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When subjected to potentially traumatic events, adults can develop psychological trauma with varying levels of severity. For preventive and therapeutic purposes, these psychological traumas must be assessed and managed by psychologists and/or psychiatrists who are well trained and experienced in performing these complex professional acts., (Copyright © 2020. Publié par Elsevier Masson SAS.)

The European Journal of Psychotraumatology (EJPT) was launched in 2010. In this editorial, we review the journal's developments over the past 15 years, and discuss some of the current ethical challenges in scientific publishing, including the impact of generative AI. How can we responsibly use these new technologies? Additionally, we present 15 years of journal metrics, highlight past and upcoming special issues on ‘hot topics,’ and are pleased to announce awards for the best paper and best reviewer of 2023, recognizing two outstanding recipients.

Dans cette communication, nous montrons que la littérature sur la prévalence des troubles psychiatriques et liés à l'usage de substances en milieu pénitentiaire est riche. Son interprétation se heurte toutefois à plusieurs difficultés : (i) une grande hétérogénéité des systèmes judiciaire et de soins de santé mentale entre les pays et (ii) des spécificités de l'environnement carcéral parfois négligées dans la méthodologie des études. Forts de ce constat, nous développons les résultats d'un certain nombre de travaux de référence sur la prévalence des troubles psychiatriques et liés à l'usage de substances dans les prisons françaises. Nous discutons enfin les perspectives en termes d'épidémiologie psychiatrique en milieu pénitentiaire. In this paper, we show that the literature on the prevalence of psychiatric and susbtance use disorders in prisons is substantial. However, there are a number of difficulties one encounters in interpreting this literature: (i) there is considerable heterogeneity between countries' judicial and mental health care systems, and (ii) the specific features of the prison environment are sometimes overlooked in the methodology used to conduct such studies. With this in mind, we discuss a number of benchmark studies on the prevalence of psychiatric and substance use disorders in French prisons. Finally, we discuss the perspectives for psychiatric epidemiology in prisons. [ABSTRACT FROM AUTHOR]

Research has shown that the impact of traumatic events and circumstances on individuals is cumulative and potentially has a wide range of harmful consequences, including negative consequences on mental health. One such consequence is the development of a personality disorder, a persistent mental condition characterized by a pronounced pattern of difficulties in impulse control, emotional regulation, cognitive functions, self-esteem, and interpersonal relationships. A wide array of studies indicates that the personal history of individuals with a personality disorder is often marked by exposure to traumatic events or other types of adverse childhood experiences (ACEs). Because existing treatments for personality disorders are usually long and costly, it is essential to continue exploring alternative and complementary interventions. Nowadays, knowledge and clinical experience in regard to personality disorders have been gained in addressing ACEs by processing memories of these events through eye movement desensitization and reprocessing (EMDR) therapy. In this paper, we present a theoretical framework for this treatment approach, based on Shapiro’s Adaptive Information Processing (AIP) model, describe its current empirical basis, and provide guidance on how to formulate a useful case conceptualization that can serve as a basis for the treatment of personality disorders with EMDR therapy. This approach is illustrated with a case example.

Abstract Background Potentially traumatic events may lead to the development of a wide range of adverse psychological responses, including symptoms of anxiety, depression, and (complex) posttraumatic stress disorder (PTSD). Despite the high prevalence of potentially traumatic events in Iran, there is no population data nor evidence-based instrument to screen for cross-diagnostic psychological responses to trauma. The Global Psychotrauma Screen (GPS) is a transdiagnostic self-report instrument for the detection of trauma-related symptoms, as well as risk and protective factors related to the impact of potentially traumatic events. Objective The present study seeks to 1) translate and cross-culturally adapt the GPS in the Persian (Farsi) language and 2) examine the psychometric properties of the Persian GPS. Method The translation and adaptation were performed using the Sousa and Rojjanasrirat (2011) method. A pilot study (n = 30) was carried out to test the content validity and test–retest reliability of the GPS. Next, in a representative sample (n = 800) of residents of Kermanshah City, the GPS, the General Health Questionnaire (GHQ) and the PTSD Checklist for DSM-5 (PCL-5) were administered. Construct validity of the Persian GPS was assessed using exploratory and confirmatory factor analysis. Additionally, we evaluated the convergent validity and internal consistency of the GPS. Results Exploratory and confirmatory factor analyses indicated a three-factor model as the best solution with factors representing 1) Negative Affect, 2) Core PTSD symptoms and 3) Dissociative symptoms. The GPS total symptom score had high internal consistency and high convergent validity with related measures. A GPS total symptom cut-off score of nine was optimal for indicating a probable PTSD diagnosis based on the PCL-5. About half (52%) of the current sample met criteria for probable PTSD. Conclusions The current findings suggest that the GPS can be effectively adapted for use in a non-Western society and, specifically, that the Persian GPS represents a useful, reliable and valid tool for screening of trauma-related symptoms in Iran.

