The effectiveness of combined writing in preventing psychological problems: the role of ambivalence

Janine Cristina Marinai The Effectiveness of Combined Writing in Preventing Psychological Problems: The Role of Ambivalence junho de 2021 The effectiveness of combined writing in preventing psychological problems: the role of ambivalence Janine C. Marinai UMinho | 2021 Janine Cristina Marinai The Effectiveness of Combined Writing in Preventing Psychological Problems: The Role of Ambivalence Dissertação de Mestrado Mestrado em Psicologia Aplicada Trabalho realizado sob a orientação do Doutor João Batista e do Professor Doutor Miguel M. Gonçalves junho de 2021 ii DIREITOS DE AUTOR E CONDIÇÕES DE UTILIZAÇÃO DO TRABALHO POR TERCEIROS Este é um trabalho académico que pode ser utilizado por terceiros desde que respeitadas as regras e boas práticas internacionalmente aceites, no que concerne aos direitos de autor e direitos conexos. Assim, o presente trabalho pode ser utilizado nos termos previstos na licença abaixo indicada. Caso o utilizador necessite de permissão para poder fazer um uso do trabalho em condições não previstas no licenciamento indicado, deverá contactar o autor, através do RepositóriUM da Universidade do Minho. Licenc ! a concedida aos utilizadores deste trabalho Atribuição CC BY https://creativecommons.org/licenses/by/4.0/ iii Agradecimentos Agradeço a todos os que caminharam comigo na realização desse trabalho. Ao João Batista, que me orientou sempre com muito empenho e dedicação, pelas longas e produtivas conversas, pelos feedbacks acertados nos textos e apresentações, que constituíram a tese da forma como ela existe hoje. Ao Miguel Gonçalves, pelo acolhimento caloroso e pelos feedbacks, que por vezes me tiraram o chão, mas que foram fundamentais para tornar esse trabalho melhor. À Melissa Gouveia, pelo companheirismo neste projeto compartilhado. Ao Nelson Garzeri, por estar ao meu lado neste último ano, pelas madrugadas sem dormir para garantirmos a entrega do aplicativo writenletgo.pt, pelas conversas sobre os conceitos da psicologia na perspetiva de um engenheiro e economista, e pelas revisões incansáveis dos textos e apresentações. À Noela Gigliotti, por me socorrer e acolher quando meu pai faleceu, me ajudando a seguir adiante com a vida e com o mestrado, além das leituras e revisões da tese, os treinos de apresentação e as discussões divertidas sobre a ambivalência. Aos meus pais, que não tiveram oportunidade de presenciar esse momento fisicamente, mas que seguem tão presentes em minha vida quanto antes. Por fim, agradeço a todos os amigos que me inspiraram durante a escrita da tese, e à vida por me trazer até esta cidade, universidade e equipa. Confio que é aqui que eu deveria estar, mesmo sem ter presenciado ainda o desenrolar completo dessa história. iv STATEMENT OF INTEGRITY I hereby declare having conducted this academic work with integrity. I confirm that I have not used plagiarism or any form of undue use of information or falsification of results along the process leading to its elaboration. I further declare that I have fully acknowledged the Code of Ethical Conduct of the University of Minho. Signature: _____________________________________________ v A eficácia da escrita combinada na prevenção de problemas psicológicos: O papel da ambivalência Resumo Objetivo: A escrita expressiva tem uma longa tradição na psicologia com programas de baixo custo dirigidos à melhoria da saúde física e mental de diversas populações. Este estudo desenvolveu um programa piloto online baseado em escrita para estudantes universitários. Os objetivos foram testar a eficácia de instruções combinadas na redução do sofrimento psicológico e estudar o papel da ambivalência no contexto da intervenção. Método: Os estudantes, recrutados em universidades portuguesas (n=165), foram aleatorizados em 2 grupos. O grupo experimental realizou tarefas de escrita de 20 minutos em 4 dias consecutivos sobre um problema do participante. O grupo de controle ficou em lista de espera. Medidas psicológicas foram recolhidas no início do estudo, após cada tarefa, uma e duas semanas após a intervenção. Resultados: A análise multivariada entre grupos identificou uma redução significativa na ambivalência, mas nenhuma alteração nos sintomas e no bem-estar, embora o sofrimento psicológico aferido após as sessões se tenha reduzido significativamente. Discussão: A escrita combinada mostrou-se promissora na melhoria da ambivalência envolvida nas dificuldades psicológicas, havendo ainda indicações que sugerem uma diminuição do mal-estar entre sessões. A confirmação destes resultados pode ser um aspeto a favor da generalização do uso desta metodologia, dado o baixo custo envolvido. Palavras-chave: escrita expressiva, escrita combinada, ambivalência, entrevista motivacional, estudantes universitários vi The effectiveness of combined writing in preventing psychological problems: The role of ambivalence Abstract Aim: Expressive writing have a long tradition in psychology with low-cost programs aimed at improving the physical and mental health of various populations. This study developed an online writing-based pilot program for university students. The goals were to test the