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Emotionally focused therapy (EFT) is an evidence-based treatment for relational distress based on experiential, humanistic, and attachment theories. Despite the empirical support for EFT, there are no studies on EFT delivered via teletherapy. In this study, we aimed to understand therapists' experiences delivering EFT through teletherapy using open-ended questions on a web-based survey of certified EFT therapists (n = 69). Reflexive thematic analysis identified five themes: (1) Delivering EFT via teletherapy is similar to in-person therapy, (2) Delivering EFT via teletherapy is more challenging than in-person therapy, (3) Delivering EFT via teletherapy is more challenging with certain clients, (4) therapists adapted EFT for teletherapy, and (5) teletherapy and the COVID-19 pandemic changed therapy practice. The themes illustrated the mixed experiences of EFT therapists using teletherapy. Whereas some found it straightforward to use EFT via teletherapy with couples, others experienced exhaustion and barriers. Practice recommendations for delivering EFT via teletherapy are outlined, including modifying assessment strategies, implementing new safety protocols, and providing additional psychoeducation., (© 2024 The Author(s). Family Process published by Wiley Periodicals LLC on behalf of Family Process Institute.)

Clinical education programs are positioned to train future health care professionals to provide excellent health care for transgender and gender-diverse patients. The purpose of this resource, Advancing Inclusion of Transgender and Gender-Diverse Identities in Clinical Education: A Toolkit for Clinical Educators, is to facilitate critical inquiry among clinical educators regarding their approach to teaching about sex, gender, the historical and sociopolitical context of transgender health, and how to prepare their students to apply standards of care and clinical care guidelines set forth by national and international professional organizations.

This study sought to understand how transgender and gender non-binary (TGNB) individuals skillfully cope with healthcare services and to explore how childhood experiences impact expectations, habits, and meaning-making when utilizing healthcare services. Using an interpretive phenomenological approach, we sampled 17, White TGNB adults in the United States, ages 19 to 57, using semi-structed interviews about childhood experiences with healthcare utilization and adult experiences seeking genderaffirming healthcare. Analysis identified one main theme-Anticipate the worst in healthcare and be pleasantly surprised-and three subthemes: i) contrast between positive childhood and negative adulthood experiences in medical care; ii) coping practices for the worst; and iii) finding your unicorn doctor and medical staff for pleasant experiences. Results indicate participants experienced a disruption and acquisition of new coping practices in healthcare settings and the cultivation of a radical imagination for a more liberated medical world for TGNB people. Implications for providers and medical offices for empowering TGNB adults are described., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest, and all authors confirm accuracy., (Copyright © 2023, the Author(s).)

Background: Lack of transgender health education among health professional education programs is a limitation to providing gender-affirming care. Educational interventions have advanced in the past decade using a variety of pedagogical approaches. Although evidence supports that educational interventions can significantly improve student knowledge, comfort levels, preparedness, and clinical skills, few studies have addressed student perceptions of or receptiveness towards transgender health education. The study purpose was to explore student perceptions of transgender health education using a qualitative approach., Methods: We utilized a basic qualitative design to explore student perceptions of transgender health education at a Catholic, Jesuit institution. Participants were medical students (n = 182), medical family therapy students (n = 8), speech, language and hearing sciences students (n = 44), and dietetic interns (n = 30) who participated in an Interprofessional Transgender Health Education Day (ITHED) in partnership with transgender educators and activists. Participants completed an online discussion assignment using eight discussion prompts specific to the ITHED sessions. Data were analyzed using the constant comparative method and triangulated across four medical and allied health programs., Results: A total of 263 participants provided 362 responses across eight discussion prompts. Three major themes resulted: (1) The Power to Help or Harm, (2) The Responsibility to Provide Health Care, and (3) A Posture of Humility: Listen and Learn. Each theme was supported by three to four subthemes., Conclusions: Health professional students were highly receptive towards transgender health education delivered by transgender community members. First-person accounts from session facilitators of both positive and negative experiences in healthcare were particularly effective at illustrating the power of providers to help or harm transgender patients. Reflection and constructive dialogue offers students an opportunity to better understand the lived experiences of transgender patients and explore their identities as healthcare providers at the intersection of their religious and cultural beliefs., (© 2023. The Author(s).)

Background: Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth., Aims: The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness., Method: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized., Results: 49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed., Conclusions: Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems., Aims: This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches., Method: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes., Results: After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image., Conclusions: Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities., (© 2023. The Author(s).)

