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Examining the Impact of a Short-Term Psychological Skills Examining the Impact of a Short-Term Psychological Skills Training Program on Dancers' Coping Skills, Pain Appraisals, and Training Program on Dancers' Coping Skills, Pain Appraisals, and Injur Follow this and additional works at: https://researchrepository.wvu.edu/etd Recommended Citation Bryant, Leigh A., "Examining the Impact of a Short-Term Psychological Skills Training Program on Dancers' Coping Skills, Pain Appraisals, and Injuries" (2017). Graduate Theses, Dissertations, and Problem Reports. 5277. https://researchrepository.wvu.edu/etd/5277 This Dissertation is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Dissertation in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Dissertation has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. Examining the Impact of a Short-Term Psychological Skills Training Program on Dancers’ Coping Skills, Pain Appraisals, and Injuries Leigh A. Bryant, MS, MA Dissertation submitted to the College of Physical Activity and Sport Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Doctorate of Philosophy in Sport and Exercise Psychology Damien Clement, PhD, ATC, Chair Edward F. Etzel, EdD Kelly Knox, MFA Monica Leppma, PhD Sam Zizzi, EdD College of Physical Activity and Sport Sciences Morgantown, West Virginia 2017 Keywords: intervention, injury, psychological skills training, dance, pain appraisal, coping Copyright 2017 Leigh A. Bryant ABSTRACT Examining the Impact of a Short-Term Psychological Skills Training Program on Dancers’ Coping Skills, Pain Appraisals, and Injuries Leigh A. Bryant Psychological skills interventions are often conducted with individual athletes and sports teams in an effort to build mental toughness, prevent injury, or enhance performance. Dancers remain an underserved population in the delivery of sport/performance psychology services, with extremely limited literature addressing college dance students. The dance community has several inherent physical and psychosocial demands, which can promote resilience. However, dancers may also strive to meet these demands by employing unhealthy coping strategies that could be linked to maladaptive appraisals and increased injury risk. The present study examined the impact of a psychological skills intervention program on college dance students’ (N = 30) coping skills, pain appraisals, and injuries over a six-week period. A two-group pre-test/post-test quasi experimental methodology was used to capture the potential influence of the intervention program. At the end of the six-week period, there were no significant differences observed between the treatment and control groups on the three major constructs. In particular, the results demonstrated the need for a single, operational definition of injury within the dance context. A focus group discussion led to several recommendations for future research and improvements for mental skills and life skills intervention programs. Best practices for scholars, applied practitioners, and dance educators are also discussed. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM iii ACKNOWLEDGEMENTS I would like to thank my Committee Chair, Dr. Damien Clement, for your thorough feedback and encouragement throughout the dissertation process. I would also like to thank the other members of my committee—Dr. Ed Etzel, Dr. Monica Leppma, Professor Kelly Knox, and Dr. Sam Zizzi—for the time and energy that you put into helping me complete this project. A big “thanks” to all of the faculty, staff, and students in the Sport & Exercise Psychology and Counseling programs at West Virginia University. Another big “thanks” to the dancers who took part in this study, and the instructors and administrators who supported their participation. Special thanks to Alison Coates, Jana Fogaça, Stefanee Maurice, and Anna Onderik for your interest in and contributions to this project. Finally, thank you to my parents—Neil and Jennifer Bryant—and to my husband—Kurt Skvarla—for your love and support. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM iv TABLE OF CONTENTS Page Introduction …………………………………………………………...……………….……….. 1 Methodology ………………………………………………………………...……………......... 8 Research Design ………………………………………………………...……….……... 8 Participants ………………………………………………………...……………..…...... 8 Dance Program Characteristics and Setting ……………………………………...…….. 9 Instrumentation …………………………………………………….……………...…... 12 Basic Demographics Survey …...………………………….…………………….…...... 12 Athletic Coping Skills Inventory-28 ……………………….…………...…….….…..... 12 Pain Appraisal Inventory .……...………………………….………………....……....... 15 Injury Tracking Survey ……………………………………………………...……..….. 17 Dance Experiences Survey ……………………………………………..….………….. 18 Intervention Program …………………………………………………..…….………... 19 Adherence Journal ……………………………………………………..….………...… 21 Procedure …………………………………………………….……………..…………. 21 Data Analyses ……………………………….…………………………..…………...... 25 Results …………………………………………………….……………………..…………..... 27 Descriptive Statistics ………………………………….……………………..……...… 27 Quantitative Results ..……………………………………………………..………..…. 28 Qualitative Results ……...…………………………………………….…..…...……… 29 Exploratory Findings ….…………………………………………………..………..… 33 IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM v Discussion ……………………………………………………………………….……..……... 36 Limitations ……………………………………………………………….…….…..…. 53 Future Recommendations …………………………………………….….…...….…… 57 Implications for Practice ……………………………………………………….…..… 62 Concluding Thoughts ……………………..……………………………….……….… 66 References ……………………………………………………………………….………..….. 67 Tables ………………………………………………………………………………....……… 77 Appendices ……….………………………………………………………………….....…...... 88 Appendix A: Extended Review of Literature ….……………………………….…….. 88 Appendix B: Basic Demographics Survey ………………………………………...…138 Appendix C: Athletic Coping Skills Inventory-28 ………………………………….. 141 Appendix D: Pain Appraisal Inventory …………………………………...…..…….. 144 Appendix E: Injury Tracking Survey………………………………………….…….. 146 Appendix F: Dance Experiences Survey …………………………………....………. 149 Appendix G: Intervention Protocol Outline ……………………………...…………. 155 Appendix H: Intervention Program Exercises and Activities …………..……...…… 157 Appendix I: Adherence Journal …………………………………………………….. 167 Appendix J: Participant Contact Information Form………...………………..…...… 168 Appendix K: Semi-Structured Interview Guide for Focus Group Discussion ….….. 169 Appendix L: Stakeholder Interview Findings …………………………………..….. 170 Appendix M: Sample Self-Talk Statements and Associated Bible Verses ……..….. 