*2.1. Extended TPB and Preventive Behaviors for COVID-19*

Ajzen [14] introduced the TPB model as an extension and improvement of the theory of reasoned action [18]. The TPB model consists of three exogenous constructs, namely attitudes, subjective norms and perceived behavioral control. The underlying premise of the TPB model is that individuals' attitudes toward behavior, subjective norms and perceived behavioral control together can shape their behavioral intentions or actual behaviors. Since its proposal, the TPB model has been extensively used to understand behaviors in a variety of domains, including a number of health-related behaviors [19–21]. Recent studies have also provided empirical support for the utility of the TPB model in explaining COVID-19 preventive behaviors. For instance, Prasetyo et al. [22] assessed the variables that affect the perceived effectiveness of COVID-19 prevention measures in the Philippines based on TPB and protection motivation theory. Sturman et al. [23] established a modified TPB model by incorporating knowledge to better understand adherence to restrictions during the COVID-19 pandemic by respondents in metropolitan Melbourne, Australia. Furthermore, Trifiletti et al. [24] used the TPB model along with perceived risk to evaluate protective behavior against COVID-19 in adults residing in Italy. The studies mentioned above indicate that the TPB model may benefit from reasonable expansion or modification to make it suitable for preventive behaviors for COVID-19 within different contexts.

The literature in the higher education research field has explicitly elaborated the critical impact of institutional factors, such as the structures, policies and practices of HEIs, on students' experiences, beliefs, attitudes and behavioral outcomes [25,26]. After systematically comparing the TPB model and several other behavioral theories applied in the research of infection control practices, Kretzer and Larson [27] noted that real behavioral change does not happen by targeting the individual alone; the institutional context must also be taken into consideration when seeking to improve infection control practices. Based on these perspectives, our study was designed to include institutional climate in rgw TPB model as an antecedent factor of both TPB variables and preventive behaviors for COVID-19. In addition, COVID-19 has been proposed to be more dangerous and unpredictable than other infectious diseases [28], and different students may possess different levels of risk in the same environment. Therefore, we further considered perceived risk associated with COVID-19 as a moderating factor in the extended TPB model. The extended TPB model in the current study is presented in Figure 1.

**Figure 1.** Research model.

#### *2.2. Institutional Climate and Preventive Behaviors for COVID-19*

Institutional climate is defined here as university students' perception of their affiliated HEI's formal policies, procedures and practices concerning the prevention and control of COVID-19 on campus [29]. According to previous research, organizational factors within the public sector play a vital role in the prevention and control of epidemics [30]. Researchers have also provided abundant empirical evidence for the relationship between institutional factors and various kinds of individuals' health-related behaviors. For example, Cheung [31] found that organizational regulation of worksite noise helped promote employees' protective behaviors for hearing loss. Ko and Kang [32] revealed that the organizational climate had a positive and significant influence on school dietitians' food safety and hygiene behaviors. Schwatka et al. [33] found that organizational safety and the health climate were positively correlated with the healthy behaviors of workers in small businesses. During the COVID-19 pandemic, although no study has directly examined the relationship between the institutional climate and preventive behaviors of COVID-19, several recent studies have provided insight into the role of institutional factors that protect against the negative effects of the COVID-19 pandemic and promote precautionary actions to minimize risk while sustaining psychological wellbeing [34,35]. In particular, Tausen et al. [36] reported that the response and support of universities combating COVID-19 increased the subjective well-being of Asian students at a predominantly white university during the COVID-19 crisis in the US. Thus, based on previous evidence, our study proposes the following hypothesis:

**Hypothesis 1 (H1).** *The institutional climate is positively associated with university students' preventive behaviors for COVID-19.*


CHO supernatants and whole leaf extracts are prepared for purification.

responses and rapid treatment or booster administrations.

attachment domain (PRAD) of ColQ gene (Altamirano & Lockridge, 1999).

symptoms of Gulf War illness in soldiers exposed to these compounds (US DOD, Pesticides-Final Report, 2003).

Currently, the standard (approved) treatment for acute OP pesticide poisoning involves administration of intravenous (iv) atropine and an oxime e.g. obidoxime, pralidoxime to reactivate inhibited AChE (Worek et al., 2010). However, the effectiveness and safety of oxime administration in acute OP pesticide-poisoned patients has been challenged and a recent clinical trial showed no clinical benefits and a trend towards harm in all sub-groups, despite clear evidence that these doses reactivated AChE in the blood (Buckley et al., 2011).

