The identification and diagnosis of children with autism currently rely on behavioral presentation and developmental history. Cultural norms and other socio-demographic factors can influence what is expected or non-expected behaviors in a developing child. Perceptions, beliefs, and causal attribution of early signs can influence families’ help-search behaviors. Lack of recognition of autism’s first manifestations can critically delay the age of diagnosis, the provision of informed guidance to families, and the implementation of adapted interventions during the critical period of early development. Furthermore, a lack of understanding of early signs as the manifestations of a developmental condition may increase stigma and non-conventional explanations. Still, cultural and socio-demographic factors are largely understudied, particularly in low-and middle-income settings. Based on the hypothesis that non-specialists such as family members and friends are one of the first sources of referral in Latin American contexts, we aimed to study the general population’s perceptions and the explanatory causes of autism’s early signs. One-hundred-and-eighty-three Ecuadorian adults responded to a questionnaire developed for this study, describing sixteen ASD-related behaviors. Results indicated that, with the exemption of language impairment and self-injurious behaviors, a substantial proportion of participants did not endorse many behaviors as “concerning and requiring professional attention.” Also, language impairment was the only behavior identified as related to a developmental disorder. Additionally, most participants attributed the majority of behaviors listed in the questionnaire to causes unrelated to ASD, such as child personality. We discuss the impact of those findings in clinical practice and on awareness programs. Autism Spectrum Disorder (ASD) refers to a group of neurodevelopmental conditions characterized by difficulties in social communication, and unusually restricted or repetitive behavior and interests . AlthougStudies conducted in high-resource settings have reported several barriers to ASD-targeted diagnostic services, such as reduced availability of specialized services, lack of familiarity with tools, and perceptions of ASD as a not well-defined condition . AdditioSimilarly, a lack of response to parents’ directions might be interpreted as “willfulness” or be related to a child’s personality . A reducA low degree of concern and unconventional causal explanations may also impact the nature and quantity of information that caregivers provide to clinicians and professionals’ interpretation of this information . BesidesThese studies suggest that a better understanding of contextual factors, including perceptions of typical and atypical behaviors and culturally influenced explicative causes, is critical to inform awareness and mental health literacy programs supporting early diagnosis and intervention. However, most studies have been performed on causal explanations parents provide to their child’s autism , and limEcuador is an upper-middle-income country with a population under 18 years old, estimated at 6,298,788 in 2018 . As prelAs has been the case in many countries, parent associations in Ecuador have contributed to increasing the understanding of the needs of the autism spectrum community through public conferences and participation in the development of social policies . In 2012More recent efforts include the publication of an official guide that provides information on identification and treatment in clinical practices  and the Understanding the general population’s perceptions and interpretation of symptoms in this context is essential to inform both educational programs for specialists and local awareness programs. This understanding is particularly relevant in low-to-middle income contexts, where toddlers may not be seen systematically for well-being child visits, and child-health programs may focus predominantly on life-threatening issues with less attention to developmental disabilities . MoreoveTo the best of our knowledge, perceptions and causal attribution of ASD symptoms in young children have not been documented in Latin American countries. In the current study, we used a questionnaire with items about social communication, play, and disruptive behaviors described in the literature presented to a group of adults from the general population. Based on the hypothesis that in Ecuador, as in many other countries, awareness of ASD symptoms is limited, we expected that a minority of ASD characteristic behaviors would be identified as “concerning and requiring professional attention” and that a minority of behaviors would be understood as the manifestation of a developmental condition. We also examined the types of explanations provided for each behavior. Finally, we examined whether demographic factors influenced participants’ endorsement of ASD-related behaviors as “concerning” and as manifestations of a neurodevelopmental disorder.The description of behaviors presented in the questionnaire was inspired by 18 behaviors related to social communication and play described in the literature  and avaiseeing the behavior,” These behaviors were excluded from the questionnaire.A group of ten local advisors  was required to verify each of the 21 items in terms of understandability and adaptability to an Ecuadorian context. Five advisors perceived five items  as “abstract” and “difficult to understand for adults who are not familiar with children” or “difficult to understand without actually The sixteen behaviors described in the questionnaire included: three joint attention behaviors, nine social communication behaviors , two idiosyncratic responses to sensory stimuli and unusual motor patterns, one behavior related to play and two challenging behaviors.Considering the variability of the onset of symptoms during the first years of life  and aimiAs an essential aim in the first section of the questionnaire was to capture the intensity of concerns elicited by the depicted behaviors, participants were required to select one of three options: (a) the behavior depicted corresponds to what is “expected at that age,” (b) the behavior is “peculiar, but it does not need for professional attention,” or (c) the behavior is “concerning and requiring professional attention.” The second section of the questionnaire aimed to collect participants’ causal attribution for each behavior through an open-ended question.age = 36.63, age-range = 18–79) from different socioeconomic statuses, professional and educational backgrounds, reporting to be born or raised in Ecuador, were enrolled through face to face recruitment  between 18 and 79 years old  and the response to the open-ended question . The question related to the degree of concern and the question related to the explanatory cause were identical for each of the sixteen behaviors; participants responded in approximatively 30–35 min to the entire questionnaire. Participants also responded to a short demographic questionnaire. The research ethics committee of the first author provided approval for the study.The responses to 16 open-ended questions were transcribed verbatim and classified using content analysis, a valuable method to identify emerging categories or themes from participants’ responses . The priIn a second phase, the first researcher and a Spanish-speaker postgraduate student in anthropology independently verified that each response was assigned to at least one of the different constructed categories. Aiming to ensure reliability, a medical resident fluent in Spanish and blind to hypotheses independently reviewed by double-checking the constructed categories. Conflict situations (8% of responses) were resolved after discussion.Eight categories were defined during the process of coding. (1) Personality Attitudes and Preferences; (2) Developmental Problems; (3) Physical or Sensory Issues; (4) Psychological Problems; (5) Rearing/Parenting; (6) Unspecified Causes; (7) Immaturity; (8) Does Not Know. Finally, frequencies of responses were calculated for all closed-ended and open-ended questions for each of the 16 behaviors.Hits his Head with Hands or Objects. Key social communication behaviors, such as Doesn’t Respond to Name, Doesn’t have Interest in Other Children, Doesn’t Understanding Emotions, and Doesn’t Understand Instructions, also received a high endorsement as “concerning” behaviors. The behavior that attracted less concern was Play Concentrates on Specific Toy Parts.As shown in The three joint attention behaviors presented, Doesn’t Respond to Pointing, Doesn’t Point at Desired Objects, and Doesn’t Point at Interesting Objects, were considered by most respondents as peculiar but not sufficiently alarming to search for professional advice. Two other behaviors related to social-communicative difficulties that were also considered peculiar are Doesn’t Imitate, Avoids Eye Contact, and Doesn’t Show Interesting Objects to Adults. Finally, the behaviors mostly considered “expected” were Play Concentrates on Specific Toy Parts, Covers Ears to Common Sounds, Angers Abruptly if Environment Changes, and Produce Unusual Finger Movements.The explanatory cause most commonly cited (ten out of sixteen behaviors) was Personality, Attitude, or Preferences . Some exPhysical or Sensory Issues explanations such as, “No oye bien” [He doesn’t hear properly], were mainly associated with Doesn’t Respond to Name and Cover Ears in Response to Common Sounds. Scarce explanations were provided for the category Psychological Problems; examples included “Está traumado” [He is traumatized] or “Está estresado” [He is stressed] and were mainly associated with Hits his Head with Hands or Objects. Scarce explanations were also provided in the category Parenting; for example, “Sus padres no le han enseñado” [His parents haven’t taught him] was provided to the behavior Doesn’t Point to Desired Objects. The category Unspecified Reasons assembled responses that acknowledge a behavior as unusual but did not provide an explanatory cause, such as “Algo le pasa” [Something is happening to him], “Algo hay” [There is something]. Supranatural explanatory causes were provided by less than 1% of participants and were also included in this category. Explanatory causes related to the category Immaturity, such as “Todavía es chiquito” [He is still young], were provided by a small proportion of participants for all the behavior presented. Finally, an important rate of responses was associated to the category I don’t know and was provided to most of the behaviors presented.We also aimed to study if the level of education, age, and parental status influenced the identification of behaviors as “concerning and requiring professional attention” and the explanatory causes related to a developmental condition.H0:PO = YP.In order to explore the effect of these factors, participants were classified by age , parenthood status , and level of education . The data was coded and entered into Statistica (Tibco) to analyze the differences between proportions testing the following hypotheses H1: PO > YP with a level of significance of 5%. Z-value equals the observed difference between proportions (p1-p2) divided by the standard error:“concerning” among older participants on the following behaviors: Avoids Eye