2022 was a year of crises, not just one but multiple intersecting crises that caused traumatic stress in billions of people worldwide. COVID-19 is still not over. New wars have started, and the climate change impact is bigger than ever. Will the Anthropocene be an era of continued crises? This past year the European Journal of Psychotraumatology (EJPT) has again tried to contribute to how to prevent or treat the consequences of these major crises as well as other events and we will continue to do so the year to come. For instance, we will have special issues or collections addressing these big issues, such as climate change and traumatic stress, or early intervention after trauma or in times of conflict. In this editorial, we also present the past year's excellent journal metrics regarding reach, impact, and quality and the ESTSS EJPT award finalists for best paper of 2022 and look forward to 2023.

There is growing evidence that parental trauma is associated with psychosocial disorders, externalizing and internalizing problems, and higher sensitivity to posttraumatic stress disorder (PTSD) in children. Recent research findings suggest multidimensional relational, psychological, and neurobiological interrelated pathways of intergenerational influence. Moreover, the intergenerational effects of parental trauma need to be understood within a broader systemic context, as a part of family adaptation. This article explores research findings and clinical practice to enhance our understanding of intergenerational processes and presents directions for therapeutic interventions. A trauma-focused multi-family therapy, aiming to restrict the relational consequences of parental trauma and strengthen family resilience, is described. The proposition is that to facilitate and improve the quality of parent–child interaction in response to psychotrauma, fostering emotion regulation capacities and mentalization is crucial. These efforts offered through family group interventions may benefit various families coping with adversity in culturally diverse societies.

BackgroundThe mass terrorist attack in Nice, France, in July 2016 caused deaths and injuries in a local population, including children and adolescents. The Nice Pediatric Psychotrauma Center (NPPC) was opened to provide mental health care to the pediatric population (0–18 years) who experienced traumatic events.ObjectivesThis study describes the specificity of the care pathway for young trauma victims, with an explanation of how the NPPC works during the first three years.MethodsIn this retrospective study, we conducted quantitative and qualitative data collection about new and follow-up consultations, primary and comorbid diagnoses, and the kind of trauma (terrorist attack versus other kinds of trauma). Ethics approval was obtained from the local Ethics committee.Results866 children and adolescents were followed in the NPPC. We found a high rate of Post-Traumatic Stress Disorder (PTSD; 71%) in this population with a high rate of comorbidities (67%), mainly sleep disorders (34.7%) and mood and anxiety disorders (16.2%). A high number of children and adolescents impacted by the terrorist attack required follow-up consultations after exposure to the mass terrorist attack, the first care-seeking requests continued to occur three years later, although at a slower rate than in the first and second years. New consultations for other kinds of trauma were observed over time.DiscussionThis study supports previous findings on the significant impact of mass trauma in the pediatric population showing even a higher level of PTSD and a high rate of comorbidities. This may be explained by the brutality of the traumatic event, particularly for this age group. The findings of this study have implications for early interventions and long-term care for children and adolescents to prevent the development of chronic PTSD into adulthood.

