Transgender and nonbinary (TNB) people report experiencing elevated rates of discrimination and psychological distress (James et al., 2016). Transgender-affirming interventions are recommended to address psychological distress (e.g., anxiety, depression) reported by TNB individuals (Craig & Austin, 2016). TNB people in rural areas report barriers (e.g., lack of financial resources, long commutes) to accessing affirmative and/or quality treatment (Knutson, Koch, Arthur, Mitchell, & Martyr, 2017). Electronically delivered interventions, if found to be effective, could be used to reduce barriers and increase the accessibility of affirmative care to TNB people, especially people in remote areas and during pandemics such as the 2019 novel coronavirus (COVID-19). The current study presents pilot feasibility data examining a 6-month transgender-affirmative intervention based on short message service (SMS). Participants (N ϭ 14) were 18 years old or older and identified as transgender and/or nonbinary. Anxiety, depression, and social support were assessed at pre-and posttreatment and at 3-month follow up. Anxiety, t(13) ϭ 2.95, p ϭ .01, d ϭ 0.40, and depression, t(13) ϭ 2.76, p Ͻ .05, d ϭ 0.73, decreased significantly from pre-to postintervention. Anxiety, t(13) ϭ 3.26, p ϭ .01, d ϭ 0.65, further decreased from preintervention to follow-up, and social support, t(13) ϭ Ϫ2.45, p Ͻ .05, d ϭ 0.29, increased from preintervention to follow-up. The intervention demonstrated good feasibility and acceptability, based on participant feedback. We discuss the implications of our results for technology-based TNB-affirmative care for individuals, as well as future directions for research. Public Significance StatementThis study provides initial support for the effectiveness of a transgender-and nonbinary-affirmative intervention delivered through text messages. The results suggest that the individuals experienced statistically significant reductions in anxiety and depression symptoms as well as increases in social support.

Purpose: Employee turnover is a major issue for health care organizations. Burnout is a leading contributor to such turnover. Extensive research on burnout has been conducted in health care settings; however, it has primarily been focused on health care professionals ignoring other critical staff. In particular, traumatic brain injury rehabilitation is an area of health care that includes unique challenges and stressors that may contribute to burnout. Brain injury professionals report experiencing high levels of burnout that further increase as they spend more time with patients; however, little is known about the experiences of brain injury paraprofessionals. This study explores the unique experiences of support staff in traumatic brain injury rehabilitation centers. Method: The present study used a grounded theory method to explore the phenomena of burnout, turnover, and job satisfaction from the perspective of paraprofessional support staff in 1 posthospital brain injury rehabilitation center. Support staff participated in the research via small group interviews (N = 4) and survey (N = 11). Results: The analysis resulted in a grounded theory model, entitled "The Balance model of Rehabilitation Support Work." This model is a framework of risk and protective factors that appeared to influence whether these frontline rehabilitation staff experienced negative outcomes from this often challenging/stressful work environment. The model includes 4 axial-level themes: doing the work, protective factors, risk factors, and imbalance of factors. Within the 4 axial categories are twenty open-coding level categories. Implications: Implications for traumatic brain injury rehabilitation organizations and areas for future research are discussed. Impact and ImplicationsThe imbalance of risk and protective factors can lead support staff to experience of burnout and turnover. Support staff are committed to their work and patient care, but team and organizational level factors can lead to burnout and turnover. Organizational level changes that increase protective factors and reduce risk factors can improve support staff work experience and patient care.

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Scholars note that therapist performance is one of many factors that contribute to client treatment outcomes. Given that the performance of therapists matters, researchers have identified several methods and models for improving therapist effectiveness. However, scholars have yet to explore highly effective therapists' perspectives on their motivation to develop, the methods they use, and the impact of their efforts to develop. The present study used a consensual qualitative research (Hill & Knox, 2021) approach to explore dynamics underlying therapist development of expertise. Semistructured interviews were conducted with 12 therapists whose outcome data placed them in the top 25% of clinicians of their respective clinics, according to their supervisors. The researchers reached consensus at each stage of analysis as they organized data into domains, core ideas, and cross-analysis. Domains and corresponding subdomains were: (a) struggle with personal, external, and response to barriers subdomains, (b) therapist characteristics with striving, presence, skills, and values subdomains, and (c) development with early career, formal, feedback, relational, personal/identity subdomains. Implications for practice and areas for future research are discussed. Clinical Impact StatementQuestion: What do highly effective therapists do to improve and what motivates them to improve? Findings: Therapists experience struggles in their development, they possess personal characteristics that orient them toward growth, and they engage in a range of developmental activities. Meaning: These findings indicate that therapists who view struggles as opportunities for growth, value growth, and engage in individualized growth process continue to improve. Next Steps: Future research should seek to understand the individualized methods therapists engage in to improve, how they engage in feedback processes, and how they personalize therapy based on each individual client's needs.

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