity/overweight, an unhealthy diet, depressive symptoms, and quality of life [The screen time was increased, both due to distance learning and for entertainment , as emph of life ,32. By t of life . Some au of life ,35. I was very worried that we would graduate with less competence as the others.” Belief in self-efficacy is an important predictor of successful learning too [About self-esteem and self-efficacy, a student reported this feeling: “ning too ,36. Thisning too .The hands-on workshops and simulations were discontinued. These workshops are, of course, important for the development of practical skills, but not only. They are always followed by a debriefing where the practical aspect is put into perspective with the theoretical learning, allowing a good anchoring of the knowledge. Blended learning with face-to-face courses, especially in vocational training, makes sense. Psychomotor skills cannot be developed through video conferencing. For example, Currat et al. found that adding face-to-face training to an e-learning module increased proficiency and enhanced skill retention in student paramedics ,38.“was pissed off” when the school announced the cancellation of the 24-h high-fidelity simulation with nurses, emergency physicians, firefighters, policemen, and policewomen. It takes time to understand others’ priorities and problems. This impacts the development of key concepts such as professional acknowledgement, reciprocity and respect, cooperation, communication skills, working on protecting turf, and workplace culture [All interprofessional learning activities were stopped in the first wave of COVID-19. To illustrate that, a student reported that he  culture . InterprIn the general population, the GHQ-12 mean score varies from 1.63 points (SD 1.98) in Korea  to 5.9 aCloser to our population, a study among French-speaking Swiss paramedics in 2011 , using GA part of the GHQ-12 score was related to depressive symptoms, and anxiety. In semi-structured interviews, a large portion of students used words such as “anxiety, fear.” One student reported fear of infecting his relatives. Similar findings were noted in a descriptive study of baccalaureate nursing students, where 84% reported that it was a major cause of fear, followed by the fear of contracting COVID-19 . In DeceFatigue, and lack of sleep are not good conditions for learning. As described above, major parts of the courses were conducted via videoconferencing. Clearly, this allowed the curriculum to be continued, but the “Zoom fatigue” effect could also be a barrier to learning, as mentioned by Hattie about a lack of sleep . could be useful and support the ambulance services and when we were in confinement we could work a lot, and that’s cool”; “As soon as the lockdown started, I very quickly started working in EMS so I didn’t feel isolated at all at any point. I could still be active. I had a chance to work in an ambulance because our internships were all cancelled.” “I was working in an EMS, I always felt invested.” “Working in an ambulance service saved my degree.”In the semi-structured interviews, students involved in EMS have more positive discourses on the experience of COVID-19 outbreak. In comparison, a study among emergency medical workers in Spain showed that the COVID-19 pandemic may have been a traumatic event. Indeed, one-third of them reported a possible diagnosis of post-traumatic stress disorder in the emergency department . The meaThese testimonies seem to show that the perception of control over a stressful experience could determine its impact on the individual. Helplessness against adversities could be a factor in stress-related psychiatric illnesses, such as depression, anxiety, and post-traumatic stress disorder . ConversDespite the wide psychological support offered , these results show that there is room for improvement, in particular in being more proactive to ensure the well-being of students.The study has several limitations. The primary analysis was based on only one specific exam, thus not necessarily reflecting the actual global performance of the paramedic students. The choice of thresholds for the GHQ-12 analysis could be debated, but we reported the detailed results, thus allowing their interpretation with different thresholds. The samples were different for each analysis, preventing us from assessing the same participants using different approaches. It does, however, allow the depiction of an overview. The semi-structured interviews were conducted about 18 months after the lockdown, which leaves the results subject to recall bias. The sample size was extremely limited, thus restricting the generalizability. As with all qualitative studies, it is never possible to guarantee that another study sample would not have led to a different result. Nevertheless, the data collected provided rich material describing many different individual situations, and experiences.The COVID-19 pandemic period appears to have had an impact on the psychological state of the paramedic students, with an effect on their theoretical knowledge performance.The lessons learned from this pandemic should help train institutions to better anticipate this type of crisis. First, by reinforcing social and psychological support in cases of interruption of courses, by developing a reliable tool dedicated to distance learning and designed pedagogically for this purpose , and by training teachers to use this tool so that they do not simply put online contents usually taught face-to-face. In view of the decline in school results, tutoring should also be considered.Students represent a resource that can be mobilized in a context of crisis, all the more because students who were actively involved on the front line seemed to experience the period better than those who stayed passively at home.


Meaningful activities and Recovery (MA&R) is a peer coled occupational therapy intervention, to support occupational engagement among persons with psychiatric disabilities. Material and Methods. A qualitative study with a phenomenological-hermeneutic design. Individual semistructured interviews were conducted with three women and ten men who had participated in MA&R. Participants were recruited from community mental health centres and municipality mental health services in two Danish municipalities. Analysis strategy was based on Malterud's Systematic Text Condensation.  To investigate participants' perspectives on how MA&R influenced occupational engagement and recovery processes.  MA&R was perceived as a practical approach to recovery, by providing an opportunity for reorientation, meaning, making in mundane activities, and a new outlook on everyday life. Participating in MA&R challenged a black and white approach to activities, put emphasis on “the little things”, and enhanced curiosity, presence, and joy in occupational engagement.  MA&R supported participants in developing a new “lens” on meaningful activities. The lens enhanced occupational engagement and made it possible to live according to personal preference. Results can inform further development and delivery of recovery-oriented occupational therapy interventions and add to the understandings of how occupational engagement and recovery are intertwined and manifested through everyday experiences. Thus, occupational engagement is an important target for recovery-oriented interventions. Occupational therapists and peer-workers coleading such interventions is feasible and makes good sense to the participants. Mental disorders are one of today's largest public health challenges, estimated to affect 38 percent of the EU population each year , 2. MentResearch investigating the links between recovery and occupational engagement has found that recovery is experienced through engagement in ordinary everyday activities in line with the “normal” roles and responsibilities, hereby rebuilding hope and connecting to an ordinary life in the community. , 25–28. Meaningful Activities and Recovery (MA&R) is a novel curriculum-based program to facilitate occupational engagement among persons with psychiatric disabilities . MA&R diA qualitative study with a phenomenological-hermeneutic design –50 was cMA&R is based on principles from the Lifestyle Redesign ® program  and was Thirteen participants were recruited from a larger sample of individuals with psychiatric disabilities, included in the MA&R RCT. MA&R was evaluated in a multicentre trial, with community mental health centres (CMCHs), a rehabilitation team, and activity and social support centres (ASSCs) as participating sites. The CMCHs delivered multidisciplinary treatment according to the Flexible-Assertive Community Treatment model, while the rehabilitation team delivered various rehabilitation services, mainly group