173 IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 1 Introduction Dancers are considered to be both artists and athletes, given the rigor of their physical training, the necessity of self-expression, and the emphasis on the mind-body connection (Dick et al., 2013). A dancer’s body is trained to move in complex, highly-technical ways and to stand in atypical positions (e.g., on the tips of one’s toes). For this reason, dancers often have time limited careers, with very few individuals performing beyond their thirties (Kelman, 2000; Turner & Wainwright, 2003; Watson, 2013). Additionally, the path to artistic perfection is a never-ending process, because one’s performance cannot be objectively measured by a judge or audience member (Dick et al., 2013; Estanol, Shepherd, & MacDonald, 2013). Many dancers spend the entirety of their careers making technical and aesthetic improvements. They strive to maintain a slim and athletic physique, endure long rehearsal hours, and execute advanced technical requirements (Grove, Main, & Sharp, 2013; Hamilton & Robson, 2006; Shah, 2008). With no final score to use as a measure of success, dancers often need to engage in self-reflection to assess their strengths and areas for growth. As Kelman (2000) has stated, “dancers must be physically strong and have a high tolerance for pain. The performing artist’s instrument is their body” (p. 431). The mentality of “no pain, no gain” that is often used to characterize an intense sport climate may also be an appropriate description of a passionate dancer’s assessment of pain or injury (Anderson & Hanrahan, 2008). When adopted and reinforced, this “push through it” mindset can be one that is self-motivating and temporarily adaptive. Nevertheless, it is also possible that this mindset can contribute to injury risk if the pain is not properly identified and addressed (Anderson & Hanrahan, 2008; Rip, Fortin, & Vallerand, 2006). In other words, dancers who conceal or ignore physical pain in order to keep training and performing (Krasnow, 2005; Noh & Morris, 2004) IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 2 may be doing more damage to their body, and negatively influencing the environment in which they want to thrive (Anderson & Hanrahan, 2008). The physical demands and the socio-cultural climate of many schools and studios (Dick et al., 2013; Grove, Main, & Sharp, 2013) may lead dancers to a metaphorical tipping point. In some cases, dancers demonstrate resilience in the face of such pressures and engage in strategies that can enhance performance and well-being (e.g., Rivers, 2014). However, a lack of coping skills can lead to disruptions in dancers’ ambitions, or the adoption of destructive behaviors (Kelman, 2000; van Staden, Myburgh, & Poggenpoel, 2009). For instance, obsessive passion can lead to inattentiveness to pain and injury (Rip, Fortin, & Vallerand, 2006). Similarly, low levels of self-awareness about how to properly manage pain or recognize injuries that require medical attention might put dancers’ short- and long-term health at risk (Nordin-Bates et al., 2011). Therefore, it is critical to understand dancers’ appraisals of pain, how these appraisals relate to the desire to keep improving, and what factors influence dancers who engage in positive or adaptive coping strategies, such as those that might be introduced in a prevention or intervention program. As stated by Noh, Morris, and Andersen (2007), “the focus on enhancing coping skills…[may] help dancers cope more effectively with the demands of the dance environment and reduce injury incidence” (p. 28). To date, very little research has examined the delivery of psychological skills training programs to dancers (Noh, Morris, & Andersen, 2007). Historically, these programs have focused on repairing—rather than preventing—dysfunctional coping strategies, unhelpful cognitive habits, and injuries (Hays, 2002). The literature shows that in an eight-month period, up to 97% of university dance majors may experience an injury (Kerr, Krasnow, & Mainwaring, 1992). Other researchers have also reported high rates of injury, with one sample of pre-professional dancers sustaining an average IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 3 of 1.42 injuries per dancer over the course of a year (Ekegren et al., 2013). Dancers deal with both acute and chronic injuries such as ankle sprains, anterior cruciate ligament tears, tendonitis, and stress fractures (Bauman, Gallagher, & Hamilton, 1996; Dick et al., 2013). As such, they are likely to cope with injury related pain in addition to generalized pain that may stem from training and performing. Sustaining an injury may have several consequences for a dancer (Mainwaring, Krasnow, & Kerr, 2001). More specifically, being injured may necessitate taking time off from dancing, which may equate to missed opportunities to advance one’s development. Dancers who have a strong athletic identity (Brewer, Van Raalte, & Linder, 1993) and/or contingent self-worth (Hall & Hill, 2012) may experience decreases in self-esteem should they become injured or have to manage chronic pain. Moreover, for dancers who are employed or seeking employment, the inability to work can result in financial strain (Kelman, 2000; Wainwright, Williams, & Turner, 2005). Financial pressures could lead to additional stress, and possibly the need to pursue a different career. These potential consequences may serve as motivation for dancers to keep injuries hidden. Dancers may self-medicate in an effort to treat or cover-up injuries and/or pain without interfering with regular training and performances (e.g., Wozny, 2016). While researchers have noted that some dancers do inform a teacher or director that something is bothering them, they will nevertheless continue to dance (Nordin-Bates et al., 2011). Nordin-Bates and colleagues (2011) have further suggested that dancers may view rest as a form of “non-constructive passivity” that could have consequences for their fitness, technical training, and/or status, as previously described (p. 82). Therefore, although missteps or improper technique can lead to physical injury in dance, sometimes injuries may occur due to one or more psychological and/or IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 4 psychosocial factors (e.g., Noh & Morris, 2004; Noh, Morris, & Andersen, 2005; Nordin-Bates, Quested, Walker, & Redding, 2012; Smith, Ptacek, & Patterson, 2000). Coping skills, pain appraisals, and injury status may be important to a dancer’s mental well-being and performance-related outcomes. To characterize dancers’ perceived stressors, Noh, Morris, and Andersen (2002) conducted a qualitative investigation with a sample of professional ballet dancers. The researchers found that fear of injury, dance directors’ criticism, and competition for roles were prevalent. Additionally, over 60% of the dancers in their sample reported engaging in dysfunctional coping behaviors (e.g., drinking alcohol) as a means of dealing with perceived stress. Consistent with literature focused on stress and coping, researchers have identified several factors that may make individuals more susceptible to injury in a stressful situation. These factors include low levels of coping skills, high state-trait anxiety, and a history of several negative life events (e.g., Yatabe et al., 2014). Consequently, it is important for dancers, and those who work with them, to be equipped with accurate, evidence-based knowledge about healthy coping skills, adaptive pain appraisals, and injury risk. Andersen and Williams (1988) have developed and revised a model that explores the relationship between stress and injury in sport (Williams & Andersen, 1998). The model emphasizes personality, coping skills, and history of stressors as antecedents to injury risk (Andersen & Williams, 1988; Noh, Morris, & Andersen, 2005). Researchers have previously used this model with dancers to target coping skills as a protective factor for injury (e.g., Noh, Morris, & Andersen, 2007). In the present study, Williams and Andersen’s model (1998) was used as a lens through which to view the role of interventions focused on coping skills, cognitive appraisals of pain, and injury risk in a collegiate environment. In particular, the impact that intervention content may IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 5 have on cognitive appraisal was of interest to the primary researcher. While the model is often said to be linked to acute injury prediction, it was used in the present study to understand the relationship between intervention programming and cognitive appraisal of situations that could lead to or