Unaccompanied refugee minors—or unaccompanied minors—are children and adolescents who have been separated from parents and other relatives and are not being cared for by an adult. Unaccompanied minors are a vulnerable population, with numerous stressors and complex psychiatric symptoms necessitating specialized mental health care. This study explores patients’ experiences of a Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM), which encompasses cultural, biological, narrative & institutional approaches to care.MUCTUM is a co-therapy program for unaccompanied minors, with a psychiatrist, psychologist, native-language interpreter, and caseworker for each patient. In this qualitative study, we interviewed adolescents about their experiences with MUCTUM and analyzed these semi-structured interviews using a phenomenological framework .Qualitative analysis of 16 interviews discovered that unaccompanied minors felt misunderstood before participating in MUCTUM, describing a sense of strangeness and loneliness in relation to psychiatric symptoms. Several youths experienced triple stigmatization: of being unaccompanied minors, of suffering from psychotrauma, and of being mental health patients. We further describe three overarching domains that inform on MUCTUM support to unaccompanied minors: (1) A safe space for unaccompanied minors; (2) Helpful interventions during therapy; and (3) Narrating one’s story can “set us free” if guided carefully by care providers.limited reparenting in therapy. Delayed and progressive inquiry about traumatic events may be beneficial. Replication of these findings and their field application is warranted.This study suggests that MUCTUM therapy may efficiently support unaccompanied minors’ mental health by acknowledging their hierarchy of needs. Psychotherapeutic strategies include creating a safe place, providing culturally appropriate care and patient-centered therapy, addressing concrete problems, supporting relationships, and making use of The online version contains supplementary material available at 10.1186/s13034-022-00518-2. Unaccompanied refugee minors—or unaccompanied minors (UM)—are children and adolescents who have been separated from both parents and other relatives and are not being cared for by an adult . The refUM frequently exhibit mental health problems, with a high prevalence of anxiety 10–85%), depression 12–76%), post-traumatic stress (17–85%), and behavioral problems, and these symptoms are often chronic –8. UMs’ 5%, depre–76%, posProviding appropriate care for UM is a challenge for healthcare institutions due to cross-cultural factors. UM’s personal trajectories can affect the acquisition of certain competencies in their native culture and may create difficulties with acculturation . CulturaTo date, few studies have been published on therapies for UM –14, requIn the Adolescent Medicine department of Cochin Hospital, Paris, France , a speciMUCTUM operates monthly, or weekly during acute phases. The team includes ethnically diverse providers and consists of a psychiatrist, a psychologist, the caseworker assigned to the adolescent, and an interpreter. The interpreter is a professional translator who is also trained in cultural mediation and attends every session . MUCTUM During the first session, care providers introduce themselves and the purpose of MUCTUM. Care providers explicitly welcome the patient , and explain the set-up and the “rules” of the program . Up to three sessions are dedicated to creating a safe place for the patient, psychiatric and psychological assessment, and first-line therapeutic actions. The remainder of MUCTUM is implemented following the course described in Fig. First-line therapeutic actions include addressing physical symptoms (including pain and sleep problems) and active communication with other professionals caring for the UM . These first-line actions help build a therapeutic alliance by showing the UM that care providers can solve concrete problems, give priority to what the youth sees as a priority, and restore a feeling of security in his/her daily life environment.Care providers accomplish the usual biological approach by performing a standard psychiatric assessment, but the multimodal emphasis allows psychiatrists to include social factors. Facilitated by the caseworker and the interpreter, care providers are therefore able to relate the UM’s symptoms to social factors and respond accordingly, rather than having a solely pharmacological approach.An institutional approach is accomplished by the caseworker, who provides a link with the Children’s Foster Home, and who can help address the patient’s behavior, daily life and school problems, and administrative aspects.In addition to speaking the UM’s native language and being from the patient’s cultural group, the interpreter is preferably trained as a cultural broker . This alThe co-therapy model includes a narrative approach: Narration is based on positive life events, positive attachment figures, good memories in the native country , personal affiliations , and verbalization of the UM’s competencies. For example, some adolescents initially deny ever attending school, but are then able to clarify that they acquired some education at religious school. UMs narrate their migratory journey, including adverse life events if comfortable doing so, and set the pace of this sharing process. Being allowed to narrate only positive life events for several sessions promotes a feeling of safety in the therapy setting.Narration is supported by two exercises that materialize the patient’s journey. First, in the “circles of time,” the patient draws three circles, one for the past, present, and future, and attributes colors to each. The UM then explains why they drew, shaped, and colored the circles in such a way, as a support of narration of their path. Second, in the “three objects,” the patient is invited to bring (or think about) three objects that symbolize past, present, and future, to support the narrative process .This qualitative monocentric study follows the consolidated criteria for reporting qualitative research , Central Africa , Northern Africa , Asia , and Europe (Albania). Most participants suffered from anxiety, depressive, or post-traumatic disorders, with a few experiencing psychotic disorders and addictive disorders. Sixteen interviews were conducted from April 2021 to April 2022, ranging from 20 min to one hour. Participants’ characteristics are described in Table " I can have problems in my life and I call Mrs. X on her number. It's really... I don't know about the others, but for me, it's not only a follow-up at the hospital, it's really a follow-up that was really very thorough (...) I improved a lot of things, like anger. I, I worked with that with Dr. Y... anger and everything.... It was something that I couldn't handle... It allowed me to... really deal with some of the things about myself that I didn't like…”The perception that caregivers were compassionate, engaged in care, and steadily present despite repeated missed sessions was cited by participants as a major factor in building therapeutic alliance. Participants considered their care providers “trustful,” “skilled,” “deeply caring,” “generous,” knowledgeable on their culture, and always providing “thorough explanations.”“At first, I thought it was too much. I said to myself: there are too many people. But then I realized that when there are several people, we talk more. When there are several people, we discuss more, everyone gives their opinion. That's good. That's really good. I think that... Just at the beginning… I thought it was too much, but then I saw that it's better, when there are several people, each one speaks. They also, they talked a little bit about themselves. That's good.”According to UM, care providers offered much-needed guidance, giving advice and helping to find concrete solutions to daily life problems. They were perceived as role models, and even compared to a parent by some participants, “like a mother.” Several participants reported having the personal phone numbers of care providers  in case of crisis: “I could call or send a message (…) and that's what helped me even more, that made things easier for me.” All participants stressed that feeling welcomed at the first session had been essential: “The first time I came, it was great, I felt at ease just like at home.” Laughter was a notable event during the first meeting: "The first day, I was with my caseworker. It worked out well. [Care providers] had a good laugh with me too." According to participants, consistency of care increased adherence, even despite some missed appointments. Said one participant, “Only God knows how many times I didn’t come,” with continuation of MUCTUM contrasting sharply with previous care that canceled follow-ups after only two missed sessions. Care providers became secure references during transfer of care, sharing “knowledge” about participants with new care providers who “don’t know how to handle [them] yet.” Nevertheless, some participants mentioned that the presence of four adults – two care providers, one caseworker and one interpreter – led them to feel “afraid” or “lost” at the beginning. Despite being overwhelming, the presence of several adults was overall seen as helpful to discuss a variety of opinions.“With them, I was not alone, we were several. In addition, there was someone who spoke..., who interpreted, who was there, who knows me well, who knows where I come from. He knows the place, he knows my culture and everything.”Participants perceived interpreters as instrumental in achieving full understanding of their identity, origins, language, and culture. Interpreters prevented possible misunderstandings (“so that I don't understand the opposite meaning”) and helped overcome language barriers."I can explain to him what I have. I speak French but I don't really speak, there are things I don't know in French. With him, I can explain and he can understand me. I don't know how to tell you. (...) Often, when I spoke with him in my language, when I explain it to him, the explanation he gives... If it had been me, it would not be the same explanation. He knows the French language well. He explains well, in fact. He explains well compared to me and I wouldn't have explained well like him."Participants also valued interpreters’ ability to help them articulate difficult subjects to the care providers.“I am of Somalian origin and I am in France since I was little and also when I arrived I did not see Somalian people. So when I see the interpreter every time here it was a pleasure to see a person from the same country as me (...) I felt sometimes that I spoke the same language and all that sometimes I asked questions about my country because I was little when I left my country (...) [the interpreter spoke] about the cultures of the villages, all that, all that, all the things, the food to eat”For many, interpreters illustrated a bond with the native country, especially for UM who had not seen “anyone from the same country” since arriving in the host country."In fact, at the consultation when I go there, when they send me to the consultation, but sometimes when I arrive at the consultation, when we speak, I don't really like it, so I let my caseworker talk, as I really trust her, when we speak. After that, that's when I can talk.”Some participants identified caseworkers as a reassuring support during sessions.However, for some participants, the caseworker’s continuous presence was perceived as intrusive and created a disincentive to talk, especially about very “personal” migratory life events. Some participants criticized the framework as too rigid, preferring to be “asked” if they consented to the caseworker’s presence during therapy.Participants identified several helpful interventions during their follow-up." I am someone, I get very, very angry. Even sometimes when I speak, I get angry very, very quickly. So Mrs. Y taught me and I'm learning to breathe and not to get angry very quickly. If someone comes to get me, I will try to speak calmly to these people, so as not to be very aggressive. (...) Once she finds that the situation is very hard, she tells me that I take a breath, I drink a glass of water, that it calms me down and then I speak again. Sometimes when I'm upset or sad, even when I'm at home, I take a drink of water and my throat feels better.”Participants valued education on coping skills and appropriate behaviors, especially during conflicts.