based, such as self-esteem groups. The ASSCs were drop-in services, which means that they did not require referral or visitation. The ASSCs offered a wide range of activities, e.g., social happenings, open cafes, and creative activities. Participants in this study were affiliated to one of the sites when they enrolled in the MA&R trial.The sampling strategy was based on maximal variation sampling regarding sites, sex, age, and time since completing the intervention, for variations in experiences to be explored , 55. ParAn interview guide was developed addressing the research question. Extracts from the interview guide are presented in The analysis strategy was guided by Malterud's Systematic text condensation (STC) , 58, a dThe study was conducted in conjunction to the MA&R RCT approved by the Danish Ethic Committee (H-18017307), and the Danish Data Protection Agency . It followed the principles from the Helsinki declaration . InformaTen men and three women participated: age 25 to 50 years old. Four participants were students, the others were either job searching or received early retirement pension. The participants had various psychiatric diagnosis, about half had schizophrenia spectrum disorders. Participants had all completed MA&R, 0, 4, or 12 months prior to the interview .A practical approach to recovery, along with three subthemes, each describing change processes in relation to occupational engagement and recovery  and is preparing to rebuild your everyday life—and there she (another participant) was in what seemed to be the worst crisis of her life—and here, by talking with my MA&R mentor, he enabled me to use less energy on other participants situation (…) where, in other group-settings I have become an “assistant-teacher” (…) and thus forgetting my own needs” (participant 4).Here, the peer-worker enabled participants to draw parallels from the themes in MA&R and everyday life. Further, the peer-worker brought authenticity by still being in the recovery-process, introducing recovery as a possibility. Overall, participants perceived their engagement enhanced as they felt met with respect and equality from the MA&R mentors.The fact that MA&R was a course and not a therapy was important to several of the participants before entering the course. It was valued that MA&R was not centred around illness or psychoeducation. Participants felt enabled to contemplate upon bettering their personal circumstances and valued the opportunity for personal exploration and perceptivity of everyday life.not a therapy!” (participant 2).“It was just what I could use, somebody who brings something positive and some ideas and suggestions, as to how I can better my life, without digging in what went wrong. And that is why I said “yes, please”, also because it was a course, Having the curricula in focus provided participants with a relaxed and informal climate during group sessions, where illnesses became less prominent. The focus on activities and recovery initiated a process of altering perspective. From going through the day on autopilot to identifying which activities they wanted to engage in, and thus discovering that they already had several meaningful activities in practice.It was important for the individuals to feel recognized for their personality by MA&R mentors to perceive their encouragement as sincere. Hence engagement was fostered during the course when advice given was trusted e.g., MA&R mentors having a humble approach without dictating tasks. This inspired participants to engage enthusiastically throughout the course.“One of the greatest things was their ability to see me. When the course ended, we all got a little postcard on how they perceived us and it was like they pointed out some things that weren't noticeable for me, and that was quite moving it made me feel very comfortable and there was a warmth to it, and it was not a clinical experience (…) but safe” (participant 9).Feeling seen by the MA&R mentors, strengthened a sense of positive obligations in participants. Moreover, having the MA&R mentors to share their commitments with, promoted engagement in MA&R and a collaborative process around engaging in activities.did something, you know, when she (the OT) suggested something, then I had to try it out or try to look into it (..) it kept me on my feet, I had to do it before we saw each other again, whereas if it wasn't for the course, I would have been like “oh yeah, I will do it another day” and then it wouldn't amount to anything” (participant 13).“It made me not give up, because hell, I wanted to be able to say that I Conversely, not all participants did perceive MA&R as engaging. Some participants had entered MA&R with expectations of getting practical help or better managing everyday activities, so they became less arduous. They expressed disappointments by the end of the course, as they felt that these expectations were not met by the MA&R mentors, or they did not experience improvements in relation to performing everyday activities more effortless.It was commonly expressed that throughout MA&R, participants became aware that the term “activity” could be understood in several ways, in the sense that activities are individually defined as meaningful. Flow-theory and the discovery of absorption in seemingly mundane activities were highlighted by many as a concrete tool, easily available, and gradually adopted into ordinary day-to-day activities.“It has definitely broadened my understanding of it (recovery), in the sense, that to me it is a rather uplifting thought, that it isn't just appointments with a psychologist or medication, that can stabilize me (…) but that these more concrete things, these small buttons, seemingly obvious buttons close to you, can mean that your symptoms can be dismantled” (participant 4).Hereby, participants felt disburdened, enabling them to lower their expectations towards feelings of accomplishment now becoming more in line with their capabilities. It nurtured a curiosity of exploring meaning and pleasure in well-known everyday activities. The participants stated that it helped in applying a new perspective on daily activities available right at their grasp. However, one participant could not lower his expectations of authoring a book, for instance, by starting a process of write and rewrite, not aiming for the text to be perfect at first try, and felt inert, passive and not able to succeed during the course.Several participants stated that the “little things”, mundane, often taken-for-granted activities, were not irrelevant, just because they were “little”. They felt inspired by the idea of “size” of activities, “It's not either skydiving or sleeping, but it can be somewhere in between” (participant 7). Knowing that they need not do “grand” things, to make up a day of achievement, meant a greater appreciation towards ordinary elements in their everyday life. Several participants described that a new perspective led to further engagement in available tasks e.g., making plans to go shopping and engaging in self-care beforehand, now made grocery shopping a meaningful activity, or simply smiling or saying hello to a stranger there, meant having had an interaction that day.“Just such a thing as watering the plant you haven't nurtured, after having starred at it for three weeks, hell, that quality of life. So, this has also changed. Definitely. In the sense that these smaller things they have a catalysing effect on many other things, like quality of life. And this is where I find meaning, in the small, close to home things” (participant 1).Realizing that meaningful activities encompassed multiple types of activities that were deeply personal in terms of how they were performed and what meaning they had to people was highly valued among the participants. Identifying everyday activities that were meaningful, fostered self-determination in the participants, and helped them to avoid comparing themselves to others. Participants stated that this notion, made the meaningfulness more evident in the activities they were occupied with. It also enhanced their motivation to try out small activities, and their realization that not all practical tasks had to be chores but could also be enjoyable. Importantly, it was primarily these close to home activities that were possible. Social activities, such as seeking a tutor to initiate writing a book, or (re)establishing social relationships, were, for many participants, hindered by Covid-19 restrictions.Some participants described that MA&R had altered their perceptions of their living situation, acknowledging its potential in rebuilding a steady fundament for wellbeing in everyday life. No longer a place to hide, the home became a safe environment and a catalyser for further activities. One participant who had a sleeping disorder as comorbidity, made her bedroom a sound space, since much of her time was spent there: adding flowers, making the bed, and airing out. Another participant let his spiritual beliefs stand out in his home, making it his sanctuary. Hence, meaningful engagement could be grounded in something as fundamental as watering ones plants.