Contact, Doesn’t Handle Interesting Objects to Adults, Doesn’t Have Interest in Other Children, Doesn’t Understand Instructions, Doesn’t Understand Emotions. Parental status had a significant impact on the perception as “concernin” among older participants only on Avoids Eye Contact. The level of education was not found to have an effect on the perception of any of the behaviors as “concerning”  were not considered “concerning,” and, as in the former example, most of the responders could not provide an explanatory cause or attributed it to a child’s personality. Those findings have a critical implication for clinical practice considering that they are commonly present in children who will receive a diagnosis. Furthermore, attribution of autistic symptoms to a child’s personality as “timidity,” “independence,” or “strong character” may have at least two potential impacts. Firstly, if caregivers and family friends underscore those behaviors parental help-seeking actions could be delayed. Secondly, rearing style can be affected, for example, if parents understand those behaviors as their child not wanting to cooperate or is voluntarily ignoring them. The same conclusion could be drawn for the items Doesn’t Have Interest in Other Children and Doesn’t Understand Instructions, which are considered “concerning” but mainly explained as the manifestation of a child’s personality.Similarly, the three joint attention behaviors (Lack of response to name was identified as “concerning” by many participants but was primarily related to a hearing impairment, a type of explanation that may be pertinent in some cases and requires a differential diagnosis; however, in ASD cases, it has been associated with an increase in the age of diagnosis in the United States (self-injurious behaviors were not identified as signs of a developmental disorder but rather as a personality problem. These perceptions could lead caregivers not to seek professional advice even though emerging self-injurious behavior can be associated with unfavorable outcomes and can be addressed through intervention.d States . This fiPlay Concentrates on Specific Toy Parts, which in the United States has been associated with a decrease in the age of diagnosis (Covers Ears to Common Sounds, Angers Abruptly if Environment Changes, was mainly perceived as expected and principally explained by personality. In the case of Unusual Finger Movements, participants provided several reasons unrelated to a developmental disorder, such as boredom, and it was mainly expected in typical development. Interestingly, these three behaviors are not related to social communicative abilities but rather to repetitive behaviors and sensory issues. It is difficult, at this stage, to know if the Ecuadorian population tends to identify non-social communicative ASD markers as less problematic and if those results reflect more tolerance of diversity in repetitive play and sensory issues. Further research is also needed to understand if identifying behaviors as problematic can help children and families in Ecuador access services or whether there is a risk of pathologizing certain behaviors in children that could otherwise be accepted and adjusted within their communities. A higher level of concern elicited by the social communicative markers is also consistent with the findings of a study performed in a group of Latin American countries, where more than half of the parents reported communication and social interaction deficits as the main challenges for their child with ASD (The item iagnosis , was conwith ASD .Expressive language delay, as anticipated, was mainly endorsed as “concerning” and attributed to a developmental disorder suggesting that this difficulty could prompt families to seek professional consultation. However, because many children with ASD do not have a language delay, the presence of language could be a factor of late referral.A very modest rate of supranatural explanations was found in our sample and was classified as unspecified causes. This finding is congruent with recent research. For example, a Canadian study found that the most common causal attribution provided by Latin American parents of children diagnosed with ASD was not related to religious explanations , and a sPreliminary analyses did not suggest a clear association of perception of behaviors as “concerning” or as a sign of a developmental disorder and socio-demographic factors. Although the sample size limits these results, they suggest that awareness of ASD symptoms may be needed across all segments of the population in Ecuador, without distinction of age, parental status, or education. Community awareness remains an essential concern for families in Latin America despite significant recent efforts deployed . AwareneThese results suggest that parent education programs remain necessary, even if retrospective studies have shown that parents recognize signs of autism far earlier than it is diagnosed, particularly when they have an older child with autism . EducatiGeneralizing those findings to other Latin American cultural contexts requires more extensive and more diversified participation. Although Latin American individuals share a language and many cultural references, they belong to a range of cultural sub-groups resulting from a complex interplay of self-perceived identities, socioeconomic factors, and level of education.Produce Unusual Finger Movement, which might be difficult to understand or visualize by non-specialists. This is an important point for the cross-cultural validity of parent-addressed checklists. As those instruments are essentially based on the description of behaviors, the understandability of such descriptions in various populations may need further study. Also, the questionnaire describes behaviors that could be present in other conditions, such as sensory impairments, receptive language disorder, or epilepsy (This study also presents methodological limitations related to some items, for example, epilepsy , which cepilepsy .Furthermore, all questions were related to behaviors that can be displayed in “un niño,” a masculine noun used as a generic for “a child” in Spanish, that could produce a gender bias as participants visualize these symptoms only in young boys. Further studies will need to be conducted to observe if the description of these behaviors elicits different degrees of concern and other causal explanations if applied to young girls. Further studies are also needed to determine if the concern elicited by certain behaviors, the type of explanation provided, or the presence of certain demographic traits could predict families’ help-seeking actions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethical Committee of the Faculty of Psychology and Education at Geneva University approved this study. The patients/participants provided their written informed consent to participate in this study.PB and EG designed the study and analyzed the data. PB acquired the data. PB and GV wrote the article’s first draft. All authors have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Global aging continues to progress. The shortage of human resources involved in long-term care (LTC) is a serious problem worldwide. It is necessary to promote the stable employment of foreign care workers. The purpose of this study was to identify which factors, including well-being, work engagement, and original items, contribute to foreign care workers’ intent to continue working.We conducted an anonymous self-administered questionnaire survey of 259 foreign LTC workers at LTC facilities in Japan. The questionnaire survey items included the Japanese version of the Subjective Well-being Scale (J-SWBS), the Japanese version of the Utrecht Work Engagement Scale (J-UWES), and original items related to educational needs and issues. We used multiple regression analysis to predict variability from correlations among variables. And after that, we conducted a path analysis using structural equation modeling (SEM), and added that the explanatory variables (IV) were well-being, work engagement, and the original item component, and that the outcome variable (DV) was intention to continue working. We set a hypothetical model based on structural equations, corrected by path analysis, and examined its suitability.The number of returned questionnaires for 259 foreign care workers was 147 (response rate 56.7%), and the number of analyzable questionnaires was 129 . For intention to continue working, the results of structural equation modeling showed direct effects for satisfaction with low back pain measure guidance (β = .255), satisfaction with the national examination guidance method (β = .217), well-being (β = .046), and work engagement (β = .026). In work-engagement, there was a direct effect of happiness (β = .715), willingness to learn good care (β = 4.849), and confidence in my ability , whilst in well-being, satisfaction with low back pain measure guidance (β = 1.582) and confidence in my ability (β = 1.999) were found to have direct effects.To increase the intent of foreign care workers to continue working, appropriate guidance should be given related to the development of lumbago. In addition, to provide a place and scene where they can learn good care, having a relationship in practice where foreign care workers can feel that their abilities are being utilized, and developing and maintaining educational support that motivates them to learn good care may be effective. The estimated demand for LTC personnel in Japan in fiscal year 2025 is 2.53 million. On the other hand, the estimated supply, which reflects the projected decrease in the working-age population in the future, is 2,152,000, resulting in a shortage of 377,000 workers , the annPrevious studies have identified a number of factors related to turnover of staff involved in older care, such as poor quality of older care , occupatThe purpose of this study was to identify which of the original items extracted based on the results of our own previous study contributed to well-being and work engagement, as well as to the intention of foreign LTC workers to continue working. Promoting the stable employment of foreign LTC workers will help to solve the problem of human resource shortage in the field of LTC for the older adults. This study focuses on securing LTC human resources in a comprehensive manner, including securing and training diverse human resources, preventing turnover, promoting retention, improving productivity, and improving the environment for accepting foreign human resources. We focused on the recruitment and development of diverse human resources, prevention of turnover, promotion of retention, improvement of productivity, and improvement of the environment for accepting foreign human resources. Solving the shortage of human resources is thought to lead to enhancement of employee welfare and improvement of physical and psychological health, and this study targeting foreign nationals has implications for transnational health.https://www.bing.com) to search for the keywords “foreign human resources,” “long-term care,” and “receiving facilities.” The description for website search has been modified.The survey included 223 facilities that accept candidates based on the Economic Partnership Agreement (EPA), whose names have been disclosed