“It didn't really go away but I evolved a lot on it because before, it was due to everything I had been through, I had the feeling that I was going to be found, no matter what. So that's a little bit of what fueled that feeling too... But then I was made to understand that this is France and all... I was reassured a lot by Mrs X and Dr. Y too and uh I started to let go a little bit, they made me understand that I wasn't going to be attacked overnight in the street... Or kidnapped and everything... So that kind of... calmed me down a bit…”Skills that participants cited included emotional regulation, relaxation methods , planning (e.g. writing to-do lists in a notebook), and reflection (e.g. “practicing speech in front of [a] mirror”). Participants who had experienced violence and detention also explained how the care providers’ explanations about security in France increased their feeling of safety:One participant explained that she continues to apply these negative affect regulation techniques now that she is a mother, which increases her self-confidence. “I worked [on] self-confidence a lot (…) and it is going very well”."I was the one who was really struggling and uh it was really really um... The follow-up that allowed us to tighten up.... Strengthening the ties, no but... Allowed me to have… uh… a discussion with [my caseworker] because having a discussion with her was not possible...Researcher: Yes.Participant: We couldn't understand each other at all.Researcher: Yes.Participant: Because here I was really saying everything I wanted to say and who I really was… [care providers] had the ability to transmit that to another person, so that the person could understand me too…Researcher: Yes.Participant : So uh, [my caseworker] had to go through them to understand how I functioned and me too how she functioned and sometimes we had big meetings where there were people and uh... It was partly thanks to them that I was able to establish a link with my caseworker...”Care providers facilitate links with the other institutions caring for UM, particularly social workers, who facilitate support for the youth at Children’s Foster Home and school. Although some participants initially expressed displeasure at the presence of caseworkers in therapeutic sessions, most participants said that inclusion of their caseworker in MUCTUM unlocked communication and improved the relationship with the caseworker.“Basically, you know as I said, basically, I didn't talk to anybody. So everybody was like, how do I talk to this individual? (...) So it was complicated for them... And in the end uh... (...) So, since there are certain things that I don't want to tell them about. So I invited them to come and participate in my sessions. That way, they will hear certain things. So, when we go back [home], [if] there are certain things that they don't (...) understand or that kind of thing, they call me, we talk about it, they ask me questions. And I answer, if I feel it... I answer. And so with that, it allows them to know how (...) to talk to me, how, how to handle the situation with me.”For others, MUCTUM provided a place to air discontents about their caseworkers, such as daily conflicts or misunderstandings. Some UM “felt bad” at the Children’s Foster Home, and shared that MUCTUM allowed them to express this opinion. Participants identified that the care providers could help the caseworkers learn how to navigate certain situations more effectively, such as one participant experiencing social withdrawal or mutism:In another example, one participant’s need for privacy due to his traumatic history was acknowledged, and he obtained access to an individual room. In addition to collaborating with the social workers, care providers use a problem solving approach to address social, educational and legal problems. One participant reported how care providers supported her to pursue her academic studies and advocated for her with social services. Another reported that he felt supported for minority recognition administrative procedures with his lawyer, to whom he “did not say everything” previously because of fear and uncertainty."There were problems with the family. My mother, who was not present, left us long ago. I was with my aunt and her children. Often it was not going well. That's why I left there. There is all that, we talked about all that too, with them."Family issues were often discussed during therapy, such as the violent loss of parents, or the family relational difficulties that had led the UM to exile."I told all my stories to Mrs. X. In any case, she found some words. She called my mother to explain something to her. She made it clear that I don't work here, that I'm studying, that I won't have enough money, as much as she asks, that I won't be able to finance everything. So my mother, I don't know, but she has trouble understanding, my mother. She had a hard time."In particular, participants valued phone calls and advice from the care team to family back home. In the case of one participant who had previously been sending money home due to being a victim of prostitution, care providers called the participant’s mother to explain that her daughter, now in school with no income, could no longer send money back home:This communication induced a change in parental expectations, which “relieves more and more” for adolescents seeking reassurance that it is okay to refuse to send money to over-demanding family members. For another participant, interpreters facilitated a conversation with the participant’s mother back in Somalia in order to restore family links, relationships, and childhood memories, which had been erased because of traumatic amnesia: “All my culture (…), when I was a child, lullabies, all this.” For this participant, finding her mother was a “huge relief” and allowed this adolescent to “reconnect to reality.” Now, the ability to call her mother frequently has “changed” and “energized” the participant: “It gave [me a] smile, me who was always sad.”kénu in Soninke language, a certain conception of worry, or undusu, a “heart discomfort” in Malenke language), or explanations for certain phenomena  and their cures. Some had no cultural hypothesis because they had left their country too young and their only solution was to “talk to my parents, and they will take care of me.” Other participants knew traditional etiological explanations, such as possession by spirits, like djinns, but associated djinns with problems more severe than their own. Participants also described various traditional treatments, specific to their home countries, including herbal treatments, massages, reading the Bible and listening to music, reading, and alms . Some participants reported that their families in the native country recommended these traditional treatments, which they completed in France or their native country with the support of their MUCTUM care providers, such as prayers, alms, and sacrifices."I had a dream about an old man (…) I had to get out the alms and I managed to call my mother to do that alms and since then it's been fine."Cultural etiology and treatment were acknowledged and employed as needed, as cultural etiologies had variable importance for participants across the sample. Most participants did have representations of their conditions in their native culture  They know their work well and they know very well that when it goes too far, they also know how to stop the person when it goes too far. So I like that.”Participants appreciated the care providers' attention to preventing participants from sharing “too much” at once:“Participant: As I said earlier, I'm not someone who likes to re-explain that part.Researcher: YesParticipant: But afterwards, it was really a moment when you had to talk.Researcher: Yes.Participant: It was really. They gave me time, they let me... I think it took a year and a half before... That we really got into it. We only talked about myself, my fears, my mother. And then we really went through the process where ... well I had to explain my story to them and that was it…”Consequently, narrating one’s history was not perceived as obligatory, and in fact some participants recalled relief at being explicitly asked not to talk about their story during early stages of therapy, because it was too painful.Narration encompassed both positive and negative life events: "I talked about my memories, times that went well and times that didn't go well, too." Some UM, on the contrary, did not narrate adverse life events: "I didn't tell my story to them." Narration was at times difficult for participants whose memories remained mostly “images” rather than easily-verbalized stories."Participant: It was very, very, very hard. Uh to say again what I… I had experienced, uh… You had to respect… and especially that they, when you explained, they illustrated for you.Researcher: That is to say?Participant: In itself... they take examples from you or do as if I tell them, for example, I crossed the sea: they tell you: by boat, the sea? Basically, to make you really live the thing, but in an intense way so that you can free yourself once and for all, and I think it was not bad for me anyway…Researcher: Yes…Participant: Because when I said uh when I took the example of Italy with the prostitution, really it was illustrated to me... And that was really what I wanted to say. So I was led to say what I had inside me without forcing myself.For example, a person can't understand your past, he's not in your shoes, but in fact, he tries to put himself in your shoes and all that, it feels good."Although this would seem self-evident for most practitioners, participants frequently and independently volunteered these reflections on providers' attitudes during narration of traumatic events, making it a notable theme in UM's experiences. Care providers were described as empathetic and non-judgmental, which contributed to trust and openness. Participants described how narration involved rephrasing by care providers, creating active, participative, and empathetic listening by care providers: "It was really like, ‘I experience the story with you. It helps you to let it go." Care providers with knowledge of the “sea crossing” helped participants feel understood, as did using “images” when they talked.Care providers helped UM stop feeling guilty and provided explanations that helped participants “talk more openly.” Said one participant, "When I would say that when I was in Italy, I was prostituting, they would say, ‘yes, we know you were forced. How did this happen to you?’”