An efficacious prophylactic therapeutic treatment for preventing insecticide poisoning that can bind and scavenge the OP before it reaches and targets AChE in neuromuscular junctions is therefore a high priority. The leading candidate of this type is native (plasma) butyrylcholinesterase (BChE) whose potent OP bioscavenging ability has been demonstrated in many animal models and against varied OP neurotoxins (Doctor et al., 2001; Lenz et al., 2001). While several new catalytic and other stoichiometric enzymes also exhibit this ability (Lenz et al., 2007), based on availability, broad spectrum efficacy, stability and safety (Sun et al., 2005), BChE is the most advanced in terms of development of a human treatment. In Turkey, frozen plasma (BChE levels of 3,000 - 5,700 units) given as an alternative or adjunctive treatment with atropine and oximes, has been shown to prevent mortality and intermediate syndrome in acutely insecticide-exposed and hospitalized individuals (Güven et al., 2004). Currently, BChE also finds use as a treatment of cocaine overdose and for the alleviation of succinylcholine-induced apnea.

Structurally, BChE (also known as pseudocholinesterase or non-specific cholinesterase) is a serine esterase (MW=345,000) comprised of four identical subunits each containing 574 amino acids, held together by non-covalent bonds, with 36 carbohyrdrate chains (23.9% by weight) (Lockridge, 1990; Nachon et al., 2002). BChE is found in all species at levels of 1-20 ug/ml in plasma (Rosenberg, unp. data) and is also abundant in liver, intestine and lung. Recombinant (r) human butyryl-cholinesterase (HuBChE), like the native form, is also a potent bioscavenger of OP neurotoxins (Doctor et al., 2001; Lenz et al., 2001; Raveh et al., 1997) but its development as a human treatment for pesticide exposure has been disadvantaged by: (i) poor in vivo stability (bioavailability) of the unmodified forms and the presence of potentially immunogenic glycans using certain expression systems (ii) a 1:1 stoichiometry between the enzyme and OP (Raveh et al., 1997) and (iii) the high LD50 of insecticides (ug-mg/kg levels). This necessitates the delivery of large, costly, rBChE doses to detoxify exposed individuals which is problematic when intramuscular (im) or subcutaneous (sc) injections are the chosen routes of delivery. In this chapter, we shall describe our experience of how the chemistry, glycosylation, chemical modification, animal model and route of administration may reduce or enhance the potential of BChE bioscavengers as prophylactic therapeutic human antidotes for OP insecticide exposure.

#### **2. Production of tetrameric and monomeric forms of rMaBChE and rHuBChE**

Macaque (Ma) and human (Hu) BChE molecules are very similar molecules differing by only 22 amino acids and sharing ~96% DNA sequence identity, critical glycosylation sites, cysteines and disulfide bridging (Boeck et al., 2002; Rosenberg et al., 2010). Thus, most anti-BChE antisera react with both molecules. Native HuBChE and MaBChE in plasma are composed predominantly of tetramers (98%) with the tetramerization domain being located within the last 40 C-terminal residues of each monomeric subunit (534-574) (Blong et al.,

symptoms of Gulf War illness in soldiers exposed to these compounds (US DOD, Pesticides-

Currently, the standard (approved) treatment for acute OP pesticide poisoning involves administration of intravenous (iv) atropine and an oxime e.g. obidoxime, pralidoxime to reactivate inhibited AChE (Worek et al., 2010). However, the effectiveness and safety of oxime administration in acute OP pesticide-poisoned patients has been challenged and a recent clinical trial showed no clinical benefits and a trend towards harm in all sub-groups, despite clear evidence that these doses reactivated AChE in the blood (Buckley et al., 2011). An efficacious prophylactic therapeutic treatment for preventing insecticide poisoning that can bind and scavenge the OP before it reaches and targets AChE in neuromuscular junctions is therefore a high priority. The leading candidate of this type is native (plasma) butyrylcholinesterase (BChE) whose potent OP bioscavenging ability has been demonstrated in many animal models and against varied OP neurotoxins (Doctor et al., 2001; Lenz et al., 2001). While several new catalytic and other stoichiometric enzymes also exhibit this ability (Lenz et al., 2007), based on availability, broad spectrum efficacy, stability and safety (Sun et al., 2005), BChE is the most advanced in terms of development of a human treatment. In Turkey, frozen plasma (BChE levels of 3,000 - 5,700 units) given as an alternative or adjunctive treatment with atropine and oximes, has been shown to prevent mortality and intermediate syndrome in acutely insecticide-exposed and hospitalized individuals (Güven et al., 2004). Currently, BChE also finds use as a treatment of cocaine

