This article overviews my recent acceptance of a Lifetime Achievement Award from Sapienza University of Rome, in which I discussed three decades of my work on the right brain in development, psychopathogenesis, and psychotherapy. In the following, I offer current brain laterality and hemispheric asymmetry research indicating that right brain emotional and relational processes operate beneath conscious awareness not only in early human development, but over the lifespan. I discuss recent interdisciplinary studies on the central role of ultrarapid right brain-to-right brain intersubjective communications of face, voice, and gesture and the implicit regulation of emotion in nonverbal attachment dynamics. Special emphasis is on the fundamental psychobiological process of interpersonal synchrony, and on the evolutionary mechanism of attachment, the interactive regulation of biological synchrony within and between organisms. I then present some clinical applications, suggesting that effective therapeutic work with “primitive” nonverbal emotional attachment dynamics focuses not on conscious verbal insight but on the formation of an unconscious emotion-communicating and regulating bond within the therapeutic relationship. Lastly, I review recent hyperscanning research of the patient’s and therapist’s brains during a face-to-face, emotionally focused psychotherapy session that supports the right brain-to-right brain communication model. I end suggesting that the right brain is dominant in both short-term symptom-reducing and long-term growth-promoting deep psychotherapy. The background of this article is my recent acceptance of a Lifetime Achievement Award from Sapienza University of Rome, and my response to this honor, a presentation on the right brain and its central role in development, psychopathogenesis, and psychotherapy to a large psychiatry audience. In the following I’d like to briefly overview three decades of this work, offer some comments on what I view as the major current trends in psychotherapy practice and research, as well as what I see as changes and future directions of the mental health field. You’ll note that I frequently use the literal voices of scientists and clinicians to show convergence and common language now being used to describe the underlying psychobiological mechanisms central to the change processes in the mother–infant attachment and therapist–patient psychotherapy relationships.Affect Regulation and the Origin of the Self published in 1994 (and re-released as a Classic Edition in 2016), I explored the neurobiology of human emotional development, concluding that affective processes, acting beneath levels of awareness, lie at the affective core of the subjective self [In my first book ive self . By thisThe Right Brain and the Unconscious: Discovering the Stranger Within, the clinical neuropsychologist Rhawn Joseph [conscious self-image is associated with the left half of the brain in most people. However, this self-image is also subject to unconscious influences. By contrast, the unconscious self-image is maintained within the right brain mental system and is tremendously influenced by current and past experiences… the two self-images… interact. Indeed, sometimes the conscious self-image is fashioned in reaction to unconscious feelings, traumas, and feared inadequacies that the person does not want to possess, but that nevertheless, are unconsciously maintained.Just as we have a conscious and an unconscious mind, as well as a right and left brain, we also have two self-images. One is consciously maintained and the other is almost wholly unconscious. The Towards that end I continue to cite an expanding body of neurobiological and clinical studies indicating that the functional and structural differences between the two brain hemispheres is profound , 5. A man Joseph  observedIf what one means by consciousness is the part of the mind that brings the world into focus, makes it explicit, allows it to be formulated in language, and is aware of its own awareness, it is reasonable to link the conscious mind to activity almost all of which lies ultimately in the left hemisphere. The right hemisphere both grounds our experience of the world at the bottom end, so to speak, and makes sense of it, at the top end…this hemisphere is more in touch with both affect and the body…neurological evidence supports what is called the primacy of affect and the primacy of unconscious over conscious will see Fig. .Continuing this theme, the neurologist Guido Gainotti  offered Another central area of my work is in neuropsychoanalysis, the science of unconscious processes, where I contend that the right brain is the psychobiological substrate of human unconscious mind first described by Sigmund Freud. Recent authors are now describing a right hemispheric dominance in nonconscious processing, concluding “The right hemisphere has an advantage in shaping behavior with implicit attention whereas the left hemisphere plays a greater role in expressing explicit knowledge” . Indeed sensitively tuned to receive these intersubjective salient emotional communications. Following this up in my 2003 volumes I stated in contrast to a static deeply buried storehouse of ancient memories buried and silenced in “infantile amnesia”, contemporary psychoanalysis now refers to a “relational unconscious”, whereby one unconscious mind intersubjectively communicates with another unconscious mind [Ucs of one human being can react upon that of another, without passing through the Cs”, [In 1994 I proposed that the right brain is dominant in maintaining an unconscious cohesive, continuous, and unified sense of self [the Cs”,  and the the Cs”, .intrapsychic unconscious that expresses itself in dreams at night to an interpersonal relational unconscious, in which the unconscious mind of one communicates with the unconscious mind of another, and is omnipresent in everyday life. In parallel writings to my own, Karlen Lyons-Ruth offered a “two-person unconscious” asserting, “Most relational transactions rely heavily on a substrate of affective cues that give an evaluative valence or direction to each relational communication. These occur at an implicit level of rapid cueing and response…too rapidly for simultaneous verbal transaction and conscious reflection” [The interpersonal neurobiological construct of a relational unconscious is the most radical transformation of Freud’s psychoanalytic theory. Updated reformulations of the unconscious have shifted from an lection” . I wouldsynchronize, align, and couple their neural activities with other brains. The term synchrony derives from Greek syn, same or common, and chronos, time, and thereby means occurring at the same time, in the same moment, and thus simultaneous. There is now agreement that the process of interpersonal synchrony acts as a primal social bonding mechanism, and that early synchronous shared social interactions are the foundation of the human experience [At the core of my developmental work on intersubjectivity and attachment is the central principle of interpersonal neurobiology: the self organization of the developing brain occurs in the context of a relationship with another brain, another self . Utiliziperience , 4, 15.In classic research Colwyn Trevarthen documented the early origins of human intersubjectivity at 2–3 months, when infants are ready to engage in behavioral turn-taking and expect social contingency and predictable back-and-forth interactivity . He obsesynchronized and thereby shared positive affective brain states. But his model also focuses on internal structure–function events, where he states that the intrinsic regulators of human brain growth in a child are specifically adapted to be coupled, by emotional communication, to the regulators of adult brains.According to Trevarthen, this two-way traffic of intersubjective visual, auditory, and tactile signals induces instant positive emotional effects, namely excitement and pleasure build within the dyad. These collaborative emotional transactions trigger interpersonal resonance within the emotionally communicating dyad, thus generating the intercoordination of In a recent article on the interpersonal neurobiology of intersubjectivity I have cited a recent body of brain asymmetry studies to argue that Trevarthen’s synchronized intersubjective protoconversations represent rapid, reciprocal, bidirectional visual–facial, auditory–prosodic, and tactile–gestural right brain-to-right brain implicit nonverbal communications between the mother and her developing infant . In suchThe right TPJ has been suggested to be a central hub for…non-verbal emotional communication and interaction between a caregiver and an infant . This caregiver-infant pre-verbal prosodic, gestural, and facial emotional expressions, provides a basis for the development of attachment…Successful emotional communication and downregulation of infant’s negative emotions relies on right hemispheric functions of both the caregiver and infant.Soon after, the neurologist Kaisa Hartikainen  writing Furthermore, the right TPJ is also involved in “emotional arousal linked with positive emotion (Schore)”, and in “the synchronization between the brains of two people.”In classic writings, John Bowlby proposed attachment communications are accompanied by the strongest of feelings and emotions, and, like Trevarthen suggested they occur within a context of facial expression, tone of voice, and posture . A largeIndeed, the essential task of first two years of life is the cocreation of an intersubjective right brain-to-right brain attachment bond of emotional communication and interactive regulation between the infant and primary caregiver. Secure attachment occurs via the mother’s attention and implicit “background presence” of synchronized attunement, recognition, and regulation not of the infant’s voluntary behavior, but with moment-to-moment alterations of right brain autonomic involuntary emotional arousal, the physiologic dimension of child’s affective state. Hartikainen observes a central role of the right hemisphere in attention, emotion, and arousal .The research of Manini’s laboratory reports that synchronization of the mother’s responses to infant signals in their dyadic interaction is a central aspect of sensitive parenting, because it directly relates to the promptness of the mother’s response and her adaptation moment by moment to the child’s emotional state . This emThat said both research and clinical evidence indicate that the primary caregiver is not always attuned, that there are frequent moments of stressful misattunement in the dyad, ruptures of the attachment bond. A major attachment process is expressed in “interactive repair” following misattunement, in which the caregiver who induces a stress response, in a timely fashion spontaneously