according to the survey by the Ministry of Health, Labor and Welfare, as well as 69 facilities that disclose the acceptance of foreign workers on their websites. We used Microsoft Bing  or those with equivalent or higher proficiencies were selected. There are five levels of the Japanese Language Proficiency Test: N1, N2, N3, N4, and N5. The easiest level is N5, and the most difficult is N1. N5 is the level at which you can understand basic Japanese to some extent, and N1 is the level at which you can understand Japanese used in various situations.For foreign care workers, the text of the request form was simplified into easy Japanese. All the survey forms were accompanied by a request form explaining the study’s purpose, methodology, ethical considerations, and so forth. The form also contained a statement that the respondent’s participation in the study was wholly voluntary, and after completing the survey, the participants themselves placed the questionnaire into the provided envelope and sealed it carefully.This study was conducted with the approval of the University of Tsukuba medical ethics review committee .The participants filled in questions about their nationality, biological sex, age, Japanese Language proficiency, years of work experience (months) in Japan, qualifications, and residency status.This item was “I want to continue working at my current workplace.” The response options were “Strongly agree,” “Agree,” “Neutral,” “Disagree,” and “Strongly disagree.”The Japanese version of the Subjective Well-being Scale (J-SWBS) , 11 was To measure work engagement, a Japanese version of the Utrecht Work Engagement Scale (J-UWES) , 13 was Nineteen items were created on the basis of the results obtained from a previous study . The purThe primary endpoints were intent to continue working, well-being, work engagement, and original items. and the secondary endpoints were basic attributes.The Mann-Whitney U test was used to test for differences among the residency statuses of participants in well-being, and the Kruskal-Wallis test was used to test for differences among the nationalities of participants in work engagement. We used the Spearman rank correlation to analyze the correlation between the ordinal scale and the proportional scale for “intent to continue working” and “demographics,” SWBS, UWES, and “original items.” Also, referring to the analysis results, variables showing significant correlation with the SWBS, UWES, “demographics,” and “original items” were defined as independent variables. Multiple regression analysis was performed by inputting the variables by the forced input method, with “intent to continue working” as the dependent variable. Next, multiple regression analysis was conducted, where work engagement and well-being, which have high internal correlation, were analyzed separately. Path analysis using structural equation modeling (SEM) was conducted to analyze the hypothetical model created based on the variables that were found to be significant in the multiple regression analysis. The reliability of the original items in the questionnaire used in this study was verified by use of the Cronbach α coefficient.Probability values below .05 (both sides) were considered to indicate significance. The statistical software used was SPSS Statistics, ver. 28 and Amos, ver. 27 (IBM).Of the 259 foreign workers, 147 responded (response rate: 56.7%). Fifteen people whose number of years (months) worked at LTC facilities or whose Japanese proficiency did not meet the study criteria were excluded. Of the 132 people who met the inclusion criteria, 129 people were analyzed , excluding 2 missing answers and 1 incorrect answer such as duplicate answers.Table Table As shown in Table Well-being had a positive correlation with sense of being valued , and comfort of conversation with users in Japanese  had a weak correlation that was not seen between the intent to continue working and work engagement.2 = .590, p < .001): work engagement , satisfaction with the national examination guidance method , and sense of performing good care , confidence in my ability , and satisfaction with low back pain measure guidance . In Table 2 = .561, p < .001): well-being , willingness to learn good care , confidence in my ability , and satisfaction with low back pain measure guidance .Tables We used the Mann-Whitney U test to analyze the difference between the 2 groups of Specific activities and Technical intern training, excluding Study abroad and Specific skills and Others, for which the sample size was small. The results showed that there was no significant difference between the 2 groups in subjective well-being (significance level [2-sided] 0.05). Furthermore, we attempted a comparative analysis in 3 countries, Indonesia, the Philippines, and Vietnam, except for a few nationalities whose sample sizes were extremely small (less than two). Since normality cannot be assumed for the data of these 3 countries and the sample size is small, the Kruskal-Wallis test was conducted. The results showed that there was no significant difference in work engagement and all its subscales among the 3 countries (significance level [2-sided] 0.05).A hypothetical model was set as shown in Fig. 2 = 29.589.It consists of 7 variables that showed significant association with the intention to continue working as a result of multiple regression analysis with the intention to continue working as the dependent variable. The path (direction of the influence among variables) was constructed concerning the results obtained from the Spearman rank correlation analysis in this study. The goodness-of-fit index of this hypothetical model was goodness- of-fit index (GFI) = .950, adjusted goodness of fit index (AGFI) = .743, comparative fit index (CFI) = .917, root mean square error of approximation (RMSEA) = .159, and χLooking at the standardized coefficients, the direct effects on the intention to continue working were work engagement , well-being , confidence in my ability , satisfaction with low back pain measure guidance , and satisfaction with the national examination guidance method . There was no direct effect of motivation to learn on good care .Toyoda  stated t2 = 18.912, indicating a high degree of fit. Looking at the characteristics of each variable revealed by the model, the following direct effects were found for intent to continue working: satisfaction with low back pain measure guidance , satisfaction with the national examination guidance method , well-being , and work engagement . In addition, work engagement was found to have direct effects on well-being , willingness to learn good care , and confidence in my ability , whilst well-being was found to have direct effects on satisfaction with low back pain measure guidance  and confidence in my ability  had a direct effect on wellbeing.Figure In the questionnaire used in this paper, the Cronbach α coefficient for the reliability of the original 20 items including the intent to continue working was 0.827.The purpose of this study was to identify which of the original items contribute to “well-being” and “work engagement,” as well as to the “intent of foreign care workers to continue working.” Therefore, in the SEM, a hypothetical model was set and path analysis was performed concerning the Spearman rank correlation and multiple regression analysis results. The path analysis showed that “well-being,” “work engagement,” “satisfaction with low back pain countermeasure guidance,” and “confidence in my ability” were factors that directly affect the “intent to continue working” among foreign care workers. Factors that indirectly affect the “intent to continue working” were “sense of learning good care,” “sense of performing good care,” and “willingness to learn good care.”From the goodness-of-fit index of the model, it is considered that a scientifically valid model with no discrepancy between the data and the model was generated.In the multiple regression analysis in this study, “satisfaction with salary” did not show a significant effect on “intent to continue working,” showing the same trend as the report that wages alone cannot promote employee retention . In addi“The direct and indirect effects on “well-being” and “work engagement” were indicated by “satisfaction with low back pain measure guidance,” “satisfaction with the national examination guidance method,” “sense of performing good care,” “willingness to learn good care,” and “confidence in my ability.”On the other hand, the Spearman rank correlation results showed that “salary satisfaction” and “Japanese language ability” were correlated with “intent to continue working,” but in the path analysis, no causal relationship was found with “intent to continue working.” Direct or indirect effects on “well-being” and “work engagement” were shown in the “sense of learning good care,” “willingness to learn good care,” and “confidence in my ability.” This means that acquiring high-quality care and utilizing individuals’ abilities in LTC work amplifies their well-being and that willingness to learn for quality care, rather than salary or Japanese proficiency, enhances the individuals’ work engagement in the intent of foreign care workers to continue working. It can be explained that it is not wages or Japanese language acquisition that brings pride, enthusiasm, and vitality in work. These findings differ from those of a report showing that a factor related to turnover is that foreign care workers think that it is enough if they can acquire high wages and Japanese ability  and of aTo increase the intent of foreign care workers to continue working, it is important to provide appropriate guidance for the development of back pain, to provide a setting and scene where good care can be learned, to utilize their abilities, and to provide educational support that motivates them to learn good care. In addition, to increase the motivation to learn good care, it is necessary to devise ways to take in more opportunities to feel that good care is being practiced. Employees in the high engagement group have been found to have higher levels of psychological well-being and personal accomplishment, whilst employees in the low engagement group had higher levels of emotional exhaustion and depersonalization . This reThe limitations of this study are that the causal relationships between variables excluded from the hypothetical model during the SEM and latent factors other than the observed factors were not sufficiently analyzed this time. It is not possible to set up a hypothetical model using existing theoretically established factors/variables, and reliance on statistical analysis may have caused deviations in the results. Also, the multiple regression analysis result that “sense of performing good care” was negatively correlated with “intent to continue working” differed from the Spearman rank correlation and path analysis results. In multiple regression, the number of analysis targets ≥ 50 + 8 m is proposed with “m” as the explanatory factor , 30. In However, these theoretical models/methods of educational support generated based on the findings of previous studies are useful in promoting the retention of foreign care workers involved in LTC based on work engagement and well-being. It is considered that the current results will contribute to solving the shortage of human resources in the field of LTC and welfare in Japan.To increase the motivation of foreign care workers to continue working, it is desirable to provide appropriate guidance related to the accumulation of back pain that is characteristic of LTC workers, and to create an environment where they can learn good care for national certification. It is effective to develop and maintain a relationship in practice that allows the individual to feel that his/her abilities are being utilized and educational support that motivates him/her to learn good care. And to increase the motivation to learn good care, it is necessary to incorporate many opportunities to feel that good care is being practiced.