include dance-related pain and/or injury. The model also highlights the potentially meaningful role of coping skills when managing perceived stress. Thus, learning skills to identify and manage stress has implications not only for dancers’ performance-related outcomes, but also for their other life pursuits. A life skills approach to the intervention content may help dancers to better recognize the applicability of psychological skills training to their academics, social situations, and/or personal development (e.g., Danish, Petitpas, & Hale, 1993). Accordingly, the primary researcher developed and selected instruments and program content tailored to a dance population, and, more specifically, for university-level dance students. The psychological skills training program was ultimately aimed at dancers’ coping skills, appraisals of physical pain, and self-reported injuries over a six week time frame. The present study sought to contribute to the current applied research literature in the field of sport/performance psychology. Noh and Morris (2004) previously used Williams and Andersen’s (1998) model to design injury prevention programs with a sample of Korean dancers (N = 105). The authors examined the predictive power of coping skills, stress, social support, and anxiety on injury frequency and duration, further testing the veracity of the stress-injury model to the dance population. Building on this work, Noh, Morris, and Andersen (2007) published the findings of two intervention programs used with a sample of dancers (N = 35) for the purpose of injury prevention across a 24-week period. The first 12 weeks of the intervention program consisted of the delivery of coping skills content, and the subsequent 12 weeks were used to IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 6 collect follow-up data as dancers practiced these skills. Their results suggested that teaching broad-based coping skills could in fact influence the duration of dancers’ injuries. Noh and colleagues (2007) reported that dancers who were assigned to a treatment group spent less time injured than dancers who were assigned to a control group. While some research focused on coping skills and injury has been conducted within the dance population, the current literature contains few intervention programs delivered to dancers in a group context. Consequently, the present study’s methodology is rooted in literature from psychology, counseling, and family systems, which all, to some extent, utilize group sessions, cognitive-behavioral approaches, and brief interventions. Researchers have suggested that, in just a few sessions, individuals have the capacity to learn new material and make long-term behavioral changes (e.g., Bell, Skinner, & Fisher, 2009; Meichenbaum, 1993). In this way, the present study allowed dancers to learn and then apply psychological skills into their training and performances. It was hoped that these skills and strategies might positively influence dancers’ stress management and injury susceptibility, and also translate to other life pursuits such as social situations or academics. Hamilton and Robson (2006) have stated that consultants who work with performing artists have the opportunity to teach “constructive strategies that enhance performance” while helping dancers to recognize and change self-destructive behaviors or coping methods (p. 257). The constructive strategies that they discussed included diaphragmatic breathing, relaxation exercises, positive self-talk, and imagery (Hamilton & Robson, 2006). These strategies have previously been taught to non-elite and collegiate athletes across a variety of sports, including gymnastics and rowing. For instance, over the course of a competition season, Kerr and Goss (1996) conducted individualized sessions with young adult IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 7 gymnasts (N = 24) that focused on thought control, imagery, and self-talk. While no statistically significant findings were reported, the researchers found that the gymnasts who had participated in the intervention program had lower levels of negative athletic stress at the end of the season. Furthermore, Perna, Antoni, Baum, Gordon, and Schneiderman (2003) conducted a three week intervention program that focused on stress management for college rowers (N = 34). Two practitioners taught athletes assigned to a treatment group a variety of skills for performance enhancement and personal development. These skills included deep breathing, progressive muscle relaxation, and imagery. At the conclusion of the intervention program, the researchers found that athletes who had been assigned to the treatment group had fewer reported injuries and illnesses compared to the athletes who were assigned to a control group. The results of these studies, in combination with their limitations and future recommendations, suggest that interventions focused on psychological skills and life skills development can have an important impact on young adult athletes with respect to performance and overall well-being. Therefore, the purpose of the present study was to examine the impact of a short-term psychological skills training program on college dancers’ self-reported coping skills, pain appraisal, and injuries. This psychological skills training program was rooted in the stress management and performance enhancement literature, and adopted a cognitive-behavioral approach. In accordance with the study’s purpose, the four main research questions were: (1) Is there a difference in self-reported coping skills between dancers who participate in the intervention program and those who do not? (2) Is there a difference in self-reported pain appraisals between dancers who participate in the intervention program and those who do not? (3) Is the rate and severity of injuries affected by the intervention program? (4) What are the IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 8 dancers’ reactions to this intervention program, and, more specifically, what aspects of the program were useful and not useful, and why? Methodology Research Design The present study utilized a two-group pre-test/post-test quasi-experimental design (Gay & Airasian, 2003). Participants were assigned to a condition, as a group, based on the dance course in which they were enrolled for the spring 2016 semester. One class was assigned to be the treatment group; this group completed study-related instruments and received a short-term psychological skills intervention program on a weekly basis. The other class was assigned to be the control group; this group also completed study-related instruments without participating in the intervention program. This type of research design is commonly utilized in educational settings, where purely random assignment of participants to groups is not feasible or practical (Gay & Airasian, 2003). The treatment group participants were currently enrolled in a modern dance course, and the control group participants were currently taking a dance conditioning course. These classes were part of the dance program curriculum and led by full-time faculty members at the institution. Participants Participants were male (n = 4) and female (n = 26) dance students (N = 30) studying at the same institution in the Mid-Atlantic region of the United States. Students were encouraged to participate by their instructors, but ultimately the decision to participate was their own. One student was deemed ineligible to participate due to age (less than 18 years), and one student in the control group asked to be removed from the study. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 9 Participants’ ages ranged from 18 to 22 years (M = 19.77, SD = 1.45). On average, dancers reported a range of 3 to 19 years of dance training (M = 13.30, SD = 4.50). Participants represented all four class years, namely freshman or first year (n = 13), sophomore (n = 2), junior (n = 12), and senior (n = 3). Prior to their participation in this study, few dance students had experience working with a sport psychology consultant (n = 3). The remaining students (n = 27) indicated no prior experience with a sport psychology consultant in an individual or group setting. At the start of the study (i.e., during the first week), almost half of the participants (n = 13) indicated that they were currently suffering from one or more injuries; four injured dancers were in the control group, and the other nine were in the treatment group. On average, dancers in the treatment group were 2.4 years older than dancers in the control group. Dancers in the control group were slightly younger (Mage = 18.60, SD = 0.91) than dancers in the treatment group (Mage = 20.93, SD = 0.80). Members of the control group reported a range of 14 to 25 hours of dance training per week. Members of the treatment group reported a range of 11 to 28 hours of dance training (see Table 1 for basic demographic information). The sampling procedure used in this study was both convenient and purposive (Patton, 2002). An appropriate sample size was determined prior to the start of the study. A sample of 28 participants was deemed suitable by the primary researcher in consultation with a statistician and G*power software (Faul, Erdfelder, Lang, & Buchner, 2007) by adopting a moderate effect size of 0.56 (Cohen, 1988) with a desired power of 0.80. Dance Program Characteristics and Setting Based on self-reported data from the participants, their dance program was somewhat rigorous, requiring a number of hours of class, rehearsal, and/or performance that is comparable to the 20 countable hours put forth by the National Collegiate Athletic Association (NCAA) for IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 10 college student-athletes. Of the 30 participants, 29 reported that they had to audition in order to be admitted into the program. When asked to describe the technical focus of their program, 77% of dancers (n = 23) described their program as ballet-based, and the other 23% of dancers (n = 7) described the program as either mixed-repertoire or consisting of more than one technical discipline (e.g., ballet, modern). Dance majors at this liberal arts institution could receive either a Bachelor of Arts degree in Dance or a Bachelor of Fine Arts degree in Dance, with the latter degree traditionally requiring additional studio work to prepare students for a professional career in the dance industry. The program is housed in an on-campus building, which consists of several dance studio spaces, dressing rooms, and faculty/staff offices. There were pianos in the studios for times when live accompaniment was offered for class. The studios were well-lit, clean, and had flooring that was appropriate for dance conditioning and performance. Outside of the studios, there was a lounge where dancers could stretch, eat, socialize, use their phones or iPods, and complete written homework between classes. Based on the primary researcher’s observations, this lounge area encouraged a sense of “community,” such that multiple conversations could be held at once, and people would make the space their own by spreading out textbooks, lunch boxes, or their own bodies when they needed to recover from or prepare for a technique class. The lounge area also housed resources for students, such as exercise DVDs, stretching equipment, and dance program photo albums. When the primary researcher arrived to the site each week to meet with the dancers in the treatment group, the lounge area served as the “home base” for the project. It was here that dancers could seek out the primary researcher for questions and concerns. One dancer used this space for a few brief individual consultations with the primary researcher about managing stress IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 11 and expectations. Another dancer approached the researcher in the studio space to inquire about an approach to stress management that a family member had utilized. A third dancer asked the researcher for more information on health/wellness careers such as performance psychology, and the researcher shared resources in a brief in-person meeting and via email correspondence. It should be noted that many dancers in the treatment and control groups acknowledged the primary researcher’s (and research assistant’s) presence in the lounge, but very few asked for advice or consultation over the six-week period, particularly when in the presence of other dance students. The primary researcher and research assistant observed that classes seemed to consistently begin a few minutes late, either due to students still transitioning from a previous class, or the faculty member needing to take a few minutes to switch focus from a meeting and/or to finalize content. The most commonly observed dance class was the one that the treatment group participants were taking (i.e., modern dance). This class was fairly structured, and it was clear from observing that the students were accustomed to this structure. Sometimes the students faced the front of the studio so that they could pay attention to the instructor and/or see themselves reflected in the wall-length mirror. Other times they faced different directions for individual or small group exercises, or stood in a circle to do community-focused dance work. Despite the program having an emphasis on classical ballet technique, dancers did not look uniform in appearance and dress code. The dance students represented many body types and wore a range of dancewear, including leotards, tights, sauna pants, t-shirts, sweat pants, and leggings. Women’s hair was typically pulled back in a loose or tight bun or ponytail. Both the primary researcher and research assistant noted the presence of coffee, tea, and water bottles placed around the borders of the dance studio, which dancers would visit during short breaks. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 12 Although a somewhat casual tone was established, there were clear classroom norms as well. For instance, dancers would never re-enter a studio space during an exercise or dance number. They would wait until the music stopped and a combination or section of dancing was complete. Additionally, dancers clapped for the pianist at the end of each class. They also thanked any person of authority, including the primary researcher and research assistant, before leaving. Instrumentation Basic demographics survey. The primary researcher developed a basic demographics survey specifically for this study in an effort to contextualize the sample (see Appendix B). Survey items included participants’ age, gender, year in school, total number of years dancing, total number of hours dancing per week, and current injury status. The demographics survey also asked participants to rate their level of familiarity with the skills to be introduced during the intervention program (i.e., diaphragmatic breathing, progressive muscle relaxation, imagery, self-talk, and mindfulness). Information gathered via this instrument was intended to help describe the sample’s characteristics, rather than to answer a particular research question. Athletic Coping Skills Inventory-28. The Athletic Coping Skills Inventory-28 (ACSI 28; Smith, Schutz, Smoll, & Ptacek, 1995) is a multi-dimensional measure of self-reported psychological skills utilized in sport (see Appendix C). Seven sport-specific subscales make up the full measure, each subscale having four items answered on a 4-point Likert scale from 0 (almost never) to 3 (almost always). A total score, combining all 28 items, is used to assess overall coping skills, with a possible range of 0 to 84. The primary researcher chose to use this survey due to its multi-dimensional measure and the fact that it had previously been used with a dance population. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 13 Researchers Estanol, Shepherd, and MacDonald (2013) have previously reported a mean total score of 49.34 and a standard deviation of 10.14 on the ACSI-28 for their sample of dancers (N = 205). Their sample consisted of collegiate-level ballet and modern dancers, professional dancers, and contemporary dancers. The researchers’ descriptives are comparable to the present study’s sample for both week one (M = 48.83, SD = 9.79) and week six (M = 48.72, SD = 10.66). The reliability and validity of the ACSI-28 has been tested with multiple samples and has been used to study coping skills and behaviors in the sport context (e.g., Mummery, Schofield, & Perry, 2004; Omar-Fauzee, Daud, Abdullah, & Rashid, 2009; Smith et al., 1995). Researchers have indicated questionable to acceptable reliability for the concentration subscale, with a Cronbach’s alpha of 0.62, and good reliability for the peaking under pressure subscale, with a Cronbach’s alpha of 0.78. These statistics represent the lowest and highest measures of internal consistency across all subscales of the instrument (Noh, Morris, & Andersen, 2007; Smith et al., 1995). Additionally, researchers reported that one-week test-retest coefficients from a sample of 90 college students and athletes had a median of 0.82 (Noh, Morris, & Andersen, 2007; Smith et al., 1995). In the present study, the primary researcher examined five-week test-retest reliability of the ACSI-28. The correlation between ACSI-28 total scores collected during the first and sixth weeks of the study was strong, r = 0.756, p = 0.000. Additionally, the primary researcher observed the relationship between pre- and post-intervention total scores on this instrument by group condition. There was a strong relationship between pre- and post-intervention ACSI-28 total scores for the treatment group, r = 0.870, p = 0.000. There was also a statistically significant correlation between these scores for the control group, r = 0.555, p = 0.039. These IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 14 correlations are relatively consistent with the reliability statistics reported by the instrument’s developers (Smith, Schutz, Smoll, & Ptacek, 1995). As for convergent and discriminant validity, the developers reported moderate correlations between the ACSI-28 and other similar instruments. These instruments included the Self-Control Schedule (Rosenbaum, 1980) (r = 0.44), Sport Anxiety Scale (Smith, Smoll, & Schutz, 1990) (r = -.43), and Self-Efficacy Scale (Coppel, 1980) (r = 0.58). In contrast to other coping questionnaires that are non-specific to sport (e.g., COPE; Carver, Scheier, & Weintraub, 1989), the ACSI-28 was developed specifically for use with athletes. However, it should be noted that the instrument is not grounded in one or more theories of stress and coping (Croker, Kowalski, & Graham, 1998), but may be considered as having originated from a cognitive behavioral approach (Estanol, Shepherd, & MacDonald, 2013). For the purpose of this study, some of the items were modified to reflect a dance-specific context. The words “coach” or “manager” were replaced with “instructor” or “choreographer.” Similar changes have been made to the ACSI-28 by others in their research with dancers (e.g., Estanol, Shepherd, & MacDonald, 2013; Noh, Morris, & Andersen, 2007). Estanol and colleagues (2013) reported a Cronbach’s alpha of 0.84 for the ACSI-28 when modified and used with their sample. Noh and colleagues (2007) reported slightly lower reliability with these modifications. However, the ACSI-28 had been translated into Korean, and so the translation could also have influenced their reliability estimates. In the present study, a Cronbach’s alpha of 0.727 was observed for week one across 30 participants, and a Cronbach’s alpha of 0.741 was observed for week six across 29 participants. As for the subscales, internal consistency coefficients ranged from a low of 0.508 for the confidence and achievement motivation subscale, to a high of 0.861 for the peaking under IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 15 pressure subscale (see Table 2 for internal consistency at week one compared to the developers’ alphas). These numbers are fairly consistent with the findings of Estanol, Shepherd, and MacDonald (2013). They reported low internal consistency for one subscale (i.e., coachability), with all other subscales having a Cronbach’s alpha greater than 0.65. This was also the case in the present study, although the subscale below this 0.65 cut-off point was confidence and achievement motivation, instead of coachability. Pain Appraisal Inventory. The Pain Appraisal Inventory (PAI; Unruh & Ritchie, 1998) is a self-report instrument comprised of 16 items that quantifies and classifies individuals’ beliefs about physical pain. The PAI also helps to evaluate what respondents think about their pain, and how these thoughts make them feel (see Appendix D). Based on literature in stress and coping research, the developers of the PAI included two scales within this instrument: threat appraisal and challenge appraisal. Threat was defined as “anticipated or actual physical or psychological harm, loss, injury or damage associated with a pain event,” while challenge was defined as “a test of strength, endurance or abilities, with the potential for growth, mastery or gain associated with a pain event” (Unruh & Ritchie, 1998, p. 106). One might expect these two subscales to be negatively related. However, researcher Anderson and Hanrahan (2008) reported the relationship between threat and challenge to be weak to moderate (r = 0.41) in a sample of dancers (N = 51) who represented a variety of styles and training levels. Each subscale contains eight items that are scored on a six-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). A total composite score for pain appraisal can be calculated by summing the 16 items, with a possible range of 16 to 96. The sum of each subscale can also be calculated, with a possible range of 8 to 48. However, it should be noted that the developers stated that they initially considered a rating of “3” or higher to indicate an appraisal IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 16 of pain (Unruh & Ritchie, 1998), and so the total scores and possible ranges for this instrument and its subscales may be highly dependent on the severity and duration of pain that participants are experiencing when this survey is administered. Previously, Anderson and Hanrahan (2008) have reported a range of 8 to 43 for the threat subscale, and a range of 8 to 41 for the challenge subscale. No total scale psychometrics were reported in their study. Compared to Anderson and Hanrahan’s (2008) sample, the present study’s participants reported a similar range of scores on the PAI subscales. The threat subscale had a range of 8 to 37 for week one (M = 18.31, SD = 9.35) and a range of 8 to 32 for week six (M = 18.68, SD = 7.94). Similarly, the challenge subscale had a range of 8 to 42 for week one (M = 20.62, SD = 10.27) and a range of 8 to 43 for week six (M = 21.03, SD = 9.52). The instruments’ developers reported evidence of good validity and reliability. Concurrent criterion validity was determined by comparing the PAI’s properties to other pain instruments, including the McGill Pain Questionnaire (MPQ; Melzachk, 1987) and the Pain Disability Index (PDI; Tait, Chibnall, & Krause, 1990). Using data collected from a sample (N = 46) of college students, health professionals, and community members, the developers reported that the threat subscale yielded a Cronbach’s alpha of 0.86 and the challenge subscale yielded a Cronbach’s alpha of 0.81. In the present study, internal consistency was also strong. Cronbach’s alpha for the PAI at week one was 0.881. At week six, Cronbach’s alpha was 0.886. When observing the two subscales separately, the threat subscale had a Cronbach’s alpha of 0.914, and the challenge subscale had a Cronbach’s alpha of 0.904. The developers of the PAI have discussed some of the instruments’ limitations. Among these limitations is the unexplored relationship between appraisals, and chronic versus acute pain; the developers have suggested that differences in type of pain and their direct or indirect IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 17 effects on appraisal is unknown. The instrument’s developers have also reported a lack of test retest reliability. Given this fact, the primary researcher in the present study decided to run correlations on the PAI total scores as well as both subscales across all participants. The correlation coefficient for the PAI total scores was moderate, r = 0.399, p = 0.035. When observing PAI threat subscale scores, no meaningful relationship was observed between the first and second set of scores, r = 0.111, p = 0.575. In contrast, the PAI challenge subscale scores were strongly correlated, r = 0.527, p = 0.004 (see Table 3). When examining test-retest reliability by group condition, there were slightly different findings. The relationship between pre- and post-intervention PAI total scores in the control group was weak, r = 0.229, p = 0.430. The threat subscale showed no relationship, r = -0.196, p = 0.502, and the challenge subscale showed a moderate relationship, r = 0.497, p = 0.071 (see Table 4). In contrast, the pre- and post-intervention PAI total scores for the treatment group showed a strong relationship, r = 0.702, p = 0.005. The threat subscale data showed a weak relationship, r = 0.336, p = 0.240, and the challenge subscale data showed a moderate relationship, r = 0.664, p = 0.010 (see Table 5). Injury tracking survey. The primary researcher developed an injury tracking survey specifically for this study (see Appendix E). The content of this survey was inspired by several sources, including an injury tracking form developed by members of the Dance/USA Task Force on Dancer Health, and researchers Noh, Morris, and Andersen (2007). Previous research suggests that “dancers may under report injuries on surveys,” and, therefore, multiple questions about injury were presented (Thomas & Tarr, 2009, p. 51). Dancers were asked to report their current injury status; where their injury or injuries occurred on the body; if the injury or injuries caused them to miss or modify any training, rehearsals, or performances; whether they sought IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 18 medical attention; and the presence and severity of pain they may have experienced. Participants in the present study were incentivized to submit their injury reports every week throughout the study in order to be eligible to receive a $100 Visa gift card via a raffle system. The National Collegiate Athletic Association (NCAA) has defined a physical injury by focusing on three specific criteria. First, the injury must occur within the training or competition setting, and not in a different environment. Second, the injury must require the attention of an athletic trainer or physician affiliated with the particular group/team. Third and finally, the injury must restrict or prevent the athlete’s participation in sport for at least one day subsequent to the day in which the injury occurred (Dick, Agel, & Marshall, 2007). Due to the fact that dancers may be inclined to keep their injuries hidden, the primary researcher adopted a modified version of the NCAA’s third criterion. Specifically, any self-reported time lost was considered an instance of injury, rather than having dancers wait until the following day to “start the clock” on minutes or hours of dancing missed. Dance Experiences Survey. The Dance Experiences Survey (Krasnow & Mainwaring, 1990) was used in the present study to capture stressors that individuals may experience as a result of their role as dancers (see Appendix F). The instrument consists of 48 items, and asks participants to use “Yes” or “No” to indicate if each item applies to them at the present time. For those items that do apply, participants indicate the impact that these stressors have on them from -3 (extremely negative) to +3 (extremely positive). The instrument begins with an example so that participants are clear on the instructions and the format of the survey. At the end of the 48 items, participants are provided space to write-in any other stressors that they are experiencing, and to report the perceived impact of these stressors. The developers did not provide psychometric data via personal correspondence with the primary researcher, and there is a lack of psychometric IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 19 data available in the literature that uses this survey. As such, the information gathered via this instrument was intended only to describe the sample. Intervention program. The short-term psychological skills intervention program consisted of six sessions, with one session being conducted each week for the treatment group. This six-week time frame was determined through a search of the literature focused on short term behavior change and psychological skills interventions in sport (e.g., Bell, Skinner, & Fisher, 2009; Johnson, 2000; Meichenbaum, 1993). The primary researcher developed the intervention program content in collaboration with other sport psychology and counseling professionals, and from the content presented in the existing research literature. Face and content validity was confirmed by meeting with a licensed counselor and counselor educator to review all materials (see Appendix G for an overview of the intervention program protocol). Additionally, pilot testing was completed on all activities and handouts with two volunteer undergraduate students who reported a background in dance. During pilot testing, these two students provided verbal and written feedback about the aspects of the program’s content that they liked and did not like, and what they thought could be improved upon before its delivery to treatment group participants. The primary researcher compiled this feedback in written format and used it as a guideline for finalizing all intervention program materials. The primary researcher also asked these two students to complete all self-report surveys so that an estimated time period could be established for the data collection packets to be administered during the first and sixth weeks of the study. All sessions followed a similar outline, with exception of the first and last, which focused on data collection procedures. For the second through fifth weeks, the primary researcher’s routine for each session consisted of: (1) having the participants review what they had learned or IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 20 practiced in the previous week, (2) introducing the