Introduction: Peer support specialists (PSS) are people with previous psychiatric illness or substance use disorders who use their experience to support those facing similar hardships. PSS offer a range of beneficial outcomes to both the PSS and clients. The most immediate social connections to those seeking treatment are often their families, yet no PSS studies are inclusive of family involvement. Strong theoretical and empirical support exists for family involvement in addiction treatment, but no studies to date on families in substance use treatment include PSS. This study offers a first look at PSS's experiences with client families. We aimed to describe experiences and attitudes of PSS in working with families of those seeking substance use treatment., Methods: This qualitative study included 25 adult PSS with at least 1 year of work experience in substance use treatment and state credentialing board certification. Participants had one interview either in a focus group format or individually. The recruitment and data collection phase lasted from November 2020 to June 2021. The semi-structured interview protocol included six main questions and interviews lasted 60 to 75 min. Upon completion of each interview, the recordings were transcribed and inductively coded. Thematic analysis of the codes identified overarching themes and their implications were described with associated quotes., Results: Thematic analysis generated three interrelated themes. First, participants described the various ways they often work with the families of their clients, which seemed to be dependent on the age of the client. Second, participants identified the negative aspects of working with families such as family drama, stress, and co-dependency issues. Last, the third theme identified the ways in which PSS assist families in healing from the effects of addiction. The themes identify a complicated and conflicting approach to work with families. Overall, it seemed PSS were operating on their own experiences or suggestions given by supervisors to guide them with no training on how to approach families., Conclusions: This study highlights a deficit in PSS training on their role with families, family intervention, and the impact of family on substance use treatment for adults and youth. More research needs to establish the PSS role with families and with clients from marginalized backgrounds. Credentialing and national associations that support PSS should develop additional training and education opportunities related to working with families for PSS, supervisors, and organizational leadership who employ PSS for substance use treatment., Competing Interests: Declaration of competing interest We have no known conflict of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to explore the impact of an Interprofessional Transgender Health Education Day (ITHED) on student knowledge and attitudes towards the transgender population., Methods: This mixed-methods study involved a pre-test and post-test survey administered to students (n=84 pre-test and n=66 post-test) in four health professional education programs (medicine, family therapy, speech, language, and hearing sciences, nutrition and dietetics.) surrounding participation in the ITHED. Differences in total and subscale scores of the Transgender Knowledge, Attitudes and Beliefs (T-KAB) before and after participation in the ITHED scale were analyzed using independent samples t-tests; qualitative responses were analyzed using a thematic, inductive process., Results: Independent samples t-tests revealed no significant differences in pre- and post-ITHED total T- KAB scores, the three subscales, or for those who reported previous training, clinical experience, and regular contact with transgender individuals. Qualitative themes included: enthusiasm for learning about transgender health; need for healthcare providers to provide excellent care for transgender patients; and power of learning directly from the transgender community., Conclusions: Though participation in the ITHED did not result in significant changes in T-KAB scores, participants demonstrated high baseline T-KAB scores and expressed strong enthusiasm for learning about transgender health. Positioning transgender voices at the forefront of the education can foster a powerful student learning experience and honor ethical guidelines.