“These meaningful activities are very close to home and daily life (….). It relates to taking care of myself, taking care of my home, and making this work, getting the basis to function” (participant 1).One participant, however, did not feel satisfied as his wishes of wanting help to move and start over in a new place, could not be met by the MA&R mentors.By focusing on existing resources, participants enhanced their awareness towards activities they already did, instead of focusing on the things they did not.“…And realizing that everything doesn't have to be perfect according to other people's standards, but that you set your own standard, and the apartment does not have to be shiny and perfect. This is what I can do, this is my level, then other people can do what they are good at” (Participant 9).Several participants described being more realistic about, and no longer ashamed of their capabilities. This led to a change of approach from neither-nor to “I can do both”, with limits. The acceptance fostered new insights, where disabilities were not a failure, but just a part of being that person at that time. This softened up a black and white perspective, where either you do the activity, or you do not. Participants experienced how formerly good activities felt detrimental when too much was initiated at once. This led to a focus upon what they could in fact do, creating more balance towards initiating activities in line with personal levels and meanings. Importantly, was to overcome the embarrassment that activities mundane to others, e.g., getting out of bed and on with the day, could be a struggle. Leading one participant with the courage to ask for help with his apartment, so that he could focus his energy upon engaging in other activities.Throughout MA&R, participants felt supported in identifying their resources and utilizing these when engaging in activities, and conversely exploring how activities could be used as resources. Participants found it easier to engage in activities for their personal benefits, when they were curious about those in which they could fully immerse themselves. Participants reported that awareness and understanding of one's possibilities for wellbeing, when engaging in activity, came from realizing that focus was not devoted to symptoms if they were actively participating in activities. This gave rise to taking charge e.g., going to the park outside when sensing anxiety, or simply just placing yourself on the couch with a pet, just do something different. By noticing when activities felt good, opportunities arose to enforce these, and opposite, to distance from activities which felt draining.Accessible activities became part of a personal toolbox. Walking became a proactive strategy for one participant when he felt apathic. Another started to take breaks to lean back and be attentive of own needs when his OCD took charge. Some participants focused on the feelings accompanied with an activity, such as tidying up could foster engagement and be enjoyable. Others adopted the notion that it is okay to slobber, when cleaning and not do 100%, which motivated to engage in activities.“I have given myself permission to slobber, I like this principle of slobbering, at least now, so when I am cleaning, I do not have to get into every corner, but superficial cleaning is also a thing. Where before (…) when having to be this extreme, resulted in me not being able to handle anything at all” (participant 9).When asked about daily patterns and routines, most participants deemed that their everyday life looked the same as before MA&R, with few alterations. However, contemplation upon known routines and activities, stirred several participants away from “autopilot”, meaning that everyday life did not feel the same, due to an altered perspective of self-determination upon what makes up an activity.being able to sit there, it gives me so much joy and all I want to do is improve this, what I have, more than I want to add anything, that's how I feel (Participant 9) ”.“Tomorrow, we are going to the laundromat, and I am looking forward to it. The walk down there, and sometimes we sit and wait for the laundry to finish. And where this earlier was associated with a lot of anxiety, it has now become much better, to be able now to tell yourself “I'm just going to sit here”. But actually, Those participants who adopted new perspectives particularly did this in relation to “smaller” everyday activities, and by increasing their awareness of the opportunities these arose. For instance, one participant explained that bringing his camera, when taking a walk in the park, introduced new possibilities of experiencing a sense of flow when capturing nice motives. For some participants, routines were changed with emphasis upon favouring own needs and wants, e.g., one participant now started to make coffee as a morning routine:“During my sick leave and while I was in MA&R, I practiced making myself a good cup of coffee every morning on my slow brewer, because making coffee or tea for myself was something I had never done, only if there were others” (Participant 4).Reflecting on how activities could be a barometer for the recovery process, this participant reduced her working hours to resume good routines.MA&R created a space for trial and error where participants could experience success both inside and outside the group. Learning that engaging in activities took practice and not worrying about a “perfect outcome” was motivational and made it easier to initiate activities and feel more ease and presence in them.“I would rather just try it out, and maybe it's not fun for me, or maybe I'm not good at it, but it might become enjoyable, or you could get better at it (…) but then you know your limits in that period and this might change as well” (participant 8).One participant challenged his all-or-nothing approach, (job or no-job), and asked for job-training at the job centre, leading to developed job-abilities, slowly easing his way back to work-life routines.This contributed to a different approach to activities, as opportunities for creating momentums.“I think there is a positive spill over effect, if something is enjoyable, then it becomes easier to do other things too” (Participant 11).Some participants expressed being able to, to some degree, manage their own wellbeing through activities. Participants highlighted that learning about flow-theory and being able to identify with a state of flow, was a positive experience. Knowing that flow could appear in their natural environment merely by putting on music or folding laundry, made participants aware that this was attainable for them and that they could feel “normal”.“I have become aware of it (flow red.), and I think that is the important part. I have become aware that I, for brief periods can feel like everybody else and be occupied by something and go into that state. That process is what has become clear to me” (Participant 1).Initially, it required a lot of awareness to engage, but over time “just” engaging in activities became more intuitive e.g., by taking your camera with you on a walk. By focusing on “the good” in activities and letting achievements outweigh defeats, several participants were enabled to see possibilities in their surroundings, where the “to-do” list was replaced with a “try-this” list. When a participant in the interview was asked if she was better able to do what she wanted to do, she answered:“Yes, I feel that I am, that I do. There is always that thought when you deal with recurring mental illness “it will come back”, you know? Right now, I am on a positive road, and hopefully, when it goes uphill again, then I will try and focus more on doing some of the things that I have discovered makes me happy and does me good, by taking me out of my head—having had this year to figure out what these things were” (Participant 13).The participants felt more equipped to verbalize their concerns and avoid situations that could result in defeat. Several participants felt more able to express their needs towards friends and family.Through engagement in activities and by enhancing the experiences of respite, participants felt their illness less prominent. This made recovery seem attainable by using activities as an indicator for mental wellbeing, e.g., the reattainment of bicycling or the awareness of skipping good morning routines.