."That's the hardest part. But once you get it all out, you feel good about your body. Plus, we open up to people and they give us ideas, advice on how to be able to deal with our past." Several participants mentioned a feeling of "liberation" in relation to the therapy, particularly through the ability to "talk.""It hurt and at the same time, when I was talking, that's when I was able to work on it. When I was able to talk to people where at the same time it relieves my heart and it relieves me in my head."Sharing one’s story was experienced as “painful”  but provided relief and allowed care providers to find solutions. "It feels good to talk about the things that are in your heart. When you've told someone, it's like everything has gone from your heart." Narrating one’s story, though painful, reduced participants’ feeling of pain and loneliness.It was often the first time they shared what they had endured with someone. “That way, at least someone knows.”In this qualitative study of semi-structured interviews of UM participating in MUCTUM , we explored participants’ experiences of this therapeutic approach: how UM experience mental health problems, what contributes to creating a safe place, what interventions are helpful during therapy, and UMs’ experience of the narrative approach supported by care providers.limited reparenting in therapy, providing culturally appropriate care and focusing on narrativity of trauma when basic needs have been addressed. Working on family relationships and with families remains relevant, despite the apparent isolation of UMs.An important finding is the importance of implementing interventions successively within this multimodal therapy, i.e. the narration of trauma occurs after other interventions. In this sense, MUCTUM follows the fundamental teaching of Maslow’s hierarchy of basic needs . Maslow’Fear of stigma, suspicion, misunderstandings and negative cultural representations of mental health problems cause denial of mental suffering and are a barrier to mental health care of adolescent refugees. These results are consistent with a qualitative Australian study among 85 refugees aged 13 to 17, in which stigma and misbeliefs about psychiatric conditions were identified as barriers to mental health care . Particisafety for asylum-seeking children: predictable patterns in daily rhythm, going to school, receiving medical care and “finding trust-worthy, reliable and companionable people, adults and peers” [A warm and reliable setting, including care providers’ long-standing commitment despite missed appointments, is a key ingredient for safety and trust, especially for UM who feel lonely and misunderstood. Other studies describe how to create spaces that allow UM to feel comfortable and valued, to speak openly, and to recover a sense of self , 28. Kohd peers” . SimilarPatient-centered therapy is a relevant approach for UM, as suggested by our study, because UM have very heterogeneous profiles, and treatment should therefore be based on their unique experience and social situation. This is consistent with Van Es et al.’s study, which advocates for flexibility in treatment approaches for UM . SimilarSolving concrete problems, e.g. housing, school or medical needs, is essential because it shows UM that care providers understand their priorities. Our participants perceived this problem-solving approach as a sign of their care providers’ competence, leading to increased trust and therapeutic alliance. Other authors highlighted the importance of day-to-day stressors such as missing one’s family, difficulties accessing education, homelessness, sleeping or somatic problems , 14. TogSupporting communication with social workers and foster care providers appeared helpful for this study’s participants. Alto et al. state that nurturing UMs’ foster family environments is central, as enduring conflicts can exacerbate adolescents’ symptoms . The typlimited reparenting may be a useful component of psychotherapy for UM. Arguably, UMs do not have their core emotional and educational needs met, as they do not have caregivers in the host country. Schema psychotherapy argues that emotional deprivation has three components: deprivation of nurturance , deprivation of empathy , deprivation of protection (absence of guidance and direction from others) [limited reparenting by a care provider might partially compensate for this deprivation, provided that appropriate professional boundaries are maintained. According to our participants’ experience, creating “safety, stability, and acceptance” may require care providers to consider sharing their personal phone numbers with patients in case of crisis [Limited reparenting. Participants reported that they benefited from the reliability of care providers who appeared as secure figures, providing emotional and behavioral guidance. This finding suggests that  others) . In the f crisis .Culturally appropriate care is central in MUCTUM, with interpreters who double as cultural mediators. This is consistent with other recent studies, which emphasize the importance of native language and cultural explanation across native and host countries’ cultures, for the young patients and the professionals who care for them , 32. TraSharing trauma experiences through narrative can have beneficial effects on health and well-being . In our Working with families is a valuable aspect of UM’s experience of MUCTUM. While UMs are perceived as isolated in the host country, they are often burdened by various family problems, fears, and requests, or traumatized by a complete separation from their families or the loss of relatives. Our participants reported that care providers’ calls to their relatives to support and improve their relationship contributed greatly to their well-being.Limitations. Our study possesses several strengths and limitations. The qualitative design allows in-depth analysis of participants’ unique experiences, which helps refine a patient-centered and flexible therapy for the culturally and psychologically heterogeneous population of UMs. Nonetheless, our participants faced challenges that impaired their ability to express themselves, resulting in fragmented answers that occasionally necessitated rephrasing as written text instead of direct quotations: Our participants were young people, were non-native speakers (some of them wanted to speak French despite the presence of an interpreter), had psychotrauma, and often had limited educational attainment. These barriers to fluid communication raise the question of how to most accurately represent the perspectives of populations who may produce disjointed discourse within current qualitative research methods. Additionally, this study does not assess MUCTUM’s efficacy. This objective could be addressed with a randomized, comparative, patient-goal-centered quantitative study, designed for a small population (i.e. using Bayesian statistics). Until then, the results of this qualitative study cannot be generalized. Another limitation is that no Asian UM consented to participate in the study, as most of them stated that they were afraid of speaking of bad memories. Future studies could determine more effective ways of recruiting Asian participants. Finally, some interviews were conducted within the hospital. Participants may not have dared to disclose negative opinions of MUCTUM in this setting.limited reparenting in therapy, providing culturally appropriate care, and supporting family relationships. Inquiring about traumatic events may be beneficial only after these needs have been addressed.Multi-modal Co-Therapy for Unaccompanied Minors (MUCTUM) aims to provide a pluralist approach in which care providers address biological, transcultural, institutional and narrative approaches. Our qualitative study analyzes the experiences of UM participating in this program, with main findings highlighted in Table Additional file 1. COREQ  Checklist.


Photovoice is a widely used approach for community participation in health promotion and health promotion research. However, its popularity has a flip-side. Scholars raise concerns that photovoice drifts away from its emancipatory roots, neglecting photovoice’s aim to develop critical consciousness together with communities. Our four-year photovoice project aimed to unravel how the health of (un)paid care workers was shaped at the intersection of gender, class and race. This article springs from first, second and third-person inquiry within our research team of (un)paid care workers, academic researchers and a photographer. We observed that critical consciousness emerged from an iterative process between silence, voice and vocabulary. We learned that photovoice scholars need to be sensitive to silence in photovoice projects, as silence can be the starting point for finding voice, but also a result of silencing acts. Social movements and critical theories, such as intersectionality, provide a vocabulary for participants to voice their critical perspectives to change agents and to support collective action. We discuss our experiences using Frickers’ concept of ‘epistemic justice’, arguing that critical consciousness not only requires that communities are acknowledged as reliable knowers, but that they need access to interpretative tropes to voice their personal experiences as structural. Photovoice is a widely used approach for community participation in health promotion and health promotion research . PhotovoThe goal of photovoice is threefold . First, Photovoice, as developed by Wang and Burris, is grounded in critical social theory, including feminism, postcolonialism, social justice theory and Paolo Freire’s work on the pedagogy of the oppressed ,3,8. In “analytical, pro-active and empowering” endeavor that honored participants’ expertise and wisdom. She argues that “part of honoring this wisdom and experience requires us to facilitate critical reflection on structurally embedded experiences, and that the knowledge emerging from this reflection is both given a platform from which to be voiced, and equally important, amplified in ways that are heard”. In other words, photovoice is not solely meant to voice participants’ lived experiences to policy makers. Photovoice should also amplify participants’ perspectives on structural systems of oppression to these policy makers. Failing to address these structural issues could—unintentionally—turn photovoice projects into a disempowering experience  is both given a platform from which to be voiced, and equally important, amplified in ways that are heard” . We hopeIn our photovoice project, that was part of a broader PHR process, we collectively unraveled the complex interplay between gendered (theme 1), classed (theme 2) and racialized (theme 3) inequities in relation to the health and wellbeing of paid care workers in long-term care. Living up to photovoice’s and PHR’s emancipatory intentions, we particularly aimed to foster critical consciousness about these structural embedded experiences in dialogue with community researchers. Collectively reflecting upon our process, we came to understand that critical consciousness emerged from an iterative and dynamic process between silence, voice and vocabulary. This has implications for PHR scholars in general and for photovoice facilitators in particular. Our reflections illustrate that facilitators need to be sensitive to the different meanings silence can have in photovoice projects. Silence can be the starting point for finding voice, but it can also signal unsafety as the result of silencing acts. Engaging with critical theories, such as intersectionality, played a pivotal role in developing critical consciousness. Theories provide a vocabulary that enabled participants in understanding their experiences as structural and allowed them to voice their critical perspectives to each other, to the researchers and to change agents. Intersectionality, in particular, enabled the unraveling of the complexity and intersecting nature of these inequalities, and this understanding sparked collective action. We learned that engaging with theories requires relational and ethical sensitivity from photovoice facilitators in a horizontal and dialogical manner, which includes being responsive to the vocabularies of community researchers/participants and more. We will discuss our findings in relation to literature on silence, voice and vocabulary below. In our reflections, we illuminate the importance of theories as they support the critical consciousness of community researchers in particular. The importance of these vocabularies resonates with the work of philosopher Miranda Fricker on epistemic injustice . PHR schmore likely than others in a position (…) where they do not have the concepts or interpretative tropes to render their experiences intelligible to others, possibly even to themselves” [First, testimonial (or: witnessing) injustice occurs when someone is not acknowledged as a reliable knower; their knowledge is ignored, made irrelevant, or judged as untrustworthy because of who they are. This happens, for example, when clients’ experiential knowledge is seen as less credible than professional knowledge . Second,mselves”  (p. 257)enables the hearer to the word of another with the sort of critical openness that is required for a thoroughly effortless sharing of knowledge”. In other words, developing critical consciousness is a reciprocal learning process. Therefore, in this project, we learned that as facilitators we also needed to take up space for our own expertise and knowledge in dialogue with community researchers, granting them access to these interpretative