Researchers display an interest in studying aspects like the mental health of high-performance athletes; the dark side of sport, or the earliest attempts to study the so-called dark triad of personality in both initiation and high-performance athletes. Therefore, the objective of this paper is to determine the possible existence and magnitude of negative psychological aspects within a population of competition sailors and from a probabilistic point of view, using Bayesian Network analysis.The study was carried out on 235 semi-professional sailors of the 49er Class, aged between 16 and 52 years .The results show the existence of a Negative Tetrad—formed by achievement burnout, anxiety due to concentration disruption, amotivation and importance given to error—as a probabilistic product of the psychological variables studied: motivation, anxiety, burnout and fear of error.These results, supported by Bayesian networks, show holistically the influence of the social context on the psychological and emotional well-being of the athlete during competition at sea. The center of attention in Psychology applied to Sport is twofold, dealing with both intervention and prevention. If the focus is on prevention, empirical and/or experimental studies need to be carried out to find variables or factors not detected and/or studied enough, and, once detected, try to decrease their occurrence as much as possible.In that vein, researchers display an interest in studying different aspects like the mental health of high-performance athletes ; the “daAs some collateral, or complementary, findings, certain psychological variables have been studied regarding anti-social behavior and/or attitudes, such as gamemanship and cheating in sport . Such anThe most intensively and extensively studied psychological variables in the realm of sport have two aspects, one “positive” , and the other “negative” (associated with loss of concentration or motivation).It is evident that there is currently no single, well-studied conceptual link between all the possible "negative" variables, which are multiple and come from diverse sources and psychological levels. Therefore, to include some of them in a study like this one, other justifications for carrying it out must be used. In this case, the authors have considered different criteria such as their previous empirical experience, the central position that some of them occupy in applied and even experimental studies, and, finally, the weight they have -sufficiently studied- on sports performance. or on other psychological variables. Thus, the central place of the study is occupied by the different factors of the Self-Determination motivational Theory and the anxiety associated with competition, accompanied by the variables of fear of making mistakes or failing, and the sportive burnout.The SDT used by the authors to study how human behavior is influenced by the social and interpersonal environment identified the existence of three psychological needs: competence, relationship with others, and autonomy, which are defined as essential nutrients for human personal development and well-being . The addWithin this line of work, research studies show that the frustration of psychological needs leads to controlled motivation, which relates to moral detachment , burnoutIn sports, athletes generally display a fear of failure and self-assessment of their performance . The expWithin the argument that is being carried out, one of the most widely-studied emotions in sports is anxiety, traditionally split between state anxiety and trait anxiety. State anxiety specific to sports is one that appears immediately prior to the start of a competition and while the competition is taking place . At presFinally, among the selected variables for this study, there is burnout, one of the most debilitating states that athletes can experience, and which arises as a result of continuous exposure to the chronic effects of stress . It is cOn the basis of the above rationale and of the literature consulted, the objective of this study is to try to find out -through a probabilistic analysis by Bayesian Networks within a population of competition sailors- if there is a connection between the selected variables, and if that link occurs between their "negative" aspects or between their "positive" factors. And yes, in the case of finding a relationship of probability of occurrence between some variables (and their factors), knowing which of them occupy a more determinate place and which are the consequence of the other events.The study was carried out on 235 semi-professional sailors of the 49er Class, comprising 146 males and 89 females aged between 16 and 52 years , from different sailing clubs in the Spanish region of Andalusia. The criteria for inclusion in the study were that they voluntarily completed the informed consent and all the questionnaires administered.The selection of the instruments corresponds with the selection of the variables to be included in the study, the reason for which has been explained in the Introduction. Methodologically, a two-round Delphi Method was carried out among the members of the Research Group on Physical Activity and Sports (GICAFE) of the UIB. This methodology resulted in the selection of the variables considered, and, consequently, of the corresponding instruments.Scale of Basic Psychological Needs towards Physical Exercise, validated for the Spanish context by Trigueros, Álvarez, Cangas, Aguilar-Parra, Méndez-Aguado, Rocamora and López-Liria )BN have been used to discover relationships between negative features in sport , and inTo produce the BN, it was first necessary to determine the structure via a Directed Acyclic Graph (DAG) and to assign conditional probabilities to each node of the DAG. Therefore, learning a BN involves the following two tasks: (i) structural learning, in other words, identifying the topology of the BN, and (ii) parametric learning, or estimating the numerical parameters  given the network’s topology.bn learn package Reviewers' comments:Reviewer's Responses to Questions  Comments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?  The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********  2. Has the statistical analysis been performed appropriately and rigorously?   Reviewer #1: YesReviewer #2: Yes**********  3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #1: NoReviewer #2: Yes**********  4. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: NoReviewer #2: Yes**********  5. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The current manuscript reports a Bayesian approach to examine the empirical network across several so-called ‘negative’ constructs within sport. I am excited to see the application of novel methodological approaches applied to sport and exercise psychology. My review is nevertheless relatively brief because I struggled to understand the goals of this research, its conceptual foundation, and ultimately the steps taken when conducting the analysis. In part this was through limitations in the written qualities of this manuscript in English, but in part this also relates to how more work is required to clearly justify and explain this work relative to the field of sport psychology. This means that I focused my review on several specific notes for the authors to consider when resubmitting their work to this journal or another in the future. I hope that this feedback is helpful as the authors proceed with the examination of Bayesian networks into the future.General comments.INTRODUCTION PREPARATION. The introduction touches on a wide spectrum of topics – personality, the dark triad, self-determination theory, fear of failure, anxiety, burnout. Each of these concepts is introduced in 1-2 paragraphs and then there is a brief statement before leading into the methods. Whereas some of these concepts are indeed needed to introduce their goal, the introduction leaves out crucial assumptions the authors make when conducting this study .One way to clarify my concern is that the approach to develop the dark triad was relatively different from that seen in the current study. That construct was initially uncovered through arguments that the concepts  nevertheless are each personality traits that share a large degree of variability and appear together with regularity. Furthermore, the status of the dark triad has been defended through tests of whether other potential constructs  may also fit. What types of similar assumptions shaped the design of the current study?In contrast to something like the dark triad, the current authors also selected constructs that seemed ‘negative’ but that come from different domains . There is no clear theoretical foundation for integrating these concepts. Although analyses ultimately included 18 constructs, how did the authors select these 18 subscales from amidst other ‘negative’ construct that could just as easily have been included within the current study .Summing up these points, the introduction is difficult to understand and mainly introduces a list of concepts that seem to be connected because we see some of them as ‘negative’. The introduction provides not insights into the value of conducting the current analyses  nor does it give any sense for how the selected constructs relate to one another or are unique from the other ‘negative’ constructs that could have been selected.COULD ‘NEGATIVE’ PHRASING BE THE MAIN THING UNITING THESE CONCEPTS? I am curious e authors didn’t reveal ‘positive’ constructs as being involved in the network via negative associations.METHODS DESCRIPTION. Several areas within the methods section were challenging to fully understand. For instance, it was not particularly clear how given measures relate back to past-validated tools or to theory. Notably, the authors note one psychological needs tool that included a subscale termed ‘relationship with others’, which seems to relate to relatedness from basic needs theory? Furthermore, although I agree that need frustration is indeed a key way to examine the basic needs separate from need satisfaction, it is unclear what it means that there was a higher-order frustration factor?LOW INCIDENCE OF MEASURED CONSTRUCTS. It would be valuable to see further efforts to introduce the descriptives for key constructs as preliminary analyses. This is especially because many of the ‘negative’ constructs were reported at such a low level, it would be useful to see these responding patterns in ways other than those captured in the Bayesion network (described only as whether they were classified as ‘low’ or ‘high’).DATA AVAILABILITY. In the submission, the authors noted that all data were available in the document or related files. PLOS requires that 'original' data be made available  - which authors often do through links to online data repositories. It does not seem like this submission, then, has made data available.Specific comments.