“I remember how good it felt when I started riding my bicycle around town again, because I have always identified myself as one of those city-types who rides their bicycle around town. But all those years being ill I only took the bus, and I was in the back of the bus hiding, primarily riding the bus in knowing, that in this place I wouldn't run in to anybody I knew. (…), and it made a huge difference for me when I started bicycling again, because it was a recognition that, all right, now I am aware that I can possibly run into someone, so in doing this I felt like I moved on to an open world again” (Participant 4).Choosing daily activities more in tune with own preferences such as their ability of feeling absorbed or respite or simply perceiving taking a break as an activity, nurtured hope, and experience of living meaningful lives. Several participants also spoke of the possibility of becoming peer-workers themselves.The findings in this study illuminate whether and how MA&R supported activity engagement and subsequently, the recovery process from the participants' perspectives. The program's emphasis on reorientation in daily life, for instance in relation to meaning making of occupational experiences, and rethinking interests, values, aspirations, and identities, the personal orientation, and its pragmatic approach with emphasis on trial and error was highlighted by the participants. The activity-oriented focus, together with a respectful tone, supported participants to engage and experience meaning in activities within their reach during MA&R. Participants adopted several considerations for mundane activities learning that these could provide joy and immersion, and their homes and surrounding became pivotal for wellbeing and a safe space to recoup.Being refers to the temporal unfolding of meaning, being well in everyday life, belonging, and accepting. Doing refers to participating and contributing through everyday activities within a social context where the person feels valued. In our study, participants distinguished between daily life looking the same, and feeling the same. We interpret this as recovery through the descriptions from MA&R participants, possibly being closely linked to temporality and occupational engagement, more than to occupational performance. This poses a question whether MA&R first and foremost support recovery in terms of wellbeing and experiences of meaning, and how this can be achieved with or without making actual changes in daily activities, but by changing perspective. Contemplating on the findings, that the smaller day-to-day activities took presence could be a result of the Covid19 pandemic, having affected accessing—the third process by Sommer et al., when restrictions and lockdowns closing opportunities to attend activities in the greater social surroundings. Thus, restrictions could have had serious consequences on quality of life [Our findings align with results from Sommer et al.'s metasynthesis on recovery , identif of life –64. But,Present results also have ties to findings from a scoping review by Doroud et al. , examinia subjective experience of engagement became clear, with examples such as riding the bicycle across town again, being mindful about the bedroom or the different aspects of going to the laundromat, and just be with a friend.Activities on hand and their tangibility through trials rendered as a solid basis, and a prominent theme appeared through the interviews, that daily life did not feel the same by applying a new focus of temporality whilst being in activity. By working with “trial and error” in activities in- and outside MA&R, engaging in these became less fearful through the perception of it as practice for the “real world”. This is in line with Doroud et al. , who fouin the eye of the beholder. People have different ideas about what make meaning in their lives. Consequently, promoting occupational engagement is not a process that should be taken for granted by merely assuming what kind of occupational opportunities people with psychiatric disabilities need, for instance by building mental health services that solely offer predefined activities. Assisting a person to discover where feelings of absorption appear, and to strengthen the awareness of activities, mundane, familiar, or new, can foster a feeling of connectedness to everyday life. Enabling the person to build upon the personally defined occupational life, in line with Doroud et al. [recovery through engagement in the stream of everyday life.Although there often might be overlaps between activities that are culturally and personally valued  , 66, find et al.  can suppdevelop identity through occupation [Findings from this study stress the importance of meeting the person's recovery goals. Participants became disengaged when they did not feel met by the MA&R mentors. Persson et al. proposes in their analysis of value dimensions, meaning and complexity in occupations, that occupations have symbolic value on a personal and cultural level. Through choices of occupations, the individuals communicate aspects of themselves, to the immediate world. The social environment communicates “back”, to the doer, providing feedback on whether the behaviour is acceptable and valuable according to cultural norms and ideologies.  Participcupation  in knowicupation .Findings from this study point to both similarities and differences with qualitative studies on participants experiences with BEL –37, AOI A stepwise purposeful sampling  was chosWhile phenomenological philosophy is not as explicitly stated in STC as in Giorgi's method  or InterTo enhance trustworthiness and improve credibility, authors were engaged in a constant dialogue to consolidate on each level in the analysis, thus supplementing and contesting each other's findings to strengthen the understanding of the phenomena , 74, 75.Findings from this study show that MA&R was perceived as a practical approach to recovery and that the activity focus in MA&R supported this approach. Participants highlighted the experiences of recovery through the “small things” in life, often taken for granted. They appreciated MA&R for its positive and future-orientation and personalized approach alongside opportunities for trial and error. The findings provided understandings of how occupational engagement and recovery are intertwined and manifested through everyday experiences. Aiding in personal recovery was an altered perspective upon activities, challenging the “big” or “small” activities and applying own terms towards meaningfulness and presence in daily life. Moreover, the findings indicate that occupational engagement can be enhanced, with or without increased occupational performance.The MA&R course-setup enabled participants motivation to take-in curricula and apply knowledge towards activities. Knowledge was empowering in giving participants tools right at their grasp. The results from our study suggest that MA&R supported the participants in developing a new “lens” on meaningful activities—highlighting the value of everyday experiences for recovery and wellbeing.


Interpersonal synchrony is the alignment of responses between social interactants, and is linked to positive outcomes including cooperative behavior, affiliation, and compassion in different social contexts. Language is noted as a key aspect of interpersonal synchrony, but different strands of existing work on linguistic (a)synchrony tends to be methodologically polarized. We introduce a more complementary approach to model linguistic (a)synchrony that is applicable across different interactional contexts, using psychotherapy talk as a case study. We define linguistic synchrony as similarity between linguistic choices that reflect therapists and clients’ socio-psychological stances. Our approach involves (i) computing linguistic variables per session, (ii) k-means cluster analysis to derive a global synchrony measure per dyad, and (iii) qualitative analysis of sample extracts from each dyad. This is demonstrated on sample dyads from psychoanalysis, cognitive-behavioral, and humanistic therapy. The resulting synchrony measures reflect the general philosophy of these therapy types, while further qualitative analyses reveal how (a)synchrony is contextually co-constructed. Our approach provides a systematic and replicable tool for research and self-reflection in psychotherapy and other types of purposive dialogic interaction, on more representative and limited datasets alike. Interpersonal synchrony is the alignment of neural, perceptual, affective, physiological, and behavioral responses during social interaction . ExampleThe key role of language in psychotherapy has fostered considerable interest in the nature of linguistic synchrony in therapist–client interaction. It is generally