Centre for Gambling Education & Research
The stigma of problem gambling: Public prejudice, private pain and implications for public health
Professor Nerilee HingThis study was funded by the Victorian Responsible Gambling Foundation
International Gambling Conference 10-12 February 2016, Auckland
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Background
Recreational gambling is a popular, socially accepted and normalised activity.
But problem gambling appears to be highly stigmatised.
People experiencing PG report that stigma deters or delays:
• problem acknowledgement• disclosure to others• help-seeking• treatment adherence
But, very little previous research into PG and stigma.
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What is stigma?
A social process which occurs when individuals are devalued or discredited in a particular social context because of a perceived negative attribute which disqualifies them from full social acceptance.
(Goffman, 1963; Crocker, Major, & Steele, 1998) • Reaction of others (labelling, stereotyping, judgment, prejudice)• To an undesirable attribute (e.g., race, obesity, addiction, disability)• Context specific (varies by culture, gender, time period, etc)• Spoiled identity (from a “normal” to “tainted” identify)• Become “them” rather than “us”
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Types of stigmaPublic stigma: the reaction of society to those with a stigmatising condition and the formation of negative attitudes towards the stigmatised population (Corrigan 2004). Problem gamblers are stupid and irresponsible.
Perceived stigma: the belief that others have passed judgment and/or hold stigmatising thoughts and ideas about a stigmatising condition (Barney et al. 2006).Most people believe that problem gamblers are stupid and irresponsible.
Self-stigma: when individuals with a stigmatised condition internalise and apply negative societal conceptions to themselves, resulting in diminished self-esteem, self-efficacy and perceived social worth (Corrigan 2004). Can occur whether stigma is directly experienced or perceived.I am stupid and irresponsible because I am a problem gambler.
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Overall project aimTo examine the characteristics, causes, and consequences of PG stigma to:
• deepen understanding of how and why problem gambling is stigmatised, and
• how this stigmatisation impacts on people with gambling problems.
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Research approach1. Literature review
2. Victorian adult survey (N = 2,000)
3. Survey of people with gambling problems (N = 203)
4. In-depth interviews with 44 people with problem gambling
5. In-depth interviews with 9 gambling counsellors
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Stage 1: Literature review• Not much!
• All previous studies based on student samples (Dhillon et al., 2011; Feldman & Crandall 2007; Horch & Hodgins 2008, 2013) – except Horch & Hodgin 2015 on self-stigma.
• Except a qualitative study (Carroll et al., 2014).
• We drew on literature, research designs and measures for mental health stigma.
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FocusThe public stigma of PG in the Victorian adult community:
• Perceived dimensions of PG that might affect its public stigmatisation
• Process of stigma creation for PG
• Relative intensity of public stigma associated with PG
• How public stigma stigma associated with PG varies amongst different groups
• But first, some theory…
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Dimensions of a condition that affect public stigma (Jones et al. 1984)
Origin• Attribution theory (Weiner 1986)• Perceived origin determines emotional responses, attitudes and behaviours.• External attributions (e.g., genetics, accident) pity, helping.• Internal attributions (e.g., poor choices, lack of self-control) anger, punishing.• Explains why mental illness, esp. addictions, are most stigmatised.
Peril (to others)• Danger appraisal hypothesis (Corrigan et al. 2003)• Perilous conditions fear and avoidance response (e.g. schizophrenia).
Noticeability: more noticeable more stigmatisedCourse: more recoverable/reversible less stigmatisedDisruptiveness: more disruptive to self more stigmatised
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The process of stigma creation (Link et al. 2004)
Labelling
Stereotyping
Separating
Emotional reactions
Status loss & discrimination
• E.g. “mental illness”, “problem gambler” emphasises difference, defines person by their condition, triggers stereotypes.
• Apply beliefs about a particular social group to someone perceived to be a member of that group.
• Stigmatised social groups categorised as “them”, resulting in social distancing from (the more powerful) “us”.
• Pity/helping when external cause. Irritation/anger when internal cause. Fear/apprehension when perceived as perilous.
• Stigma provides rationale for powerful actors to devalue (attitudes) and discriminate (behaviours) e.g. interpersonal, employment, housing, etc.
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MethodsSample:
• 2,000 adult residents of Victoria• Recruited thru online panel provider• Representative age, gender & location quotas• Weighted to 2011 Census
Measures:• based on responses to vignettes of PG• and vignettes of other health conditions• perceived dimensions of PG• the process of stigma creation• individual difference variables – demographics, gambling
involvement, PGSI, level of contact with PG
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Vignettes
Conditions:1. Problem gambling2. Alcohol use disorder3. Schizophrenia
Controls:4. Sub-clinical distress5. Recreational gambling
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Whole sample saw vignettes 1 and 4, and
were randomly allocated to 2, 3 or 5.
Order of vignettes randomised.