Background: A substantial proportion of clinical World War Two survivor offspring reports intrusions about war events they did not experience themselves. Objective: To help identify factors that contribute to the development of such indirect intrusions (i.e. intrusions about non-self-experienced traumatic events), we examined the personal characteristics of survivor offspring that were related to the presence of indirect intrusions. To explore the specificity of these relationships, we compared characteristics related to the presence of indirect and direct intrusions (i.e. intrusions about self-experienced traumatic events). Methods: Participants (N = 98) were post-war offspring of World War Two survivors in treatment in one of two clinics specialized in mental health services for war victims. We assessed the presence of indirect and direct intrusions as well as the following personal characteristics: gender, education level, trait dissociation, affect intensity, attentional control, mental imagery, fantasy proneness, and current psychopathology. Results: Reports of indirect intrusions were more frequent in individuals high in fantasy proneness, trait dissociation, and current psychopathology. Reports of direct intrusions were more frequent in women, individuals scoring high on trait dissociation, affect intensity, and current psychopathology. Fantasy proneness was a unique correlate of indirect intrusions. Conclusions: These findings are consistent with the idea that intrusions are the result of (re)constructive processes affected by several factors including personal characteristics. HIGHLIGHTS Offspring of World War Two survivors often experience indirect intrusions. We examined personal characteristics related to indirect and direct intrusions. Fantasy proneness was the best predictor of indirect intrusions. Gender was the best predictor of direct intrusions.

BackgroundShame and guilt are involved in suicidality and in post-traumatic stress disorder. However, few studies have explored the implication of those emotions in the suicidality of patients exposed to traumatic events.ObjectiveThe objective of this literature review was to examine the implication of shame and guilt in the suicidality of individuals who have experienced potentially traumatic events or been diagnosed with post-traumatic stress disorder. These two emotions are part of post-traumatic stress disorder and suicidality. Moreover, when individuals perceive that their coping strategies are inadequate, they may view suicide as a relief from suffering.MethodThis review was conducted according to PRISMA method. We used combinations of search words for traumatization, suicide ideation and behavior and shame and guilt to search for empirical studies in common databases in psychology and medicine.ResultsAmong 137 identified articles, 9 full texts were retained. Results suggest that shame and guilt were involved in all aspects of suicidality in patients who had experienced traumatic events or been diagnosed with post-traumatic stress disorder. The degree of shame and guilt differed with the type of traumatic event, notably affecting individuals who had experienced military combat, physical or sexual abuse, or emotional or physical neglect.ConclusionShame and guilt are implicated in suicide's risk. Future research is now needed to determine whether greater attention to these two emotions would enhance our understanding and anticipation of suicidal behavior in those who have experienced a potentially traumatic event or been diagnosed with post-traumatic stress disorder.

Introduction: On 2 October 2020, a violent storm (Alex) reached the French Riviera and caused significant damage in three inhabited valleys in the hinterland of the city of Nice. Entire populations were exposed to prolonged stress (no means of communication, electricity nor water) and were particularly at risk of suffering from psychological consequences. We first hypothesized that a majority of children would experience an acute stress reaction. However, we also hypothesized that their clinical expression would differ depending on their developmental age. Thus, we aimed to evaluate, according to the child’s level of development, the presence of acute stress symptoms. Methods: Consecutive interviews with the child/adolescent and his/her parents were conducted by child and adolescent psychologists and psychiatrists to assess symptomatology following storm Alex (from day 1 to day 3). Each interview assessed nine classes of symptoms that have been compared according to age-groups. Results: 116 children have been evaluated (0.2-17.6 years, mean 9.1). The 0-5-years-old showed more agitation as well as developmental regression than children aged 6-11 (p = .011, p = .045) and 12-18 years (p

BackgroundMost asylum seekers experience stress, not only due to the reason for fleeing and their travel but also due to their compulsory stay in the asylum seeker center in the Netherlands and the asylum procedure. This often leads to self-medication and addiction which causes lower self-esteem and lower quality of life. Adverse life events, forced migration, and prolonged asylum procedures, in addition to the complexity of the acculturation process, can all contribute to higher levels of psychopathology.ObjectiveWhat are the threats to wellbeing in terms of mental health, psychosocial, and addiction problems, and what are the effective interventions for wellbeing for asylum seekers in asylum seeker centers in the Netherlands, reported in the literature?MethodFollowing the descriptive nature of the research question and the need for identifying knowledge gaps, an overview of existing knowledge was created by executing a scoping review on influencing factors on the mental health of asylum seekers. The Neuman system model was used as a guiding framework to understand the complexity of the issues this population experience and to identify the stressors and the factors which cause the imbalance and also the disease.ResultsThe literature review resulted in 26 articles that met the criteria for inclusion. The threats included the influence of staying in the environment of an asylum seekers center, drug abuse among asylum seekers, health-care professionals and employees who do not detect or underestimate the underlying suffering of asylum seekers, and frequent relocations of asylum seekers. The two assessment instruments used were the Rapid-Assessment-Response method (RAR method) and the Health Information Assessment Tool Asylum Seeker tool (HIATUS tool). Finally, the five interventions were identified: therapy for asylum seekers diagnosed with post-traumatic stress disorder (PSTD), art therapy, education focused on prevention as intervention, cultural interview, and mindspring.ConclusionThe knowledge on identifying and reducing threats, assessment, and treatment interventions for asylum seekers living in an asylum seekers center found in the literature provided perspectives on improving their wellbeing. The great diversity of cultural aspects and continuous changes in the number and origin of refugees in the Dutch asylum seekers centers disrupted the continuity of care.