Introduction: Caregiver and family engagement in dialysis decisions varies over the end-stage kidney disease treatment trajectory, with family preferences as primary consideration factors for patients starting dialysis. This interpretive phenomenological study explores how dialysis patients and their partners experience dialysis decisions., Methods: Thirteen patient-decision partner dyads (26 participants) were interviewed together about their experience with dialysis decision-making. A 5-step iterative process of data analysis occurred concurrently with data collection., Results: The patients received in-center hemodialysis ( n = 6) and home dialysis (peritoneal dialysis or home hemodialysis ( n = 7). Decision partner relationships included romantic partners ( n = 9) and either parent, sibling, or friend ( n = 4). Fifty-7 percent of participants were White; 46% of patients were women, and 76% of decision partners were women. Three interrelated themes were identified: Their body, but not their life; Seeking semiliberation, and Decision-making is caring., Discussion: Dyads were attuned to patient autonomy while managing the collateral effects of dialysis. Shifting the paradigm of dialysis treatment decisions from promoting patient autonomy to dialogues exploring relational autonomy helps providers balance the competing demands of incentivized standards to promote home dialysis with patients and their decision partners realities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Introduction: Transgender and nonbinary (TGNB) adults face significant barriers to healthcare, including healthcare denials, limited access to clinicians, and mistreatment by healthcare clinicians. While prior studies have explored the consequences of overt discrimination in healthcare, they often overlook the possible impacts of more subtle forms of discrimination., Aim: Is there a relationship between specific healthcare experiences, including both overt and subtle forms of discrimination, and mental health/substance use among TGNB adults?, Methods: This study was a secondary analysis of the 2015 U.S. Transgender Survey (USTS), a cross-sectional survey conducted by the National Center for Transgender Equality (NCTE) that included 27,715 TGNB adults from across the US and several US territories. This study analyzed variables including healthcare experiences, mental health, and substance use outcomes., Results: Doctors refusing to give non-TGNB-related care was associated with 71% increased odds of severe psychological distress and 95% increased odds of suicidal ideation. Further, having to teach doctors about TGNB care and doctors asking invasive questions were associated with all our studied negative mental health outcomes. Doctors asking invasive questions was additionally related to increased odds of heavy alcohol use, marijuana use, and illicit drug use., Conclusions: The results of this study indicate that negative health care experiences are significantly associated with mental health and substance use for TGNB adults. Specifically, these results emphasize the role of more subtle forms of discrimination, including a lack of clinician knowledge about the care of TGNB patients, asking invasive questions, and treating TGNB patients with respect., Competing Interests: Conflict of interest: None., (© Copyright by the American Board of Family Medicine.)

Gender identity change efforts (GICE) and sexual orientation change efforts (SOCE) continue to be practiced by mental health professionals and religious organizations. It is frequently sought out by families who are rejecting loved ones with marginalized sexual orientations and gender identities. This study explored the impact of religious and nonreligious GICE on the mental health of transgender and nonbinary adults through a secondary data analysis of the U.S. Transgender Survey. Results found that both nonreligious and religious GICE were associated with increased odds of suicidal ideation and attempts. Only nonreligious GICE was associated with severe psychological distress. Black individuals showed increased odds of binge alcohol consumption when exposed to nonreligious change efforts, while White individuals showed decreased odds with both nonreligious and religious GICE. This study supports ethical and legal bans on GICE., (© 2021 American Association for Marriage and Family Therapy.)

Chronic diseases continue to contribute to the leading causes of death in Missouri, and behavioral health plays a key role in their management. Patients receive most of their healthcare in primary care, suggesting primary care providers may serve an important role in the patients' chronic disease management and the behavioral health sequalae. This paper overviews the behavioral health impact of three chronic diseases impacting Missourians and reviews evidence for behavioral health interventions for each disease., Competing Interests: Disclosure None reported., (Copyright 2022 by the Missouri State Medical Association.)

Nephrology interdisciplinary guidelines, professional codes of ethics, principle-based ethical standards, and literature promote patient autonomy and self-determination through shared decision making as ethical practice. Healthcare professionals are accountable for practice that is mindful of the impact of cultural diversity and community on the values and beliefs of the patient, an important part of shared decision making (SDM). Despite previous research regarding dialysis decision making, relational autonomy in chronic kidney disease (CKD) and end-stage kidney disease SDM conversations is not well understood. This systematic literature review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for identifying peer-reviewed literature on SDM for CKD. The findings were summarized into four broad themes: (1) promoting autonomy is a foundation of medical caring; (2) providers have a responsibility to respond to their asymmetrical social power; (3) autonomy is situated within the context of the patient; and (4) dialogue is a tool that negotiates clinical recommendations and patient goals. The caring practices of promoting autonomy with a dialogical resolution of a conflict acknowledging the interdependence of the parties and the patient's social-relational situatedness support a perspective of relational autonomy in dialysis decision-making practice and research., (© 2021 National Association of Social Workers.)

Minority stress impacts the mental health of bi+ individuals (e.g., bisexual, pansexual, queer), similar to gay and lesbian individuals. Bi+ individuals may have difficulty accessing social supports for mitigating minority stress. A religious upbringing may complicate this process. This study sought to compare a survey sample of bi+ individuals ( n = 153) and their gay/lesbian ( n = 231) peers from religious families on minority stress factors, depression, and partnering. Results highlighted differences between gay/lesbian and bi+ individuals in partnering and LGB community connection with bi+ group reporting more minority stressors. Bi+ individuals in same-gender partnerships reported lower parent rejection and being more out than those who were single or in different-gender partnerships. Family religiosity was associated with family rejection; however, it did not directly predict minority stress factors or depression for bi+ individuals. Implications for future research are discussed in light of the distinctions emerging between gay/lesbian and bi+ adults.