effectiveness of combined instructions in reducing psychological distress and to study the role of ambivalence in the context of the intervention. Method: Students were recruited from Portuguese universities (n = 165) and randomized into 2 groups. The experimental group performed 20-minute writing tasks on 4 consecutive days related to the participant’s problem. Controls were wait list. Psychological measures were collected at baseline, after each session, one and two weeks after the intervention . Results: Multivariate analysis between groups identified a significant reduction in ambivalence, but no change in symptoms and well-being, although psychological distress assessed after the sessions has reduced significantly. Discussion: Combined writing has shown promise in improving the ambivalence involved in psychological difficulties, with indications that suggest a decrease in distress between sessions. The confirmation of these results can be an aspect in favor of the widespread use of this methodology, given the low cost involved. Keywords: expressive writing, combined writing, ambivalence, motivational interviewing, university students vii TABLE OF CONTENTS The effectiveness of combined writing in preventing psychological problems: ....................................... 9 The role of ambivalence ...................................................................................................................... 9 Meta-Analyses on Expressive Writing ............................................................................................... 9 Writing Paradigms ........................................................................................................................ 11 Ambivalence and Expressive Writing .............................................................................................. 13 The Present Study ........................................................................................................................ 14 Method ............................................................................................................................................. 15 Participants .................................................................................................................................. 15 Procedure .................................................................................................................................... 18 Data Analysis ................................................................................................................................ 20 Within-group Analyses ............................................................................................................... 20 Results ............................................................................................................................................. 20 Preliminary Analysis ...................................................................................................................... 20 Between-group Analyses ............................................................................................................... 22 Moderation and Mediation Analyses .............................................................................................. 23 Within-group Analyses ................................................................................................................... 24 Discussion ........................................................................................................................................ 25 LIST OF TABLES Summary of Meta-Analyses ............................................................................................................... 10 Experimental Condition ..................................................................................................................... 19 Descriptive Statistics for Psychological Measures by Group ................................................................ 21 Independent-Samples t-Tests Results Between Groups ....................................................................... 22 One-Way Repeated Measures MANOVA Between Groups ................................................................... 23 Paired-Samples t-Tests Results Within the Experimental Group ........................................................... 24 14 These concepts are part of Motivational Interviewing (hereafter MI; Miller & Rollnick, 2013), a method developed by the authors to facilitate change, by working to resolve ambivalence. MI was conceived as a way to handle problems using a client-centered approach and has been extensively researched and developed clinically (Engle & Arkowitz, 2006). The method presupposes that change involves internal conflicts and encourages the person to increase intrinsic motivation for changing. It emphasizes the importance of clients’ agency, while recognizing their stage of change (Miller & Rollnick, 2013). Although described as a directive approach, the therapist role is not to directly influence change, but to foster reflection and raise awareness of ambivalence. Using an empathetic posture, the therapist asks open questions and reflects back to the client. Several exercises