Structurally, BChE (also known as pseudocholinesterase or non-specific cholinesterase) is a serine esterase (MW=345,000) comprised of four identical subunits each containing 574 amino acids, held together by non-covalent bonds, with 36 carbohyrdrate chains (23.9% by weight) (Lockridge, 1990; Nachon et al., 2002). BChE is found in all species at levels of 1-20 ug/ml in plasma (Rosenberg, unp. data) and is also abundant in liver, intestine and lung. Recombinant (r) human butyryl-cholinesterase (HuBChE), like the native form, is also a potent bioscavenger of OP neurotoxins (Doctor et al., 2001; Lenz et al., 2001; Raveh et al., 1997) but its development as a human treatment for pesticide exposure has been disadvantaged by: (i) poor in vivo stability (bioavailability) of the unmodified forms and the presence of potentially immunogenic glycans using certain expression systems (ii) a 1:1 stoichiometry between the enzyme and OP (Raveh et al., 1997) and (iii) the high LD50 of insecticides (ug-mg/kg levels). This necessitates the delivery of large, costly, rBChE doses to detoxify exposed individuals which is problematic when intramuscular (im) or subcutaneous (sc) injections are the chosen routes of delivery. In this chapter, we shall describe our experience of how the chemistry, glycosylation, chemical modification, animal model and route of administration may reduce or enhance the potential of BChE bioscavengers as prophylactic therapeutic human antidotes for OP insecticide exposure.

**2. Production of tetrameric and monomeric forms of rMaBChE and rHuBChE**  Macaque (Ma) and human (Hu) BChE molecules are very similar molecules differing by only 22 amino acids and sharing ~96% DNA sequence identity, critical glycosylation sites, cysteines and disulfide bridging (Boeck et al., 2002; Rosenberg et al., 2010). Thus, most anti-BChE antisera react with both molecules. Native HuBChE and MaBChE in plasma are composed predominantly of tetramers (98%) with the tetramerization domain being located within the last 40 C-terminal residues of each monomeric subunit (534-574) (Blong et al.,

overdose and for the alleviation of succinylcholine-induced apnea.

Final Report, 2003).

1997). In human serum, the association of lamellipodin proline rich peptides with the monomeric chains results in the formation of BChE tetramers (Li et al., 2008). Recombinant BChE produced in mammalian cells, in contrast, has only 10-20% tetrameric forms and therefore optimal tetramerization requires the addition of either poly(L-proline) to the culture medium or co-expression of the full length BChE monomers with the proline-rich attachment domain (PRAD) of ColQ gene (Altamirano & Lockridge, 1999).

To date, rHuBChE and rMaBChE molecules have been produced in transgenic mammalian cells (Chilukuri et al., 2008; Rosenberg et al, 2010), goat milk (Huang et al., 2007) and in plants (Geyer et al., 2010; Jiang, unpub. data). Our approach has been to utilize two expression systems for the production of rMaBChE and rHuBChE. Initially, Chinese hamster ovary cells (CHO) were used because of their human-like glycosylation. More recently, a transient plant expression platform was adopted to increase the yield and reduce the time and cost of producing rBChE. Although CHO cells and plants are able to produce significant levels of tetrameric BChE molecules (Li et al., 2008; Geyer et al., 2010), in the present studies, co-transfection of the BChE and PRAD genes has been shown to increase both levels of tetramerization and yields in each expression system. While the CHO cell expression of recombinant proteins is very well established, recent innovations in transient plant expression systems e.g. Bayer's Magnifection system (Gleba et al., 2005) and the Cow Pea Mosaic Virus Hyper-translatable Protein Expression System (PBL Technology) (Sainsbury et al., 2008) have been shown to be some of the most rapid, cost effective and productive expression systems in existence; capable of producing grams of recombinant proteins in weeks (Goodin et al., 2008).