Couple and family therapists are increasingly using telehealth platforms to deliver services. Unfortunately, the literature on relational teletherapy is not well developed. This study sought to understand experiences of teletherapy with couples and families as it contrasts with individual clients and in-person therapy. We utilized a hermeneutic phenomenological approach to qualitative inquiry from data collected through open-ended questions on a web-based survey of graduate student trainees (n = 66) in COAMFTE-accredited couple and family therapy programs. Thematic analysis identified the body-of-the-therapist and client as they exist (and are obstructed) due to technology for creating barriers and opportunities in translating CFT intervention to telehealth platforms. Relational teletherapy cultivated therapist creativity and exhaustion. It also made plain the need for systemic interventions with children and adolescents that engages their parents and home environments. Implications for CFT practice, training, and intervention research are outlined., (© 2021 American Association for Marriage and Family Therapy.)

Lesbian, gay, bisexual, and queer (LGBQ) young people from religious families are at increased risk of family rejection, poor mental health outcomes, and are overrepresented in mental health services. This article describes a two-part qualitative study aimed at exploring the experiences of LGBQ young adults from religious families in psychotherapy, identifying positive and negative psychotherapy experiences, and understanding the influence of family and religion on the psychotherapy experience. Data were collected through a web-based survey (n = 77) and interviews (n = 7) with LGBQ young adults (ages 18-25) from religious families. The study followed an interpretative phenomenological approach. Integrated results found often invisible, relational therapy processes, and religious discourses as significant to LGBQ young people who seek psychotherapy. Implications for future research, effective systemic family therapy practices with LGBQ young people from religious families, and a critique on ethical and legal limits of confidentiality with policy implications are outlined., (© 2020 American Association for Marriage and Family Therapy.)

Background: Lesbian, gay, bisexual, and questioning (LGBQ) adolescents are at increased risk of poor mental health due to minority stress, a chronic stress associated discrimination, social rejection, and victimization brought on by prejudicial attitudes towards LGBQ individuals. To improve understanding of the differential impact of various kinds of victimization on mental health outcomes for LGBQ adolescents, we analyzed data from the 2015 Youth Risk Behavior Survey (YRBS) for victimization and mental health symptom clusters and associations high school youth and compared by sexual orientation and gender., Methods: Separate Latent Class Analysis (LCA) was conducted to identify profiles of both victimization and mental health symptoms for participants (N = 15,624). Subsequently, stratified weighted logistic regression models were used on an eligible analytic sample of 11,458 to assess differences in the association of victimization and mental health between LGBQ and heterosexual high school students., Results: In each LCA, participants were assigned to one of 3 classes for victimization (minimal, 81.3%; bullying, 12.5%; or physical/sexual violence, 6.2%) and 1 of 2 classes for mental health symptoms (minimal, 81.2%; severe, 18.8%). LGBQ participants were overrepresented in physical/sexual violence and bullying victimization profiles. Both bullying and physical/sexual violence profiles were associated with almost 5 times the odds of endorsing severe mental health symptoms., Conclusions: This study expands our understanding of the relationship between types and effect of peer victimization for LGBQ and heterosexual youth with implications for school health and prevention efforts through increased positive school climate for LGBQ students., (© 2020, American School Health Association.)