thought that therapists and clients attain synchrony by developing shared mental representations, or a “common language,” through “mutual adaptation to another’s linguistic behaviors” , p. 7. HThe influential Interactive Alignment Model  synthesiComputational linguistics research, which applies computational techniques to analyze natural language, offers potential quantitative solutions for evaluating (a)synchrony. On the unconscious-versus-strategic alignment debate described above, computational evidence suggests that “alignment is not a completely automatic process but rather one of many discourse strategies that speakers use to achieve their conversational goals” . This isIn summary, linguistic synchrony research in contexts like psychotherapy would benefit from a more explicit sessional focus and complementary techniques to model and interpret both the global and contextual aspects of (a)synchrony. The following method section will detail each step of the presently proposed approach, and the results and discussion section will report a demonstration of the approach on three sample dyads from different therapy types.analytical thinking, clout, authenticity, and emotional tone, and are the focus of the present approach. LIWC is a computer text analysis program used in many language and discourse studies. Its motivating assumption is that “the words we use in daily life reflect what we are paying attention to, what we are thinking about, what we are trying to avoid, how we are feeling, and how we are organizing and analyzing our worlds” , p. 30—ianalytical thinking score reflects formal, logical, and hierarchical thinking versus informal, personal, here-and-now, and narrative thinking. This is based on college admission essays where those with more articles and prepositions were rated as more formal and precise in describing objects, events, goals, and plans, while those with more pronouns, auxiliary verbs etc. involved more personal stories , but hedge their advice (clout) and use more positive words  to come across as more personal (authenticity) and optimistic. Similarly, other studies have applied LIWC to profile how language works across diverse contexts like social media  are maximally similar and each group is maximally dissimilar to one another. It is used in classification tasks in diverse fields like marketing, image analysis, and bioinformatics, on quantitative as well as qualitative data types .k-means clustering (where k = no. of clusters). Cluster analysis can be performed on most statistical software packages. We use the Python 3.8 programming language, code available upon request.There are many clustering algorithms that differ on key parameters like how (dis)similarity is defined and what constitutes a cluster . Most ge1–T10 and C1–C10. We call these “sub-transcripts.” The properties of each sub-transcript are its LIWC variable scores computed in “Step 1.” Whichever algorithm is preferred, the aim is to offer a distributional measure of synchrony where for each session x, if sub-transcripts Tx and Cx fall into the same cluster, then session x is considered synchronized. Otherwise, session x is asynchronized. The basic rationale is that therapist and client language within the same session ought to be more similar to each other than they are to other sessions, if we want to claim that session as synchronized. Step 2, therefore, yields the following concrete outcomes: (i) which sessions across the treatment span are (a)synchronized, (ii) the percentage of synchronized vs. asynchronized sessions as an overall measure of the dyad, and (iii) the distribution pattern of (a)synchrony across time. Each outcome can be further probed with reference to the actual transcripts in context.For the present application, the set of objects to be clustered are the session transcripts of therapist-only and client-only language. For example, a 10-session dyad will have 20 objects labeled Thow and why (a)synchrony is co-constructed in selected extracts. As mentioned earlier, this helps us connect the “global” quantitative synchrony measures with what actually goes on in therapist–client interaction, and potentially reveals higher-order communication strategies as well as other context-specific features that may deepen our understanding of the nature of (a)synchrony.Qualitative analysis of examples in context is integral to virtually all linguistic approaches to psychotherapy. This may be complemented by relevant quantitative analysis either before, after, or in an intermittent way . A key rCounseling and Psychotherapy Transcripts, an online subscription database for research and education.We now demonstrate the above steps on three sample dyads from different therapy types. The source of the transcripts is z-score, or number of standard deviations from the variable mean score. This is not critical because all four variables are measured on the same scale of 0–100, but must be done otherwise to prevent scales of larger magnitude from biasing cluster formation. Some researchers also advise performing mean-centering in cases where within-person scores  are likely to be more consistent than between-person scores , leading to entangled within and between-subject effects. There is debate regarding the benefits of mean-centering  between the clusters and objects. This distance inherently decreases with an increasing number of clusters, reaching zero when the number of clusters equals the number of objects. However, since too many clusters are neither parsimonious nor analytically useful, we determine an optimal number by comparing distortion values for a range of cluster numbers. The resulting “elbow plot” shows how distortion decreases as the number of clusters increase. The optimal point, which looks like an elbow, is the number after which the decrease in distortion tapers off. Introducing more clusters after this point no longer improves distortion at the same rate as before, and hence does not compensate for the loss of parsimony.k-means clustering algorithm for each dyad using the optimal number. The outcome, known as the “clustering solution,” is a unique assignment of each sub-transcript to one of the clusters. This outcome is validated to ensure that the clusters are indeed sufficiently distinct from one another. An efficient validation method is to compare the mean variable scores of members between clusters. These mean scores are also known as “cluster centers.” A good outcome is one where the magnitude and/or direction of these means are clearly distinct, suggesting that the clusters they constitute are also distinct.We then run the authenticity and emotional tone scores for the second psychoanalysis cluster only mean that they are relatively lower in sub-transcripts in that cluster, compared to the other two psychoanalysis clusters; (ii) recall that the variable scores were converted to z-scores, so negative values mean that the scores are below the average of that dyad. Visual inspection adequately shows that the cluster centers are indeed distinct in magnitude and/or direction.The final step is simply to note which sub-transcripts belong to which clusters in order to determine (i) which sessions across the treatment span are (a)synchronized, (ii) the percentage of synchronized sessions as an overall measure of the dyad, and (iii) the distribution pattern of (a)synchrony across time. Note that the number of (a)synchronized sessions in each dyad might be systematically influenced by the optimal number of clusters, a point to be investigated in future work. As a final visualization, We proceed to the final step of qualitative analysis at the two levels as described above: (i) a discussion of whether the synchrony measures reflect the general philosophy of their represented therapy type, and (ii) a more specific analysis of transcripts in context for how (a)synchrony is interactionally constructed across the three dyads.Firstly, the measures show that the psychoanalysis sample dyad is the most synchronized (33%), followed by humanistic therapy (25%) and CBT (0%). Psychoanalytic and humanistic interventions are known to be less structured and adherent to established models, attaching more importance to the therapist–client relationship . HumanisOur sample dyads generally conform to these expectations. The psychoanalytic (33%) and humanistic dyads (25%) are comparable and both much higher than CBT (0%). It is also possible to examine the distribution of synchronized sessions across time. In our case, the psychoanalytic dyad is barely synchronized at the beginning of treatment but experiences four near-consecutive synchronized sessions near the end, while synchrony in the humanistic dyad is more intermittent, also in the latter half of treatment. The relatively