\*All tobacco plants and leaves from *Nicotiana tobacum* and *N. benthamiana* were transfected using Agrobacterium-mediated infiltration


*4.1.2 Causes*

	- Airway disease- Chronic Obstructive Pulmonary Disease, Asthma, Cystic Fibrosis, Bronchiolitis Obliterans Syndrome
	- Interstitial lung disease- Interstitial Pulmonary Fibrosis, Sarcoidosis, Interstitial pneumonia e.g. Covid 19 pneumonia
	- Alveolar filling Pulmonary Edema, Left heart failure, Acute Lung Injury/ Acute Respiratory Distress Syndrome, Pneumonia, Trauma, Contusion, Alveolar hemorrhage/proteinosis, Transfusion Related Acute Lung Injury, Acute interstitial pneumonitis, Acute eosinophilic pneumonia, Bronchiolitis Obliterans Organizing Pneumonia/Cryptogenic Organizing Pneumonia, Aspiration, Upper airway obstruction, Near drowning

## *4.1.3 Evidences of NIV in acute hypoxemic respiratory failure*

Oxygen to improve hypoxia in acute hypoxic failure appears to be standard of care and in 2005 it was shown that NIV is better than oxygen in improving PaO2/ FiO2 by unloading of respiratory muscles [2]. In Earlier studies it was shown when used appropriately NIV is as effective as invasive mechanical ventilation in improving PaO2/FiO2 by Antonellii et al. thereby avoiding all complications related to endotracheal intubation and related ventilation [3]. But the most important aspect of success versus failure of NIV in acute hypoxic respiratory failure is 'Timing of initiation vis a vis progression of inciting disease as well as severity of respiratory failure" [4]. In Acute Hypoxic Respiratory Failure, NIV needs to be initiated for mild to moderate hypoxia and before the disease has progressed (a) as window of opportunity to use NIV is narrow (b) as once disease has progressed IMV is indicated.

Failure of NIV in acute hypoxic respiratory failure needs to be identified early to prevent higher mortality. Meta-analysis of NIV use in ALI/ARDS showed intubation rate of 46% (30–86%) and mortality of 35% (19–69%) and these widely variable results indicate that different diseases states causing hypoxic respiratory failure as well as baseline characteristics of individual patients along with threshold of intubation of the centre contribute to success or failure of NIV [5]. But studies are clear that milder is the hypoxia, lesser are the chances of failure indicating baseline PaO2 is one of the determinant of NIV outcome [6]. Further studies also showed earlier is the better as disease has potential for reversibility. Immunosuppressed patients also showed good success rates with use of NIV in acute hypoxic respiratory failure [7]. Hence, use of NIV in acute hypoxic respiratory failure is indicated as follows [8]:

Level 1: in acute cardiogenic pulmonary edema as well as immunocompromised patients with acute hypoxic respiratory failure.

Level 2: evidence is to use in post-operative hypoxic respiratory failure, COPD with community acquired pneumonia as well as to prevent hypoxic failure in acute severe asthma. However NIV in severe community acquired pneumonia without any underlying comorbidity to support use of NIV needs to be used with caution as in to prevent Extubation failure. Also in patients with do not intubate or resuscitate orders.

Level 3: in patients with thoracic trauma, upper respiratory tract obstruction, partial upper airway obstruction as well as treatment in acute severe asthma but with caution to use in severe ARDS.

Level 4: In very elderly (>75 years), obesity hypoventilation syndrome and in IPF with caution.

*Non-Invasive Ventilation in Acute Hypoxemic Respiratory Failure DOI: http://dx.doi.org/10.5772/intechopen.104720*

### **Figure 2.**

*Rationale of using NIV in acute hypoxic respiratory failure.*

### **Figure 3.**

*Showing modes of bi-level NIV used in hypoxic respiratory failure (spontaneous and spontaneous timed).*

Rationale of using NIV in acute hypoxic respiratory failure is that the primary or secondary lung failure, both lead to acute hypoxia which can be either due to abnormality in the exchange of gas or failure of the respiratory pump which leads to increase in minute ventilation, this is reversed by the use of NIV (**Figure 2**).

Modes of bi-level NIV used in hypoxic respiratory failure are defined by triggering: S-Spontaneous (a. patients efforts only triggering NIV), S/T- Spontaneous timed (b. patient's own as well as timed triggering to give back up RR in case patient has irregular and slow breathing pattern to safe guard adequate ventilation, misses a breath (**Figure 3**).

Helmet ventilation is the most secure form of NIV in severely hypoxic patients but claustrophobia may prohibit its use. It can be used in severe hypoxic respiratory failure and it's use in Covid 19 pneumonia and ARDS showed favorable results vis a vis oxygen therapy. However, cardiac instability is contraindication.