are proposed, such as to query the extremes looking back and forward, hypothesize change, reflect on pros and cons of change, aiming to develop discrepancy, voice and balance both sides of the conflict, support self-efficacy, enhance confidence and elicit change talk. Recent work leveraged MI in the context of EW, with a program to help people reflect about the COVID-19 pandemic impacts (Welch et al., 2020). Expressive interviewing, as denominated by the authors, is an automated system that combines EW and MI techniques. For Welch at al. (2020), MI share common fundamentals with EW in a sense that when speaking, or writing, people gain a sense of agency and coherence of the thoughts and emotions that surround their experience. Reflections around the pandemic impacts were promoted with the use of open-ended questions around multiple topics and through reflexive feedback. The Present Study Write ‘n’ Let Go uses combined instructions with close attention on ambivalence results and the role it plays in the context of the intervention. The program consisted of 20-minute writing tasks on 4 consecutive days related to a problem identified by the participant. The combined instructions guided participants in a journey of expressing emotions (1st task), organizing thoughts (2nd task), recognizing strengths and resources (3rd task) and imagining the problem solved (4th task). On the negative emotion’s tasks (1 and 2), the mechanisms used for problem activation intended to foster emotional ventilation, raise awareness of emotions, gain insights, make sense or reappraise the problem, and form a coherent story (Pennebaker, 1993; Range & Jenkins, 2010). On the positive emotions tasks (3 and 4), resource activation intended to elicit positive emotions, raise awareness of values, strengths, competencies, and simulate successful outcomes about the problem (Frattaroli, 2006). According to Gassmann and Grawe (2006), problem activation and resource activation are general change mechanisms that when combined may lead to therapeutic progress in psychotherapy. Resource activation was studied in the context of EW 15 with instructions designed to elicit and recognize personal resources (Toepfer et al., 2016). Besides, a core component in all instructions was the emotional expression, expected to act as a change enabler by raising awareness of the different positions of the self and the world (Gassmann & Grawe, 2006) and to try to avoid contents in total absence of affect (Engle & Arkowitz, 2006). Our main hypothesis was that the mechanisms evoked by combined instructions may lead participants to increased awareness, self-regulation, and self-efficacy, facing the conflict in a more resourceful way, hence reducing ambivalence. This, in turn may promote adaptive changes leading to an increase in well-being and a decrease in psychological symptoms and distress. Although speculative, this was an innovative aspect of our work since ambivalence has been little explored outside the context of psychotherapy and can be a relevant factor as a potential mediator or moderator in the effectiveness of writing interventions. In sum, since Pennebaker and Beall's (1986) original study, EW has been target of an extensive body of research. The multiple applications of this accessible intervention have led researchers to test its efficacy in different formats with different populations. With this study we aimed to assess the effectiveness of an online writing-based program for university students in Portugal. More specifically, we sought to test the efficacy of combined instructions that guided participants to write about their chosen problem or life situation while studying ambivalence in this context. Assessing a potential mediator or moderator of the intervention results can contribute to the literature by exploring alternative underlying mechanisms of EW effects. All activities were carried out online and autonomously, thus the program could be widely offered. From a pragmatic perspective, this study was justified by the need to rapidly expand the capacity to provide continuous care in mental health, which is still very limited and asymmetric (Conselho Nacional de Saúde, 2019). EW interventions are inexpensive, easy to implement, and could become a preventive tool to enable self-reflection and increased awareness about the importance of mental health care. Method Participants Between September 2020 and May 2021, 320 university students signed up for screening on our program’s website (http://writenletgo.pt). Eligible participants had Portuguese as native language, were of legal age (>=18 years old), and did not present severe anxiety (GAD-7>=15), severe depression (PHQ-9>=20), suicidal ideation or risky behaviors such as self-mutilation or substance abuse. In the screening process, 93 participants were excluded according to the reasons: undergoing psychotherapy (23%), severe anxiety (22%), severe depression (10%), suicidal ideation (3%), self-mutilation behavior (4%), 16 didn’t complete the screening (29%), or didn’t sign the informed consent (5%). The students with severe anxiety or depression, suicidal ideation, and risky behaviors were recommended to look for psychological or medical