- Certain words are capitalized when it is not clear why they are treated in such a way - L50-L58 – The paragraph detracts from the goal of this paper. First, some of the wording and language used is not correct . Second, I do not believe there is evidence that sport research is undergoing any particular shift toward prevention compared to before, and that the health psychology model is applied .- L67-L73 – When describing the foundation of personality research in sport I recommend that the authors consider sources like “Allen, M. S., Greenlees, I., & Jones, M. (2013). Personality in sport: A comprehensive review. International Review of Sport and Exercise Psychology, 6(1), 184-208.”- L91 – self-determination theory should be introduced in full here. Furthermore, the authors here are mainly focused on basic needs theory as opposed to the broader self-determination theory.- L115 – I don’t know if this description of how fear of failure comes from a lack of control is entirely accurate – and I also am not certain that all athletes demonstrate fear of failure as claimed by the authors.- L114-L122 – An extremely long run-on sentence.- L151 – More demographic or sport background features of the sample would be useful, beyond age and sex.- L158-L164 – It is challenging to interpret the descriptions for the scales. For instance, the authors stated: “This factor consists of 17 items: autonomy; competence; relationship with others and novelty. In addition, Trigueros et al. (2020) grouped the four factors into one of a higher order, called Frustration. The study subjects were required to respond using a Likert scale ranging from 1  to 7 .” Do the authors mean ‘scale’ instead of ‘factor’? Following ’17 items’ it seems that the authors mean that there were 17 items that were all ultimately classified within three subscales. Furthermore, the authors refer to a frustration factor of ‘higher order’ – and this is unclear.- L181 – What does ‘de-concentration’ mean?- L200 – What does the term ‘expert pollster’ relate to?- L211 – The following is an example of one statement that is difficult to interpret: “information on the probability of occurrence of events  related to performance in sports or, for example, the likelihood of sports injuries.”- L205 – The approaches used to complete data management  as well as any preliminary analyses should be introduced in data analysis.- L279 – Another example of a statement that is challenging to understand and that seems inaccurate: “the most relevant variable, which has no probabilistic dependence, is not a motivational one but rather the devaluation of playing sports due to a fear of being at fault or failing. This variable has a much more basic sense than those derived from the SDT .It may also be interesting to indicate at what time of the season the data was taken .Among the strengths of the study, it should be noted that the variables studied are currently of great interest in the scientific literature lately, and the articles consulted are recent and reliable.The discussion is interesting and the authors explain these relationships very well. However, in the second paragraph of the discussion, the authors say that these predictions occur even in a sample where they are unlikely to occur, but is that because they are not professionals? Do the characteristics of sailing make it less demanding than other sports or what characteristic are they referring to? (lines 347-351).Please, also check some quotes where there are small errors such as indicating the author's initial or missing a dot after "et al" .I hope that the authors consider my suggestions and I congratulate them for the work.**********  6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.  Reviewer #1: NoReviewer #2: Nohttps://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  21 Jun 2022Reviewer 11.1 INTRODUCTION PREPARATION. The introduction touches on a wide spectrum of topics – personality, the dark triad, self-determination theory, fear of failure, anxiety, burnout. Each of these concepts is introduced in 1-2 paragraphs and then there is a brief statement before leading into the methods. Whereas some of these concepts are indeed needed to introduce their goal, the introduction leaves out crucial assumptions the authors make when conducting this study .1.2 One way to clarify my concern is that the approach to develop the dark triad was relatively different from that seen in the current study. That construct was initially uncovered through arguments that the concepts  nevertheless are each personality traits that share a large degree of variability and appear together with regularity. Furthermore, the status of the dark triad has been defended through tests of whether other potential constructs  may also fit. What types of similar assumptions shaped the design of the current study?1.3 In contrast to something like the dark triad, the current authors also selected constructs that seemed ‘negative’ but that come from different domains . There is no clear theoretical foundation for integrating these concepts. Although analyses ultimately included 18 constructs, how did the authors select these 18 subscales from amidst other ‘negative’ construct that could just as easily have been included within the current study .Response: 1.1. Like all the reviewer’s comments regarding the concepts involved in the study, they are absolutely necessary, in the opinion of the authors, to be able to correctly situate this study, and have caused them to reflect deeply on the conceptual points, as well as the of obtaining results. The first thing that has been decided (and the introduction has been rewritten in this sense) is NOT to assume any a priori relationship between those selected - below the basic reasons for their inclusion are explained- and in that regard, to remove all those points of the work that could imply that idea, 1.1. both in the Title, the Introduction and the Discussion.1.2. Although this answer partially overlaps with that of point #2, and continues with the one corresponding to point #1.3, the basic assumption -which was being worked on in parallel in two different studies- was that competitive anxiety  occupies a secondary place -and the authors were interested in highlighting it given the importance given to the appearance of physiological “signs” of it (this point has been introduced in the introduction) , and it was desired to test its probability weight with respect to the other variables, that is, which factors of the SDT would have a greater probability of occurring; the same with respect to the perception of error, and the most “dangerous” factor for sports abandonment or for sports practice to be carried out in a “negative” way.1.3. Thank you very much for this comment, which also directly affects the design of the work as a whole. We can say that 1) the choice of constructs is due to the fact that the authors had previous experience of having worked with them -both in the application and practical intervention in competitive sport, as well as in various publications, using the same methodology, especially in the case of SDT or anxiety associated with competition, while, e.g., the two cited by the reviewer  were foreign to the previous experience of the authors. Based on this, an explanatory paragraph is introduced in the methodology ; 2) Although it is totally true that there is no common background between them, it is not claimed at any time that it is, nor is anything commented about it in the discussion or in the objective of the study, but rather, in light of the results, those cited are within the same probabilistic chain of occurrence; 3) as the reviewer indicates later, the relevant core is the SDT (the Introduction has been rewritten in this sense), and the relevance given by the authors to the frustration of basic needs has also been corrected, highlighting even more the factors of the SDT.2. COULD ‘NEGATIVE’ PHRASING BE THE MAIN THING UNITING THESE CONCEPTS? I am curious e authors didn’t reveal ‘positive’ constructs as being involved in the network via negative associations.Response: Thank you very much for the question. Indeed, too much weight has been given by the authors to the assumption that there really is a "negative" link, beginning with the title of the manuscript, which has been rewritten . Likewise, in the comments to the RB, the “positive” factors that have low probability values have been highlighted, as is the case of novelty frustration, which has a very low probability of occurrence in this population. However, this possibility indicated by the reviewer is not at all common in BR, and what has drawn the attention of the authors have been the differences in position in the network, and the values  different between the variables that have been called "negative" What happens with them is that they occupy non-determining nodes of the outcome variables, nor do they occupy top positions, which can trigger probabilistic occurrences in the other variables.3. METHODS DESCRIPTION. Several areas within the methods section were challenging to fully understand. For instance, it was not particularly clear how given measures relate back to past-validated tools or to theory. Notably, the authors note one psychological needs tool that included a subscale termed ‘relationship with others’, which seems to relate to relatedness from basic needs theory? Furthermore, although I agree that need frustration is indeed a key way to examine the basic needs separate from need satisfaction, it is unclear what it means that there was a higher-order frustration factor?Response: Thank you very much for your comment, I hope it is now better understood.…and López-Liria (2020). This scale consists of 17 items distributed among four subfactors: autonomy; competence; relationship with others and novelty. In addition, Trigueros et al. (2020) grouped the four subfactors into a single factor, called Frustration. The study….4. LOW INCIDENCE OF MEASURED CONSTRUCTS. It would be valuable to see further efforts to introduce the descriptives for key constructs as preliminary analyses. This is especially because many of the ‘negative’ constructs were reported at such a low level, it would be useful to see these responding patterns in ways other than those captured in the Bayesion network (described only as whether they were classified as ‘low’ or ‘high’).Response: Thank you for this indication from the reviewer. However, the authors want to indicate that the results are in line with others in this sport, for example,  and this has been noted in the introduction, since they had been found using classical methodology. It must be said that the fact that, although it has a low probabilistic value, the fact that the external regulation variable hardly has a probabilistic weight on the occurrence of "negative" variables is remarkable in itself, as indicated in the commentary of the results and in the discussion.However, the authors take note of this suggestion and we will try to carry out a classical statistical treatment with the same database to answer this question.5. DATA AVAILABILITY. In the submission, the authors noted that all data were available in the document or related files. PLOS requires that 'original' data be made available  - which authors often do through links to online data repositories. It does not seem like this submission, then, has made data available.Response: PLOS ONE does not require data to be fully available. In this respect, we do not have the consent of the participants to disseminate and publish the database. However, you can make a substantiated request to the corresponding author, through the journal's editorial office, to access the database and in case of a leakage we can easily detect its origin and take appropriate legal action.5. Specific Observation.