Early trauma and failures in attachment attunement can affect future relational patterns, health and well-being. The processing of trauma, especially complex trauma, through adequate interventions may help integrate traumatic experiences, enhance health and quality of life. Despite years of clinical practice with Identity oriented psychotrauma therapy (IoPT), there is a lack of scientific research on the subject.Objective: The study's aim was to explore the experiences and value of IoPT for persons with experiences of IoPT, whether as a therapist, client, representative and/or observer.Methods: The study has an explorative, qualitative design. Data collection through individual in-depth interviews and focus groups with 20 participants and data analysis were inspired by grounded theory.Results: The results showed an exploratory process of self-discovery and self-development, Getting to know the inner self, to which all categories were interrelated through their contribution to the process. The findings shed light on the experiences and tangible value of IoPT for the participants from the perspectives of client, therapist, representative and observer. These perspectives were intertwined and illuminated in terms of their contribution to the process.Conclusion: IoPT seems to have transformative potential in terms of a self-exploratory journey from multiple perspectives. The need for effective treatments to enhance health and prevent further ill health in persons affected by complex trauma motivates the exploration of novel treatment approaches and formats to support clients toward health enhancing strategies. Further quantitative and qualitative research is motivated to enhance our understanding of the workings and value of IoPT for self-development, health and quality of life.

Background: The coronavirus pandemic appears to put psychiatric patients with pre-existing symptomatology at risk of symptom increase, but evidence is scarce. While the pandemic and stringent governmental measures have accelerated the use of clinical videoconferencing (VCT), patient satisfaction with VCT is unclear. Objective: Aim of the study was to assess the wellbeing of patients in psychotrauma treatment during the coronavirus pandemic and to evaluate their use of and satisfaction with VCT. Method: This study used data from a routine outcome monitoring assessment completed by patients in treatment at a specialized psychotrauma institute and administered before the easing of governmental measures in June 2020. Wellbeing (Brief Symptom Inventory, Cantril Ladder, perceived stress level, and symptom change), VCT use and VCT satisfaction, and their association with demographic variables (gender, age, education level, and refugee status) were analysed. Results: Of the 318 respondents (response rate 64.5%), 139 (43.7%) reported a symptom increase, which was associated with a higher coronavirus-related stress level and general psychopathology as well as lower life satisfaction. There were significant effects of age and education level on wellbeing. VCT was reported to have been used by 228 (71.7%) patients. VCT satisfaction ratings were higher among women and those with lower levels of stress (r = −.20, p

This letter provides an update on the activities of “The Global Collaboration on Traumatic Stress” (GC-TS) as first described by Schnyder et al. in 2017. It presents in further detail the projects of the first theme, in particular the development of and initial data on the Global Psychotrauma Screen (GPS), a brief instrument designed to screen for the wide range of potential outcomes of trauma. English language data and ongoing studies in several languages provide a first indication that the GPS is a feasible, reliable and valid tool, a tool that may be very useful in the current pandemic of the coronavirus disease 2019 (COVID-19). Further multi-language and cross-cultural validation is needed. Since the start of the GC-TS, new themes have been introduced to focus on in the coming years: a) Forcibly displaced persons, b) Global prevalence of stress and trauma related disorders, c) Socio-emotional development across cultures, and d) Collaborating to make traumatic stress research data “FAIR”. The most recent theme added is that of Global crises, currently focusing on COVID-19-related projects.