support. The exclusion of participants undergoing psychotherapy ceased in the middle of the study due to the high demand from students in this situation. The 227 eligible participants were randomly assigned to the experimental group (n=114) and control (waitlist) group (n=113). The 27% dropout at various points along the program led to 165 completers, 78 in the experimental group and 87 in the control group. University of Minho (hereafter UMinho) psychology students that received credits for participating in the program represented 57% of the eligible participants and 77% of the completers. Figure 1 details the study design and the participants’ flow from enrollment to follow-up. Figure 1 Study Design and Participants’ Flow 17 Participants’ mean age was 22.8 years (SD = 6.97). The majority of the sample was female (86%), Portuguese (88%), single (94%) and student at the Integrated Master’s Degree program (68%). Although we had participants from 10 different universities, most of them (91%) were from the UMinho. The mean baseline symptomatology scores were mild depression (M = 6.04, SD = 3.96) and mild anxiety (M = 6.14, SD = 3.89); 49% of the participants have had psychotherapy in the past and 10% are currently undergoing psychotherapy. The sociodemographic characteristics at baseline didn’t differ between the groups (all p values > 0.05). Measures Generalized Anxiety Disorder Scale (GAD-7) (Spitzer et al., 2006; adapted by Sousa et al., 2015) A self-report questionnaire with 7 items that assesses symptoms of general anxiety. Participants rated symptoms experienced within two weeks prior to the administration of the questionnaire, through a 4-point Likert scale, from 0 (not at all) to 3 (nearly every day). Scores range from 0–21, with a severity classification of minimal (0–4), mild (5–9), moderate (10–14), and severe (15–21). The Portuguese version showed internal consistency of .88 (Sousa et al., 2015). The GAD-7 was collected during the screening process/baseline, at post-test, and follow-up. Patient Health Questionnaire (PHQ-9) (Kroenke & Spitzer, 2002; adapted by Monteiro et al., 2013) A self-report questionnaire with 9 items used to monitor depression symptomatology. Participants rated each item with the symptoms experienced two weeks before the administration of the questionnaire, through a 4-point Likert scale, from 0 (not at all) to 3 (more than half of the days). Total scores range from 0–27, with a severity classification of minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27). The Portuguese version showed an internal consistency of .86 (Monteiro et al., 2013). The PHQ-9 was collected during the screening process/baseline, at post-test, and follow-up. Positive and Negative Affect Schedule (PANAS) (Watson et al., 1988; adapted by Galinha & PaisRibeiro, 2005) A self-report measure that assesses to what extent individuals experienced positive and negative emotions in the last two weeks. Positive affect (PA) and negative affect (NA) scales consist of 10 items each. Responses to each item use a 5-point Likert scale (from 1 = very slightly or not at all to 5 = extremely). Scales scores range from 10–50. Higher scores indicate higher levels of positive or negative affect. The Portuguese version showed internal consistency of .86 for the PA scale and .89 for the NA scale (Galinha & Pais-Ribeiro, 2005). The PANAS was collected at baseline, post-test, and follow-up. 18 Revised Life Orientation Test (LOT-R) (Scheier et al., 1994; adapted by Laranjeira, 2008) A self-report measure that assesses dispositional optimism. It consists of 10 items, of which only 6 are scored (items 1, 3, 4, 7, 9, and 10). The 4 items not scored (2, 5, 6, and 8) are distractors and were not included in this study. Responses to each item use a 5-point Likert scale, from 0 (strongly disagree) to 4 (strongly agree). The minimum score is 0 and the maximum is 24. The Portuguese version showed internal consistency of .71 (Laranjeira, 2008). The LOT-R was collected at baseline, post-test, and follow-up. Satisfaction with Life Scale (SWLS) (Diener et al., 1985; adapted by Neto, 1993) A self-report measure that assesses life satisfaction perception. Each of the 5 items are rated on a 7-point Likert scale (from 1 = strongly disagree to 7 = strongly agree) with the total score ranging from 5–35. Higher scores indicate greater satisfaction with life. The Portuguese validation showed an internal consistency of .86 (Neto, 1993). The SWLS was collected at baseline, post-test, and follow-up. Ambivalence in Psychotherapy Questionnaire (APQ) (Oliveira et al., 2020) A self-report measure that provides a global score of clients’ ambivalence levels towards change, and two sub-scales scores: demoralization and wavering. It is composed of 9 items answered on a Likert scale (from 1 = totally disagree to 5 = totally agree), with total scores ranging from 9–45. The demoralization dimension consists of 5 items (1, 6, 7, 8, and 9) and “ emerges as the consequence of a perceived lack of skills to achieve change and the confusion of goals due to internal conflict” (Oliveira et al., 2020, pg. 6). The wavering dimension consists of 4 items (2, 3, 4, and 5) and “refers to the oscillatory movements