reinvokes a re-attunement and regulates the infant’s negatively charged emotional arousal , 15. Thicommunication of emotion, while attachment represents the regulation of states of affective arousal. Thus, the evolutionary mechanism of attachment represents the regulation of biological synchrony within and between organisms. It is accessed by the secure mother to implicitly track and regulate the infant’s emotional arousal. A central tenet of the theory dictates that the structural organization of attachment circuits self-organize in an early critical period of growth of the emotional right brain from the last trimester of pregnancy until the third year when the left begins one, and that the infant’s anterior right orbitofrontal  cortex, the apex of limbic system, matures over this period. This right-lateralized system acts as attachment control system of effortless, subliminal, implicit affect regulation.In 2008 my wife Judith and I published an article “Modern Attachment Theory”, where we suggested a body of experimental and clinical data on how affective bodily-based processes are nonconsciously interactively regulated had shifted attachment theory to a regulation theory . I use tNeuroImage, “EEG effective connectivity during the first year of life mirrors brain synaptogenesis, myelination, and early right hemisphere predominance” [The right hemisphere is predominant during the preverbal epoch in infants…and lasts during the first three years of life . The right hemisphere is understood as an executive regulatory system of the emotional brain involved in inhibitory control. In particular the right orbital prefrontal region acts as an executive control for the entire right brain . The right predominance starts shifting to the left hemisphere by the age of 3 years.In the most comprehensive study to date on early right brain development, Bosch-Bayard and colleagues offer a study in minance” . These aOver the first two years of human infancy the growth and lateralization of infant’s early developing right hemisphere is thus dependent upon the implicit safe and trusting emotional interactions generated in the mother–infant attachment relationship .Studying brain development at the beginning of the first year, developmental neuroscientists conclude, “In early life the right cerebral hemisphere could be better able to process... emotion (Schore). This idea appears consistent with our findings of rightward asymmetry in limbic structures. These neural substrates function as hubs in the right hemisphere for emotion processes and mother and child interaction” . TronickFurthermore, the mother–infant attachment relationship impacts the developing right brain for better or worse. It can either facilitate a healthy resilience to stress or create a vulnerability to characterological affect dysregulation and deficits in social relationships, and thereby later psychopathology. In the right brain critical period what I have termed “relational trauma”, chronic attachment trauma that results from repeated and prolonged exposure to highly dysregulated early relational and emotional experiences without repair induces disorganized insecure attachments that imprint a physiological reactivity and susceptibility to later disorders of affect regulation . These mWhen multiple models of a single figure are operative they are likely to differ in regard to their origin, their dominance and the extent to which the subject is aware of them. In a person suffering from an emotional disturbance, it is common to find that the model that has had greatest influence on his feelings and behavior, is one developed during his early years and is constructed along fairly primitive lines, but that the person may be relatively unaware of while simultaneously there is operating within him a second, and perhaps radically incompatible model that developed later, that is much more sophisticated, and that the person is more clearly aware of and he may mistakenly assume to be dominant.Fifty years ago Bowlby  suggesteModern attachment theory offers an early unconscious right brain preverbal model of implicit “primitive” emotional attachment dynamics, while “classical”, “academic” attachment theory describes the explicit conscious behavioral/cognitive functions of the later-forming verbal left brain. The Oxford English dictionary defines primitive as “of or pertaining to the first age, period, or stage; early, ancient.”The right brain attachment dynamic is a central focus of regulation theory, and affect dysregulation plays a critical role in the both the symptomatology and treatment of all psychiatric and personality disorders. In my studies I offer interdisciplinary and clinical evidence indicating that the co-constructed psychotherapy relationship itself plays a major role in symptom-reducing and growth-promoting treatment, and that the right hemisphere is dominant in psychotherapy , 15. EffThis conceptualization attends to two fundamental questions—how do we work directly with the patient’s and our own emotions, and how do we access “primitive” nonverbal intersubjective emotional communications within the psychotherapy session? In any session the empathic therapist is consciously, explicitly attending to the patient’s verbalizations in order to objectively diagnose and rationalize his or her dysregulating symptomatology. However, the therapist is also intersubjectively listening and interacting at another level, an experience-near subjective level, one that implicitly processes the patient’s implicit moment-to-moment nonverbal bodily-based emotional communications at levels below awareness, beneath the words.In “heightened affective moments” of a session the empathic therapist “follows the patient’s affect”, and transiently callosally shifts out of the left brain into a right brain state of wide-ranging evenly suspended attention , 5, 15. Human Brain Mapping [coupling of the therapist’s and patient’s right brains, also enables the patient’s embodied subjective self to implicitly experience “feeling felt” by the empathic therapist.In 2012 Goodkind and colleagues published “Tracking emotional valence: the role of the orbitofrontal cortex” in  Mapping . These r.” Note this this positional reference describes the nonverbal right hemisphere and coupled right brains. This right-lateralized psychobiological system intersubjectively synchronizes and couples with another “emotional” right brain that is “attuned” and “on the same wavelength.” This right brain-to-right brain coupling allows the empathic therapist to share and regulate the patient’s subjective affective states, especially during stressful transferential–countertransferential clinical reenactments of early attachment trauma within the therapeutic relationship, common in the treatment of early forming personality disorders [Writing on “Physiological synchrony in psychotherapy sessions” Tschacher and Meier  state thisorders , 5, 15.Emotions are deepened in intensity and sustained in time when they are intersubjectively shared. This occurs at moments of ‘deep contact’ .Every time we make therapeutic contact with our patients we are engaging profound processes that tap into essential life forces in our selves and in those we work with. With direct implications for the therapeutic relationship Decety and Chaminade observe, “Mental states that are in essence private to the self may be shared between individuals…self-awareness, empathy, identification with others, and more generally intersubjective processes, are largely dependent upon…right hemisphere resources, which are the first to develop” . More reThe Science of the Art of Psychotherapy I suggested that across disciplines we were witnessing a paradigm shift from a one-person intrapsychic to a two-person relational psychology, a shift in perspective from within a brain to an intersubjective relationship between brains, such as the right brain-to-right brain mother–infant attachment and therapist–patient psychotherapy relationships [Similarly, the neuropsychologist Julian Keenan and colleagues state, “The right hemisphere, in fact, truly interprets the mental state not only of its own brain, but the brains (and minds) of others” . In my 2ionships .independent of the treatment…We need to proclaim publicly what decades of research have discovered and what hundreds of thousands of practitioners have witnessed: The relationship can heal…What does not work are poor alliances in adult, adolescent, child, couple, and family psychotherapy as well as low levels of cohesion in group psychotherapy. Paucity of collaboration, consensus, empathy, and positive regard predict treatment dropout and failure.Decades of research evidence and clinical experience converge: the psychotherapy relationship makes substantial and consistent contributions to outcome In a recent comprehensive overview of studies of the psychotherapy relationship Norcross and Lambert  concludeAnother large body of psychotherapy research focuses on the critical role of “common factors”, qualities of “effective therapists” associated with successful treatment outcomes, such as collaboration, empathy, conveyed respect, acceptance, genuineness, maintaining a warm emotional bond with the patient, and capacities for alliance building , 39. Mor“Allan Schore writes about a right brain-to-right brain channel of affective communication—a channel that he sees as ‘an organized dialogue’ comprising ‘dynamically fluctuating moment-to-moment state sharing. I believe it to be this process of state sharing that allows ‘a good psychoanalytic match” [Over the last three decades I continue to offer brain laterality research and clinical data on working right brain-to-right brain in the therapeutic alliance. These spontaneous nonverbal communications of self states take place in the present moment, a time frame of thousandths of a second to 2 to 3 s. My colleague Russel Meares referred to a form of therapeutic conversation that can be conceived as a dynamic interplay between two right hemispheres . The relc match” . Note thAccording to Koole and Tschacher interpersonal synchrony establishes interbrain coupling that provides “patient and therapist with access to another’s internal states, which facilitates common understanding and emotional sharing” . WritingThe implicit sharing process is temporal and bidirectional between…people…a mutual dynamic process is occurring, whereby partners make micro-adjustments over time driven by implicit information from high-resolution perceptions of the others’ states and intentions . Mutual interaction…involves a complex fitting-together of the individuals involved, producing a resonance between two attuned systems and feelings of psychological closeness .Kaiser and Butler  now asseThis fitting together of an emotional engagement is the outcome of a synchronized, intersubjective, nonverbal dialogue embedded in a collaborative right brain-to-right brain communication system at the deep psychobiological core of the therapeutic alliance.In 1994 my right brain-to-right brain communication model was based on theoretical principles, clinical explorations, and extant neuroscience research. Even more direct evidence of the “two-person”, “two-brain” model awaited an emergent technology that could simultaneously measure two brains interacting face-to-face in real time. Over the last decade “hyperscanning” methodologies utilizing electroencephalography, near-infrared spectroscopy, functional magnetic resonance, and magneto-encephalography providing simultaneous measurements of two individuals are now available. This technological advance allows for the study of two brains in real time social interactions with each other, during rapid bidirectional nonverbal communications.