Enactive Phenomenological Approach to the Trier Social Stress Test: A Mixed Methods Point of View

Podsumowanie

Here, we present an original mixed method combining a quantitative and a qualitative approach to examine accurately participants' experiences during the Trier Social Stress Test and the Trier Social Stress Test for groups.

Streszczenie

The single Trier Social Stress Test (TSST) and the TSST for groups (TSST-G) are the most used protocols to experimentally induce psychosocial stress. These tests are based on uncontrollability and social-evaluative threat, inducing psychological and physiological consequences (e.g., anxiety, emotional states, salivary cortisol increases). Many quantitative experimental studies have investigated these stress inducers and these consequences. But, as far as we know, this study is the first to provide a qualitative analysis to access the participants' voices so as to understand the dynamics of their experience throughout the TSST and the TSST-G. This paper outlines a mixed methods approach to the TSST. This approach can help to maximize the information that can be gained from the TSST, which researchers often use without looking more closely at what is qualitatively happening psychologically for participants during the stressor itself. In this way, this protocol is an example of mixed methods, showing the added value of using the enactive phenomenological approach to analyze experimental protocols more deeply. This kind of mixed methods is helpful to access the experience, to understand the actor's point of view, and to analyze in-depth the dynamics of cognitive processes like intentions, perceptions, enacted knowledge, and emotion. The discussion section shows the different uses of a mixed methods protocol, exploiting the enactive phenomenological approach to analyze a protocol or to give a cross vision of the same research subject. This section deals with different existing applications, pointing out some critical steps in this mixed methods approach.

Wprowadzenie

Mixed methods give various advantages when trying to understand a phenomenon^1,2,3,4,5. Greene et al.⁶ define them as protocols that include a quantitative method to analyze numbers and a qualitative method to analyze words. This approach aims to move beyond paradigm wars or conflicts between qualitative and quantitative research. The goal is to increase the strengths of studies and diminish the weaknesses of single studies³; thus, it functions as a third research paradigm. Combining different kinds of analyses on the same object makes it possible to have different points of view. This paper presents a particular form of mixed methods, combining an experimental protocol with experiential data using the single TSST⁷and the TSST-G⁸. The TSST is the most used protocol to experimentally perform psychosocial stress investigations^9,10. These tests are based on uncontrollability and social-evaluative threat, linked with physiological and psychological consequences. Different empirical, theoretical, or meta-analysis studies¹¹ have shown that the TSST and the TSST-G elicit psychological effects and activate the HPA axis, leading, for example, to negative emotional states, self-reported anxiety, and cortisol rise. Many experimental studies investigated these markers of stress, their relations, and their influences¹². However, only one qualitative approach has been conducted¹³ to understand the participants' lived experiences during these tests.

The present protocol develops the original mixed methods approach mainly used in an earlier publication¹³. The originality of this mixed methods research lies in the qualitative approach based on an enactive phenomenological framework^13,14,15,16 to examine accurately participants' experiences when confronted with the TSST and the TSST-G. Qualitative investigations can be heuristic because they make it possible to characterize and analyze what is happening psychologically for participants in a particular situation¹⁷. Last, the enactive phenomenological approach allows researchers to understand the participants' points of view and, thus, to analyze stress and emotion^18,19,20. Following this approach, participants can describe, comment on, and show their lived experience step-by-step. This enactive phenomenological framework has two main assumptions^16,21. First, action and situation are coupled^22,23 (i.e., the dynamics of the action emerge within a specific context). This assumption provides access to the dynamics of the participant's experience confronted with the TSST and the TSST-G and to identify particular components of the context for the actor. Secondly, every action carries significations for the actor^23,24. This approach provides access to the actor's signification construction of the experience during the action, thanks to a rigorous method originating from phenomenological interviews and named enactive interviews^16,25. The actor's experience can be characterized in its emotional, perceptional, and situational dimensions²⁶. Different kinds of mixed methods are based on this enactive phenomenological approach, which has already produced heuristic results in different areas, namely sport^14,15,18,27, doping²⁸, work²⁹, and education^30,31,32.

The mixed methods presented here aim to give confirmation and comprehension to findings in the TSST literature: confirmation through a comparison of the effect of the TSST and the TSST-G on physiological indicators (like cortisol), on self-reported indicators (like anxiety and emotional states), and on experiential indicators (like participants' voices) and comprehension through the qualitative method accessing participants' dynamics of action as they emerge in these stressful protocols. This is an original way to access in-depth the dynamics of psychosocial stress and to understand the participants' voices about the stressful moment of the TSST and the TSST-G. This protocol is, thus, an example of mixed methodology, showing the added value of using the enactive phenomenological approach to analyze the experimental protocol more deeply.

Protokół

The Institutional Review Board of the University approved this research.

NOTE: An example of mixed methods using the enactive phenomenological protocol.