between two (or more) positions regarding a given object” (Oliveira et al., 2020, pg. 6). Both the global score and sub-scales exhibit good psychometric properties. For the purpose of this study, APQ was adapted to switch from the psychotherapeutic setting to the EW pilot program. The APQ was collected at baseline, after each writing task, at post-test, and follow-up. Outcome Questionnaire 10.2 (OQ10.2) (Lambert et al., 2005; adapted by Oliveira et al., 2019) A self-report measure that monitors symptomatic change in the dimensions of psychological wellbeing and psychological distress. The 10 items are rated on a 5-point Likert scale ranging from 0 (never) to 4 (almost always). Higher total scores indicate more symptomatic distress. The Portuguese validation showed an internal consistency of .80 (Oliveira et al., 2019). The OQ-10.2 was collected after each writing task. Procedure The study was approved by the Research Ethics Committee in Social and Human Sciences at the University of Minho (process CEICSH 072/2020). A web application http://writenletgo.pt was developed 19 specifically for the program. Its workflow included enrollment, screening, online consent, data collection, and writing tasks that were accompanied by explanatory videos besides the written instructions. The application provided an exclusive area for each participant with a panel of planned activities/dates to be performed throughout the program and sent email with task reminders. Write ‘n’ Let Go was promoted at national and regional media, at social networks, at the UMinho School of Psychology’ credits platform, and through direct emailing universities and its student associations. Students registered at the website and filled in the screening questionnaires. Eligible participants gave online consent and were randomly allocated to the control or the experimental group. In both conditions, participants began by performing the pre-task, which consisted of collecting additional baseline measures and identifying a 'Problem’, i.e. a life situation, or an emotionally disturbing event that was causing psychological distress and significantly affecting life. A brief description of this problem, its nature, and the problem severity were registered and became the central theme of the writing intervention. Participants in the experimental group wrote for 4 consecutive days, 20 minutes per day about their identified problem and responded to questionnaires. Different instructions were provided each day (see Table 2 for details). Table 2 Experimental Condition Session Writing Task Name Writing Instructions (summarized ideas) “Write about your most intimate thoughts and feelings about...” 1 Express your emotions …your problem, your behaviors facing the problem, your relationships with others, the impact this problem has in your past, present, and future, in your life, and the person you are. Þ +collect psychological distress/ambivalence levels 2 Organize your thoughts …your problem, describe it in detail, its origins, obstacles, maintenance factors, consequences if resolved, and the role of others. Þ +collect psychological distress/ambivalence levels 3 Recognize your strengths …your skills, strengths, and resources, how these skills can be useful in solving the problem, how you dealt with other difficulties in the past, which resources were most useful to you, and the support of others. Þ +collect psychological distress/ambivalence levels 4 Imagine your problem solved …your life in the near future, in which the problem you identified has been resolved or has stopped causing such great discomfort. Imagine everything went as smoothly as possible, and you were able to better deal with the problem or resolve it properly. Þ +collect psychological distress/ambivalence levels 20 The control group was a waitlist and responded to post-test measures 2 weeks after the pre-task. At this point, participants were able to begin the experimental condition activities. For the experimental group, post-test and follow-up measures were collected, respectively, 1 and 2 weeks after the last writing task (refer back to Figure 1 for details). Data Analysis All analyses were done using IBM SPSS Statistics for Mac, Version 27.0. Preliminary Analysis Independent-samples t-tests were used to validate if the experimental group differed from the control group on the measures collected at baseline. Between Group analyses: The impact of the intervention on the measures and its sub-scales, when applicable, and the corresponding effect sizes were estimated using independent-samples t-tests comparing the difference in means (post-test minus baseline) from the experimental condition and the control group. A one-way repeated measures MANOVA (multivariate analysis of variance), including all measures at baseline and post-test as dependent variables, was used to confirm the results obtained in the previous test. Moderation and Mediation Analyses The analyses of moderation and mediation of ambivalence were conditioned to the intervention producing significant effects on at least one other measure, and followed the models described in Baron and Kenny (1986). Within-group Analyses We estimated the effect size of the intervention using