- Certain words are capitalized when it is not clear why they are treated in such a way Response: Those mistakes have been fixed. - L50-L58 – The paragraph detracts from the goal of this paper. First, some of the wording and language used is not correct . Second, I do not believe there is evidence that sport research is undergoing any particular shift toward prevention compared to before, and that the health psychology model is applied .Response: Thanks for your observation. Accordingly, the entire paragraph has been reformulated at all.Furthermore: Traditionally sport psychology has focused its interests on improving sports performance. Currently, a large number of high-level athletes have highlighted the importance of mental health in sport. This has made sports psychology more interested in aspects related to health. Toni Núñez- L67-L73 – When describing the foundation of personality research in sport I recommend that the authors consider sources like “Allen, M. S., Greenlees, I., & Jones, M. (2013). Personality in sport: A comprehensive review. International Review of Sport and Exercise Psychology, 6(1), 184-208.”Response: We have taken into account your suggestion, and we have added a paragraph related to said reference. It has also been included in the list of bibliographical references. - L115 – I don’t know if this description of how fear of failure comes from a lack of control is entirely accurate – and I also am not certain that all athletes demonstrate fear of failure as claimed by the authors.Response: Thank you for this precision. The entire paragraph has been reformulated, although the authors have based it fundamentally on studies of the fear of failure that analyze it from a cognitive point of view, as well as its relationship with different emotions and anxiety associated with competition. But other possible sources of it have been included, such as learning , or by a low level of self-efficacy, both process and result.- L114-L122 – An extremely long run-on sentence.Response: Sentences have been shortened to make them more understandable as a whole. - L151 – More demographic or sport background features of the sample would be useful, beyond age and sex.Response: The only information we have about the participants in the study is that they are sailors in the 49r class, their age and where they practice sport. Therefore, we have added the following in the limitations section:Finally, it would be useful to have more demographic or sporting characteristics of the participants in the study.- L158-L164 – It is challenging to interpret the descriptions for the scales. For instance, the authors stated: “This factor consists of 17 items: autonomy; competence; relationship with others and novelty. In addition, Trigueros et al. (2020) grouped the four factors into one of a higher order, called Frustration. The study subjects were required to respond using a Likert scale ranging from 1  to 7 .” Do the authors mean ‘scale’ instead of ‘factor’? Following ’17 items’ it seems that the authors mean that there were 17 items that were all ultimately classified within three subscales. Furthermore, the authors refer to a frustration factor of ‘higher order’ – and this is unclear.Response: Thank you very much for your comment, I hope it is now better understood.…and López-Liria (2020). This scale consists of 17 items distributed among four subfactors: autonomy; competence; relationship with others and novelty. In addition, Trigueros et al. (2020) grouped the four subfactors into a single factor, called Frustration. The study….- L181 – What does ‘de-concentration’ mean?Response: It was a little mistake, now it’s fine.- L200 – What does the term ‘expert pollster’ relate to?Response: We prefer to remove both words, now it is better understood.- L211 – The following is an example of one statement that is difficult to interpret: “information on the probability of occurrence of events  related to performance in sports or, for example, the likelihood of sports injuries.”Response: Thank you very much. The authors acknowledge their lack of ability to express the underlying idea, that is, the scarcity of studies in which a chain of probabilities of occurrence of psychological variables is combined with objective data on performance or the occurrence of a sports injury. It has been replaced by: “…information on the chain of probabilistic events of psychological variables related to objective data of sports performance, or, for example, with the occurrence of sports injuries”. P8, L16-18- L279 – Another example of a statement that is challenging to understand and that seems inaccurate: “the most relevant variable, which has no probabilistic dependence, is not a motivational one but rather the devaluation of playing sports due to a fear of being at fault or failing. This variable has a much more basic sense than those derived from the SDT . Self-efficacy conception of anxiety. Anxiety Research. 1(2), 77-98. Núñez, A., Ponseti, F. X., Sesé, A., & Garcia-Mas, A. (2020). Anxiety and perceived performance in athletes and musicians: Revisiting Martens. Revista de Psicología del Deporte, 29(1), 21–28.Rachman, S. (1997), The conditioning theory of fear acquisition: A critical examination. Behaviour Research and Therapy, 155(5), 375-387.https://doi.org/10.47197/retos.v0i39.75356Salom Martorell, M., Ponseti, F., Contestí Bosch, B., Salom Ferragut, G., García-Mas, A., & Núñez Prats, A. (2021). Ansiedad competitiva y rendimiento en deportistas de vela (Competitive anxiety and performance in competing sailors). Retos, 39, 187-191. Turner, P., & Raglin, J. (1996). Variability in precompetition anxiety and performance in college track and field athletes. Medicine & Science in Sports & Exercise. 28(3), 378-385.Reviewer 21. It is possible that the authors have more information about the sample that they can show in the work, for example, the years of experience of the athletes or specify the level of the competitions .Response: The only information we have about the participants in the study is that they are sailors in the 49r class, their age and where they practice sport. Therefore, we have added the following in the limitations section:Finally, it would be useful to have more demographic or sporting characteristics of the participants in the study.2. It may also be interesting to indicate at what time of the season the data was taken .Response: The questionnaire was administered during the season under the supervision of a member of the research group, who explained and answered questions as they were completed.3. Please, also check some quotes where there are small errors such as indicating the author's initial  or missing a dot after "et al" .Response: We have corrected it.AttachmentReviewer 2.docxSubmitted filename: Click here for additional data file. 22 Jul 2022Can we speak of a negative psychological tetrad in sports? A probabilistic Bayesian study on competitive sailing.PONE-D-20-37037R1Dear Dr. Trigueros,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. 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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #2: All comments have been addressed**********  2. Is the manuscript technically sound, and do the data support the conclusions?  The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Yes**********  3. Has the statistical analysis been performed appropriately and rigorously?   Reviewer #2: Yes**********  4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #2: Yes**********  5. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #2: Yes**********  6. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #2: Thanks for attending all suggestions. I believe that the article meets the publication requirements.**********  7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.  Reviewer #2: No********** 2 Aug 2022PONE-D-20-37037R1 Can we speak of a negative psychological tetrad in sports? A probabilistic Bayesian study on competitive sailing. Dear Dr. Trigueros:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. 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This view is theoretically justified in various ways: first, it is accounted for through contemporary spatiotemporal neuroscience, which aims to connect mental and structural aspects via a common dynamic property or, according to Northoff, the “common currency” of a brain’s orientation along its embeddedness in its contextual world, i.e., body and environment. Second, it is justified through the physics concept of “spontaneous symmetry breaking,” which is used analogously to “suffering from symptoms.” If the sufferer is willing to experience a process of “going back,” that is, moving away from the previous narrative (or aspect) by verbally relating to the felt aspects of the symptom in question , they are moving toward symmetry or an underlying dynamic alignment with their world context. Clinical predictions are derived from the theoretical arguments.A key element of successful psychotherapy for the treatment of psychosomatic disorders is that patients recognize and change the meaning of their experiences. Such changes are brought about by appropriate verbal referencing of symptoms currently experienced within a given narrative. The present theoretical paper argues that changes are not based on better, more adaptive narratives  Alliance, expectations, and empathy have been denominated as common factors of therapeutic effectiveness for different psychotherapeutic contexts . Moreoveper se that is effective, even if these narratives elicit newer and more advantageous meanings; rather, it is the transitive (or linkage) process between the two substantive concept forms itself that is beneficial. Arguments to this end are obtained from the psychotherapist Eugene Gendlin, modern physics, and the Jung-Pauli conjecture, considering the contemporary spatiotemporal neuroscience perspective (references given below). Theoretically grounded recommendations for clinical use are derived from the presented arguments.To answer this question, I aim to derive arguments from empirical data, which show that it is not the achievement of adaptive concept forms, that is, “adaptive narratives” To investigate the research question concerning the primary relevance of the transition process between narratives in psychotherapy—as outlined above—three premises are required: the choice of (i) a suitable patient, (ii) an intervention at the subject level of the patient and (iii) the patient’s willingness to engage in the therapy process.I firstly focus on a case selected