“two-body” methodology allows for a simultaneous measurement of brain activities of each member of a face-to-face dyad during a two-way intersubjective nonverbal communication, where “both participants are continuously active, each modifying their own actions in response to the continuously changing actions of their partner.”Inspired by the developmental research of Beebe, Tronick, and especially Trevarthen on the intersubjective nonverbal communication and coordination between a mother and her infant see Fig. , Dumas atime scale of milliseconds, of right centroparietal regions, a neuromarker of social coordination in both interacting partners, as well as a synchronization between posterior right temporoparietal junction (right TPJ) of one partner and right TPJ of the other. They cite studies showing that the right cortical TPJ is activated in social interactions, empathic understanding, and making sense of another mind, all outside conscious awareness. The following top-down view shows this right-lateralized interbrain synchronization during a nonverbal communication. Note what I have termed a right brain-to-right brain interaction between one subjective self and another subjective self, whereby one unconscious mind intersubjectively communicates with another unconscious mind across an intersubjective field  and interpersonal brain synchronization of the right temporoparietal junction (right TPJ) in both the clinician’s and patient’s brains. This increased right-lateralized interbrain synchronization was specifically related to subjective ratings of the affective “bond or positive personal attachments between dyads.” The authors interpreted these findings as showing that the clinician and client form an interbrain synchronization that plays an essential role in building a working alliance and a positive therapeutic relationship, and that this brain-to-brain coupling facilitates the development of an emotional bond in the therapeutic alliance in the first session. They conclude that that this important nonverbal skill improves the working alliance, and that training should now focus on how to effectively synchronize with clients.In a more current publication this laboratory offered another functional near-infrared spectroscopy study “Experience-dependent counselor–client brain synchronization during psychological counseling” . Here thThis laboratory again documented a counseling-induced right-lateralized interpersonal synchronization, a right TPJ-to–right TPJ alignment that was especially evident with clinicians who had more psychotherapy experience. The researchers show that in the first session the clinician’s ability to specifically focus on the client’s emotional states and to interpersonally synchronize with her or him is an expression of therapeutic expertise. They concluded that increased right-lateralized interbrain synchronization over the session is associated with tighter interpersonal closeness/connectedness and better alliance/emotional interaction, and that this study confirms an interpersonal synchrony model of psychotherapy which dictates that “the more tightly the client and counselor’s brains are coupled, the better the alliance” .In both Zhang studies during the session synchronous brain activity is seen in an alignment of metabolic physiological activity of the right temporoparietal junction of both members of the therapeutic dyad. This patient–therapist right-lateralized brain synchronization is the same as the Dumas’ “two-body” nonverbal intersubjective communication see Fig. . As in tOverviewing current “multi-brain neuroimaging” and “hyperscanning” data, Ray and his colleagues  assert tbrain interactions between individuals transcending the boundary of the skull.” Recall my earlier assertion that we are now experiencing a paradigm shift in psychotherapy from a one-person intrapsychic into a two-person interpersonal perspective (and thus ultimately an integrated model of both). In such synchronized interactions nonverbal relational and emotional therapeutic change mechanisms are activated in a face-to-face dialogue of two coupled right brains across an affectively energized intersubjective field (see Fig. In offering the same Dumas hyperscanning image as above of coupled, synchronized right brains, Ray points out that all mental disorders unfold in an interpersonal context, and that in most social settings, the human brain works in interaction with other brains establishing a “coupling” between themselves. They conclude, “At present functional neuroimaging is on the brink of a paradigm shift, quantifying the see Fig. .“dark matter” of live social interaction [the dark side of consciousness” [Recent authors are now suggesting a “two-body approach” that captures interbrain synchronization, unconscious mutual attunement, and the dynamic exchange between individuals represents the eraction . Indeed,ousness” . In totaPsychotherapy, the flagship journal of the American Psychological Association Division of Psychotherapy, “The right brain is dominant in psychotherapy”, wherein I offered interdisciplinary evidence indicating that psychotherapy, “a relationship of care”, can alter more than the patient’s left-lateralized conscious mind. It also directly influences the growth and development of the unconscious “right mind” [In 2014 I published an article in ht mind” . Note onht mind” , group pht mind” , workinght mind” , and theht mind” . And so And I thank you for both your attention and for the great honor of this award.


In cross-sectional gambling studies, friends, family, and others close to those experiencing gambling problems (concerned significant others ‘CSOs’) tend to report detriments to their quality of life. To date, however, there have been no large, population-based longitudinal studies examining the health and wellbeing of CSOs. We analyse longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey to examine the 18-year trajectories of general, social, health and financial wellbeing of household CSOs (n = 477) and compare these to those without a gambling problem in the household . CSOs reported significantly worse long-term wellbeing than non-CSOs in their satisfaction with life, number of life stressors, and social, health and financial wellbeing. However, both social and financial wellbeing showed a temporal effect, declining significantly for CSOs at times closer to the exposure to the gambling problem. This finding suggests a causal link between living in a household with a person with a gambling problem and decreased CSO social and financial wellbeing. Policy responses, such as additional social and financial support, could be considered to assist CSOs impacted by another person’s gambling problem. The impacts of gambling-related harm on the health and wellbeing of close family and friends of people who gamble  contribute to the public health burden associated with gambling problems . Harm atHowever, many of these relationships are bi-directional. For example, gambling can be used to try to improve finances ; where aThere are very few quantitative studies exploring the impact of gambling on CSOs longitudinally. One short-term study examined health and wellbeing factors associated with being close to someone with a gambling problem, following up a year later . At the The present study seeks to understand whether gambling is a direct causal factor in wellbeing outcomes for household members of individuals experiencing a gambling problem. People who co-habit with a person experiencing a gambling problem are a key subset of the broader group of CSOs. They tend to have a very close relationship with the gambler, sharing household and financial responsibilities, and therefore tend to be the most acutely affected. We analyse longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey, a large-scale population study, to explore the trajectory of wellbeing factors in CSOs. Using data from 2018, the most recent to assess gambling problems, the present study identifies household CSOs, that is, those people living with another person experiencing moderate or severe gambling problems at that time . We then examine the trajectory of the CSOs’ overall, social, health and financial wellbeing variables over the preceding 17 years and compare these to respondents who were identified as non-CSOs in 2018 as a non-experimental control group. Unfortunately, data on household gambling problems are not available for every year; however, gamblers are known to transition in and out of experiencing problems  and, as A key assumption is that the CSOs in this study were unlikely to have been exposed to gambling problems for the preceding 17 years. Their level of exposure involves two factors: how long the gambler has experienced a gambling problem, and how long the CSO has had an active relationship with that person. Overall, the bulk of evidence supports that more serious gambling problems may fluctuate over reasonably short periods of time . While, In sum, this study examines a range of social, health and financial wellbeing factors up to and including the time at which the CSO is known to be exposed to another person’s gambling problem. We examine retrospective trajectories of wellbeing in CSOs impacted by gambling problems in 2018 compared to people without a gambling problem in the household. We expect that social, health and financial wellbeing are primarily outcomes of exposure to the gambling problem (rather than other causes or confounds that were measured), and accordingly hypothesise that CSO wellbeing should decline closer to a known time when they are impacted by the gambling problem. Since data on CSO status was also available in the 2015 wave, we also check assumptions against this data, examining the proportion of affected respondents who were also household CSOs three years prior.The Household Income and Labour Dynamics in Australia Survey HILDA;  is a lonThe current study is a prospective