1. Exclusion Criteria

1. Use a questionnaire before the experiment in order to exclude some participants, as necessary, on the following criteria: smoking (over five cigarettes per day), drinking (over two glasses of alcohol per day), taking medication, using drugs, having an endocrine problem, experiencing chronic stress (e.g., as determined by the French version of the Perceived Stress Scale [PSS])³³, and experiencing psychological distress (e.g., as determined by the French version of the General Health Questionnaire [GHQ-12])³⁴.

2. Preliminary Instructions

NOTE: The following preliminary instructions need to be given 1 day before the experimentation.

1. Tell the participants not to take any medication, perform physical exercises, or consume alcohol the day before the test.
2. Tell the participants to wake up at least 3 h before the test.
3. Tell the participants to not drink or eat anything, smoke, or brush their teeth 1 h before the test.

3. Pretest Measurements

NOTE: The protocol presented in this section was used in the earlier publication mentioned in the introduction¹³. Prestress measurements can be done after an inactive wait of 45 min¹⁰; also, the first point of measure can be done 20 min before the TSST³⁵.

1. First saliva collection
   NOTE: Salivary cortisol is commonly used as a physiological marker of stress with the TSST^9,36.
   1. Use the passive drool method: ask the participant to tilt their head forward to allow saliva to pool in their mouth, and instruct them to guide it into a small polypropylene tube.
   2. Freeze the tube immediately at -20 °C.
2. First questionnaire collection
   1. Measure the participant's anxiety. Ask them to fill out the State-Trait Anxiety Inventory (STAI)³⁷ questionnaire.
      NOTE: STAI is an example of a questionnaire that can be used to measure anxiety. It is a Likert scale with a range of four options (1 = not at all, 4 = very much so); using this range, participants were asked to respond to 12 items (e.g., "I feel tense"). A composite variable was constructed with the scores of all items.
   2. Measure the participant's emotional state. Ask them to fill out the Self-Assessment Manikin (SAM)³⁸ questionnaire.
      NOTE: SAM is a Likert scale that uses a nonverbal pictorial technique with nine figures to evaluate pleasure, arousal, and dominance. Participants have to circle a figure for each item.
   3. Then, bring the participant into the TSST room.

4. Performance of the TSST or the TSST-G

NOTE: Different aspects of the TSST have already been described in other JoVE articles^10,12,39.

1. Protocol context
   1. Position the participant in the protocol room on a red cross drawn on the floor.
   2. Question the participants one by one for the TSST.
   3. Use a group of participants (e.g., six participants separated by little walls to limit social and visual interaction¹³) for the TSST-G.
   4. Ensure that the experimenters (two or three) are neutral and look like scientists with white lab coats.
   5. Explain that the committee members are specialists in nonverbal behavior analysis and all actions are filmed for future analysis.
2. Mock job interview
   1. Ask the participant to imagine a job of their choice.
   2. Give the participant 3 min of preparation time (10 min for the TSST-G).
   3. Specify that preparation notes cannot be used during the interview.
   4. Give the participant 5 min of presentation time (2 min for the TSST-G, performed in random order) in front of the committee to explain why they are the best candidate for this job.
   5. Tell the participant to continue when they stop talking by saying "You still have time remaining."
   6. Remain silent for 20 s when that participant stops talking for the second time.
   7. Ask standardized questions if the participant does not resume speaking (e.g., "Please list your weaknesses.").
3. Mental arithmetic task
   1. Ask the participant to count aloud backward from 2023 in steps of 17. For the TSST-G, the numbers are different for each participant.
   2. Explain the participant they must calculate as quickly and correctly as possible.
   3. Point out each mistake and tell the participant to start all over again.
   4. Make sure the task lasts 5 min (80 s for the TSST-G, performed in random order).

5. Posttest Measurements

NOTE: Then, collect a second saliva sample and let the participant complete questionnaires in another room (same process as the first collections, described in section 3 of this protocol).

1. Second saliva collection
   NOTE: The measurement of cortisol levels is repeated (6 to 9 times) to analyze the cortisol response.
   1. Following the passive drool method, collect saliva from the participant into a small polypropylene tube, as described previously (step 3.1.1).
   2. Freeze the tube immediately at -20 °C.
2. Second questionnaire collection
   1. Measure the anxiety. Ask the participant to fill out the STAI³⁷ questionnaire.
      NOTE: STAI is a Likert scale with a range of four items (1 = not at all, 4 = very much so); using this range, participants responded to 12 items (e.g., "I feel tense"). A composite variable was constructed with the scores of all items.
   2. Measure emotional states. Ask the participant to fill out the SAM³⁸ questionnaire.
      NOTE: SAM is a Likert scale that uses a nonverbal pictorial technique with nine figures to evaluate pleasure, arousal, and dominance. Participants have to circle a figure for each item.