paired-samples t-tests comparing the experimental group measures at baseline and post-test. For the variables with significant results, the analysis was repeated using post-test and follow-up measures to assess if the gains persisted at follow up. To test the impact of the writing tasks on the measures collected immediately after each task, we used one-way repeated measures MANOVA. Post hoc pairwise comparisons using a Bonferroni correction for multiple comparisons assessed the impact of each pair of tasks individually. Results Preliminary Analysis Table 3 presents the descriptive statistics of psychological measures collected at baseline, posttest and follow-up as a function of group. Preliminary analysis did not produce any significant differences 21 on baseline measures between the experimental and the control group (all p values >.05), indicating a successful randomization of participants. Table 3 Descriptive Statistics for Psychological Measures by Group Psychological measure Baseline Post-Test Follow-up n M SD n M SD n M SD Anxiety Experimental 114 5.96 3.83 81 6.19 4.26 78 6.21 4.94 Control 113 6.32 3.96 87 6.33 4.53 Depression Experimental 114 5.84 3.86 81 5.77 4.25 78 5.71 4.19 Control 113 6.25 4.07 87 6.45 4.65 Negative Affect Experimental 106 19.63 7.42 81 17.95 6.63 78 17.37 6.44 Control 103 19.14 7.32 87 18.17 7.29 Positive affect Experimental 106 26.25 8.02 81 25.42 7.93 78 25.09 7.91 Control 103 27.31 7.94 87 25.86 7.38 Dispositional Optimism Experimental 106 14.01 4.95 81 13.91 5.17 78 14.21 5.08 Control 103 14.7 4.59 87 14.82 4.68 Satisfaction with Life Experimental 106 16.64 3.72 81 17.53 3.77 78 17.63 3.68 Control 103 17.27 3.69 87 17.69 3.15 Ambivalence Experimental 106 30.43 7.01 81 25.36 7.81 78 25.49 7.68 Control 100 30.87 6.44 86 29.52 7.03 Ambivalence Demoralization Experimental 106 15.84 4.72 81 12.68 4.98 78 12.94 4.79 Control 100 16.34 4.07 86 15.49 4.45 Ambivalence Wavering Experimental 106 14.59 3.20 81 12.68 3.54 78 12.55 3.54 Control 100 14.53 2.99 86 14.03 3.30 Note. Empty cells are measures not collected at follow-up for the control group. 22 Between-group Analyses The estimation of the impact and effect size of the intervention on the psychological measures between groups using independent-samples t-tests indicated a significant ambivalence reduction in participants of the experimental group ( t (165) = -4.12, p < .001, d = -.64). Significant differences were found in the ambivalence sub-scales, with participants in the experimental group reporting lower levels of demoralization ( t (165) = -3.61, p < .001, d = -0.56) and lower levels of wavering ( t (165) = -2.95, p = .004, d = -0.46) than participants in the control group. The experimental group did not differ from the control group in depression, anxiety, positive affect, negative affect, dispositional optimism, and satisfaction with life (detailed results are presented in Table 4). Table 4 Independent-Samples t-Tests Results Between Groups Psychological measure Difference in Means t df p Cohen's d Experimental Control Anxiety 0.47 0.21 0.49 166 .628 0.08 Depression 0.38 0.10 0.53 166 .594 0.08 Negative Affect -1.38 -0.94 -0.48 166 .631 -0.07 Positive affect -1.00 -1.67 0.77 166 .442 0.12 Dispositional Optimisma -0.01 0.13 -0.34 145 .734 -0.06 Satisfaction with Life 0.44 0.39 0.17 166 .862 0.03 Ambivalence -4.93 -1.64 -4.12 165 .000*** -0.64 Ambivalence - Demoralization -3.00 -0.94 -3.61 165 .000*** -0.56 Ambivalence - Wavering -1.93 -0.70 -2.95 165 .004** -0.46 Note. Difference in means calculated by subtracting the baseline mean from the post-test mean in each group. All p values in this table are two-tailed. a Equal variances not assumed, Glass’s Delta effect size used. ** p < .01, *** p < .001 23 The results of a MANOVA, including all measures at baseline and post-test as dependent variables, indicated a significant effect on the group*time interaction (Pillai's Trace = 0.108, F (7.159) = 2.76, p = .010, ηp2 = 0.11). From a univariate perspective, ambivalence was significantly different between the experimental and the control group (F(1,165) = 16.98, p < .001, ηp2 = 0.09). No differences were found in depression, anxiety, negative affect, positive affect, dispositional optimism, and satisfaction with life (see table 5 for detailed MANOVA univariate results). Post hoc pairwise comparisons analyses using a Bonferroni correction indicated that ambivalence reduced significantly at post-test in both groups, but the reduction was more pronounced in the experimental group ( p < .001) than in the control group ( p = .004), confirming the independent-samples t-tests results. Table 5 One-Way Repeated Measures MANOVA Between Groups Psychological measure M Experimental M Control F (1,165) p ηp2 Baseline Post-test Baseline Post-test Anxiety 5.72 6.19 6.13 6.24 0.44 .510 0.003 Depression 5.38 5.77 6.28 6.43 0.20 .659 0.001 Negative Affect 19.33 17.95 19.03 17.84 0.04 .834 0.000 Positive affect 26.42 25.42 27.58 25.94 0.54 .463 0.003 Dispositional Optimism 13.93 13.91 14.74 14.92 0.22 .643 0.001 Satisfaction with Life 17.09 17.53 17.43 17.81 0.04 .845 0.000 Ambivalence 30.28 25.36 31.16 29.52 16.98 .000*** 0.093 Note. 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