tropes. In our project, the academic researchers actively provided knowledge on gender, class, race and intersectionality theory. At the same time, facilitators need to stay attuned to interpretative tropes that are introduced by the community researchers themselves or by societal discourses. In our project, such narratives were provided by the yellow-vest and BLM movements. We conclude that photovoice facilitators should not shy away from engaging with these vocabularies, as these are necessary for hermeneutic justice. However, at the same time, engaging with theories requires reflexivity and relational sensitivity from facilitators to not compromise participants’ witnessing justice. Fricker  (p. 84) What You Don’t See” show how the health of care workers was shaped at the intersection of gender, class and race. Intersectionality enabled us to unravel these multiple and interlocking inequities within our photovoice process, and it gave us a vocabulary to talk about these inequities. Moreover, we observed that some single-axe analyses such as a “gender perspective” did not resonate with participants, as has been described by other intersectionality scholars [Another lesson learned from this project is that intersectionality provided essential interpretative tropes to foster hermeneutic justice. The empirical findings from our photovoice process captured in the portraits and book “scholars . Seeing focused on explicit utterances and their intelligibility to others” and plea for a “thick” conception of voice that includes “a thick interpretative discernment of utterances, silences and bodily expressions” [the burden of social change is placed upon those least empowered to intervene in the conditions of their oppression” and state that such an equation shifts “the focus away from the labor that might be demanded of those in positions of power to learn to listen to subaltern inscriptions—those modes of expression that are often interpreted as “silence”” [In addition, we paid attention to the many meanings of silence in our research project. Our reflections resonate with the literature on silence in the research process. Scholars have critiqued simplistic (or “thin”) conceptions of voice that are “essions”  (p. 2). essions” ,64,65. Sessions” ,67. Otheessions” . Such anessions” ,67. In ailence””   said when we speak about the health and wellbeing of care workers, such as their experiences of poverty and racism. In our photovoice project, rendering social experiences understandable to ourselves was not the biggest bottleneck. However, we did experience how speaking about (multiple and interlocking) systems of oppression was in particular a painful “interpretative trope” to others. This became tangible in tensions within our own research team (in relation to gender and race) as well as in relation to the steering group (in relation to gender/class/race). Interpretative tropes such as gender, class and race are often contested and can be hard to acknowledge in particular by those in a privileged position. This has since long been described by critical race scholars, such as political philosopher Charles Mills . His conIn this article, we reflected upon a photovoice project as a team of academic researchers, community researchers and a professional photographer. In doing so, we have been able to capture a wide array of voices and perspectives. Fostering reflection together with all participants contributes to the quality of the study and to ethical research practice. However, we also described how the white, male community researcher withdrew from the study, as he felt his perspective was not sufficiently addressed. As a consequence, the reflections in this paper mainly focused on women’s experiences, while we know that men’s experiences are differently shaped by norms around masculinity . PhotovoIn this paper, we have described how critical consciousness in photovoice, as part of a broader PHR project, springs from an iterative process between silence, voice and vocabulary. This has several implications for participatory health scholars in general and for photovoice scholars in particular. First, we conclude that facilitators need the courage and sensitivity to engage with “vocabularies” from academic theories or emancipatory movements. These vocabularies support critical consciousness and are essential for epistemic justice in photovoice. Second, we conclude that intersectionality is a useful interpretative framework within PHR and photovoice. Intersectionality enables critical consciousness about complex and intersecting inequities and supports collective action. Third, we conclude that PHR and photovoice should go beyond fostering voice to those whose experiences are marginalized. The responsibility for social change lies with those in power who can learn to listen to care workers’ silences, particularly on issues that are not easily said in relation to their health and wellbeing, such as gendered poverty and racism.


Using the area under the ROC curve (AUC), the locus of control significantly identified those who maintained weight . The maximum combination of sensitivity and specificity was shown at the cutoff point of 39. Qualitative results show a difference in the type of attributions and expectations according to current weight maintenance or weight regain status. Conclusion: Participants’ self-efficacy expectations, locus of control, and attributions change in accordance with the outcome achieved in terms of weight regain or weight maintenance.Background: Bariatric surgery is the most effective method for achieving accelerated weight loss. However, in the short- and medium-term, between 20% and 40% of patients regain a significant percentage of the weight lost. Cognitive and attitudinal psychological variables contribute to explaining weight regain. The aim of this study was to analyze differences in self-efficacy, locus of control, and attributions among bariatric patients, in accordance with weight maintenance or weight regain. Methods: Participants were classified according to weight regain (≥15% weight regain) and weight maintenance (<15% weight regain). A receiver operating characteristic (ROC) curve analysis was employed to assess the diagnostic value of the locus of control for weight loss and to establish a cutoff point to differentiate those who maintained weight loss from those who regained more than 15% of the weight lost. Results: Those who maintained weight loss showed a statistically higher locus of control ratio than those who regained weight. The locus of control ratio was associated with a lower risk of weight regain (odds ratio 0.760,  Bariatric surgery is the most effective treatment for obesity ,2. HowevFor some years now, various authors have been studying certain psychological variables of a cognitive-attitudinal nature, such as self-efficacy and locus of control, as well as, to a lesser extent, attributions and their association with body weight regulation, specifically in terms of adherence to the lifestyle changes required to maintain weight loss ,14,15.“Self-efficacy” ,17 is deSelf-efficacy has been found to predict success in both losing and maintaining body weight ,20,21,22“Locus of control” (LC) was first described by Rotter  and refeMore specifically, existing evidence suggests a positive association between having an ILC and successfully completing a weight-loss program and maintaining a 10% reduction in body weight ,15,28. AWeiner’s attribution theory  defines Qualitative studies in this field have provided valuable information about the course of obesity, as well as the motivations and variables associated with weight maintenance and regain among bariatric patients. It is well-known that patients who undergo surgery have often experienced weight-related problems since childhood and/or adolescence ,33. MostThe present study offers quantitative and qualitative data to further our understanding of weight maintenance and regain among bariatric patients, combining information gathered from psychometric instruments with an analysis of narrated experiences and the explanations provided by participants regarding their outcomes.For the quantitative analysis, we used a non-probabilistic convenience sampling method to recruit 97 patients who had undergone bariatric surgery between 2002 and 2017. For the qualitative analysis, participants were invited to participate following a convenience sampling. Thirteen people agreed to be interviewed and it was considered that a percentage close to 20% of the total sample was sufficient for this analysis, as the results of the qualitative analysis allowed us to identify and analyze the explanations patients have for their current state of weight maintenance or weight regain. The inclusion criteria were: men and women aged between 18 and 65 years who had undergone bariatric surgery (gastric bypass or sleeve gastrectomy). Exclusion criteria were: having received surgical treatment other than a gastric bypass or sleeve gastrectomy, having undergone a secondary procedure (revision surgery), and in the case of women, having recently been pregnant or breastfeeding.A sociodemographic and biomedical questionnaire was designed ad hoc for the present study. Data were collected regarding participants’ age, sex, marital status, and education level, among others. The biomedical variables included were: height, previous weight, previous nadir, current weight, type of surgery, and year of surgery, among others. This information was obtained directly from the participants. There was no access to patients’ medical records.Self-efficacy for losing weight : ResponsLocus of control regarding eating behavior and weight gain : The scaCurrent weight loss status: operationalized as a dichotomous variable: maintaining or regaining. To calculate the percentage of regain, a simple delta was created of the difference between TWL% at nadir and TWL% at the time of the study /] × 100) . “MaintaQualitative data were gathered by means of semi-structured interviews designed specifically for this study . Prior tThe study was approved by the Ethics Committee at the University of Concepción and the Scientific Ethics Committee of the Concepción Health Service.Quantitative data were collected between April 2016 and August 2018. Participants were recruited from monitoring sessions with the Obesity Treatment Team (ETO-Conce) and diverse other teams in Santiago. Participation was voluntary and informed consent was obtained from all participants. All instruments were self-administered.For the qualitative analysis, participants were contacted over the phone. Interviews were held in a place in which participants felt comfortable (their home or place of work) between August and December 2018. Only the interviewer and the participant were present during the interviews. All interviews were carried out in accordance with the interview protocol  and lastParticipants’ responses were audio-recorded, transcribed, and analyzed using ATLAS.ti (V.6.2). The coding process was carried out independently by two members of the research team, and the data analysis was deemed to have concluded when all researchers agreed that the saturation point had been reached.To compare groups in accordance with current status (regaining versus maintaining), a one-way MANOVA was performed to analyze the various dependent measures simultaneously . LogistiThe discriminative ability of the locus of control ratio for weight loss was estimated between those who maintained weight loss and those who regained more than 15% of the weight lost from nadir with the area under the receiver operating characteristic curve (AUC) .For the qualitative analysis, a thematic content analysis was carried out with pre-established (top-down) categories (codes). It is worth highlighting that the aim of “content analysis” techniques is to identify and explain the cognitive representations that make sense of the entire communicative narrative . Top-dowThe unit of analysis for both coding processes was the paragraph.Before coding the 13 interviews, a hermeneutic unit was created with the information. Next, the codes were generated using the Atlas.Ti software program (V.6.2). The characteristics of the codes are presented in