6. Qualitative Investigations

1. Use a wide-angle camera to record the participant's behavior and their interaction during the TSST or the TSST-G.
2. Conduct enactive interviews to access the participant's experience.
   1. Perform the interview as soon as possible after the performance of the TSST or the TSST-G to ensure the participant still remembers (preferably within 48 h).
   2. Explain that the participant must relive the past activities, helped by their own audio-visual record of the TSST or the TSST-G. Avoid stating the precise aim of the experiment to the participant.
   3. Select an experienced rater who is used to conducting enactive interviews.
   4. Confront the participant with their own recording to help them relive the experience as close as possible.
   5. Ask directive questions to help the re-emergence of the past experience. For instance, point at an image from the video and ask: "What are you doing here?"
   6. Help the participant to remember with questions focused on the video to allow them to describe, comment on, and show their lived experience step by step: "What is happening here on the video?"
   7. Investigate the experience's components as intentions and perceptions by asking: "What were your intentions here?", "What did you perceive at this precise moment?"
   8. Stop the participant if they use global discourse, a posteriori analysis, or generalization, or when they digress from the precise moment that is being discussed, as suggested for phenomenological research⁴⁰.
   9. Ask follow-up questions based on the participant's response. For example, when the participant says: "I am out", ask "What does 'I am out' mean?" and, then, continue to investigate what happens from the participant's point of view.
   10. Respect the time sequence of the video and avoid changing the time-flow to access the dynamics of the experience step by step.
   11. Allow the participant to pause the video when they want to describe their own experience.

7. Data Analysis

1. Perform a saliva analysis.
   1. Determine the participant's cortisol level by the enzyme-linked immunosorbent assay (ELISA) technique using assay kits (see Table of Materials).
   2. Measure the concentration related to the absorbance at 450 nm with a 96-well microplate spectrophotometer (see Table of Materials).
   3. Calculate the intra-assay precision with the average value of individual variability for all of the duplicates within each microplate.
   4. Obtain concentrations of unknown samples (nmol/L) with a four-parameter nonlinear regression curve fit, following the ELISA kit protocol recommendations, based on cortisol standards (82.77, 27.59, 9.19, 3.06, 1.02, 0.33 nmol/L).
2. Perform a statistical analysis using repeated measures ANOVAs with a level of significance at p < 0.05.
3. Calculate the effect sizes with a partial eta squared.
   ​NOTE: Eta squared is a statistical measure of effect size for use in ANOVA.
4. Perform a phenomenological analysis.
   1. Transcribe all the enactive interviews with the maximum of detail, such as verbal clutter, demonstration, hesitation, etc.
   2. Construct a two-part table that outlines the time flow, transcription, and a report of the behaviors and discussion helped by the recordings (Table 1).
   3. Identify components of the experience, beginning with the elementary units of meaning corresponding to the smallest units of activity meaningful to a participant.
   4. Identify perception, analyzing the meaningful sensation, sentiment, and informational aspects (visual, acoustic, or kinesthetic) in the situation.
   5. Identify intention, analyzing the participant's concern in the situation.
   6. Categorize sequences by grouping units of meaning related to the same story.
   7. For each participant, identify their typical experience descriptively, statistically, generatively, and significantly²¹ (e.g., typical action, typical intention, and typical perception).
   8. Identify the typical experiences of all the participants, finding similarities between each typical experience.
   9. Construct tables of typical experience for all the participants, using the following values: timeline, typical sequences, typical perceptions, typical actions, and typical intentions.
   10. Normalize the formulation of each category using a group of words to express the typical sequence, an "ing" for the typical action, and an infinitive verb for the typical intention.
   11. Compare the TSST and the TSST-G using the two tables of typical lived experience.
   12. Present the common aspects of experience during both protocols.
   13. Present the singular aspects of experience during each protocol.
5. Perform a case study analysis to understand the local processes, for example, the four lowest and highest cortisol responders.
   1. Identify the components of the experience (see the preceding protocol).
   2. Rebuild the meaningful experience for each participant following the TSST or the TSST-G steps.
6. Compare the mixed methods.
   1. Compare the quantitative and qualitative results conducting analyses and interpretation separately (cortisol, state anxiety, emotional states, experience data).
   2. Verify whether the quantitative analysis' results of the stress dynamics are similar to those of the qualitative analysis.
   3. Analyze whether what happened in the participants' experiences can help in understanding quantitative stress variation.

Wyniki

The results shown here come from a review of literature (for the cortisol)⁸ and two studies on stress done in our lab (for the state anxiety, the affective reaction, and the qualitative approach)^13,41. The results presented here are representative of what can be found, using the protocol, about (1) salivary cortisol levels, (2) state anxiety, (3) pleasure, arousal, and dominance, and (4) meaningful experien...

Dyskusje

In this article, we present an original mixed methods approach combining an experimental protocol with the enactive phenomenological approach. This kind of mixed methods is helpful to access experience, to understand participants' points of view, and to analyze in depth the dynamics of cognitive processes like intentions, perceptions, enacted knowledge, and emotions.

Mixed methods can be used in different ways. Green et al.⁶ present five functions: triangul...

Materiały

Name	Company	Catalog Number	Comments
Enzyme-linked immunosorbent assay (ELISA)	Salimetrics, UK	Kit-- N° No. 1-3002	Expanded Range High Sensitivity Salivary Cortisol Enzyme Immunoassay
Spectrophotometer	Thermo Fisher, Germany		Multiska FC Microplate Photometer