greater display of synchrony in the latter half is likely a result of more co-constructive interaction as treatment develops, with the consecutive block in the psychoanalytic dyad indicating a prolonged period of such activity. Importantly, we are neither claiming that the above synchrony measures correlate with real or perceived treatment quality/outcomes, nor that certain approaches inherently (dis)prefer synchrony because of high/low measures. These are important but ultimately empirical questions that lie beyond the methodological aim of the present study.In addition to the above cluster analytic insights, a more detailed level of analysis would help researchers and self-reflecting practitioners uncover specific details about the linguistic and interactional construction of (a)synchrony. The present striking example of CBT’s “perfect asynchrony” might be particularly illustrative in this regard. We now demonstrate how qualitative linguistic analysis, key to the various discourse analytic research approaches outlined earlier, can be useful for both research and critical reflection on one’s own practice . Recall Extract 1 is from dyad A  Session 8, a synchronized session see . Recall CLIENT: So he’s worked now for four years in this job, and it’s going to be so hard for him to turn the other way and I cannot will him to do anything.THERAPIST: Yeah. I guess I’m imagining that, seeing him suffer this way and be himself so sort of helpless and being so helpless yourself to do too much about it, is part of what makes it so difficult.CLIENT: Um hmm. So I sense some urgency in the, like, speeding up, or in getting the most out of therapy while he has it. That is my getting-the-most-out-of-things tendency. He does not feel this way. He′s like, “Ah, she just told me I was punishing myself.”THERAPIST: Hmm.CLIENT: Like, yeah. That’s the point.THERAPIST: It’s pretty hard to sit by, huh?CLIENT: Yeah. It’s so hard. It was so much harder in college though. God, I was like, um, I felt that I could not go on in the relationship a number of times.THERAPIST: I mean I guess the place to look would be you know, um, I mean, it does almost like you have vicariously experienced his stress and, except that you are helpless cause you cannot do all the things that you would have done if it were you. But it was him.CLIENT: Yeah.THERAPIST: You know, that is what I imagine used to hang you up about this.CLIENT: Yeah, that was probably the main thing.analytical thinking , clout , and authenticity , with a larger difference for emotional tone . These similarities, which constitute the basis for the statistical determination of synchrony, are reflected at a more general level by the observable level of concord between therapist and client. Markers of agreement like “yeah”  and “um hmm” (Turn 3) suggest that the dyad are gradually co-constructing a shared interpretation of the client’s situation. Their similarly low analytical thinking indicates a mutually informal, personal, here-and-now, and narrative style, as the therapist guides the client to explore the underlying meanings, causes, and mechanisms of her thoughts and feelings. The therapist’s display of mid-level clout is noticeable. On the one hand, she asserts her interpretations by frequently using ‘I’ and directs them towards the client with “you” . On the other hand, she carefully reduces the force of these interpretations with hedging expressions like “I guess” (Turn 2), “almost like” (Turn 8), and “I imagine” (Turn 10). The client in turn does not display a significantly lower clout as she appeared to respond well to this approach, concurring with the therapist’s interpretations. These observations also account for the similar relatively low levels of authenticity—unsurprisingly, given the general psychoanalytic aim of “making the implicit explicit,” clients may find themselves speaking in a more guarded and distanced manner when working through repressed thoughts and feelings. More interesting is the observation that the therapist also displays a comparable level of authenticity, which may suggest an explicit effort to ‘reflect’ the client in a neutral and non-interfering manner.Referring back to It is also interesting to note that, contrary to strategies like repetition and contiguity , the preExtract 2 is from Dyad B (CBT) Session 6. Recall that all sessions in dyad B are asynchronized. The therapist establishes the client’s “dire need for approval” from her mother as a key irrational belief to be disputed, and asks her to identify more potential irrational beliefs. The therapist then proceeds to point out why they are irrational.THERAPIST: So this need for approval, this dire need for approval, and very pointedly from your parents, maybe more so from your mother, is going to keep you suffering if you do not continue the good work you are doing. So, any more irrational beliefs before you dispute the life out of these ones right here and now?CLIENT: Yeah. Let me think.” I should have not been so impulsive to say what I was feeling at the time.”THERAPIST: And because I was so impulsive, that makes me…CLIENT: “And because I was so impulsive, that makes me a thoughtless daughter.”THERAPIST: As I should not be.CLIENT: “As I should not be.” See, it’s always that ending.THERAPIST: Well it usually is that ending, if the result is anxiety, panic or other unpleasantries.CLIENT: Right. God. That part always gets me.THERAPIST: You mean, until now, that part has not been as evident as you’d like it to be. You cannot say it always gets you, because always implies always: past, present and future, and you still have years of life left.analytical thinking , clout , authenticity , emotional tone , which suggest highly divergent interactional stances. The contrast in clout is evident from Turn 1 as the therapist uses many client-directed pronouns  to assume an expert-like and directive stance to establish the “disput(ing) the life out of” of irrational beliefs as a key focus of their interaction. The client obliges by reflecting on the therapist’s directions using self-directed pronouns . We see the reverse pattern for authenticity—the client’s high score is reflected in her willingness to disclose her thoughts and feelings, which is unsurprising given the present therapist-directed focus on her irrational beliefs. By contrast, the therapist’s low score is attributable to her exclusive focus on the client. The therapist’s higher scores for analytical thinking and emotional tone are likewise predictable from her general educative, problem-focused, and task-based stance. Her language contains more logical markers  compared with the client’s complementary narrative style, and she is obliged to use more optimistic or emotionally positive language in contrast with the client’s generally negative depiction of her situation. This becomes apparent later in the session (not in extract) when the therapist urges the client to remind herself that she is worth ‘approval, adoration, and acceptance’.As mentioned earlier, both speakers echo each other from Turns 3 to 6. The therapist guides this process by repeating key parts of the client’s utterances to prompt further reflection, and the client repeats them again  to demonstrate this reflection. Such repetitions and overlaps are expected when dysfunctional thoughts, beliefs, assumptions, etc. are discussed because they often involve concrete details depicted by content words. However, in accordance with LIWC’s non-emphasis on content words, this apparent synchrony does not translate to an actual high synchrony measure. Referring again to Our analyses of extracts 1 and 2 have shown how a quantitative contrast in synchrony measures is reflected in equally contrastive interactional stances between dyads A and B. We now consider dyad C (humanistic therapy), which has a synchrony measure (25%) midway between A and B. Extract 3 is from Session 9 where the client relates her frustrations with her mother and why she has been avoiding her. The therapist guides the client to explore these feelings and suggests that the avoidance is linked with her need to retain her sense of self.CLIENT: Like I have not done a damn thing about my mother since July and she’s been through hell since then, and I just completely turned off.THERAPIST: You have some feeling like there’s some resemblances between what she does and how you are sometime, that it’s absolutely necessary that you keep yourself separate from her?CLIENT: To a degree yeah, mostly because I have not sorted out what’s keeping myself separate is in a way like she’s fantastically… like I’m upset in five minutes after being with her. She’s just overwhelmingly….THERAPIST: In all of these.CLIENT: She’s like, “I am helpless. You do not talk to me.” It’s every kind of accusation