The European Journal of Psychotraumatology, owned by the European Society for Traumatic Stress Studies (ESTSS), launched as one of the first full Open Access ‘specialist’ journals in its field. Has this Open Access model worked in how the Journal has performed? With the European Journal of Psychotraumatology celebrating its ten-year anniversary we look back at the past decade of sharing our research with the world and with how the journal sits with the broader movement beyond Open Access to Open Research and we present new policies we have adopted to move the field of psychotraumatology to the next level of Open Research. While we as researchers now make our publications more often freely available to all, how often do we share our protocols, our statistical analysis plans, or our data? We all gain from more transparency and reproducibility, and big steps are being made in this direction. The journal’s decennial performance as well as the exciting new Open Research developments are presented in this editorial. The journal is no longer in its infancy and eager to step into the next decade of Open Research.

Abstract Background Health care professionals who are frequently coping with traumatic events have an increased risk of developing a posttraumatic stress disorder. Research among physicians is scarce, and obstetrician-gynecologists may have a higher risk. Work-related traumatic events and posttraumatic stress disorder among obstetricians-gynecologists and the (desired) type of support were studied. Methods A questionnaire was emailed to all members of the Dutch Society of Obstetrics and Gynaecology, which included residents, attending, retired and non-practicing obstetricians-gynecologists. The questionnaire included questions about personal experiences and opinions concerning support after work-related events, and a validated questionnaire for posttraumatic stress disorder. Results The response rate was 42.8% with 683 questionnaires eligible for analysis. 12.6% of the respondents have experienced a work-related traumatic event, of which 11.8% met the criteria for current posttraumatic stress disorder. This revealed an estimated prevalence of 1.5% obstetricians-gynecologists with current posttraumatic stress disorder. 12% reported to have a support protocol or strategy in their hospital after adverse events. The most common strategies to cope with emotional events were: to seek support from colleagues, to seek support from family or friends, to discuss the case in a complication meeting or audit and to find distraction. 82% would prefer peer-support with direct colleagues after an adverse event. Conclusions This survey implies that work-related events can be traumatic and subsequently can lead to posttraumatic stress disorder. There is a high prevalence rate of current posttraumatic stress disorder among obstetricians-gynecologists. Often there is no standardized support after adverse events. Most obstetrician-gynecologists prefer peer-support with direct colleagues after an adverse event. More awareness must be created during medical training and organized support must be implemented.

Daily news is dominated by reports of traumatic events across the world. Is trauma indeed rather the norm than the exception? What are the facts? How can we better understand, prevent and treat the consequences of trauma? This past year the European Journal of Psychotraumatology (EJPT) has again tried to address these questions. With the gold Open Access model articles in the journal are being made immediately available without any barriers to access. In Europe, promising developments with regard to Open Science emerged in 2018, for instance, cOAlition S with their ambitious Plan S boosting the transition to full Open Access. In this editorial these and other developments in the journal, such as Registered Reports as a way to reduce Questionable Research Practices (QRPs), journal metrics, and the ESTSS EJPT award finalists for best paper of 2018 are being presented.

An earlier meta-analysis and review indicated that trauma exposure may be related to lower levels of executive functioning in youth. Since different developmental trajectories were found for three core executive functions, the present study focused on working memory, inhibition, and cognitive flexibility specifically. We conducted a multi-level meta-analysis on 55 studies and 322 effect sizes published between 2001 and 2017 that were retrieved from MEDLINE, Embase, and PsycINFO. The 8070 participants in selected studies were aged 2–25 years. We investigated whether the association between constructs would be moderated by trauma-specific moderators (onset, duration, and type), and study (age, gender, ethnicity, and socio-economic status) and measurement (quality) characteristics. We found small to medium effect sizes for working memory (d = −0.49), inhibition (d = −0.46), and cognitive flexibility (d = −0.44). Moderator analyses showed that, for working memory, when studies used low-quality measurements the effect size was significantly stronger than when studies used high-quality measurements.Compared to single trauma-exposed youth, violence-exposed/abused and foster care/adopted youth showed more problems in inhibition, and foster care/adopted youth showed more problems in cognitive flexibility. Our findings imply that trauma-exposed youth have lower levels of executive functions. Clinical practice should incorporate problems in executive functioning, especially working memory, inhibition, and cognitive flexibility, in assessment and treatment guidelines.

Psychotraumatology is on the move. Worldwide, there is an increasing awareness of the negative impact of psychotrauma, which is reflected in the number of publications on the topic. These publications become more and more available to the public (Open Access), even more so than in other fields, and thus lead to quicker implementation of research findings. In this editorial, the editor of the European Journal of Psychotraumatology (EJPT) provides a brief review of how the journal has been doing, including recent accomplishments, some metrics and the ESTSS EJPT award for best paper of 2017, and identifies a number of priorities for the next year.