K = 0.77 to K = 0.85)  (186) K = 0.73 and K = 0.82   was performed to explore the differences between groups in the different dimensions of self-efficacy and LC, adjusting for sex, age, and years since surgery. Box’s M and Levene’s tests were performed to verify the assumptions. The results of the Box’s M test were not significant  and the Hosmer and Lemeshow test  indicate that the model predictions correctly describe the data presented. Thus, after adjusting for age, sex, and years since surgery, the locus of control for losing weight appeared as a potential modifiable predictor (odds ratio 0.76 (95% CI: 0.606–0.953); p = 0.018). The model explained 52.4% of the variance found in maintaining weight loss (R2 = 0.524)  see .p = 0.040)  of the LC was 0.761  . AccordiThe receiver operating characteristic (ROC) curve for the locus of control for losing weight was used to discriminate between participants who maintained 15% or more weight loss since nadir from those who regained weight. The arrows indicate the location of the selected cut-off point with the best sensitivity and specificity. The data of sensitivity (S), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and the proportion of patients correctly classified (efficiency) are shown.2 (SD = 8.5 kg/m2) and at the time of the study it was 30.6 kg/m2 (SD = 7.3 kg/m2). One-third of the participants in the study (33.3%) reported weight regain.The 13 participants who were recruited for the qualitative analysis had a mean age of 45.5 years (SD = 9.8). Their age at the time they underwent surgery was 40.3 years (SD = 10.9). Their BMI prior to the surgery was 45.7 kg/mThe three topics and six subtopics covered resulted in descriptions of the surgical process and its outcomes and enabled an understanding of it through the identification of attributions and expectations .The characteristics of the interviewees are presented in Participants described how, prior to the surgery, their bodies had gradually increased in size, in some cases since childhood, and in others since adolescence. Regardless of the time of onset of their weight issues, all participants attributed their previous excess weight to internal, stable causes perceived as uncontrollable at the time. Specifically, they attributed their increasing weight to emotional  and, to a lesser extent, genetic causes. One participant expressed these attributions as follows:“To be honest, prior to the surgery it had been a life-long struggle [with obesity] ... linked to psychological problems, mood issues. Now I realize that food was for me like drugs are for many addicts—a means of escape, a way—a bad way—of coping with distress”.(9NNR)All participants claimed to have tried a wide range of strategies to slow their weight gain and even lose weight prior to the surgery. None of these strategies had outcomes that were sustained in the short- and/or long-term. The explanations given in relation to previous strategies and their outcomes were also linked to internal, stable, and uncontrollable causes. In this case, the principal causes were also emotional in nature, with participants highlighting the boredom associated with pre-established nutritional guidelines or non-pre-established diets. In the words of two participants:“I’d be fine for one or even maybe two months, but then I’d fall back again [into eating] because I got bored of always eating the same things. It’s impossible to always eat chicken and lettuce. So I’d quit (the diet) and would go back to eating like before, or perhaps even more, and my weight would go up again”.(5NNR)“You just end up getting bored. I’d lose a couple of kilos while I was on the diet, or at first when I did acupuncture, but then it was really hard, almost impossible, to keep going. So I’d gain the weight back, and then some, and it was exhausting. At some point I just got so bored I said “hey, what does it matter?” It was very frustrating”.(8NRE)All participants saw the surgery as a means of achieving diverse results, such as health improvement, disease remission, and a better quality of life. Consequently, all had expectations regarding the outcome of the operation. In the words of two participants:“My main aim was to prolong my life and to not have diseases that were so complex. Because I’m really scared of diabetes and that was what prompted me to have the surgery”.(2NRE)“I wanted to have a decent life, because before I found it really hard to walk ... everything was torture: climbing the stairs, doing the most mundane, everyday things that other people find easy ... it was all a major effort for me”.(1NNR)Among participants who had managed to maintain their weight loss, a change in initial expectations was observed. Once food intake restriction was relaxed, expectations associated with the outcomes of the surgery turned into expectations regarding its effectiveness; or in other words, into perceptions regarding their ability to follow through with a specific course of action in order to achieve a desired outcome. Participants accepted that the surgery had “done its work”, but after a time, the outcome no longer depended on the procedure, but rather on their own ability to maintain a lifestyle that was different from the one they had had before. Therefore, expectations shifted from what the surgery could give them in terms of outcomes, to what they were capable of doing to maintain said outcomes, something they considered to be as (or even more) necessary than the surgery itself. One participant explained it as follows:“There are a load of physical signs, and it’s like you can forget about it because your body just tells you ... [food intake restriction], but then, after a while, your stomach expands again and you have to take responsibility. So, of course, at first I lost 70 kilos, but then the curve started to reverse and since I wasn’t really in touch with what was happening, I gained 10 kilos without realizing. And that’s when you say no, I can’t trust exclusively to the effects of the surgery. And I went back to thinking that surgery is only a support for a much more complex process ... And today I feel, I feel much more empowered; I’m much prouder of where I am now than of where I was straight after the surgery. Before, it was the result of the surgery, but now, to a large extent, it’s down to the things I’ve done rather than to just the staples I have in my belly”.(4NNR)This shift in expectations was not observed among those who had regained 15% or more of their TWL%. Among this group, outcome expectations continued to be prevalent, and these people remained focused on food intake restriction, with some even considering a second bariatric procedure. According to one participant:“The weight loss I achieved with the surgery makes me want to have another one ... I think it’s the best solution”.(13NRE)Differences were observed in the explanations given by participants regarding their current status (maintaining/regaining). Participants who had regained 15% or more of their TWL% generally attributed the outcome of the surgery at the moment of the study to external, stable, and uncontrollable causes. These explanations were linked to the surgery itself, lack of perceived support for maintaining a healthy lifestyle, and other external problems, such as personal finances, which prevented them from engaging in “healthy” eating habits. In the words of two participants:“What happened was that food intake restriction didn’t last long and I thought the surgery hadn’t worked. I remember that a few months after the procedure, I asked the nutritionist what would happen if I ate two boiled eggs instead of one. She told me it would be impossible, that even if I wanted to eat two, my stomach wouldn’t be able to take it. And I replied, well it can—it can even take three!”.(2NRE)“The truth is I lacked support. At first I had a lot [of support] but then it was just me and my new habits against everyone [family] and in the end you give in. If I had had the support of my family, I’m sure things would have been different”.(7NRE)In contrast, participants who had managed to maintain their weight loss made internal, stable, and controllable attributions, emphasizing that while the surgery had helped them, their ability to maintain the outcome currently depended on their behavior, attention, and concern regarding their diets, as well as on the constant monitoring of their status. These participants were constantly aware that they needed to look after themselves in order to avoid relapsing to their previous state. One participant expressed it in the following manner:“I think that, with things like this, you can’t rely on anyone else. The support of your family and friends is important, but at the end of the day you have to have the ability to self-regulate, because everything ultimately depends on self-regulation”.(6NNR)According to Prochaska and DiClemente’s stages of change , partici“Look, I know perfectly well what eating healthily means; I know what I should and should not be eating, what is good for me and what will keep me healthy and help me lose weight. And at this moment in time, my (eating) patterns are clearly not healthy”.(7NRE)In contrast, participants who were maintaining their weight loss were mainly in the action and maintenance stages. For example, as one participant put it:“I’ve gradually been taking charge of this. I mean, I started going to a psychologist because I decided it was best; I found an expert gastroenterologist to help me control myself  and I sat down and decided to change my diet, and that’s what I’m working on now”.(3NNR)Participants who were maintaining, however, had not yet reached the consolidation stage of change. This was because they claimed that what enabled them to maintain the changes was the fact that they saw the whole enterprise as an ongoing process. In relation to this, one participant stated that:“This is a lifelong process. I’m fine now, I feel well and there may even be some days in which it’s not an effort, but others days it is. I know I have to remain alert to my habits, because it’s very easy to get distracted and start relapsing”.(12NNR)Our research evaluated the relationship between weight maintenance and weight regain after bariatric surgery and the psychological variables—locus of control, self-efficacy, and attributions. Therefore, what follows should be understood with the limitations that imply not having evaluated maintenance–gain from a multidimensional approach, considering, for example, health determinants, genetics, homeostatic balance, and other factors that influence weight and the development of obesity.Our results reveal an association between the outcomes of bariatric surgery in terms of current status (maintaining weight from nadir) and the LC, self-efficacy, and attribution variables. Both the quantitative and qualitative analyses returned similar results from different perspectives, integrating both the psychometric measures and the thematic analysis of participants’ narratives.n = 4) of those in the qualitative analysis reported weight regain from nadir, a finding that is consistent with the current literature in this field [In general terms, around 20% of participants in the quantitative analysis and 33.3% .The present study focuses on the personal characteristics of patients who have undergone bariatric surgery and their associations with outcomes in terms of maintaining the weight lost. We found that those with a higher internal locus of control, self-efficacy, and efficacy expectation levels reported better outcomes in terms of weight loss maintenance in the medium- and long-term. These findings highlight the importance of empowering people with obesity, since “being aware of their condition and their ability to maintain a viable level of health” helps them become the protagonists of the changes they need to make, rather than mere spectators of their chronic obesity.It is important to highlight the suitability of the mixed research design used. The qualitative analyses enrich our comprehension of the results returned by the quantitative ones, and in our opinion, are highly relevant to gaining a more specific understanding of people who undergo bariatric surgery as a means of promoting their health.