cohort study. We used linear mixed models to examine 18-year trajectories of general, health, social and financial wellbeing outcome variables associated with those identified as CSOs or non-CSOs in 2018. The sample of interest for this study was participants aged 15 years or over (adults) who lived in households where all individuals completed the Problem Gambling Severity Index PGSI;  in 2018.First, gambling problems were identified using the Problem Gambling Severity Index PGSI;  as measuThe study then identified all the household members of participants who had been classified by their completed PGSI as either a ‘moderate-risk’ or ‘problem’ gambler. These participants were classified as CSOs as they lived with someone experiencing a gambling problem. M = 41.7 years, SD = 19.9) compared to the analytic sample ; Welch (5884.70) = 190.40, p <.01).There were no significant sex differences between the excluded (missing household PGSI) group and the analytic sample. However, the mean age was significantly lower  could not be categorised in 2015 as they, or their other household members, did not complete the PGSI in that wave.Health. Health state utility was measured by the SF-6D. This health index health state score is derived from the SF-36 [he SF-36 , a measuhe SF-36 . Scores he SF-36 , 51. TheSocial support. The HILDA social support scale is used to assess an individual’s perceived social support [ support –54. The Community participation. Community participation was assessed using a 12-item measure adapted for use in HILDA from the Australian Community Participation Questionnaire [ionnaire . QuestioFinancial stressors. Indicators of financial stress were assessed via seven yes/no questions. These were “could not pay electricity, gas or telephone bills on time”, “could not pay the mortgage or rent on time”, “pawned or sold something”, “went without meals”, “was unable to heat home”, “asked for financial help from friends and family” and “asked for help from welfare/community organisation”. The number of positive responses was summed with a higher number indicative of more financial stressors. Financial stressors were measured across all years except 2010.Personal stressors. HILDA assesses various life events, both positive and negative. Personal stressors were assessed from the following 14 life events “separated from spouse”, “serious personal injury/illness”, “serious injury/illness to family member”, “death of a spouse or child”, “death of a close relative/family member”, “death of a close friend”, “victim of physical violence”, “victim of a property crime”, “detained in jail”, “close family member detained in jail”, “retired from the workforce”, “fired or made redundant”, “changed jobs” and “major worsening in finances”. Participants indicated yes or no to these events occurring in the previous 12-months, and the number of positive responses was summed. Personal stressors were measured across all years except 2001. Deviant personal stressors were those associated with violence and crime. They included “victim of physical violence”, “victim of a property crime”, “detained in jail”, and “close family member detained in jail”.Subjective wellbeing (SWB). A single item life satisfaction question probed global wellbeing: “All things considered, how satisfied are you with your life?”. Specific wellbeing domains were assessed via questions that asked people to rate how “satisfied or dissatisfied you are with some of the things happening in your life”. Participants were then shown a list which included “Your financial situation”, “Feeling part of your local community”, “The neighbourhood in which you live” and “Your health”. All responses were rated on an 11-point scale from 0  to 10 . SWB was measured across all years.A range of socio-demographic variables associated with gambling problems  were incp-value of <.05 was considered significant.Participants’ characteristics in 2018 were analysed using descriptive analyses in IBM SPSS Statistics for Windows, Version 27 . These aThe HILDA Study has been conducted annually since 2001, following the University of Melbourne’s ethics guidelines. Ethics approval for data collection was granted by the Human Research Ethics Committee of the University of Melbourne Ethics (#1955879) and updated annually. This paper uses de-identified unit record data, so consent was not required for this study, and approval for secondary analysis was granted by Central Queensland University Human Research Ethics Committee (#22878).Characteristics of participants in 2018 are described in The trajectories of overall wellbeing, the average number of personal stressors, deviant personal stressors, and mean life satisfaction scores for CSO and non-CSOs are illustrated in The analyses shown in CSOs reported significantly worse social wellbeing across all social DVs than non-CSOs . The traHealth-related quality of life and satisfaction with health for CSOs are consistently lower than for non-CSOs. However, the trajectory of both is similar to that experienced by non-CSOs .We examined the health and wellbeing trajectories of a group of household CSOs in 2018, for the 17 years prior to when it was known from the survey that they were living with someone experiencing a gambling problem. This CSO group was compared to people without a gambling problem in the household at that time. As expected, some social and financial wellbeing outcomes showed a clear temporal effect, declining closer to the time they were known to be impacted by the gambling problem. However, while all measured health and wellbeing outcomes were worse for CSOs, no temporal effects were found with any measured general wellbeing or health variables. We also found around half (49.9%) of the CSO group had also been CSOs three years prior. This is relatively consistent with previous findings , 15 and The study identified clear temporal effects associated with social and financial wellbeing. That is, there were significantly different trajectories for CSOs and non-CSOs as proximity to known exposure to household gambling problems decreased. For those without a gambling problem in the household, satisfaction with their financial situation improved as they aged; however, this was not the case in CSOs, whose satisfaction remained reasonably stable over time and lacked improvement. One of the most common gambling-related harms, financial problems can be the first consequence of excessive gambling . Consequently, gambling-related financial problems might offset any normal improvements expected in a person’s financial wellbeing over time. Social wellbeing also appeared to be influenced by gambling problems. For participants not associated with a household gambling problem, social wellbeing appeared relatively stable over time. However, CSOs perceived that social support and their satisfaction with their community deteriorated closer to the point at which it was known they were living with someone with a gambling problem. While both groups reported similar levels of social wellbeing early in the study, the social wellbeing of CSOs had decreased by 2018. This finding supports previous research on social impacts associated with CSOs. CSOs can feel excluded from friends and family and limit social activities due to the fear of being stigmatised because of the gambling behaviour , feel shContrary to expectations, in other areas of health and wellbeing, no temporal effects were found. Trajectories of health-related quality of life and satisfaction with health were similar for both CSOs and non-CSOs. However, CSOs reported lower mean values, reporting consistently lower health-related quality of life and satisfaction with health than non-CSOs. These lower means are consistent with cross-sectional studies that tend to find CSOs report impaired physical and mental health e.g. , 20, 60.Our findings suggest that some of the lower health and life satisfaction factors commonly associated with CSO’s may not be directly or solely attributable to the gambling problem. While CSOs were found to experience long-standing decrements to their health and reported life satisfaction, these did not change with proximity to exposure to the gambling problem. Instead, it may be that these issues are related to some risk factors for having a gambling problem in the household, or some factor unrelated to gambling. For example, CSOs tend to be younger, less educated, and more likely to have a gambling problem themselves , 21, 60.The principal limitation of the study was that CSO status was only measured in 2018, meaning that full longitudinal modelling of this impact to consequences could not be done. The retrospective analysis undertaken rests on the uncontroversial assumption that proximity to gambling problems is not permanent: given a positive case in 2018, the probability of being a CSO in a prior year tends to decline with increasing time. Nevertheless, the unmeasured variable and the stochastic nature of the temporal relationship inject significant noise into the analysis. Additionally, the sample size and variability within the data may not have provided enough power to identify some smaller effects over-time, while clustering may have yielded anti-conservative tests of significance. Further purpose-designed longitudinal studies will be needed to make firmer conclusions, for example by measuring CSO status across all years and larger samples that enable comparative analyses of CSOs living with gamblers in the problem and at-risk categories of the PGSI. Finally, the analytic sample consisted of CSOs living in the same household as a person with a gambling problem. While an important sub-sample, those impacted by another person’s gambling comprise a much wider group , 59. Ex-Overall, the study found a temporal effect between exposure to another person’s gambling problem and negative social and financial wellbeing outcomes for CSOs. This indicates that a gambling problem in the household is likely to directly contribute to decreases in the social and financial wellbeing of other people living in that household. On the other hand, no clear temporal link was found with health, life satisfaction, or the number of stressors experienced by CSOs; that is, there were no significant changes with respect to proximity to the gambling problem. Instead, CSOs reported long-term health and overall wellbeing decrements, which likely preceded exposure to the gambling problem. This might indicate that these decrements may not necessarily be a direct outcome of problem gambling exposure. Instead, they may be related to other risk factors associated with having a gambling problem in the household. However, regardless of what is causing or contributing to health and wellbeing decrements, they should continue to be considered by policy and practice that aims to support CSOs.


Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a “burning platform” for scaling up such services. As health care organizations look to expand and maintain the use of video in the “new normal,” it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward.This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19.A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants , ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al’s 3 perspectives on crisis and digital change: as opportunity , disruption , and exposure (of vulnerabilities in both people and infrastructure).Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an “organizing vision” for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use.For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed. There has been growing interest in the use of video as a method of consultation between clinician and patient over the past 10 years, and numerous studies have shown such consultations to be acceptable, safe, and effective in selected patients . HoweverCOVID-19 created a “burning platform” for the mainstreamed use of such services, as health care organizations worldwide halted face-to-face appointments for nonurgent care. The global emergency prompted strategic , operational , and regulatory  changes with regard to the delivery of telehealth across different national contexts -10. We iDuring the first wave of the pandemic in 2020, most countries saw a rapid reduction in face-to-face consultations and an increase in remote ones in both primary and secondary care -15. GuidAs health care organizations are looking to expand and maintain the use of video in the postpandemic “new normal,” it is important to acknowledge and harness wider system changes that have emerged. In this paper, we focus on the infrastructural aspects of the rapid scale-up of video and draw lessons for ongoing developments and sustainability. To this end, we explore the impact of the pandemic in 4 NHS organizations, where we had previously identified ways in which infrastructural features influenced the limited use of video in the years preceding the pandemic .installed base .Star  defines In the years before COVID-19, we conducted ethnographic research in 4 NHS organizations in England, all of which were seeking to introduce or scale up video consultations ,27,29. TIn our application and retheorization of Star’s  notion oopportunity for accelerated innovation and removal of barriers to experimentation; disruption to organizational and occupational practices, generating new dependencies and risks; and exposure of vulnerabilities in both people and infrastructures that have previously gone unnoticed. Gkeredakis et al  happened, they put in temporary governance structures—the Pandemic Covid Outpatient Group—headed up by one of the most senior doctors in the trust. I’ve moved full-time on this and report to them. So, if I have any problems, I have someone to escalate to, who can do something about it…Also, the clinical system team [responsible for building electronic clinic schedules] usually take[s] weeks to implement changes. But I’ve been given permission to, basically, get in touch with them to say, “This is a priority.”Bridget, program manager, Petroc Health, April 2020organizing vision (clear and consistent vision among stakeholders as to what will be achieved) , we had hearing aids where you could remotely program them, and I looked into setting up a remote programming clinic…I went to information governance, and they gave me this list, and I was like, “Oh it’s not worth it—not for a few patients.” So, I didn’t bother. And that’s terrible—I should have bothered. But it was too much work. But now, when we asked them, it went straight through to the medical director, and she just said, “Go ahead with it…” So, things progressed—which is what the NHS would struggle with sometimes.Karen, consultant, Southern Trust, November 2020As described before, regulatory constraints were also reduced through national measures by NHS England, including the central procurement of Attend Anywhere (enabling unrestricted use with no cost to trusts), endorsement of video platforms by national information governance bodies (enabling experimentation), and temporary tariffs for remote consultations .temporary arrangements to deal with the pandemic, they set organizations on a particular infrastructural path, upon which they were now destined to build:However, although these were intended as One challenge is, few of us want to change what we’ve got now [Attend Anywhere]. We will have to go through this procurement—because the region will be doing it on our behalf—and there is a slim chance another provider will be chosen, and that would be a real challenge for us.Teresa, program manager, Eastern Trust, February 2021relative advantage  has turned that on its head quite quickly.Eleanor, diabetes nurse, Southern Trust, June 2020Clinicians using video talked about the advantages over phone for basic visual assessments  and nonverbal interaction. This was reflected in the video activity data across sites, in which a large proportion of consultations were conducted within psychiatry/psychology and mental health services , pediatric services , musculoskeletal and orthopedic services , and physiotherapy .reflection in action  about how you do your assessments. And all those special tests we used to do in the consultation room, we’re suddenly finding that we were not getting any value out of them. And we are now coming to realize, it is what the patients tell us, it is how they got out their chair to get their medication or how they turn around to tell their partner to turn the telly down—all these little functional cues that we are seeing. I’m finding video a lot more helpful than these clever tests we used to do.Larry, physiotherapist, Northern Trust, August 2020strategic opening for supporters of the initiative. Other opportunities and extended uses of video included remote multidisciplinary and group consultations, which would have previously been difficult to establish as physical encounters.Christianson et al  describeHowever, although the pandemic provided a context to try out and reflect on the use of video, as predicted by Gkeredakis et al , an oppoThe big question for me is whether this change is permanent or just temporary…Are we going to see clinicians just not wanting to go back to the way they were working before, or are we going to see a slip in the use?Beth, program manager, Northern Trust, April 2021The absence of prepandemic groundwork within Eastern Trust also brought uncertainties about the extent to which the new service model can be socially and technically stabilized within the organization:We built a bridge—and it was a pretty good bridge to jump over the river—but we didn’t build the foundations. We suddenly had the technology, instantly threw ourselves into it, and got over that river. But the bridge is a little insecure…As a major change project, you would never do that—implement a new technology, try to get hundreds on board, and then build the system to support it.Teresa, program manager, Eastern Trust, December 2020Viewing the pandemic as disruption highlights how staff had to adapt to widespread displacement of social and material environments, including the need to work from home. Technology shortages also demanded improvised use of computing equipment . Staff needed to reorganize work routines to accommodate and support remote consultations in the face of prolonged uncertainty and disruption. Adaptive capabilities allowed some service provision to continue but also distorted work practices and created new demands and unintended consequences.physical copresence of patients and staff. Indeed, the inertia of established routines was a major constraint on the use of video before the pandemic, in which apparent embedding resulted from elaborate workarounds. Hence, the sudden and extensive transition to virtual created significant disruption, in which a fix for one problem generated problems elsewhere in the system.Clinic workflows are complex and structured around various interacting routines  and associated spatial and material structuring devices , which hParticularly during the early stages of the pandemic, clinicians relied on the telephone to consult with patients:We turned all into blanket telephone—and in a sense that has been the legacy—and we haven’t moved forward with video clinics, because the telephone clinics have been kind of working…There is a logistical problem. If you see people at clinic, it is really easy because they turn up, there is a slip [of paper] with their name on the trolley, and you just come out, pick up the slip…And when you’ve seen them, they will leave—you can’t double-see them. With the phone, we don’t have that. You may get someone who does not answer, so you call the next person, and come back to them—but then of course, that next person wasn’t expecting a call at that time, so then doesn’t pick up…So at the moment, I’ll start the [in clinic] appointments, and the registrar starts on the phone list. And then, when there are some less complicated patients in clinic, the registrar sees them, and I start at the bottom of the phone list and work up.Frank, neuro-oncology surgeon, Petroc Health, October 2020This extract highlights how the “installed base” both enabled and constrained the rapid reorganization of clinic routines, which, in turn, became locally embedded. Feldman  describeSimilarly, the rapid expansion of video demanded a high degree of adaptation and emergence in accordance with local needs and contingencies. One of the main areas of focus was the management of patient “entry” into their video appointment. The main video platform (Attend Anywhere) uses a consistent URL for each clinic virtual waiting area. In the initial phase, most patients were sent the relevant waiting area URL on an appointment letter, which they would be required to write into their internet browser. Although quick to implement, this arrangement was prone to problems with typing errors and incomplete knowledge of the new process:They send them a sheet. I guess it must say what they have to do, but it’s very limited. In fact, I don’t think they always even send that. Sometimes, they just send a letter saying log onto this [URL] address. And 9 times out of 10, the first time they use it, they’ll go onto Google Search…which just comes up with [Attend Anywhere] websites. And then, we say ‘No, you put it into the address bar at the top…”Betty, audiology therapist, Eastern Trust, February 2021In this extract, the clinician, patient, and administrative staff lack the mutual awareness  and emboHowever, over the course of the pandemic, various changes were made to help orientate patients, depending on local human and technical resources in place. Within Petroc, for example, existing (outsourced) text reminding services adapted the text message sent to patients so they could click directly onto the URL, although this relied on the patient having a smart phone.Another route of entry, eventually established within Petroc, Northern, and Southern Trusts, was the trust website, in which patients could click a button for the relevant virtual waiting area, although this relied on the patient being able to navigate the website and locate the correct button. The following extract describes a common problem in which patients would turn up in the wrong virtual waiting area due to difficulties distinguishing between overlapping specialties. This created a high degree of “invisible routine articulation work”  for thePatients select a waiting room to go into. But often, they would be waiting in orthopedics because they had seen that department previously…But we don’t have access to that waiting room. So, we would need to contact them and tell them to come out and go into the MSK [musculoskeletal] waiting area.Nick, physiotherapist, Petroc Health, March 2021Organizational capability to endure, and even harness, locally driven adaptations depended on the people and connections in place to monitor and embed new practices. For example, the Northern Trust implementation team continued to engage with clinicians shortly after the rapid deployment of Attend Anywhere, during which they discovered some practitioners using an alternative platform (accuRx). This platform’s texting and