from a group of patients known to be unable of verbally expressing their emotional status, whilst still experiencing the somatic component related to their affective reaction  physical symptoms on the one hand vs. inability to verbalize the underlying emotional state on the other, (ii) willingness to enter a state of dispositional affect response—such as that of hypnosis—based on trustful cooperation with the therapist, and (iii) success in generating the symptom under controlled conditions with the therapist.Some useful insights into the “process interface” and transitive experience have been provided by the philosopher and psychotherapist, Eugene Gendlin, who proposed a concept to overcome the traditional “hard problem of consciousness,” that is, the irreconcilable dualization of the psyche and body, describing them as “imprecise, first-person involving” and “mechanistic, third-person space time-grid precise assumptions,” respectively . To overThis raises the question: what can encourage the sufferer to refer to their bodily experiences to unblock implicit feelings, serving to alleviate symptoms? In the words of Gendlin arrived at an answer: to reactivate the completion of this process, that is, unblocking, he proposed a “law of the reconstitution of the experiencing process: When certain implicitly functioning aspects of experiencing are carried forward by symbols or events, the resulting experiencing always involves other sometimes newly reconstituted aspects, which thereby come to be in process and function implicitly in that experiencing.” . I referIn what follows, a succinct core of symptom prescribing is illustrated using a cascade of interactions from an actual case of the author’s office. The patient (P) was defamiliarized by removing her name, age, and other details of her history to retain her anonymity, the author was regularly P’s therapist (denominated here as operator O) from February 2018 until November 2019; the session presented in subsequent paragraphs took place in the initial phase of therapy. The therapy consisted of a total of 22 sessions, initially monthly from February to September 2018, then twice a month from October 2018 to February 2019. There were no sessions from February to October 2019 because the patient was abroad. Between October and November 2019, eight weekly sessions took place. Then, the patient had to go abroad again. Subsequently, there have been no further sessions so far.To understand the connection between theory and practical procedure, the theoretical concept behind the procedure is briefly presented. To this end, the core of case description is added in the light of P’s previous findings through O’s questions and Ps answers regarding the possible meaning of the prescribed symptoms in the form of experiences reported by the patient during her trance. Strictest attention was paid on O’s part not to make any judgmental comments and only to maintain the flow of P’s experience.The relationship between P’s previous insights, her present experience during trance, and O’s attitude of only maintaining the flow of her experience during trance can be seen as P’s key to understanding future challenging experiences in a new light, being recontextualized by means of the surprising, shared experiences in trance.As already described by Hence, the commonality of various empirical drives of P is what Sartre denominates as the “empirical attitude (of P herself as) the expression of choice of an intelligible character,” namely, her “fundamental meaning” , p. 564.From this moment on, one must always be prepared for the fact that the symbols chosen by P can already change their meaning in P . Only the grasping of individual, momentary phenomena, no matter how minimal they may be, enables their grasping in the conceptual . It is exactly at this point that the implicit meaning of the symptom becomes explicit and, thus, dispensable. The possible meaning assignments of the symptom run out of further words; P begins to discover that she must no longer let herself be “driven” by her symptom. Therefore, she can now discover new degrees of freedom of action. Once P has become dispositional with respect to the assignment of meaning to her symptom, the trance experience can envelop this process of disposability with an alternative experiential context. Here, we come to hypnosis, a mutually agreed process of inner focusing that opens P’s personal space and time to experience a change in the sub-modalities  of the symptom prescribed to her, from the context of the previous conversation.“longstanding irritable bowel syndrome” and “suspected food allergies that have never been measurably verified,” combined with recurrent newly emerging episodes of tinnitus, experienced as “light and tingling sensations that started a few months ago,” associated with “fear of losing control in challenging situations.” At the end of a detailed, 2-h anamnesis, P and O concluded that the fundamental meaning of P’s unconscious bodily process since her earliest childhood was to essentially act as a mediator between her polyamorous father and her mother’s saintly figure to keep their marriage going. She continued her expert role in her profession as a mediator. She never learned to sense, recognize, or appreciate her own physical and personal boundaries. Her mother, who suffered several early miscarriages before P was born, was always caring, quiet, and reserved in P’s memory, accepting the role assigned to her by tradition, and died of ovarian cancer a few years earlier. From then on, P’s father required P to take care of him, as tradition demands of the women within the family.The therapy session conducted with P is described here. During the initial session, P’s history was taken. She grew up abroad and moved to Europe with her family over 10 years ago. She presented with a diagnosis of autonomous behavior, and thus her dignity of “being human” and not a “heteronomous function of other people’s needs,” was implicitly emphasized. In the next session, which took place about 7 weeks after the first one, P reported that she was already feeling better. She cried that her father always presented her as a “decorated little horse.” During this recollection, she felt pressure in her throat and a feeling of “thickening of breath” coupled with the account of her dreams, in which she could neither speak nor scream and her voice could not “get out” of her gullet. With the instruction to continue from this topic the next time, symptoms currently arising in the context of her memories disappeared. In the next session, she reported that when she was overwhelmed at work, during which she would function like a robot, and she would always have a similar dream at night. The physical overload caused by exceeding her stress limit often triggered violent anger and abdominal pain in her; she looked in the toilet mirror at work and said to herself, “that is not you!” Thus, she was asked by O whether she would like to “remember this sort of gut feeling” that she just talked about during trance “to make new discoveries from there.” With her consent obtained, she was told that she is not alone with her feelings, is in a safe environment, and O can be trusted. When P was in a trance with her eyes closed, O triggered a memory by asking P what she wants to start remembering first  [Pause for several seconds] What happens now?” P said, “It has moved upward, suddenly in the throat” [P is choking now]. O replied, “Please hold on, take your time, I am with you, and you are safe, wait and see what comes, slowly but surely.” P stopped choking and sat in amazement. O asked, “What is it now?” P said, “I see a tall woman with long black hair, a white face, her hair fluttering in the air, floating above the ground.” [P was crying at this moment]. O responded, “Take your time, that is right, it is good to let it all come, more and more, just let it come, let it get stronger and stronger” . As soon as O saw her body relaxing, he invited her to dehypnotize with the instruction, “Remember any experience that your subconscious mind wants you to remember now after you wake up. And once you are fully awake, please stretch your whole body so that you feel as relaxed, fresh, and strong again as if you had slept well all night” [pause]. After waking up, P said, “Crazy, that was intense!” O asked, “What do you mean, pleasant or unpleasant, or unclassifiable, but just intense?” P replied, “Violent, yes, enormous, strange” . O said, “Your body will surprise you now every other day, almost imperceptibly, [pause] as if your perspective on all events changes, especially on all challenges [pause] that you have experienced again and again in the past, with—little—changed perspective [pause]. At the same time, your perspective has changed by 0.347 or 0.591 degrees [a metaphor for arbitrarily low numbers that gift-wrap the mediated notion of minute and therefore initially imperceptible changes], and a little more each day [pause].” As soon as P began to smile (which is often the case after such a procedure), O asked, “What are you going to do today?” This question typically induced amnesia to distract P from the previous trance, bring her completely out of trance, and make her feel like everything is done for today, that she can now go about her daily activities with peace of mind. The next session was scheduled 4 weeks later because, in O’s experience, reflections on the perceived changes need some configuration time to emerge fully. At the next meeting a month later, P reported that a lot had happened. Enormous anger, but also strength, emerged in her. She had outbursts of anger in many situations, but also had corresponding feelings of guilt. She must now learn to be careful with the boundaries she feels, so as not to hurt anyone. She was also suddenly able to distinguish mendacity and feigned kindness from genuine kindness, which gave her considerable symptom relief. Stomach pain and sleeping problems  were no longer an issue, and her tinnitus had improved by around 40%. In further sessions, her constantly new discoveries in dealing with herself and topics such as her father’s death that had taken place in the meantime, were taken up. These investigations were conducted during trance or conventional exploration, and were integrated into P’s current horizon of experience, according to her directly conveyed images or feelings that accompanied these themes. Ultimately—according to the last meeting in November 2019—P found that any food, “even foods high in histamine, such as eggplant or radishes,” was tolerable. Her breathing also improved, allowing her to breathe much deeper. She effortlessly distanced herself from her family problems and could now concentrate much better on her further plans. Stressful statements that she had learned in her childhood, such as “Nothing is free in life, my child” or “You have to pay for everything in life, be it freedom, happiness or ultimately even with life,” were now regarded as attitudes or points of view that did not belong to her and had very limited meaning. In accordance with the previous considerations, this brief example shows that the sufferer P experiences herself in a position where she can find verbal symbolizations and events related to her suffering. This has previously been described based on typical cases of somatoform “chronic pelvic pain disorder”  of early childhood that were familiar to her body from her memory, with the accompanying comment of “being perceived by everyone else as an autonomous human being with boundaries.” In other words, a reference to her childhood ability of setting isorder” .