Kappa = 0.89). Responses comprised a variety of descriptions, and we grouped them into seven themes, three of which overlapped with the prior conceptualization, namely the core elements of (a) general description, (b) cognitive appraisals, and (c) affective appraisals. Cognitive evaluations related to intrapersonal aspects, particularly having lived life fully, attained personally significant goals, and developed oneself, as well as interpersonal, generative aspects, such as having made a contribution and been able to leave something of value. These categories are mostly in line with what the Fulfilled Life Scale (FLS) measures. Further themes referred to correlates—including (d) sources—and antecedents, including (e) resources, (f) personal characteristics, and (g) quality of life, all considered worthy to be the subject of empirical investigation but which were not included in the conceptual model. Qualitative and quantitative results suggest that individuals derive fulfillment from different sources. Fulfillment from a profession and having a life task was strongly associated with longer-term fulfillment. Only a few age and sex differences were found. The overarching framework developed from the qualitative results can stimulate further investigation. Our findings underscore that a fulfilled life as a distinct construct should be measured directly rather than via a proxy. Insights into the constituents, sources, and antecedents of a fulfilled life can inform practice to promote a life well lived.Recently, we initiated a new research line on fulfillment in life by developing a conceptual framework and a self-report measure. To enhance conceptual clarity and complement theoretical considerations and empirical findings, we investigated lay conceptions of a fulfilled life in German-speaking participants at different life stages. First, we selected a qualitative approach using an open-ended question asking participants to describe a fulfilled life. Second, for a more comprehensive understanding, quantitative data were collected about the relevance of sources in providing fulfillment and ratings on a fulfilling life in the present and a fulfilled life in retrospect. Qualitative content analysis was used to assess the responses to the open-ended question. One-fifth of the data was double coded, and intercoder reliability was high ( Understanding what entails a fulfilling life and how to enhance it can be seen as a core mission in positive psychological research . Until rPrior to our work in clarifying the concept and meaning of fulfillment , the terIn our theoretical conceptualization, we defined fulfillment in life as “a cognitive-affective experience referring to a sense of wholeness, fit, and value toward the self, one’s life, and one’s impact” , p. 6. TWe proposed fulfillment in life as the generic term and distinguished between different time frames, ranging from a short-term to a long-term perspective. The four time frames differentiate between fulfillment in an activity, fulfillment in a role or life area, a fulfilling life encompassing the whole life at the present life stage, and a fulfilled life that, in retrospect, encompasses the whole lived life.The outlined conceptualization served as the basis for developing the multidimensional FLS , which aUnfolded Self and Life items assess the perception that one has been able to develop, grow, be authentic, and live a full and true life Positive Impact and Legacy items measure the extent to which one has been able to positively impact the lives of others and live a life that mattered to the well-being of others The Worthwhile Life items assess the perception that one’s pursuits have been worthwhile and that one has lived life well Fulfilled Life Affective Experience items assess the presence of positive feelings related to the lived life  and the absence of negative emotions (“I feel rather empty.”—reverse scored).Findings revealed that cognitive and affective fulfillment were needed to significantly increase the ability to predict a global fulfillment rating, which could not be sufficiently predicted by existing well-being measures. The scales were associated with several sociodemographic and contextual variables, including age, education, financial status, marital status, spirituality, self-rated health, or a good childhood experience.Prior research revealed that laypersons mention the term fulfillment in the context of conceptions of happiness and well-being. To our knowledge, fulfillment appeared in three studies that used an open-ended question or were in the form of sentence completion questions, and involved mature-aged persons . In the In summary, when asked to define happiness or well-being, laypersons mentioned fulfillment as a separate concept and considered fulfillment for evaluating their lives as a whole. However, what laypersons mean by a fulfilled life remains to be clarified. Therefore, our aim is to study people’s ideas of a fulfilled life to advance conceptual clarity. To this purpose, we will use an open-ended question that allows respondents to express in their own words what a fulfilled life means to them. Participants will be asked to give a description of their most telling example of a fulfilled life, regardless of what their life is like. To gain different types of information about the conceptions and experiences of a fulfilled life, we will employ a convergent mixed methods design. This ensures greater depth and diversity of responses than a purely quantitative approach. Furthermore, the mixed methods approach permits us to obtain and compare different perspectives from qualitative and quantitative data and gain a more comprehensive knowledge of the construct than would be possible with an isolated method . FindingThe main objective was to examine lay perspectives of a fulfilled life to better understand this previously under-researched construct. The objectives of the qualitative approach were to (1) investigate the content of lay perspectives of a fulfilled life across the lifespan, (2) examine age group and sex differences, and (3) assess the consistency of the mentioned content with the scientific conceptualization and the FLS proposed by N = 747, subsample: N = 126) are presented in Sociodemographic characteristics of the German-speaking participants : “What makes for a fulfilled life? When you look back on life, you may find it to be variously empty or full. What does a very fulfilled life look like? Please describe below the example of a fulfilled life that is most true for you. This can be an example from someone you have read about or heard about. Your example can also be about someone you know personally. It can also be an example that you merely imagine/that comes to mind. It can be based on your own life that you have lived as it has actually been and still improved by the things you wish would be there. All in all, the idea of a fulfilled life as you wish it for yourself and your loved ones. (Describe in about 5–10 sentences).”not at all fulfilling/fulfilled to 10 = entirely fulfilling/fulfilled). Example item: “Compared to your given example, how fulfilled is your life lived so far in retrospect?”The ratings of a Fulfilling Life in the present and a Fulfilled Life in retrospect are single-item measures developed for the research project on fulfillment in life. These ratings were anchored in the brief description participants gave in their responses to the open-ended question in this study and in an example, they gave of a fulfilling life in the present (not included in this study). Concerning their examples, respondents rated the two statements on an 11-point rating scale (0 = not fulfilling to 7 = very fulfilling). The list included the following 16 sources: profession, volunteer work, partnership, parenting, family, grandparenting, spirituality/religion, hobby, learning and personal development, challenges, life task, reaching a life goal, friendship and social network, creative expression, traveling, and nature. Participants could also select the category of “not applicable.” The roles and activities were identified through a previous literature review positive evaluation referred to statements that emphasized that positive things are in the foreground and predominate. This includes the idea that one has done more right than wrong with regard to one’s decisions and behavior, and that the path one has chosen in life has brought more joy than sorrow:Within this theme, the category of “When I imagine that I am old and look back on my past life, I would like to come to the realization that despite all the mistakes I have made during my life, overall, I am satisfied with the way I have spent it.” fully lived life, which entailed five subcategories. The first, abundant life, emphasized the richness and wealth of experiences that are part of a fulfilled life. One experienced a lot, had exciting encounters with people, was able to discover the world, and retains many fond memories:This theme comprised 10 categories of evaluative statements. The largest of these related to a “A fulfilled life is when you have seen and experienced many things.” having realized dreams and desires, taken chances, lived consciously, and strived for. Attained personally significant goals was the second-largest category:Other subcategories contained the aspects of “A fulfilled life allows one to look back in old age on a large number of personal successes and achievements that were important to oneself. These are not necessarily financial successes, but rather inconspicuous things that perhaps only in retrospect turned out to be successes. Or paths despised by others, which one wanted to follow at all costs, which did not bring one to the planned goal, but perhaps to an unplanned, much greater goal.” socially and professionally successful. Social success related to having been able to find a partner, start a family, have a happy family, build a solid and long-lasting circle of friends and good relationships, and see the positive development of the offspring:This category comprised two subcategories divided into “So, for example, three healthy, intelligent and satisfied children, whom you have raised to become capable human beings and valuable members of society, is a symbol of a fulfilled life for me as a mother. If one has managed to maintain one’s partnership through ups and downs and to one’s own satisfaction, if one has struggled and suffered and yet is still together, then that is a symbol of fulfilled life for me.” Developed self was another major category within the cognitive appraisals referring to how a person could learn, develop, and grow. It describes a person’s ability to make progress in various areas, learn from mistakes, experiment, develop and use strengths, and redefine oneself:Professional success was mentioned in general terms and was also described as satisfaction with what has been achieved professionally and having attained in one’s career what one wanted. “I have become closer and closer to the person I want to be.” contribution and legacy as part of a fulfilled life. This category suggests that a positive impact on the lives of others can take many forms. For example, respondents’ statements related to having raised children, having left an asset that generates profit across generations, and being able to look back on grandchildren and great-grandchildren. Having passed on learnings from one’s life and what is essential for a good life were also mentioned. Other descriptions included having done something meaningful and valuable for society and the environment, helped people, given back, and supported persons vital to oneself:Participants considered a “One has left traces. One has moved the world, even if only in small pieces.” having mastered life was composed of three subcategories. The first was having mastered difficult life phases, including having coped with crises and overcome low points in life:The category of “A fulfilling life includes difficulties that had to be overcome. Without the endangerment of the circumstances recognized as valuable, I as a human being could not feel the emptiness as a counter design, from which a fulfilling life stands out.” made the best out of life events, situations, and setbacks and the knowledge of this. The third subcategory referred to recognized redemption, in