new skill to be learned or practiced, and then (3) providing an experiential learning activity focused on the week’s topic. After each skill was introduced and practiced, participants reflected on their experiences. For instance, participants were encouraged to pose questions or concerns about the topic or activity and to share their thoughts on how to use the skills(s) in dance class or other life pursuits. The first skills introduced were diaphragmatic breathing and progressive muscle relaxation. Participants were led through a deep breathing script and then through a progressive muscle relaxation exercise (in either an active or passive manner). The next skill introduced was imagery. Participants were led through a relaxation and coping imagery script based on Jon Kabat Zinn’s Mountain Meditation, and also led through a performance imagery script intended to help them prepare for dance class. The fourth week’s focus was on cognitive reframing and self-talk. Participants were given a handout that contained many negative, maladaptive, or irrational statements related to dancing. In small groups, they came up with more positive, adaptive, and truthful statements to use when they are dancing. The final skill introduced was mindfulness. Participants were led through a mindfulness-based stress management script that asked them to focus on their breath, a small item in their hand (a rock, provided by the primary researcher), and the present moment (see Appendix H for all of the exercises and activities used in the intervention program). Throughout the intervention program, the dancers’ class instructor remained present in the dance studio for all discussion, exercises, and activities. The instructor did not observe the sessions, but rather participated in the same way as the treatment group participants. However, the instructor did not participate in any data collection procedures during weeks one and six, and did not take part in the post-intervention focus group discussion. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 21 For each week of the intervention program, the primary researcher sent the course instructor the written scripts used for each session, as well as audio-recordings of the respective exercises or activities. The instructor offered to post these files in an online portal, to which the treatment group participants had access throughout the semester. Audio-files were created via QuickTime software and could be downloaded and listened to with an iTunes account. Adherence journal. A weekly adherence journal was developed by the primary researcher and loosely based on the journal that Noh, Morris, and Andersen (2007) used in their study with Korean dancers (see Appendix I). Participants received a link to a secure, online survey so that they could complete the items on their own time following weeks two through five of the program (i.e., dance students were asked to submit an adherence report four times throughout the study). The survey asked participants to indicate which skill(s) they were practicing, and for what amount of time they were practicing them. Participants were also prompted to rate their efforts to practice the skill(s) on a 4-point Likert scale from 1 (no effort) to 4 (excellent effort). This particular item was intended to capture their perceived level of investment in the program. Findings from this instrument are reported as exploratory analyses following the results of the main research questions. Procedure The primary researcher contacted several dance program chairpersons in the Mid-Atlantic region of the United States by email. The email to these chairpersons contained a brief proposal of the research study and its anticipated timeline. Once a dance professor expressed interest in the study, a phone call was scheduled to talk to this professor one-on-one to further explore his/her interest. Then, the primary researcher and the interested professor assessed the feasibility of recruiting another professor from the same department who might also be interested in the IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 22 study. Once this second person was identified, the two professors and the primary researcher developed a schedule that worked for all parties involved. The primary researcher obtained Institutional Review Board (IRB) approval from the primary institution and completed supplemental documents for the approval of the institution at which data collection procedures occurred. These latter documents included an IRB Authorization Agreement and letters of permission from each classroom instructor. The research team—which consisted of the primary researcher, an advisor, and two research assistants—then finalized all instrumentation and the intervention program content. For six consecutive weeks, the primary researcher traveled from her primary institution to the data collection site. During weeks one and six, data collection was the main focus. At the start of the first week, the primary researcher briefly explained the research design to all participants so that they understood how group assignments were made. Participants completed the Athletic Coping Skills Inventory (ACSI-28; Smith, Schutz, Smoll, & Ptacek, 1995), the Pain Appraisal Inventory (PAI; Unruh & Ritchie, 1998), and an injury tracking measure developed specifically for this study for the first and sixth weeks. In addition, two instruments were used to contextualize the sample, and were collected during week one. These included a basic demographics survey and the Dance Experiences Survey (Krasnow & Mainwaring, 1990), the latter of which was intended to capture perceived levels of stress in dance-specific situations. A research assistant accompanied the primary researcher for weeks one and six so that the data collection procedures could be viewed by participants as a somewhat separate process from the delivery of the intervention program itself. To ensure confidentiality throughout the study, participants who volunteered to take part in data collection procedures used code names. These code names were developed during week IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 23 one of the study with both groups, and consisted of two letters and four numbers. The creation of code names was necessary given the repeated measures nature of some of the surveys. The participants’ contact information (i.e., phone numbers and email addresses) was also voluntarily provided during the first week of the study, and these details were stored as a separate file on a password-protected computer throughout the course of the study. Participants’ contact information was necessary in order to collect data for weeks two through five (see Appendix J). Emails were sent through Gmail and text messages were sent using EZ Text, a messaging service that allows recipients to opt-in or opt-out of correspondence at any time. For weeks two through five, the control group did not meet with the primary researcher. Participants in this group were sent the injury tracking survey via email or text message. The treatment group also received the injury tracking survey via email or text message during this same time frame. In contrast to the control group, the treatment group met weekly with the primary researcher to learn and practice the psychological skills previously described. While at the site, the primary researcher took field notes to capture the overall context of the dance program and the setting in which the participants were learning and training. The primary researcher also arrived early to each session to observe other classes and to be available to answer participants’ questions. After each session with the treatment group, the primary researcher remained on-site to address questions and/or comments. In addition to receiving the injury tracking survey on a weekly basis, participants in the treatment group received an email or text message that contained a secure link to the weekly adherence journal. The purpose of the adherence journal was to capture participants’ efforts to practice the skills introduced throughout the intervention program. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 24 At the end of the intervention program—and once data collection procedures for week six were complete—the research assistant conducted a focus group discussion with participants in the treatment group (see Appendix K for semi-structured interview guide). This discussion was audio-recorded so that all responses could be fully transcribed. Focus group participants were incentivized with the offer of a chance to receive a $50 Visa gift card via a raffle system. Participants were asked to describe: (1) what went well, (2) what didn’t go well, (3) what was surprising or new, (4) how participants could use information provided in the intervention in their lives, and (5) what about the delivery (and/or the deliverer) would they change. Following the focus group discussion, the primary researcher conducted two exploratory interviews (i.e., stakeholder interviews) with each of the course instructors who allowed the researcher access to their classrooms. The instructors were interviewed via phone, and the interviews were audio-recorded so that they could be subsequently transcribed. Both instructors were informed that their names and titles would not be affiliated with the results and that any identifying information would be removed from the transcriptions. These interviews focused on gathering the instructors’ thoughts on their institution, program and teaching philosophies, and investment in the research topics and/or process. Interviews ranged from approximately 30 to 50 minutes and followed a semi-structured interview guide (see Appendix L for a summary of findings from these interviews). Following the conclusion of the study, the primary researcher remained available to participants and their instructors for follow-up questions or concerns. A basic summary of results was also provided. Finally, the primary researcher worked with the instructors to make the intervention program content available to those dancers who were initially assigned to the control group. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 25 Data Analyses Before any analyses were conducted, the researcher cleaned the data set by looking for impossible values, missing data, and cases of attrition. A few issues were found. The weekly injury reports had the highest response rate at the start of and end of the study, and the lowest response rate for the weeks in between. Two inconsistent or not plausible cases were identified within the injury data. Three participants reported their injury status either twice in the same day or twice in the same week. Given the timing of these submissions, the primary researcher made the decision to interpret the first of the two submissions as the report for the previous week, and the second of the two submissions as the report for the current or upcoming week. No impossible values were discovered within the data, and no other major issues were discovered. Multiple statistical analyses were used to answer the proposed research questions. Basic descriptive and frequency statistics were run to contextualize the sample used in the present study. Then, to answer the first research question, an ANCOVA was run on the post-test data from the ACSI-28, using pre-test ACSI-28 scores as the covariate. This analysis was run on the total scores for the ACSI-28 as well as for the seven subscales of the instrument. The significance level was set to p = 0.05, with the goal of observing a small to moderate effect size. The second research question was answered by running a second ANCOVA on the post test data from the PAI, using pre-test PAI scores as the covariate. This analysis was run on the PAI total scores, as well as for the two subscales of the instrument. The significance level was again set to p = 0.05. The primary researcher chose these statistical analyses based on the fact that ANCOVA may be used to increase statistical power and may potentially help with adjusting pre-test differences between the non-random groups used in the present study (Harlow, 2014). It should be noted that the use of ANCOVA to statistically control for a covariate is a somewhat IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 26 controversial approach, and therefore statisticians recommend that results be interpreted with caution (Harlow, 2014; Miller & Chapman, 2001) The primary researcher planned to run repeated measures analysis of variance (ANOVA) to answer the third research question. This specific test could allow for the examination of the average frequency and duration of self-reported injuries throughout the intervention program. However, this analysis could not be run for two primary reasons. First, the number of dancers who reported their injury status (and injury details) varied by week. Most or all participants reported their injuries for weeks one and six. However, during the weeks in between, the number of reports decreased. Given that repeated measures ANOVA requires information to be observed or collected on the same participants at each time-point, the missing data greatly affected the ability to conduct this analysis. Additionally, there were very few dancers (n = 3) who reported any time lost due to injury. Time lost could have served as the continuous dependent variable in this analysis had more injury reports, and the details within them, been submitted each week. In the absence of this analysis, basic descriptive statistics were run in an effort to report other informative findings. As for the fourth and final research question, the primary researcher utilized qualitative analyses. The primary researcher and two graduate students followed open coding procedures (Creswell, 2007; Patton, 2002), and utilized a typological approach to identify themes and categories from the focus group discussion. This same protocol was used to analyze the two exploratory stakeholder interviews. The coding team also engaged in data triangulation (Patton, 2002) so as to determine similar and different perspectives. IMPACT OF A PSYCHOLOGICAL SKILLS TRAINING PROGRAM BRYANT 27 Results Descriptive Statistics At the start of the research study, participants in the control group had a slightly lower average score (M = 38.47, SD = 15.84) on the Pain Appraisal Inventory (PAI) than did participants in the treatment group (M = 39.42, SD = 14.77). In contrast, control group participants reported slightly higher coping skills (M = 52.00, SD = 8.26) as measured by the Athletic Coping Skills Inventory-28 (ACSI-28) when compared to treatment group participants (M = 45.67, SD = 10.42) at the start of the study. At the conclusion of the study, participants in the control group reported lower scores on the PAI (M = 36.14, SD = 16.27) when compared to treatment group participants (M = 43.07, SD = 11.49). For the ACSI-28, control group participants still had higher scores (M = 50.14, SD = 8.11) compared to treatment group participants (M = 47.40, SD = 12.73). Overall, the control group’s mean scores on the PAI and ACSI-28 slightly decreased over time, and the treatment group’s mean scores on thes
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