NIV is also used to support interventional procedures in patients with hypoxia while doing bronchoscopy or transesophageal Echocardiography.

However, in contrast to use of NIV in hypercapnic respiratory failure in hypoxic respiratory failure one needs to look beyond lungs into systemic component of disease process e.g. shock, acidosis, multi organ failure, etc. as these situations will favor invasive mechanical ventilation.

70% of failures of NIV occur within 48 hours, indicating need for intensive monitoring and identifying features of early failure proactively (**Figure 4**).

## **Figure 4.**

*Identify failing NIV early by bedside monitoring worsening of clinical features, gas exchange parameters and primary disease causing hypoxia.*

It has been shown that delaying intubation in such cases increases mortality and adds no benefit. Most common cause of failure is inability to correct hypoxia in 2/3rd of failed NIV's followed by intolerance, progression of disease with hemodynamic instability. Changing NIV machine to guaranteed volume mode (AVAP's or iVAP) can help to improve tidal volume and hypoxia. Hence all such cases should be managed in ICU settings only. Intolerance can be managed by using different types of masks or correcting into leaks. Use of sedation is strictly under observation with full facility and readiness to intubate.

NIV has penetrated deeply into the roots of medical management even in rural health facilities of India where a study conducted in rural India concluded that [9]:


**8. Recent technologies for preparation of liposomes**

Different liposome technologies developed for preparation of liposome formulations. All these technologies have their unique characteristics with unique properties for drug delivery.

#### **8.1 Stealth liposomal technology**

In stealth liposomal technology method some strands of polymer are attached to drug molecule for safety to that therapeutic agents. In PEGylation process polyethylene glycol is used. Linkage of PEG to liposomes protects drug molecules in physiochemical properties along with changes in hydrodynamic size and prolongs circulatory time. PEGylation reduces frequency of dosage and provides hydrophilic nature for hydrophobic drugs. Drug efficacy will not be changed by this method and also shows reduced toxicity [68]. With the help of this technology a liposomebased formulation Doxil® which is intravenous injection was prepared for ovarian cancer, multiple myeloma, and Kaposi's sarcoma associated with HIV.

#### **8.2 Non-PEGylated liposomal technology**

Non-PEGylated liposome technology (NPLT) is another technology for liposomes delivery in cancer treatment which has more benefits compared to PEGylation process. This technology eliminates PEG side effects and hand foot syndrome (HFS) in chemotherapy treatment. Non-PEGylated liposome Doxorubicin (NPLD) decreases cardiac toxicity related with DOX and dose limiting toxicity with Doxil® like painful HFS [69]. Myocet® is another NPLD used in advanced stage IV breast cancer which was manufactured by company Elan Pharmaceuticals.

#### **8.3 DepoFoam™ liposome technology**

This technology was invented by Pacira Pharmaceuticals for preparation of multivesicular liposomes without changing molecular structure of encapsulated drug and releases drug for long period (1 to 30 days). DepoFoam® is a core technology for liposomal marketed products in names Depocyt(e)® containing cytarabine, DepoDur® contains morphine sulfate and Exparel® contains

bupivacaine. These formed vesicles are microscopic spheroids with 3–30 μm in size having granular structure with single layered lipid molecules composed like honeycomb and drug molecules are loaded in central aqueous core [70].


*Article* **Mental and Spiritual Health Needs of Cognitively Enhanced People: A Therapeutic and Spiritual Care Model for Responding**

**Calvin Mercer**

Religious Studies Program, East Carolina University, Greenville, NC 27858, USA<EMAIL_ADDRESS>
**Abstract:** Cognitively enhanced people will have mental and possibly spiritual health needs that merit therapeutic and spiritual care response. This article addresses people who, although significantly enhanced, overlap with ordinary or "normal" (i.e., non-enhanced) people such that their status as humans is not questioned. Effective therapeutic and spiritual care approaches for these cognitively enhanced individuals will have a strong cognitive component. Cognitive therapy, originated by Aaron Beck, is an example of a therapeutic model that could prove useful with people cognitively enhanced. Four relevant elements of the cognitive therapy modality are explored: a developed cognitive structure, little consideration to unconscious factors, minimum attention to family of origin, and collaboration. Two psychological challenges with religious dimensions and import, which could be faced by individuals as a consequence of their cognitive enhancements, are concerns about physicality and fitting into community with ordinary humans and other enhanced humans.