Rationale: Intimate partners and other informal caregivers provide unpaid tangible, emotional, and decision-making support for patients with cancer, but relatively little research has investigated the cancer experiences of sexual minority women (SMW) with cancer and their partners/caregivers., Objective: This review addressed 4 central questions: 1) What social support do SMW with cancer receive from partners/caregivers? 2) What effect does cancer have on intimate partnerships or caregiving relationships of SMW with cancer? 3) What effects does cancer have on partners/caregivers of SMW with cancer? 4) What interventions exist to support partners/caregivers of SMW or to strengthen the patient-caregiver relationship?, Method: This systematic review, conducted in 2018 and updated in 2020, was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent coders screened abstracts and articles., Results: In total, 550 unique records were screened; 42 articles were assessed for eligibility, and 18 were included in a qualitative synthesis. Most studies were U.S.-based, involved breast cancer, included intimate partners, had primarily white/Caucasian samples, and were cross-sectional. Sexual minority female participants reported that partners/caregivers often provide important social support, including emotional support, decision-making support, and tangible support. Effects of cancer on relationships with partners/caregivers were mixed, with some studies finding relationships remained stable and others finding cancer either increased closeness or disrupted relationships. Participants reported partners/caregivers often experience distress and may experience discrimination, discomfort disclosing sexual orientation, and a lack of sexual minority-friendly services. No studies involved an intervention targeting partners/caregivers or the dyadic relationship., Conclusions: More work is needed to understand SMW with cancers other than breast cancer, and future work should include more racially, ethnically, and economically diverse samples. Longitudinal research will allow an examination of patterns of mutual influence and change in relationships. These steps will enable the development of interventions to support SMW with cancer and people close to them., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Having a mental health diagnosis is associated with contraceptive non-adherence and user-related contraceptive failures of short-acting methods. There is a lack of research on the relationship between mental health diagnoses and early discontinuation of highly effective long-acting reversible (LARC) methods such as the intrauterine device (IUD) and subdermal implant (SDI)., Methods: Using a Primary Care and Obstetrics and Gynecology Patient Data Registry, we conducted a cross-sectional analysis of the relationship between any mental health diagnosis (any anxiety disorder or depression) and early LARC removal (<1 year post-insertion) among 385 reproductive-aged (14-50 years) women in 2008-16. Adjusted logistic regression was used to calculate odds ratios and 95% confidence intervals., Results: Almost 10% (n = 37) of the sample had an early LARC removal, of which 62.2% were hormonal IUD and 37.8% were SDI. Women with a mental health diagnosis had a higher prevalence of early LARC removal (13.6% vs. 8.0%, p = =.090). Although non-significant, there was a trend in adjusted analyses indicating twice the odds of early removal for women with a mental health diagnosis versus no diagnosis (OR = =2.04, 95% CI = =0.97-4.27)., Limitations: This study is limited by a small sample size and availability of variables from a reportable medical record database. Pregnancy intentions and side effects of method use could not be accounted for which may have impacted timing of removal., Conclusions: Understanding why women choose early LARC removal can inform counseling to help women make informed choices about their contraceptive method that meets their reproductive needs., (Copyright © 2019. Published by Elsevier B.V.)

Sexual minority persons have an increased risk for negative mental health outcomes in adulthood. This seems to largely be due to experiences of stigma in social settings. This study sought to understand the relationship between attending a religiously conservative college, internalized homophobia (a measure of sexual stigma), and depressive symptoms for sexual minority adults. Sexual minority adult participants ( n = 384) from across the U.S. were recruited and completed a Web-based, anonymous survey. A mediation model predicting depression through college religious conservatism, college acceptance of sexual minority identities, and internalized homophobia was tested using path analysis. Results revealed an indirect effect of increased religious conservatism of a college predicted higher depression through lower college acceptance and higher internalized homophobia. Implications for the mental health of sexual minority adults and future research are examined.

Sexual minority persons from religious families may experience low acceptance by parents, however, little is known about the relationship of religiosity and parent relationships on mental health into adulthood. This study sought to test a moderated mediation model predicting depression based on religious fundamentalism, parent acceptance, and parent-child relationship quality. Sexual minority adult participants (n = 384) from across the U.S. completed a web-based, anonymous survey. Results found a conditional indirect effect of religious fundamentalism on depression through parent acceptance with the parent-child relationship quality moderating the relationship between parent acceptance and depression. This was significant up to age 52. Clinical implications and future research with sexual minority adults and their families are explored., (© 2018 American Association for Marriage and Family Therapy.)

Introduction: Lesbian, gay, bisexual, and transgender (LGBT) individuals experience more negative health outcomes compared with their heterosexual peers. The health disparities are often related to family and social rejection of the LGBT individuals. Integrated care, and Medical Family Therapy in particular, may aid in addressing the systemic nature of the negative health outcomes., Method: To better understand the current state of the integrated care literature on addressing the health needs of LGBT individuals, a systematic review of the research literature was conducted from January 2000 to January 2016 for articles including integrated health care interventions for LGBT populations. Independent reviewers coded identified articles., Results: Only 8 research articles met criteria for inclusion out of the 2,553 initially identified articles in the search. Results indicated a lack of integrated care research on health care and health needs of LGBT individuals, and none of the articles addressed the use of family or systemic-level interventions., Discussion: Implications for future research and the need for better education training are discussed. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)