video call functions aligned better with their particular workflows and systems, and so it became supported at the system level.It was kind of by chance and through discussions that we found some people had started using [accuRx]...We realized it was building a bit of momentum amongst some clinicians. So, we officially approved it, did a bit of comms, and developed some training on how to use that platform.Nathan, operational support , Northern Trust, March 2021Similarly, over the course of the pandemic, the developers of Attend Anywhere incorporated new design features based on user feedback, including the “consult now” function, allowing clinicians to send the URL link directly to patients via text or email.process multiplicity (a single process incorporates many possible “paths”), in which ICT greatly expands the “space of possible paths”; different ICTs may be used at various points within the same process. Even a simple change  creates a host of new actions and pathways.The various sociotechnical arrangements to support patient entry reflect the generative tension between ostensive  and performative (specific actions taken) aspects of routines , driven Another example of process extension was clinicians’ use of the instant messaging feature to communicate with patients in the virtual waiting area , in which patients may decide to wait or exit and re-enter at a later point. In some cases, the clinician and patient would jointly decide to abandon the video option and consult by phone instead .Although some service teams brought admin support into this process , it usually relied on the clinicians to manage. Participants talked about the need for a conceptual shift in the departmental management of these new digital spaces, if they are to be sustained:If the patient has a face-to-face appointment, it isn’t just them instantly in with a clinician and instantly out with a clinician…Outpatient departments manage the physical outpatient space, but now we’ve got all of this virtual outpatient space…which actually…other than the patient and the clinician linking up together, nobody is managing that space to make sure that link-up happens correctly…We need to be taking responsibility, full responsibility—like we do for the physical space—of that virtual space.Simon, ICT manager, Northern Trust, March 2021Perspectives on exposure revealed infrastructural challenges and tensions to video consulting that have gone largely unnoticed. As Star  points oNetworks and servers came under significant strain during the first few months of the pandemic, resulting in periods of poor service reliability. Although these problems were dealt with promptly in collaboration with technology providers, local IT issues were poorly understood and more difficult to resolve:It is difficult to test the consultation capacity, because it is very dependent on the volume of calls, how the platform is doing on that day…It is really difficult to test the actual performance because it can vary so much.Tanvi, operational support, Petroc Health, January 2021Additionally, access and dependability issues extended beyond the boundaries of the organization’s IT infrastructure, including “digital poverty” . It was reported that video tended to be lower among groups with a greater health care need and already facing health inequalities, such as older people, low health literacy, weak social networks, limited mobility, limited transport, and psychological and mental health problems:Some people don’t have [smartphones], they don’t have laptops, iPads. You have to be kind of fairly well off to be able to access video consultation. We’ve definitely seen a difference in what type of patients can and can’t access.Nick, physiotherapist, Petroc Health, March 2021Clinicians talked about limited privacy in family households, as well as differences in network connectivity. Particularly for patients living in rural areas, audio-video quality was unreliable, impacting the quality of the consultation and sometimes resulting in the use of the telephone as a backup:Because if you’re talking to someone and you’re trying to explain something or you ask them a question and then you have to wait 10 seconds for them to answer, then you think, “Are they not answering, or is it they’ve not heard me or, you know, is it the delay?”Betty, audiology therapist, Eastern Trust, February 2021It was often difficult to anticipate the needs and wishes of patients in advance, requiring flexible use, alongside nondigital alternatives. Digital exclusion was not merely down to whether a person could use technology, but cut across multiple technical and social elements, as described next:I had to say to her, “I can see your background [on video].” And I don’t think she was comfortable with that…We have a large Asian population, where there is an element of larger families and smaller living spaces. If I access their space, I will not only be seeing them, I would be seeing their family. And they may not be comfortable with that…You have to be careful.Tanisha, hepatologist, Petroc Health, October 2020Mitigating digital exclusion was an effortful accomplishment between clinicians, patients, and their support networks. However, some early strategic work had begun within Northern Trust to establish local hubs for video appointments in partnership with community centers:So now, if they need help accessing technology, they can get in touch with the community center—and we trained people in these community hubs to help people access the remote consultation. But also, in the community hub, they will get access to a full package of support, such as food packages…It has taken a while just engaging with these groups, making sure they are happy.Tessa, PPI engagement lead, Northern Trust, April 2021This extract reveals the role of collegial partnerships in order to coordinate and interface between the digital and material aspects of health care and community-based infrastructures. Perspectives on exposure, therefore, reveal not only weakness within the system but also strengths to be leveraged and built upon. In a similar vein, Sanner et al  draw on opportunity highlighted the institutional elements of infrastructure, in which conventional assumptions, norms, and governance structures were challenged. The pandemic brought about a collective understanding or organizing vision [Gkeredakis et al's  3 perspeg vision  for videdisruption drew attention to the structures and practices involved in the urgent response to the pandemic. With the displacement of deeply embedded routines, new performative patterns of action emerged, in which the virtual environment greatly expanded the “space of possible paths” within consultation workflows. A large space of possible paths makes routines more resilient to disruption (by minimizing the single points of failure), but it also makes the processes more difficult to replicate and manage [The focus on d manage . The capexposure reflected inherent properties of information infrastructures, as backgrounded and taken for granted. The accelerated scale-up of video revealed social and technical impediments to video consulting and the potential to accentuate unresolved health inequalities. This raises practical and ethical challenges to scaling up such a service model and conflicts with the policy talk of such technology as state of the art, efficient, and accessible [Accounts related to cessible . ImproviResearch on information infrastructures highlights how technology-supported change needs to be cultivated in a way that acknowledges challenging organizational needs and the inertia of the installed base -62. The Despite the policy focus on digital , the reabimodal governance offers a potential approach, in which “heavyweight” IT systems  and “lightweight” IT applications  are managed separately under differing organizational structures, cultures, and regulatory mechanisms. Such a model has been shown to work well in hospital settings, in which a partitioning of IT departments—one part dealing with the traditional core IT system and the other with new applications—allowed for a “two-speed” approach to the co-evolution of these loosely couple subsystems [First is the need to balance stability  on the one hand and openness to change  on the other. Although regulatory changes during the pandemic may have brought a new-found agility to experiment and innovate, health care organizations must still ensure a high level of safety, security, and dependability . Bygstadbsystems .Second, the extended use of remote consultations highlights a need to conceptualize information infrastructures beyond the boundaries of the health care organization. The ubiquitous use of extra-organizational ICT within professional work settings has prompted calls for more theoretical and empirical research into the intersection between institutional infrastructures and individual digital assemblages . Video cvirtual consultations vastly expand the set of possible paths within an appointment process, and therefore, it is important to visualize and understand the multiple performances that could be generated in a process (as opposed to a single version of how the process should occur). Narrative networks may provide a useful methodological device to see the terrain of possible paths and purposefully increase variation in performance (for flexibility) or try to reduce it (for standardization and control). This could help identify areas to increase resilience and choice , while also ensuring associated roles and processes are consistent and coordinated.Third, close attention needs to be paid to routines and patterns of actions underpinning virtual appointments. Our findings on the disruptive forces of the pandemic resonate with other studies focusing on the redesign of care pathways using process-mapping methods ,71. TradFinally, it is important to bridge competing institutional logics with an overall narrative or organizing vision  for videThe strength of this study is that we undertook research at 4 sites before the pandemic, through which we had already identified the importance of information infrastructures on the implementation and use of video. This provided a unique opportunity to study crisis-engendered changes from the early stages. In addition, the case studies were conducted within a wider program of research on remote consultations across the United Kingdom, providing a wider national context to the organizational settings.Pandemic restrictions meant that we could not undertake ethnographic work during this phase, and our data collection during this time was affected by the unprecedented pressures on NHS staff, raising potential sample biases toward those individuals with time available to speak with us. However, our positive and longstanding relationship with these sites helped mitigate such issues; the researcher had previously visited all sites on numerous occasions before the pandemic, adapted interview schedules, and was able to draw on multiple sources of data.A further limitation of this study includes the question of how far we can generalize from our 4 case studies on the rapid scale-up of video consultations. Our theoretical analysis helped explain the empirical data on information infrastructures in our case sites but may not explain all aspects of such infrastructure in all contexts. We chose to focus on video consultations as a topic of academic interest because it exemplifies a promising innovation that has taken decades to scale up. We encourage others to apply the same theoretical lens to explore crisis engendered changes in other digital health contexts.Gkeredakis et al’s  3 perspe