**Keywords:** Aaron Beck; artificial intelligence; cognitive therapy; enhancement; mental health; pastoral care; psychotherapy; spiritual care; spiritual caregivers; spiritual distress; spiritual health

#### **1. Introduction**

Humans, significantly enhanced cognitively and perhaps in other ways, could emerge as a result of a vast array of human enhancement technologies and therapies being advanced with significant and increasing funding from corporate and government sources. As we use the term, ordinary or "normal" human refers to people who have not been significantly enhanced. The focus of this article is on people who are enhanced, but not in ways or to a degree that their status as human being is questioned.

Several research programs are underway that could lead to enhanced humans, although skepticism abounds regarding the technical feasibility of various avenues of research. While any particular technical approach may be appropriately dubious, that a number of paths are being explored perhaps increases the chance of significantly enhanced humans. "The sheer range of enhancement methods suggests that it would be very unlikely that all current methods are ineffective or that future advances will fail to produce an increasingly potent toolbox for enhancing cognition." (Bostrom and Sandberg 2009, p. 313).

Cognitive enhancement can be defined as "amplification or extension of core capacities of the mind through improvement or augmentation of internal or external information processing systems." (Bostrom and Sandberg 2009, p. 313). Cognition is a compilation of capabilities with regard to information, including acquiring (perception), selecting (attention), representing (understanding), processing, retaining (memory), and being creative with the information. (Dressler et al. 2019; Kostikov 2021; Bostrom and Sandberg 2009). Cognitively enhanced humans will have, compared to ordinary humans, advanced capabilities in some or all of these core faculties.

Cognitively enhanced humans will likely benefit from artificial means to optimize learning and memory (Bostrom and Sandberg 2009). Research underway includes brain stimulation techniques, e.g., functional magnetic resonance imaging or fMRI neurofeedback

**Citation:** Mercer, Calvin. 2022. Mental and Spiritual Health Needs of Cognitively Enhanced People: A Therapeutic and Spiritual Care Model for Responding. *Religions* 13: 701. https://doi.org/10.3390/ rel13080701

Academic Editor: Antonio Muñoz-García

Received: 22 June 2022 Accepted: 27 July 2022 Published: 29 July 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

(e.g., Dressler et al. 2019) and transcranial magnetic stimulation or TMS (e.g., Hummel and Cohen 2005). Other research includes augmenting thinking through brain-computer interfaces (Kaku 2014; Pederson and Iliadis 2020; Warwick 2014).

The advent of CRISP-Cas9 gene editing technology is likely to greatly impact human enhancement possibilities, including cognitive enhancement.

Not too many years ago, the possibility of cognitive enhancement through genetic engineering interventions seemed to be not only very distant, but also a dead end. In few years the situation has changed: today we have available a new generation of genetic editing techniques—in particular CRISPR-Cas9—which allows to cut and paste with precision into the coding sequence of bases of a single gene, yielding results that were previously unthinkable in terms of simplicity and applicative accuracy (science fiction excluded). On the other hand, recent studies have identified some genes that can play a very important role in controlling specific cognitive functions. (Lavazza 2018)

Significantly enhanced humans may require adjustments in our legal, political, educational, economic, and other systems. The ethical discussion is underway (e.g., Lavazza 2018; Al-Rodhan 2019; Bostrom and Sandberg 2009). No religion will be immune to such developments, which, if the faith traditions are to be relevant, will necessitate theological, ethical, institutional, and other responses (e.g., Donaldson and Cole-Turner 2018). We stand at the beginning of consideration about responses to cognitively enhanced people.

I say "possibly" spiritual health challenges, because not all humans, enhanced or not, consider themselves spiritual. I use the term "spiritual" broadly, to refer to issues presented to caregivers by enhanced persons that have to do with "belief, practice, relationship, or experience associated with whatever someone deems sacred" (Exline and Rose 2013) and that may or may not be associated with a religious tradition or institutional (e.g., church) setting. This broad understanding of spiritual can include problems presented to secular therapists as well as a range of spiritual care providers, including pastors, chaplains, lay ministers, and pastoral counselors.1 Although considerations in this article may be relevant to other religions, the examples and illustrations are from Christianity.

Psychological issues enhanced people face may include emotional distress (e.g., anxiety, depression) about physicality and fitting into community with ordinary humans and other enhanced humans. Both topics have theological dimensions and implications, and I address them as two examples of mental and spiritual health challenges cognitively enhanced individuals may face.