“slowing down of time and expansion of space” in that O has perceived atmospherically between himself and P a change.At what point in the contention between P and O does the transitive state unfold? Since the transitive state is a purely subjective quality, the sequences of the process from which O selects a particular one for the following description are purely subjective, that is, they do not necessarily coincide spatiotemporally with those that P experiences. O can never know when and where P experiences transitions. This spatiotemporal non-correspondence of events is the essence of P and O’s joint engagement. It is precisely because of this empirical indeterminacy that the sufficient condition of pure quality is given, that is, therapeutic impulse in its narrowest sense. In the case described here, O experienced a transitive state after having pronounced “slowing down of time and expansion of space,” is explained in the following from perspectives of physics, philosophy, and neuroscience.This transitive state sequence, “fear of losing control”) and physical issues . This analogy follows the physical concept of “symmetry breaking” from a theoretically possible, healthy state of symmetry  into pathological, observable and, hence, asymmetrical aspects of psyche (“fear of losing control”) and body (“irritable bowel syndrome”). Subsequent predictions about these henceforth denoted observable aspects (phenomena) are deductible. On the one hand, these are subjectively experienced bodily sensations, in the form of symptoms. On the other hand, they occur together with measurable, structurally observable variables . These symptoms only become obsolete once the sufferer begins to appropriately reference them verbally as “vehicle(s) of meaning”  between psychological and physical subdomains of an underlying hypothetical background reality” , p. 202.“Whether one speaks of the ‘participation of natural things in ideas’ or of a ‘behavior of the metaphysical, that is, of things that are in themselves real,’ the relationship between sensory perception and idea remains a consequence of the fact that both the soul of those who know as well as the objects recognized in perception are subject to an objectively conceived order. Any partial knowledge of this order in nature leads to the formulation of statements that on the one hand concern the world of phenomena and on the other hand also use general logical concepts in an idealizing way. The process of understanding nature, as well as the happiness a person feels in understanding, that is, when he becomes aware of new knowledge, seems to be based on the meeting of already existing internal images of the human psyche with external objects and their behavior. As is well known, this conception of natural knowledge goes back to Plato and is also very clearly represented by Kepler” .“fear of losing control,” “irritable bowel syndrome”) of being a human. This ontic background realm corresponds to the Kantian “thing (or object)-in-itself.” According to Kant,In summary, Pauli assumed that an underlying, however undefinable, and unapproachable, ontic background realm that) grounds all aspects  “the latter can be very different.”  “Even if we could bring this intuition of ours to the highest degree of distinctness, we would not thereby come any closer to the constitution of objects in themselves. For in any case, we would still completely cognize only our own way of intuiting, that is, our sensibility, and this always only under the conditions originally depending on the subject, space, and time; what the objects may be in themselves would still never be known through the most enlightened cognition of their appearance, which is alone given to us” . This view is summarized as follows:However, are we really compelled to describe this background realm as ontic, that is, empirically inaccessible, since Kant himself claims some outer given “sensation,” which affects our intuition to form any object? Attempts to shed light on it have been put forward by Karl “Information processing is no longer regarded as [the] primary purpose of the brain’s activity, as it is replaced by the brain’s capacity to transform and integrate different temporal and spatial scales of brain, body, and environment. One example of that is consciousness that may consist in exactly that, the transformation of different temporo-spatial relations into mental features—this is well compatible with the leading theories of consciousness like the Global Neuronal Workspace Theory, the Integrated Information Theory, and especially the Temporo-Spatial Theory of Consciousness” .Consistent with this argument, Northoff concluded that, according to the paradigm of spatiotemporal neuroscience, the mind-brain relationship is less important than the world-brain relationship, owing to the dynamic spatiotemporal alignment of the brain “along” the world , that is“…The brain shows neural activity generated by itself, independently of the stimulus it encounters. This spontaneous or intrinsic activity is described in operational terms as resting-state activity. What neuroscientists observe as stimulus-induced activity is a mixture of both the brain’s intrinsic activity and the neural activity changes related to the stimulus. Consciousness and self are consequently assumed to be predisposed by the brain’s intrinsic activity  and become manifest during the resting state’s modulation by extrinsic stimuli from body and environment” , p. 357.a posteriori connection of brain and psyche  of their experience of illness (“slowing down of time and expansion of space”):Since a person’s suffering consists of contributions from various aspects .This can be illustrated, for example, with the following metaphorical picture: If you cut a piece of marble in half and only look at the cut surface, observing that “the cut surface looks like this or like that,” you may have just thought of the image of the cut surface from the third person perspective. You have no way of indicating what pattern the colors and lines might follow inside the depth of the stone. In contrast to this latter stance, the cut surface is not an end in itself; it is just a means for further departure. Seeing its patterns and enormous variety of strange arrangements of colors and lines, of which it is impossible to determine the intricate ways in which they continue into the depth of the stone, its surface can be called “the appearance of one end of the cut surface (of the piece of marble or other objects).” An important point here is admitting that by merely observing the surface, you are not able to grasp its inner pattern to recognize the object structures in it. However, instead of merely stating the surface as a sober observer, you can look at it, from the stance of the introspective observer, according to James, just as you do with dream images, hypnotic phenomena, meditative states, psychedelic, drug-induced experiences , psychoses, and mystical experiences. First and foremost, the process described here takes place in modern and contemporary art; the mind and body can be connected by the human being and all aspects can disclose together and become visible at the same time, from cubism to abstractionism, in painting and sculpture. You can ask yourself what feelings looking at it evoke in you. Thus, you allow this aspect to be experienced as something dynamic, elusive, or intangible , so it may be perceived as “stochastic.” In contrast, the latter should take place within the context of the symptom. In other words, the symbol of the symptom acts as a unifying bracket that undermines the separation into stochastic events and initiates the therapeutically effective transitive state.“slowing down of time and expansion of space”), which is very similar to Gendlin’s “Thinking at the Edge”  momentum, induced here from the physical aspect, concomitantly correlates with the activation of its counterpart in the psychic aspect, through the emergence of an inner, mental image or thought content, or simply with the liberation from previous, unwanted emotions. Relief from departing pain ensues. That is, the patient is offered a way to autonomous behavior and thus to her dignity of “being human.” Note that only the core process of symptom relief is described here again to see the transitive process’s imminent relevance. Once again, I will stress here the importance of a good starting base, that is, careful history-taking to jointly decipher the fundamental meaning of patient’s various empirical bodily processes.mental time travel, according to Conversely, you can start from the mental subdomain, such as the feeling of a form of fear. By prescribing this feeling and letting it be fully experienced, it can be denoted by its perceived meaning. In other words, the corresponding transitive (or introspective) domain is activated to mediate, for example, nausea, gag reflex, or pain in the head, stomach, or elsewhere. Anything that appears here has the sole purpose of providing experiences to refer to them. Although such experiences might be temporarily discomforting, there is an implicit sense of control over them. This changes the patient’s body posture and mood as an expression of altered bodily intero- and proprioceptive input into the brain , quoted by Figuratively speaking, the patient may experience relief from suffering when ready to board the train that is leaving the station. Such a movement enables alignment to the current sociocultural and bodily context, that is, to attain the transitive process toward the experienced state within the given context; only then is freedom of action regained in this context. In this way, Aristotle’s saying dynamic network of constantly changing social relationships. Implications for future research are compelling. What is the relevance of transitive states vs. substantive states for psychosomatic research and how does this change the approach to therapy or the dynamics of the therapist-patient relationship?In summary, the purpose of this paper is to clarify whether symptom relief in psychosomatic patients is achieved by arriving at a new narrative or by the transition process itself, which lies between the old and new narrative. It has been shown here that symptom relief through verbal symbolization of bodily experiences during joint patient-therapist interaction follows symmetry acquisition, which is only theoretically attainable in its full dimension; it is the embedding of the patient in their sociocultural and body context, initially allegorized by the patient’s changed bodily experiences in the presence of the therapist. Structurally, this is consistent with findings in spatiotemporal neuroscience showing that the transitive parts of consciousness are constructed by the resting-state activity of cortical midline structures, thereby enabling “mental time travel”  or “inteEthical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patient provided her written informed consent to participate in this study.WT wrote the article and approved the submitted version.