except that she never says it that way, so you cannot yell at her for saying it that way. It’s always done in a nice, rational tone.THERAPIST: Man, those things can cripple.CLIENT: I’ve experienced them really crippling, and I have experienced being literally nervous wrecks for a long time growing up, […] the only time that I’ve been able to handle her has been in the last year since I’ve been able to not treat her like a human being, but treat her like a patient. But if I once let myself soften to her, I am so vulnerable.THERAPIST: I know. It’d almost be a bad thing tucked away or being lost.CLIENT: Because I do not know who I am, but I know that I’m a very negative person from her. I cannot take that from her anymore, every time she staggers or it’s just like you just feel like crying, she’s so pitiful, and she’s also so good-hearted. I empathize with her too much, and I know what she feels like too much, and I know how she’s not able to cope, and it hurts.THERAPIST: And it’s like there’s too much overlap, it not only ends up maybe damaging you, but making it really hard for you to… It may sort of feel weak or like meaningless to someone else, but like it really helps to have that, at that point because it sounds like in one way you feel the same way. You’ve got to have that separation to retain any sense of yourself.CLIENT: Um hmm.THERAPIST: …sense of yourself.analytical thinking  and authenticity , with larger differences in emotional tone  and especially clout . In this sense it lies between extract 1 where three variables are highly similar, and extract 2 where none of the variables are. Interestingly, this coincides with the fact that the overall synchrony measure of dyad C is also midway between A and B.From analytical thinking and authenticity scores. Both score low in the former as the conversation is informal and narrative-like, and high in the latter as the client’s disclosure of her feelings  is met with the therapist’s open and empathetic understanding . Their emotional tone scores are not as similar, but both tend towards the negative end. Their use of negative emotion words is consistent throughout as the client relates her and her mother’s feelings , and the therapist focuses more on the personal meaning of her experiences .A closer analysis of the interactional construction of synchrony indeed reveals elements that resemble both extracts 1 and 2. The therapist attempts to clarify the client’s feelings by paraphrasing her account more precisely like ‘keep yourself separate from her’ (Turn 2) and “those things can cripple” (Turn 6). The observed concord in extract 1 is noticeable here as the client shows tacit agreement by echoing these utterances in the following turns , and markers of agreement like “(to an extent) yeah” (Turn 3) and “un hmm” (Turn 11). This general dynamic accounts for their similar clout. Notice also that the aforementioned concord is demonstrated to a lesser extent here. The client appears to agree with the therapist (only) “to a degree” (Turn 3), and unlike extract 1, she expresses her feelings more independently and does not orient her utterance as a response to the therapist at every turn.However, while the therapist in extract 1 does not seem to take the lead, the therapist here is subtly leading the process by summarizing the client’s reflections, drawing out their implications, and proposing an interpretation that is expected to be accepted . This isIn summary, the above analyses attempted to contextualize the quantitative synchrony measures and illustrate how linguistic (a)synchrony can be constructed in different ways that can be examined at the individual dyadic level. Our examples generally reflect characteristics expected at the theoretical level of therapy type—dyad A demonstrates a high level of non-judgmental “reflection” often discussed in psychoanalysis, dyad B presents a sharp contrast where the CBT therapist adopts a more institutionalized educative role, and dyad C contains element of both in the humanistic therapist’s broad adoption of a guiding, empathetic approach.We demonstrated a systematic and replicable approach that combines automated quantification of therapist and client language, cluster analysis, and discourse analysis to model linguistic (a)synchrony in therapist–client interaction. While informed by existing strands of research, its use of the session as the key unit of analysis and measurement of (a)synchrony at dyadic level presents a more intuitive account than alternatives like single turns or topics. The contextual elaboration of quantitative measures affirms the importance of a mixed-method orientation to linguistic (a)synchrony research, complementing general patterns found in a dataset with a more critical eye on higher-order communicative strategies and phenomena.Our sample analyses of three dyads from key therapy approaches were performed with both researcher and practitioner objectives in mind. The present analyses are far from representative of the therapy approaches. Depending on their interests, researchers may adopt a similar comparative approach on more representative datasets to study how (a)synchrony varies across therapy types, the temporal distribution of (a)synchronized sessions within a dyad, and/or conduct further qualitative analyses of (a)synchrony construction from different theoretical perspectives. Interested practitioners who have the required resources and skills can apply it to their own work and critically reflect on their socio-psychological stances vis-à-vis their clients, as well as their avowed therapeutic approach. It would be particularly interesting to track how one’s tendency to (a)synchronize changes across different clients and over time. Additionally, the approach could also be applied to other social contexts where there is an interest in examining linguistic (a)synchrony between speakers and across motivated intervals, such as classroom interaction  or online fora (different posts across time). The approach can also be attempted on quantification schemes other than LIWC that reflect different theoretical assumptions and underpinnings.Lastly, as alluded to earlier, while it is tempting to suggest that higher linguistic synchrony measures correlate with better treatment or interactional outcomes, such questions are beyond the present scope. This is especially pertinent given that there is evidence for the general effectiveness of all three therapy types, which raises the question of how detrimental a seemingly low-synchrony approach like CBT truly is. Our approach shares with most psychotherapy language research the inherent limitations of secondary analysis of transcripts, and has a more descriptive focus on modeling rather than prescribing language use. It nevertheless provides a basis for future work to incorporate outcome measures and investigate links between linguistic synchrony and treatment quality. Relatedly, we have not considered how linguistic constructions of (a)synchrony might vary along demographic variables like age and gender, and its non-verbal manifestations like gestures and other paralinguistic cues. These can be flexibly incorporated in future work because of the schematic nature of our proposed approach. Quantification and clustering can be extended to non-linguistic or paralinguistic behaviors and variables, and the subsequent qualitative analytic phase is not married to any particular framework. The above considerations also apply to other potential contexts of linguistic (a)synchrony where our approach can be applied.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.DT conceptualized the study including its objectives, design, methods, and analysis and also responsible for drafting the manuscript. HQ contributed to sections of the qualitative analysis. All authors contributed to the article and approved the submitted version.This work is supported by a Faculty Reserve Grant (ZVY8) of the Faculty of Humanities, The Hong Kong Polytechnic University.