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Example of vignetteProblem gamblingDan is a man who lives in your community. During the last 12 months, he has started to gamble more than his usual amount of money. He has even noticed that he needs to gamble much more than he used to in order to get the same feeling of excitement. Several times, he has tried to cut down, or stop gambling, but he can't. Each time he has tried to cut down, he became agitated and couldn't sleep, so he gambled again. He is often preoccupied by thoughts of gambling and gambles more to try to recover his losses. Dan has also lied to his family and friends about the extent of his gambling.
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Perceived dimensions of PG expected to affect its public
stigmatisation
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Perceived origin of PG16
God’s will
His bad character
A genetic or inherited problem
A chemical imbalance in his brain
The way he was raised
Stressful circumstances in his life
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
0.5
1.5
1.6
1.9
1.9
2.7
0 = extremelyunlikely
How likely do you think it is that Dan’s situation is caused by …
4 = extremely likely
Main perceived origin for:• Recreational gambling: The way he was raised • Alcohol use disorder: Stressful circumstances in his life • Sub-clinical distress: Stressful circumstances in his life• Schizophrenia: A chemical imbalance in the brain
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Other dimensions
Proble
m gamblin
g
Sub-cl
inical g
ambli
ng
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phre
nia0
2
4 Noticeable
Problem gam
bling
Sub-cl
inica
l gam
bling
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phre
nia0
2
4Course (recoverability)
Problem gam
bling
Sub-cl
inica
l gam
bling
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phre
nia0
2
4 Disruptiveness
Green bars sig lower than PGRed bars sig higher than PGBlue bars not sig diff to PG
Problem gam
bling
Sub-cl
inica
l gam
bling
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phre
nia0
2
4 Peril to others
Problem gambling was perceived as highly disruptive to self, moderately noticeable and recoverable, but not
particularly perilous to others.
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Conceptualisations of PG
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A men
tal he
alth d
isorde
r
A phys
ical h
ealth
diso
rder
An add
iction
A dise
ase o
r illne
ss
A diag
nosa
ble co
nditio
n0.0
20.040.060.080.0
100.0
28.1
66.4
1.0
37.1
14.8
37.5
28.5
3.4
35.5 33.634.4
5.1
95.6
27.4
51.6
No Unsure Yes
% o
f res
pond
ents
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The process of stigma creation
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“It’s not the social stigma.
It’s the mercury.”
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After labelling comes stereotyping …
Dan tended to be stereotyped as:
impulsiveirresponsible
greedyirrational
anti-socialuntrustworthyunproductive
foolish
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Separating: PG
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Have Dan marry into your family
Start working closely with Dan on a project
Move next door to Dan
Have a group household in your neighbourhood for people in Dan’s situation
Make friends with Dan
Spend an evening socialising with Dan
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
1.0
1.8
1.9
2.1
2.1
2.2
If you were aware of Dan’s situation, how willing would you be to …
0 = definitelyunwilling
Committed or enduring
relationships not OK
Incidental relationships
OK
4 = definitely willing
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Emotional reactions: PG
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Pity Anger Fear0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
2.5
1.7 1.7
9-item scale to measure emotional reactions to the vignette character if they met him in real life
Sorry for, sympathy,
need to help Annoyed, angry,
disgusted
Scared, uncomfortable, apprehensive
4 = strongly agree
0 = strongly disagree
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Status loss & discrimination: PG
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% agree/strongly agree that “most people would …
Think less of Dan if he needed professional help
Take Dan's opinions less seriously
Think less of people in Dan's situation
Pass over Dan in favour of another applicant
Most women would be reluctant to date Dan
Hire Dan to take care of their children
Believe that Dan is just as trustworthy as the average citizen
Accept Dan as a teacher of young children in a public school
Willingly accept Dan as a close friend
Hire Dan if he was qualified for the job
Treat Dan just as they would treat anyone
Believe that Dan is just as intelligent as the average person
0 10 20 30 40 50 60 70
19.4
35.9
39.7
59.3
66.3
9.2
11.6
14.3
20.8
25.5
30.9
42.3
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Separating: all conditions25
Problem
gambli
ng
Sub-cl
inica
l gam
bling
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phren
ia0
1
2
3
4
5
Lower scores = more social distance desired
Green bars sig lower than PGRed bars sig higher than PGBlue bars not sig diff to PG
When measured on social distance, PG was:• more stigmatised than recreational gambling and sub-clinical distress• slightly less stigmatised than alcohol use disorder and schizophrenia.
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Status loss & discrimination: all conditions
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Problem
gambli
ng
Sub-cl
inica
l gam
bling
Sub-cl
inica
l dist
ress
Alcoho
lism
Schizo
phren
ia0
2
4
Higher scores = higher expected status loss and discrimination
When measured on expected status loss & discrimination, PG was:• more stigmatised than recreational gambling and sub-clinical distress• slightly less stigmatised than alcohol use disorder and schizophrenia.