perceiving that adversity turned into something good, a painful experience produced a strong sense of justice, or something that one would have chosen differently turned out well. Another category pertained to recognizing meaning and purpose. It described the perception that one has fulfilled one’s purpose in life, had a life task, and—in retrospect—recognized meaning in everything, including one’s actions:The second subcategory emphasized having “So, the certainty of having led a meaningful life.” a suited life entailed the feeling of having been true to oneself, having made good decisions, having taken the right path in life, and having pursued one’s own ideas and interests, as well as having found ways to combine and apply them with their talents. Within the category having lived according to own values, statements described specific values that one would like to see realized. These include that one could be there for others, having been a role model for others, having acted morally right for oneself, or having lived honestly. The other two categories within cognitive appraisals were gained better self-knowledge, i.e., seeing oneself and one’s inclinations, weaknesses, and strengths more clearly, and meaningful use of talents and resources, which describes a fulfilled life in which one did not waste time and energy, but feels one has used them properly.The category referring to being in harmony. It was about being at peace and in harmony with oneself, one’s life circumstances, or the environment:In addition to the cognitive appraisals, participants provided affective descriptions of a fulfilled life, which we grouped into five categories. The largest category within the theme related to “A fulfilled life is when you are reconciled with your life in old age.” gratitude was part of participants’ descriptions, which included statements such as looking back on one’s life with great gratitude, feeling deep gratitude, and thankfulness for what is and for what one has received:In addition, the feeling of “A full life contains much gratitude and appreciation.” contentment, which entailed great inner contentment, contentment with oneself, one’s life, what one has experienced, and having become a contented person. The category widely free of regret described a fulfilled life, looking back without regretting not having done something or regretting important decisions and experiences, and without having to regret anything (in retrospect):Another category concerned “For me, a fulfilled life is when I could die without regrets, with a great inner satisfaction.” various positive emotions are feelings of pride, inner peace and serenity, and a joyful looking back on the experience.Included in the category of relationships and community, with the aspect of sharing time and life. Above all, the quality and depth of a relationship seems to enrich and fulfill life. Occupation was another main source from which people gain fulfillment, especially if the occupation provides joy, makes one happy, and fits with one’s calling:Participants’ statements referred to sources from which they draw fulfillment, which we grouped into nine categories, displayed in a separate block in “I want professional fulfillment in a job where I add value to others through my skills.” recreational activities encompassed leisure pursuits, such as engaging in music, experiencing nature, sexual fulfillment, physical exercise, or enjoying small things. In addition, people find fulfillment in learning and development, such as learning new perspectives and meeting new people, being challenged by different tasks and responsibilities, and learning new things. Participants cited social roles as sources of fulfillment, such as a fulfilling partnership or parenting. Lived spirituality and civic engagement were two other categories we identified. Lastly, savoring was mentioned as a source of fulfillment, with participants describing enjoying beautiful and magical moments.The category Participants’ descriptions also involved various aspects that facilitate a fulfilled life, including resources, personal characteristics, and quality of life see .social and psychological resources, which were seen as prerequisites for a fulfilled life. Three subcategories pertained to social resources. First, social integration means having loving people around, having a stable family and good friendships, enjoying a trusting network of relationships inside and outside the family, and having a sense of belonging. The second subcategory referred to a good childhood. It was described as carefree and sheltered, but not overprotected, in which one experienced love and support, and felt cared for. The third category on social support subsumed mentions such as support from different people, a family that provides a harbor in stormy times and confers stability, and friends one can rely on, whom one can count on and who stand by one’s side:This theme included the two basic categories of “… socially integrated are important prerequisites.” a healthy connection to oneself. Statements were made about connectedness with oneself, self-forgiveness, and self-acceptance:Psychological resources also consisted of three subcategories, the first being “When you don’t let yourself be too unsettled by external factors in difficult times and have found a secure anchor within yourself.” can master difficulties meant the ability to cope with difficulties and find solutions. The third subcategory concerned leading life with (self-) confidence, which included the idea that everything will occur as it must.A second subcategory labeled positive traits included gratitude for one’s life and what one has, modesty and realism, courage, and never giving up. Of note was curiosity, for which we formed a subcategory. Another group of statements was subsumed under the category of personal agency and referred to taking personal responsibility, developing creative initiative, being active, and shaping one’s life. Not holding anyone responsible for one’s own happiness and the ability to say no were other statements included in the responses:Participants named various personal qualities that facilitate a fulfilled life. The category of “You can’t live a full life without doing it yourself.” Acceptance and a positive attitude were other characteristics that respondents addressed, and for each of them, we created a category:“Also being able to accept things in life that you would do differently today.” .“We see everything with somewhat positive attitudes.” .health and financial well-being—the latter referring to having enough money, no existential hardships, and financial security. Another category dealt with the issue of individual freedom and opportunities, including the ability to make independent decisions and choose one’s profession and place of residence, as well as the possibility of receiving a good education:Respondents referred to the overall quality of life, including subjective perceptions and excellent living conditions. Statements were also made about specific components, such as “I grew up in a time that offered me excellent opportunities, possibilities, and conditions for a fulfilling life.” life in balance. Participants emphasized the aspects of having enough free time and achieving a balance between work and private life without burning out. The last category within this theme related to a minor but insightful topic, namely the fact of luck and being spared.Quality of life also involved the category of Looking more closely at the age categories by decade, several results are worth highlighting. Participants in their 20s and 30s made most statements about the fully lived life: 13 and 14 participants, respectively, out of 20 participants per decade. The subcategory of abundant life was the largest in both age groups, mentioned by seven and six participants each. Having attained personally significant goals was mentioned most frequently among those aged 40–79, with nine participants aged 40–49, seven participants aged 50–59, eight participants each aged 60–69 and 70–79. Equally or second-most mentioned were: a fully lived life, in the 40–49 age group (seven participants), a contribution/legacy as well as being in harmony in the 50–59 age group (six participants each), social resources in the 60–69 age group (eight participants), and developed self in the 70–79 age group (six participants).U = 1419.00, z = −3.45, p = 0.001, r = 0.31. Within this category, younger individuals more frequently addressed having had an abundant life  and having taken chances  than older adults. On the other side, the older age group emphasized positive traits as a condition for a fulfilled life more than young adults did U = 1687.50, z = −2.48, p = 0.013, r = 0.22.We used the coded data as categorical variables in SPSS to investigate group differences and examined the data when aggregated, as with themes and some categories. Because many different aspects were mentioned, we created a younger age group (20–49 years) and an older age group (50+). Forming groups for each decade would have resulted in too few participants for analyses. Two-tailed Fisher’s exact tests were used for categorical data and Mann–Whitney tests for aggregated data. There were a few age differences.p = 0.049, two-tailed Fisher’s exact test, Cramer’s V = 0.19). Second, women stated having mastered life more frequently than men. A Mann–Whitney test indicated that this difference was significant, U = 1630.00, z = −2.70, p = 0.007, r = 0.24. Within this category, women more often stated having made the best out of life events as an evaluation for the fulfilled life than men did .There were only a few significant differences between men and women in their perceptions of a fulfilled life (see footnote 2). First, only men mentioned the aspect of luck and being spared  = 13.36, p < 0.001, 2η = 0.04, spirituality, F = 17.36, p < 0.001, 2η = 0.05, learning and personal development Welch’s F = 6.49, p = 0.002, 2η = 0.02, life task F = 6.78, p = 0.001, 2η = 0.02, and nature F = 6.00, p = 0.003, 2η = 0.02. To determine significant differences among the groups, we used Games-Howell and Hochberg GT2 post-hoc test. Regarding profession, age group 40–64  and age group 65+  experienced this source as providing significantly more fulfillment than the youngest age group 18–39 . The oldest age group gained significantly more fulfillment from this source than did the middle group. Furthermore, the two older groups derived significantly more fulfillment than the youngest group regarding the following four sources, spirituality: age group 65+ , age group 40–64 , age group 18–39 ; learning and personal development: age group 65+ , age group 40–64 , age group 18–39 ; life task: age group 65+ , age group 40–64 , age group 18–39 ; and nature: age group 65+ ; and age group 40–64 , age group 18–39 .To explore potential differences in the ratings, the size of the sample allowed us to divide the participants into three age groups . Analysis of variance (ANOVA) indicated significant group differences in the categories of profession, t-tests using bootstrapping procedures. Only for the category friendships and social network, was a significant difference found. Regarding this category, women reported higher means  than men . This difference, −0.31, BCa 95% CI , was significant t(730) = −2.48, p = 0.013, Cohen’s d = 0.23.To test whether men and women differed on the level of fulfillment regarding the categories, we conducted r = 0.26, p < 0.001), and age and a fulfilled life . There was no significant relation between sex and a fulfilling life  or sex and a fulfilled life . We further calculated correlations between a self-rated fulfilling life at present, a fulfilled life in retrospect, and the rated categories for experiencing fulfillment. Strength of association ranged between small and medium  and affective  content, as suggested by the conceptual and operational definitions. More statements were subsumed under cognitive appraisals than affective experience, indicating the different facets of evaluative fulfillment. These results demonstrate the complexity of the construct and that conceptualization and operationalization must represent the cognitive experience as multidimensional. The categories of cognitive appraisals can be summarized in terms of contentment with one’s own development , with one’s lived life , and with one’s contribution to the welfare of others or a worthy cause (category: contribution/legacy). These aspects can be found in the postulated three sources  of the FiL model. The proposed criteria for a fulfilled life  are reflected within different categories. For example, the criterion of wholeness and completeness is found in the category of a fully lived life, congruence is part of the category a suited life, and meaningfulness was featured in the categories recognizing meaning and meaningful use of talents and resources. It should be noted that the category of having mastered life is not explicitly represented in our model. However, this notion can be covered by the conceptualization that a fulfilled life consists of having become a whole and complete person and being able to look back on a life well lived and to recognize meaning in difficult periods of life. Nevertheless, these results show that the elements of a fulfilled life derived from lay perspectives essentially correspond with the proposed theoretical model and are substantially represented by the subscales of the FLS. Hence, future research can build on the proposed model and employ the FLS, as it allows the construct to be measured directly rather than via a proxy, as has been done in the past.Given the number and variety of mentioned aspects, we can conclude that a model and a measure are best built at an abstract level, as we have suggested, because otherwise it would not be possible to cover all the facets of what individuals means by a fulfilled life. For instance, the subcategory socially successful is not explicitly part of the model. The goal of our model was to leave the standard of evaluation up to the respondents themselves. Whether, and to what extent, successful relationships play a role in evaluating their achievement of significant goals is left up to them. In this regard, the item on whether one could pursue personally meaningful goals to assess a fulfilled life permits persons to apply it to their preferences and life realities. Therefore, a person who has not been able or willing to start a family may still answer this item because it allows them to think in a broader context of personally meaningful goals. If a life goal has become unattainable , the ability to adjust goals and pursue a new meaningful goal is associated with subjective well-being and a sense of purpose .Participants mentioned several aspects that could be considered sources of fulfillment. One main source is meaningful relationships and community in which people share and go through life together. The importance of this source has also been demonstrated by the finding that family and social relationships are predominant categories within contextual definitions of happiness and meaningfulness  or that Consistent with our qualitative findings, the quantitative results underscore the fact that multiple sources provide fulfillment. An interesting outcome is that participants rated nature as the most fulfilling category. There are several possible explanations for this result. Since people today are less likely to belong to a religious institution, the experience of connectedness to a larger whole could be found in nature. Indeed, connectedness with nature has been identified as a source of meaning and assigned to the subdimension of horizontal self-transcendence through a factor-analytic approach . In addiThe level of fulfillment provided by sources varied across age groups. In general, the two older age groups rated various sources as more fulfilling than the youngest age group. For instance, older adults valued the sources of nature and spirituality more highly. This is consistent with previous findings revealing that older individuals more often mentioned spirituality as a domain of happiness  or that Most sources mentioned by participants were identical to our list of ratings. Although the ratings for nature and grandparenthood yielded high means in terms of the fulfillment they provide, they were rarely mentioned in the responses to the open-ended question. The reason for this could be that these aspects were not at the forefront when describing a fulfilled life. This underscores the added value of a mixed methods approach to gain a more complete understanding of fulfillment sources. The emergence of the category of savoring, on the other hand, was rather unexpected and the only one that was not among the listed sources of participants’ ratings. Savoring, which refers to the ability to note and appreciate positive experiences, can relate to the past, present, or future  and is rVarious participants’ statements referred to prerequisites for a fulfilled life. On the one hand, requirements included psychological resources such as a healthy relationship with oneself, coping skills, and confidence. On the other hand, they comprised social resources, including a good start in life, a sense of being socially integrated, and having supportive relationships. A sense of belonging, for instance, helps people believe that their lives are meaningful . MeaningAccording to the participants, positive attitudes and personal qualities are essential for a life well lived. The personal qualities mentioned included positive character traits, personal agency, acceptance, and a positive attitude. These qualities can influence the extent to which one values life and what one makes of it. Participants mentioned curiosity above all, but also bravery and humility. These traits are also referred to as character strengths, which are positively valued personality traits that are thought to contribute to individual and collective fulfillment . In addiA fulfilled life also seems to depend on resources and favorable conditions, some of which are beyond the individual’s control. In this context, participants referred to quality-of-life attributes, including health, financial well-being, individual freedom and opportunities, and a life in balance. There is ample evidence of the importance of factors such as opportunities to choose and income to people’s welfare and flourishing e.g.,  and, morWithin the two age groups, younger participants more frequently mentioned a fully lived life, having had an abundant life, and having taken chances. These three topics relate to the FiL model’s criterion of wholeness/completeness and reflects that at a younger age, many dreams, goals, and life projects that fulfill a life are yet to be realized. With increasing life experience, individuals seem more aware that a person’s character, attitude, and initiative facilitate attaining a fulfilled life, as older people compared to younger more often referred to positive traits.informational , normative , and diffuse-avoidant  Failure to develop an integrated sense of one’s identity may hinder the active shaping of one’s life and the pursuit of goals consistent with oneself, which appear essential for a fulfilled life. The results of a path analysis indicate that only the informational identity style predicted self-actualization and self-transcendence in young adults, which in turn predicted meaning in life and subjective happiness .There is empirical evidence that successfully mastering earlier psychosocial challenges predicted ego integrity in older adults, with generativity proving to be the strongest predictor . PsychosTo our knowledge, this is the first study to examine lay perspectives of a fulfilled life among adult participants across the lifespan. The fact that our sample included respondents from all life stages and had a gender balance can be considered a strength. However, the use of a convenience sample limits the generalizability of the findings. Since our sample consisted of German-speaking participants belonging to an individualistic culture, future research will have to establish whether conceptions of a fulfilled life differ across cultures, especially in comparison to collectivistic cultures. The numerous and valuable perspectives gained using both qualitative and quantitative data contribute to a deeper and more comprehensive understanding of a fulfilled life. By allowing participants to freely describe their conception of a fulfilled life, we obtained a rich, diverse, and in-depth collection of information, including conceptual components, correlates, and antecedents. Although we were able to gain a variety of perspectives and create a comprehensive framework of a fulfilled life, we cannot claim to have been exhaustive. Participants responded very carefully, personally, and with great depth. However, it is not possible to achieve the same depth with open-ended questions as with interviews, for example, which allow for further verification. Our cross-sectional design allows us to make statements about age-group differences, but not causality statements about age changes. Thus, age effects could be attributed to cohort membership, as typical mentalities of a particular cohort may shape the notions of a fulfilled life. It should be noted that significant age and sex differences are based on exploratory analyses without adjustments for multiple testing. Confirmatory studies will need to confirm these results. Finally, it should be noted that the first author, who also led the coding, was also involved in the development of the theoretical model of FiL . AlthougOur overarching framework encompasses many routes by which a fulfilled life can be attained, whether by directly strengthening areas that are considered core elements or by fostering social and psychological resources, personal strengths, or positive attitudes. At the individual level, persons can reflect on and define what an ideally fulfilled life looks like for them and derive appropriate steps. As indicated in our conceptual model, it is essential to consider the core criteria. What is fulfilling depends on whether it contributes to perceiving wholeness, congruence, and significance. In addition, they can evaluate the sources that emerge from this study for their importance and cultivate those that provide the greatest fulfillment. In particular, evaluating the sources of profession and life task as fulfilling seems to have a longer-term impact on a fulfilling life in the present and a fulfilled life in retrospect. At any stage of life, it is worthwhile to pursue a career or activity that is a good fit or even perceived as a calling . LeadingThis study contributed to conceptual clarity by revealing what laypersons understand by a fulfilled life. Our qualitative results underscore that the construct is multidimensional and comprises cognitive and affective experiences. Statements that are considered cognitive appraisals indicate what matters to people in evaluating their lived lives. They understood a fulfilled life primarily as having lived life fully, achieved personally meaningful goals, developed themselves, and contributed to others and left a positive legacy. These findings confirm that a fulfilled life consists of many facets and, importantly, involves the notion that a life well lived contains a self-transcendent component. Lay perspectives regarding the core elements are largely consistent with the proposed theoretical conceptualization and the dimension of the FLS. Laypersons recognized that a fulfilled life also depends on personal resources, personal characteristics and quality-of-life aspects. The sources of fulfillment mentioned by participants and those given in the qualitative section largely overlap. It appears that fulfillment requires a long-term view, and that the quality and personal significance of the source are critical. As people age, they seem to succeed in drawing more fulfillment from the various sources. The understanding of what constitutes a fulfilled life is quite similar among younger and older adults and among men and women. The findings help lay the foundation for this emerging line of research and suggest many routes to create a more fulfilling life.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.DB and WR: conception and design of the work, interpretation of data analysis and final approval of the published version. DB: data collection, data analysis, and drafting of the manuscript. WR: critical revision of the manuscript. All authors contributed to the article and approved the submitted version.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.