Co-creation is a process that directly involves different stakeholders in the idea generation phase of a new product development process. A pool of 112 new aquaculture fish product ideas was obtained by applying a combination of creative and projective techniques to the co-creation process with consumers in six focus groups conducted in three European countries . The subjectivity of qualitative data analysis  is one of its recognised disadvantages. To overcome this drawback, a combination of specialised software , along with word frequency, co-occurrence, and context checking, was applied to provide a different approach to data analyses in qualitative studies. The method identified the most salient dimensions behind the participants’ discourse  and inferred the importance those dimensions had for them, thus proving the existence of a correlation of 0.7 between what the participants said (frequency of mention) and what they liked the most (importance). Overall, the exploratory approach proposed is deemed useful for drawing key conclusions from qualitative research, thus offering an alternative to traditional content analysis. In future, the results obtained may be useful for selecting the co-created ideas with the greatest potential to be well received in the market. Approximately 80% of new food products launched in the market fail within the first year . One of Focus groups are often used to capture consumers’ spoken needs , gain inTo overcome some of the limitations of traditional content analysis and manual coding, other alternatives can be used to increase the objectivity of the interpretation of results, such as the use of specialised software   to propose an alternative approach to traditional qualitative content analysis by combining word frequency, co-occurrence and contextual analysis; (2) to explore the usefulness of the proposed approach in generating aquaculture fish product ideas and identify the most relevant product dimensions affecting potential acceptance by consumers; and (3) to explore whether word frequencies can be related to the subjacent relevant concepts or dimensions for the participants involved.Purposive sampling with a predetermined quota for gender (evenly split) was used to select 36 participants in three countries . A market research agency based in the three countries under study was subcontracted in June 2019 to recruit the participants and lead the moderation of the focus groups. Country selection was based on various aspects that may influence the generation of distinct ideas of fish products, including: differences in fish consumption per capita (Spain > France > Germany) ; differeIn addition, participants also met the criteria of being older than 18 years, responsible for food purchase and preparation within their household, and fish consumers. In each country, fish consumption was used to divide participants into two groups: regular (at least once a week) and occasional fish consumers (three times a month or less), as it can be assumed that fish consumption frequency may be related to the demand for different fish products.A warm-up debate about new foods and fish products.A creative approach by applying direct analogies   and storA section where participants scored their acceptance of each new product idea elicited in the creative phase on a scale from 1 (“I very much dislike this fish product idea”) to 10 (“I like this fish product idea”).A projective approach that included word association ,14,18,39Finally, a general discussion section about fish and fish products to gain a deeper understanding of people’s practices regarding their purchase and consumption, opinions, interests, motivations, barriers, and behaviour with regard to new products.Two face-to-face focus groups were conducted in each of the three countries targeted. Each focus group session with six participants lasted for two hours. The relatively low number of participants per focus group was selected based on the criteria that qualitative research does not intend to make inferences to a larger population, but to gain a deeper understanding of consumers’ perceptions and opinions about fish products . AdditioIn addition, a brief discussion of salient ideas was carried out after each task to further understand the participants’ perceptions. The above-described focus group sessions were conducted in the native language of each country, audio-recorded and videotaped, simultaneously translated into English, and transcribed verbatim for further analysis from the English translation.Prior to data analysis, the transcripts were reviewed to detect and correct possible mistakes. Three researchers who were native French, German, or Spanish speakers listened to the recordings in their national languages and checked the English transcripts. Afterwards, all English transcripts were reviewed by the same researcher, following the guidelines proposed by Dalud-Vincent . The speData analysis was divided into three main parts: (1) dimensions’ identification and their frequencies; (2) dimensions’ importance; and (3) dimensions’ importance versus dimensions’ frequency. All steps taken are illustrated in The final corpus included the transcripts from all countries, arranged according to IMAGE , allowinWords with a common root  were grouped under the same label .Filler words, meaningless words, or sounds that consumers use while talking to fill in the pauses  were removed after context checking.Some words were grouped after checking their context in semantic  and associative semantic fields  to retain the information contained in the less frequently mentioned words.Antonym words were grouped because they were considered to be extremes of the same scale .Finally, homograph words, those with the same spelling but different meanings, were merged into their corresponding groups according to their meanings after context checking.The original proximity matrix provided by Alceste had the same codes (words) in the rows and columns, while the cells were filled in with the frequency of co-occurrence (a measure of similarity), similar to a correlation matrix, but for categorical data . NeverthOnce the context was checked, the original proximity matrix provided by the Alceste software was reduced accordingly, thus grouping some words and removing others.Subsequently, a second reduction based on the frequency of mention was conducted, retaining only those words whose diagonal values in the proximity matrix were greater than 50. This cut-off was set by averaging all the values on the diagonal of the proximity matrix, rounding upward; therefore, only retaining words that co-occurred more frequently than the average. The words retained were labelled “categories”. The reduced proximity matrix was submitted to multidimensional scaling (MDS) analysis to plot the strength of the connections between co-occurring categories.Finally, some of the results from the MDS were used to group the categories into dimensions through a second pseudo-triangulation process. The selection of the final dimensions was agreed upon by the three researches, who identified them based on the categories obtained, using input from the single-item food choice questionnaire (FCQ) . The FCQThe original contingency table provided by Alceste with the word frequency count was reduced according to the process described in The importance of dimensions was calculated by multiplying the acceptability given by participants with the scores given by a group of experts see  was usedTo illustrate which dimensions had a greater influence on participant acceptability, a preference map  was creaTo determine whether there is a relationship between what consumers say (dimensions’ frequency) and what they like most about the ideas generated (inferred dimensions’ importance), an MFA between these two matrices was conducted. The dimensions’ frequencies were gathered from the reduced contingency table used to conduct the CA see . The dimAll statistical analyses were performed using XLSTAT software, version 2020.1 (2020) .The automatic merging and reduction performed with the Alceste software allowed for a reduction in words from the 36,765 that had been in the initial corpus to only 747, retained for later analysis. After the first manual pseudo-triangulation process, 747 words were reduced to 186. Finally, from the 186 words obtained, only those whose diagonal values in the proximity matrix were greater than 50 were retained, as explained above, leaving 44 categories, as shown in the MDS plot .The closer the categories are in the MDS plot, the higher the number of times those categories are mentioned together (co-occur). For example, the categories “ingredient” and “origin”  were repeatedly mentioned together, as exemplified in one quotation from a German participant: “Local ingredients are very important”. In addition, “quality” was frequently mentioned alongside the category “origin”, as shown in this quote by a Spanish participant: “It is the most determinant factor in the low quality, the origin of the fish”. As illustrated in another quotation from a focus group in France , the categories “quality”, “fish”, and “price” (which grouped the word “expensive”) were frequently mentioned together. Interestingly, participants also frequently mentioned the categories “price” and “taste” in the same phrase; for example, “It is the price that decides, and the taste, of course” (a quote from a German participant).As previously explained, some of the results obtained from the MDS were used to group the 44 categories into 12 dimensions through a second pseudo-triangulation process. For instance, the co-occurring categories “natural” and “chemical” in the MDS were grouped under the higher-order dimension “natural”. The final dimensions identified are listed in The results of the CA performed on the 12 dimensions graphically displayed the contingency table with the dimensions’ frequency of mention and the supplementary variables , which aThe German participants frequently mentioned the “food” and “health” dimensions. The dimension “ethical” was cited several times by both German and French participants. In the analysis, France was located closer to the “natural”, “occasion”, “convenience”, and “process/preparation” dimensions, but also to the “sensory”, “familiarity”, and “quality” ones, and all three were frequently cited by Spanish participants. Finally, the “price” and “variety” dimensions were also located closer to Spain.Creative techniques  encouraged participants from all three countries to generate a pool of 112 new aquaculture fish product ideas. The differences between countries were observed. The Spanish participants generated a higher number of ideas (45 ideas), followed by the German (42) and French (25) participants. Small differences were found in the proportion of ideas generated in the focus groups within the same country. A slight difference in the number of ideas generated between the focus group with participants with high (23) and low (19) fish consumption was found in Germany. The 15 ideas with higher participants’ mean acceptability per country are shown in A high regression vector (RV) coefficient (0.7) between the expert scoring allowed for the use of their mean scores given to each dimension, together with the participants’ mean acceptability, to plot a preference map for each focus group. The RV coefficient measures the similarity between two matrices of quantitative variables or two configurations resulting from multivariate analysis . The vecWhen comparing the preference maps between countries, the dimensions that had a greater influence on the acceptability scores for Spanish participants with high fish consumption were convenience, process/preparation, occasion, and variety. Spanish participants with low fish consumption attributed greater importance to ethical issues. French participants with high fish consumption placed more importance on health, quality, and natural aspects. In contrast, German participants focused on price, quality, naturalness, and ethical dimensions. Finally, participants from France and Germany with low fish consumption attributed more importance to ethical and price dimensions. It is noteworthy that in all focus groups with low fish consumption frequency, ethical issues played a relevant role (results not shown).The overall preference map allowed for the identification of the most important dimensions for the participants from all countries, and these were “natural”, “quality”, “ethical”, “price”, and “health” .The RV coefficient between matrices was 0.7, with most of the participants showing a significant correlation between the frequency of mentioning a specific dimension and the importance attributed to it. Some exceptions were found, namely one participant from Spain and four from France.The results from the MFA showed that the dimensions with the weakest relationship between frequency of mention and importance were “food product”, “ethical”, “variety”, and “process/preparation” (graph not shown).Although the Alceste software