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Who stigmatises problem gamblers? Implications for stigma
reduction
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Greater social distance desired by those who …• Believe problem gamblers are perilous to others • PG is a noticeable condition• People cannot recover from PG• PG is disruptive • PG is due to bad character or poor upbringing • Have negative stereotypical views of PG• Believe they would lose social status or be discriminated against• Feel more anger and/or fear, and less pity• Do not speak English at home• Are more conservative in political orientation• With less gambling involvement themselves• Less contact with PG
Implications for stigma reduction:• Messages and target groups• Community contact with PG
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Stage 3: Survey of people with gambling problems
Experiences of and responses to public stigma amongst those with gambling problems
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MethodsSample:
• 203 respondents• PG in previous 3 years• 18 yrs+• Living in Australia• 66.5% male, mean age = 40.9• 87.2% PGSI 8+ in previous 12 mths• Mean PGSI score = 15.3.
Recruitment: • 117 previous CGER research participants• 86 Google advertising
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Measures• Demographics• Perceived public stigma associated with PG• Self-stigma• Experiences of devaluation & discrimination because of PG• Coping and disclosure• Impacts on help-seeking, before & after relapse• Psychological measures:
• PGSI• self-esteem• psychological distress• self-consciousness• social anxiety
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Perceived stigma – how did our gambler respondents perceive the public stigma associated with PG?
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Perceived relative stigma of PG
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Drug ad
diction
Problem gam
bling
Alcoholism
Obesity
Bankru
ptcy
Depres
sion
Schizophren
ia
Recrea
tional
gambling
Cancer
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
3.1 3.02.7 2.7
2.3 2.3 2.3
1.6 1.4
4 = an extreme amount
0 = none
How much stigma do you feel society attaches to each of the following?
“a large amount”
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Perceived stigma• Perceived public stereotypes:
• irresponsible, impulsive, foolish, untrustworthy, secretive.
• weak self-control, addictive personality, would be addicted to something else if not PG, bored and lonely, always in debt.
• Underestimated how much the public thinks that PG is noticeable, recoverable and disruptive.
• Overestimated how much the public thinks/feels:• PG is the gambler’s own fault• fear and anger towards problem gamblers• how irresponsible problem gamblers are• they want to avoid problem gamblers• they would look down upon problem gamblers
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They either can’t be
bothered with you or they
just think you are an idiot
They think they’re thieves. They’re liars.
They have no life. They have no family
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Self-stigma – how did our gambler respondents feel about themselves
because of their gambling?
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Sick, ashamed, angry and guilty
I feel less of a person that I can’t control something
They’re looking at you and seeing that weakness and perhaps that’s all they’re
ever going to see … they’re never going to be
able to see you as successful or well-rounded
what they think doesn’t matter, but
I can’t get away from what I feel about myself
Makes me feel very depressed. You
know, it lowers my self-esteem
I don’t even want their pity, you know, I just want them to think of me, same as others
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Self-stigmatising beliefs
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Socially unacceptable
That you are entirely to blame
A failure or loser
That there is something wrong with you
Shocked at yourself
Embarrassed
Guilty
Disappointed in yourself
0 10 20 30 40 50 60 70 80 90 100
54.2
69.5
73.9
75.9
76.4
76.8
77.8
78.4
80.3
80.3
83.7
85.2
86.7
87.7
93.1
% agree/strongly agreeHow strongly do you agree or disagree that your gambling has made you feel …
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Devaluation and discrimination> 50% respondents reported at least occasionally being devalued because others thought they had a gambling problem:
• inferior• not smart• less politely• with less respect• as if they were dishonest• insulted or called names
Minority reported discrimination because of their gambling:• denied a bank loan (23.1%)• denied or received second-rate financial advice (9.9%)• fired from a job (8.9%)• prevented from renting somewhere to live (7.9%)• not given a promotion (6.9%)
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Probably because so few
had disclosed their PG
they look at you as lower
citizens incapable of being a
normal human
Like being looked down on, almost as if it was criminal
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Coping orientation40
Secrecy Withdrawal Challenging Distancing Education0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
3.2
2.1 2.11.8 1.7
4 = strongly agree
0 = strongly disagree
Mean scores for stigma coping mechanisms used
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Actual disclosure of gambling
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Your employer
Children
Other work colleagues
Welfare of other service providers you are in contact with
Other family members
Your doctor/other health professionals you are in contact with
Friends you don't gamble with
Partner/spouse
Parents
Friends you gamble with
Gaming venue mgrs or staff where you gamble
0 5 10 15 20 25 30 35 40 45 50
8.4
9.4
9.9
12.3
15.3
15.8
17.7
18.7
19.2
31.5
45.3
% of respondents reporting that these parties knew the extent of their gambling
Can friends be
harnessed as support?