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In the multivariable logistic regression model, a significant association was observed between prior knowledge of the concept THS and sex , continent of birth , and occupation . Almost two out of three health care professionals who participated in our study did not know what THS was. Educational activities on this topic should be implemented.There is scarce evidence on the knowledge and opinions about third-hand smoke (THS) of health care professionals. The main aim of this study was to explore the knowledge and opinions of health care professionals about THS and, secondarily, to explore the factors that are associated with this knowledge. Cross-sectional study using a snowball sample of multi-national health care professionals (n = 233). Data were obtained from an exploratory, online questionnaire. The health care professionals’ knowledge and opinions on THS were described with absolute frequency and percentage. Chi-square and Fisher-Freeman-Halton exact tests, and simple logistic regression models, were used to explore the bivariate association between the knowledge of the concept THS and sex, continent of birth, educational level, occupation, years of experience, and attitude towards smoking. Finally, a multivariable logistic regression model incorporating all the above variables was fitted. A total of 65.2% of the participants were unaware of the term THS before the study began. In the bivariate analysis, an association was found between prior knowledge of the term THS and continent of birth ( There is a direct relationship between tobacco use and premature morbidity and mortality in the smoking and non-smoking population . AccordiSHS is the smoke exhaled by the smoker and the sidestream smoke generated from the burning tip of the tobacco product . SHS conPassive exposure to tobacco smoke includes not only exposure to SHS, for which there is ample evidence of its harmful effects, but also to thirdhand smoke (THS). THS refers to the secondary pollutants and by-products of tobacco smoke that persist in the environment after a tobacco product is extinguished . These pThe tobacco epidemic is a major public health problem that needs to be addressed from different sectors and levels. In this regard, health professionals, especially those in the health care area, can play a fundamental role since they have direct contact with the population and influence their behaviors, and can therefore impact on the patients’ health outcomes . For thiTherefore, the aim of this study was to describe the knowledge and opinions of health care professionals about THS and explore what factors are associated with prior knowledge of the concept THS.Cross-sectional study using a snowball sample recruited from April to June 2021.Practicing healthcare professionals from Africa, America, Asia, and Europe (n = 233). The link to the questionnaire was shared with first and last authors’ professional contacts from different countries, working in clinics and public and private hospitals, who were asked to share the link with their colleagues. Inclusion criteria were having intermediate or higher education in Health Sciences , having healthcare functions at the time of completing the questionnaire and giving prior consent to participate in the study.Online, ad-hoc questionnaire implemented in Google Forms in English, Spanish, and German. Some of the questions were retrieved from questionnaires used in two previous studies, one on the knowledge about THS in health care professionals in the US  and anotThe questionnaire was divided into two parts: the first part addressed questions on the knowledge and opinions of the participants on THS and the second part included sociodemographic questions, related to their healthcare activity and current attitude towards smoking.Before starting the questionnaire, the participants had access to the information sheet and the informed consent form, which they were required to fill in before answering the questionnaire.Prior knowledge of the term THS was collected through the question “Have you ever heard of THS?” . Opinions on the knowledge that other people had about THS were collected through the questions “How informed do you think your coworkers in the health care setting are on THS?” and “How informed do you think the general population is about THS?”, both with the possible answers “not at all informed”, “somewhat informed”, “very informed”, and “don’t know/no answer”. Additionally, “Parents are knowledgeable about THS”, with the possible options “strongly disagree”, “disagree”, “neither agree/nor disagree”, “agree”, “strongly agree”, “don’t know/don’t answer”.Own opinions on THS and the consequences of its exposure were obtained through the questions “How much attention do you think THS is receiving in the health care setting?”, with four possible answers: “not enough attention”, “just the right amount of attention”, “a lot of attention”, “don’t know/no answer”; “how much do you think THS is harmful to health?” and “how much do you think THS affects children?” with five possible answers: “not at all”, “a little”, “quite a lot”, “a lot”, “don’t know/no answer”.Finally, beliefs of health care professionals on the recommendations health professionals should provide to the general population regarding THS were assessed through the questions “Health care professionals should promote habits of hand hygiene, mouth hygiene, etc. among smokers with children under 3 years of age to prevent exposure to THS among the child population” and “Health professionals should inform about the effects of passive smoking exposure (SHS and THS) to parents of children under 3 years of age”, with six possible answers: “strongly disagree”, “disagree”, “neither agree/disagree”, “agree”, “strongly agree”, “do not know/do not answer”.Respondents were asked to indicate their sex , age, country of birth, level of education , current occupation , professional experience in years , and current smoking behavior .Categorical variables were described with absolute frequency and percentage and age with mean and standard deviation. To explore the association between previous knowledge of the term THS and each of the covariates, Chi-square and Fisher-Freeman-Halton exact tests were carried out, and simple logistic regression models were applied to estimate odds ratios (OR) and their 95% confidence intervals (95% CI). To estimate the adjusted ORs (aOR) and their 95% CIs, a multivariable logistic regression model was performed.The significance level was set at 0.05 and the contrasts were two-sided. The statistical program used was IBM SPSS v.26.The final sample consisted of 233 participants born in 24 countries. A total of 83.7% were female; 61.0% had a bachelor’s, undergraduate, or degree; 67.4% were nurses; 52.4% had more than 15 years of experience; and 71.0% were nonsmokers .Before introducing the definition of THS, 65.2% of the participants had not heard of this term . Once itp-value = 0.030), occupation , and with prior knowledge of the concept SHS   .p-value = 0.005), continent of birth , and occupation   .Almost two out of three healthcare professionals in the healthcare area were unaware of the term THS at the beginning of the study. This lack of knowledge was associated with male sex, continent of birth, and a current occupation other than physician. Once the concept of THS was presented, about three out of four participants considered THS to be at least quite harmful to health and about nine out of ten participants at least quite harmful to children.To our knowledge, the exploration of the knowledge and opinions on THS of health personnel had only been carried out at a single-center level in the US . TherefoIt is worrying to point out that an important proportion of participants in our study, more than three out of four, estimated that in the health care setting where they work, THS is not receiving enough attention and that about 50% of their coworkers are not informed about THS. These considerations, associated with the evidence that is progressively accumulating on the harmful effects of exposure to THS ,17, leavThe vast majority of the participants (over 80%) agreed or strongly agreed that health professionals should promote hygiene habits for smokers with children under 3 years of age in order to prevent exposure to THS among the child population, as well as to inform parents of children under 3 years of age (over 90%) about the effects of passive exposure to tobacco. From this, it can be inferred that health care personnel themselves consider that they should play an active role in the empowerment and health education of the people with whom they come into contact with regard to this exposure. This is in line with Article 14 of the WHO Framework Convention on Tobacco Control, which states that health workers should participate in the diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use . In our The main limitation of our study is based on the fact that we have used a data collection instrument that has not undergone a process of cultural adaptation and validation. This has occurred, fundamentally, due to the fact that THS is a relatively new field of research. In fact, scales to assess THS knowledge, attitudes, and behaviors are currently being developed and validated . HoweverAlmost two out of three health care professionals who participated in our study did not know what the concept THS was before starting our study. Educational activities to raise awareness on this topic should be implemented.