Background In April 2011, a post election violent conflict in Northern Nigeria led to resettlement of internally displaced persons (IDPs) in a camp in Kaduna, the worst affected state. We set out to determine prevalence and socio-demographic factors associated with post-traumatic stress disorder (PTSD) among IDPs. We also determined types of psycho-trauma experienced by the IDPs and their psychosocial adjustment.MethodsCross-sectional systematic random sampling was used to select 258 adults IDPs. We used Harvard trauma questionnaire to diagnose symptomatic PTSD, composite international diagnostic interview for diagnosis of depression, and communal trauma event inventory to determine exposure to psycho-trauma. We assessed social adjustment using social provision scale. Multiple logistic regression was used to determine independent predictors of PTSD. Results Of the 258 IDPs, 109 (42.2%) had a diagnosis of PTSD, 204 (79.1%) had poor living conditions, and only12 (4.7%) had poor social provision. The most frequent psycho-traumas were destruction of personal property (96.1%), been evacuated from their town (96%) and witnessing violence (88%). More than half (58%) of IDPs had experienced 11 – 15 of the 19 traumatic events. Independent predictors of PTSD among respondents were, having a CIDI diagnosis of depression (Adjusted Odd Ratio [AOR]3.5, 95% CI 1.7 – 7.5; p= 0.001) and witnessing death of a family member ( 3.7, 1.2 – 11.5; p=0.0259).ConclusionWe concluded that exposure to psycho-trauma among IDPs in Kaduna led to post conflict PTSD. Death of a family member and co-morbid depression were independent predictors of PTSD among IDPs. Though their living condition was poor, the IDPs had good psychosocial adjustment. We recommended a structured psychosocial intervention among the IDP targeted at improving living condition and dealing with the psychological consequences of psycho-trauma.Key words Post traumatic stress disorder, psychosocial adjustment, psycho-

Résumé Cet article relate l’histoire singulière de la psychiatrie dans l’île de la Martinique, de l’époque de l’esclavage à aujourd’hui. Dans la liste des événements traumatogènes signalés par le DSM-IV et le DSM-5, l’esclavage ne figure pas. L’article néanmoins aborde la question jamais étudiée sur le plan psychiatrique du psychotraumatisme de l’esclavage et de sa transmission transgénérationnelle aux populations d’aujourd’hui ; il met en parallèle les destins de l’insensé et de l’esclave, il décrit la clinique et les thérapeutiques du xvii e au xix e siècle, en particulier l’innovation remarquable qu’a été la Maison de Santé de Saint-Pierre qui sera ensevelie sous les nuées ardentes de la montagne Pelée le 8 mai 1902 avec les espoirs de l’offre de soins psychiatriques. This article presents the unique history of psychiatry in the island of Martinique in the time of slavery to today. In the list of traumatogenic events reported by the DSM-IV and DSM-5 slavery is not. Nevertheless, the article discusses ever studied psychiatrically the trauma of slavery and its transgenerational transmission to people today; it compares the fate of the fool and the slave, it describes the symptoms and treatment from the seventeenth to the nineteenth century and it tells the remarkable psychiatric innovation that was the Health House of St. Peter to be buried May 8, 1902 under the burning ashes with the hopes of the supply of psychiatric care. [ABSTRACT FROM AUTHOR]

Background: This paper investigated adherence to a self-help web-based intervention for PTSD (Chinese My Trauma Recovery, CMTR) in mainland China and evaluated the association between adherence measures and potential predictors, for example, traumatic symptoms and self-efficacy. Methods: Data from 56 urban and 90 rural trauma survivors were reported who used at least one of the seven recovery modules of CMTR. Results: The results showed that 80% urban users visited CMTR four or less days and 87% rural users visited CMTR for 5 or 6 days. On average, urban users visited 2.54 (SD=1.99) modules on the first visiting day and less from the second day; rural users visited 1.10 (SD=0.54) modules on the first visiting day, and it became stable in the following days. In both samples, depression scores at pre-test were significantly or trend significantly associated with the number of visited web pages in the relaxation and professional help modules (r=0.20–0.26, all p