Can venues do more with
this knowledge?
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Stigma and help-seeking• Most respondents had never
sought help, except from family and friends or self-help.
• Help-seeking more common after relapse.
• Compared to non-help-seekers, help-seekers had higher scores on the various stigma scales (self-stigma, perceived stereotyping, devaluation, discrimination). Causal direction?
Counsellors emphasised the fear
clients have to overcome to attend
counselling
They’re there to help you, but everybody is judgmental in some way whether they
realise they do it or not
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Embarrassment of help-seeking after relapse
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45.7
34.8
19.5More embarrassingEqually embarrassingLess embarrassing
Did you find it more or less embarrassing to seek this help after relapsing compared to before relapsing?
(% of respondents who had sought help both before and after relapse)
Relapsers also scored more highly on the self-stigma
scale, compared to non-
relapsers.
The counsellor is just waiting for me to fall out of line, and then it’ll be
no stopping her
But counsellors maintained that addressing self-stigma and
preparing clients for relapse is an early & key part of treatment
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Scores on the self-stigma scale highest for…
• Females• Those whose most problematic form was EGMs• Higher psychological distress• Higher public self-consciousness• Higher social anxiety • Lower self-esteem• Higher PGSI scores• Help-seekers• Relapsers
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Well, I thought they’d support me but they haven’t … I’ll say, ‘Look, I enjoy going to the club’, and then I can see the look of disdain in their faces.
You know, can’t you do something better like clean your house instead of spending all the time
at [the club]? (8, F, 55-64).
It’s probably more acceptable in the
male community … women who play the pokies … it’s
the lowest form (46, F, 45-54).
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Summary• Public stigma of PG is alive and well. Why?
• PG perceived as mainly due to poor coping with stressful life circumstances (blame?) and as highly disruptive to self and others.
• Easier to blame and stereotype than to understand how difficult it is to “just stop” when addicted.
• PG not quite as heavily stigmatised as alcoholism and schizophrenia, but people with gambling problems think it is more stigmatised.
• How does this stigma impact on them?• Encourages secrecy• Delays and deters help-seeking• Undermines treatment adherence, esp. after relapse• Leads to self-stigmatising beliefs• Which diminish self-esteem and self-efficacy• Adds a double burden• Worse for some groups (e.g. female, EGMs, high psych. distress, anxiety, PGSI)
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Implications• Treatment needs to help clients overcome self-stigmatising beliefs:
• restore self-esteem• enhance stigma coping skills• foster a belief that recovery is possible• prepare clients for relapse
• Addressing public stigma of PG is critically important.
• Lowering public stigma requires improving:• knowledge (about PG, its dimensions, struggling with an addiction rather than weak)• language (labels)• attitudes (stereotypes, emotional reactions, devaluation)• behaviours (social distancing, discrimination)
• Public education strategies needed; careful not to stigmatise further.• Increasing community contact with PG a promising strategy.• Research needed into optimal stigma reduction strategies.
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Canberra: Australian National University.Corrigan, P.W. (2004). How stigma interferes with health care. American Psychologist, 59(7), 614-625.Corrigan, P.W., Markowitz, R.E., Watson, A., Rowan, D., & Kubiak, M.A. (2003). An attribution model of
public discrimination towards persons with mental illness. Journal of Health and Social Behavior, 44, 162–179.
Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D. T. Gilbert, S. T. Fiske & G. Lindzey (Eds.), The Handbook of Social Psychology: Vol. 2. (4th ed., pp. 505–553). New York, NY: McGraw–Hill Companies, Inc.
Dhillon, J., Horch, J.D., & Hodgins, D.C. (2011). Cultural influences on stigmatization of problem gambling: East Asian and Caucasian Canadians, Journal of Gambling Studies, 27(4), 633-647.
Feldman, D.B., & Crandall, C.S. (2007). Dimensions of mental illness stigma: What about mental illness causes social rejection? Journal of Social and Clinical Psychology, 26, 137–154.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. London: Penguin. Horch, J. & Hodgins, D. (2008). Public stigma of disordered gambling: Social distance, dangerousness, and
familiarity. Journal of Social and Clinical Psychology, 27(5), 505-528. Horch, J., & Hodgins, D. (2013). Stereotypes of problem gambling. Journal of Gambling Issues, 28, 1-19.Jones, E.E., Farina, A., Hastorf, A.H., Marcus, H., Miller, D.T., & Scott, R.A. (1984). Social stigma: The
psychology of marked relationships. New York, NY: Freeman and Company.Link, B.G., Yang, L.H., Phelan, J.C., & Collins, P.Y. (2004). Measuring mental illness stigma. Schizophrenia
Bulletin, 30(3), 511-541.Weiner, B. (1986). An attributional theory of motivation and emotion. New York, NY: Springer-Verlag.
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