significantly reduced the number of words automatically and objectively , a largeAs demonstrated in the present study, discarding words in the first stages of the analysis based on frequency of mention normally means losing relevant content. However, at the later stage of analysis, when words are already grouped , the frequency of mention can be used as a cut-off, which is normally used to simplify the information obtained. For example, after a manual merging process, Ares and Deliza  only retThe MDS results  plotted Moreover, some of the results from the MDS were used when the categories were grouped through the second pseudo-triangulation process into dimensions because, as pointed out by Bazeley , consideThe results of the CA  performeThe pseudo-triangulation principle, commonly applied to qualitative data analysis, requires considerable experience. Many studies have highlighted that researchers who conduct qualitative data analyses have at least two to five years of experience ,28,53,54There were slight differences in the number of ideas generated by the participants between the countries. The Spanish participants generated the highest number of ideas, followed by the German and French participants. This data contrasts with the number of new fish products available in the market over the past two years, with Spain having the lowest product assortment range (445) compared with Germany 781) and France (803) . In this1 and FraThe participants registered their acceptance scores for every idea generated within their focus group; however, there were no clues indicating which reasons or dimensions had a higher influence on their scores . It may be that they only considered a few dimensions, the most salient ones for them, when giving their acceptance scores, similar to that described in the theory of planned behaviour (TPB), where only a few salient beliefs are the determinants of consumer behaviour . IdeallyOne of the main limitations of using a preference map per focus group is that the results obtained depend on the ideas generated within that session. In this sense, when a certain dimension is missing in a preference map, it does not mean that this dimension is not important, but rather that no ideas containing this dimension have been generated. To overcome this drawback, an overall preference map was created , indepenThe dimensions with a greater influence on the consumers’ acceptance identified with preference maps define specific consumer segments . In future, the information obtained using preference maps  could be of the utmost importance for producers and marketers when selecting the ideas with greatest potential to be well received in the market, as it is likely that those ideas containing a dimension with great influence on consumer acceptance have greater potential for success in the market. In addition, it is highly advisable that the mean acceptance scores given by the participants to each idea be considered in the selection of the most promising ones. Therefore, it is likely that from those ideas gathered in Despite the many benefits of involving consumers in the generation of ideas during NPD, co-creation also has its detractors. Some authors consider co-creation to have several limitations, including the idiosyncratic nature of consumer-generated ideas , rather than addressing societal, nutritional, or environmental challenges, and not ensuring innovativeness or technological breakthroughs . Hence, The relationship between the participants’ frequency of mentioning a specific dimension and the importance attributed to it was high (RV coefficient 0.7). This finding shows that there is a strong correlation between what consumers say (frequency of mention) and what they like the most about the ideas generated (importance), thus confirming what Guerrero et al.  has alreThe dimensions with the weakest relationship between frequency of mention and importance found using MFA were “food product”, “ethical”, “variety”, and “process/preparation”. It is noteworthy that these dimensions grouped the greater number of categories each; that is, between five and six, along with the “sensory” dimension . TherefoOne of the limitations of this study is that the content analysis was conducted by combining the transcripts from all countries together. In future studies, it would be interesting to explore whether the results might have been richer if the analyses had been conducted within each country individually, as country-dependent nuances  may have been lost when the analysis was conducted for all the countries together.Another interesting area of study would be to explore new ways to simplify the methodological approach presented; although it has been proven successful, it required less experience, and it was relatively economical in terms of cost, it was very time-consuming.Finally, an additional limitation of the study is that Alceste software is not open access, a fact that may hinder its accessibility to potential users.The qualitative data analysis methodology described in this study is deemed useful for drawing key conclusions from qualitative research, thus offering an alternative to traditional content analysis. The combination of statistical qualitative research software (Alceste), word frequencies, context, and co-occurrence analysis, although more time-consuming than a simple semantic approach, provided rich and valid information, close to the real outcomes generated during the qualitative phase. In particular, the long time needed to prepare the data, conduct the pseudo-triangulation processes, and carry out statistical analysis to identify the most salient dimensions behind the participants’ discourse is the major drawback of the methodological approach presented in this study. Conversely, the strength of the approach described is the lower level of expertise required, as grouping words according to the guidelines provided required less experience and cognitive effort than the deep semantic content analysis normally applied to traditional qualitative data analysis. However, both approaches are complementary.The use of co-creation with consumers to generate new product ideas, with the consequent benefits of incorporating their voices during the early stages of the NPD process, allows us to escape from traditional firm-centred new product design. Focus groups were a useful tool for applying co-creation techniques; in particular, a combination of creative and projective techniques. Creative techniques allowed participants to generate not only food product ideas, but also product concepts, which are particularly useful when designing food packaging or advertising campaigns. For example, “more sustainability in fish-breeding” is a product concept generated by the participants that highlights their concern about sustainability and leads to the consideration of adding sustainable aquaculture quality labels . The combination of creative and projective techniques proved to be very useful, allowing for the capture of not only cognitive, but also unconscious individual desires, thus providing complementary information.Finally, the present study has proven that there is a strong correlation between what consumers say (frequency of mention) and what they attribute more importance to. This finding could be of the utmost importance when interpreting qualitative data, as the frequency of mention could be used to infer the importance for individuals. Thus, consumers talk more about the topics they like or care about the most. As the frequency of mention has been proven to be correlated with participants’ acceptance, future studies can replicate the approach presented here without the assistance of experts, thus simplifying the method, as one of the main drawbacks associated with the scoring of dimensions is the requirement for a group of experts.


Canonical quantization has created many valid quantizations that require infinite-line coordinate variables. However, the half-harmonic oscillator, which is limited to the positive coordinate half, cannot receive a valid canonical quantization because of the reduced coordinate space. Instead, affine quantization, which is a new quantization procedure, has been deliberately designed to handle the quantization of problems with reduced coordinate spaces. Following examples of what affine quantization is, and what it can offer, a remarkably straightforward quantization of Einstein’s gravity is attained, in which a proper treatment of the positive definite metric field of gravity has been secured. In our search for the proper classical variables, We first examine two important Hamiltonian functions given bydimensions of ℏ it follows that ℏ, while the last term in . With that, we have fulfilled the three surfaces—positive, zero, and negative—while the negative curvature cannot be seen like the other two. The spin coherent state stony is covered in [Rule number two will fix what kind of classical variables to choose to promote to the valid AQ operators. For that purpose, we again use the coherent states, as shown here surface , a very vered in ). ObservFor a system for which Now, still using Schrödinger’s representation, it follows that our ground state for this kinetic operator is The main reason for finding the primary ground state is to form a suitable normalization procedure. This feature puts the primary ground state in an important role in normalization. This process is a prime ingredient in , and wheClearly, relying on coherent states, has provided fine tools to create valid quantizations when using CQ or AQ.The two toy models are first a full-harmonic oscillator with classical Hamiltonian equally spaced by ℏ!An important item of the harmonic oscillator quantum Hamiltonian, n just as before. This implies that it is still equally spaced, now by The second model, using AQ and ue of 2ℏ . Clearlyℏ-term in  per hour that is If When using these new classical variables, the classical Hamiltonian, from , becomesnonrenormalizability vanishes! Such field models clearly keeps both sides of Already we see that To ensure our quantization follows the rules, we introduce suitable coherent statesIt follows thatTo offer an affine quantization for this example, we first introduce the dilation operator As usual, it may be necessary to introduce some version of a regularization for these equations, but these same equations should point the way to proceed. To offer some support, we note that although If the reader has already accepted the expressions for the half-harmonic oscillator in , they mages; see ,11,12,13c) along with the metric field O and In order to quantize gravity it is important to render a valid quantization of the ADM classical Hamiltonian . We firsg stands for Moreover, we now haveNext we present the ADM classical Hamiltonian in our chosen affine variables, which, now introducing We next introduce the coherent states for gravity. For that we use the dilation gravity operator Using Schrödinger‘s representation, we are led toFinally, we close with Schrödinger’s equationAs before, it may be necessary to introduce some version of regularization for these equations, but these same equations point the way to proceed. In that effort, note that although A full quantization of gravity must deal with first and likely second order constraints, which are designed to reduce the overall Hilbert space to secure a final quantization. This paper is not the proper place to finalize a quantization of gravity.For those who like path integration, a recent paper has found that affine quantization provides a royal path to a valid path integration of Einstein’s gravity , in whicWe have stressed the definition, procedures, and advantages of affine quantization in offering to secure valid quantizations of several different examples. We first used simple models with different coordinate spaces to quantize models that fit their coordinate space in order to insure a valid result. Following that path, we examined field models by letting affine variables remove all f-issues as unphysical for any of nature’s fields. Finally, we were able to put affine procedures to work on an f-issue-free version of an affine quantization of gravity, a contribution that has been needed for a long time. It is hoped that readers can use affine quantization procedures to help solve some of their problems.