The discussion is exploratory, suggesting lines of inquiry that may be useful in navigating the psychopathology of, and therapeutic and spiritual care services to, enhanced persons. The thesis is modest. I claim that a cognitive-focused response model will be most appropriate for mentally and spiritually disturbed individuals who have been enhanced cognitively. Cognitive therapy, originated by Aaron Beck, is an example of a therapeutic model that could prove useful with this population. Also, the cognitive therapist of the future will be learning things about the client that do not necessarily fit into standard paradigms of psychopathology, so any model adopted will be ripe for revision. While these reflections on future challenges and possible responses are broad in scope, enough specifics (e.g., responding to concerns about physicality and community) will be provided to illustrate the general points.2

#### **2. Responding to Enhanced Humans with a Cognitive Model**

A therapeutic response to those with advanced cognitive abilities would seem to benefit from a psychological model that gives primacy to cognition. That said, it is important to understand that cognition cannot be simply siloed off from other aspects of the self, whether those aspects have to do with our affective, spiritual, or other physical capabilities. Research on cognition generally sees it as intertwined with the body as well as the natural

environment in what has been termed "embodied cognition" (e.g., Raveh and Tamir 2019; Herzfeld 2017). Enhancements might occur in areas of physical, cognitive, affective, moral, and perhaps spiritual (Cole-Turner 2015) abilities.3 My focus on cognition as a therapeutic target does not mean that other dimensions of one's life should be ignored.

Additionally, there is some evidence that therapists using a cognitive-behavioral approach have a more positive view of artificial intelligence (AI) than therapists who practice with other approaches, i.e., psychodynamic and systems-relational (Sebri et al. 2020). That finding could mean that cognitive therapists, compared to other kinds of therapists, may be more predisposed to working with clients with advanced cognitive abilities.

#### *2.1. Aaron Beck's Cognitive Model*

Cognitive therapy, originated and effectively championed by Aaron Beck and associates, is a widely used and respected model of therapy that can provide a starting point for thinking about a therapeutic response to cognitively enhanced humans (Mercer 2009, pp. 131–41 for a summary of Beck's model). In this model, core cognitions (e.g., attitudes, assumptions, and beliefs) govern how we construe events (Dozois and Beck 2008, especially chapter 6, "Cognitive Schemas, Beliefs and Assumptions"). Those interpretations of events then yield emotions and behaviors consistent with the interpretations. The cognitive therapist works with the client to alter maladaptive thinking, thereby providing cognitions leading to healthy affect and behavior.

Cognitive therapy was being developed around the same time that computer technology was being advanced. Beck, himself, drew a comparison between cognitive therapy and computer programming when he noted that some pathologies have their own "program" that regulate the "kind of data admitted" (Beck and Weishaar 1989, p. 286). At the heart of this cognitive model, then, is thinking. Some other models, such as the rational-emotive therapy (RET) of Albert Ellis, also give primacy to cognition. Four features of Beck's system (cognitive structure, the unconscious, family of origin, collaboration) make it a good example of a general framework that might be helpful for addressing the mental or spiritual needs of cognitively enhanced humans.

#### *2.2. A Developed Cognitive Structure*

Beck's model is thoroughly cognitive in its orientation and structure, positing several levels of cognition. Thinking that is conscious and deliberate, which Beck calls "voluntary thoughts," constitutes our active thinking process. Beyond surface level voluntary thoughts and at the heart of Beck's program are cognitive schemas, also called attitudes, beliefs, assumptions, thought patterns, and underlying mechanisms. Schemas are the central and relatively stable structures of thinking that are usually formed early in life in association with significant others. Schemas often come in a contractual form, i.e., "If I do X, then Y will happen." Because they were formed early in life, their expression usually has a childish quality, as in "I'm stupid" or "I'm dumb."

These thinking patterns inform our "automatic thoughts," the involuntary, spontaneous thinking that drives much of our behavior and emotions. Automatic thoughts are prompted by circumstances in our lives, are generally not questioned by us, and occur without rational analysis. In other words, via automatic thoughts, our cognitive schemas mold, unconsciously, input from the outside world, producing behavior and affect. These deeper levels of the client's thinking are more revealing of psychopathology than surface voluntary thoughts. Cognitive therapy intervention, appropriately, addresses these deeper levels. When behavior and/or affect is pathological, the cognitive therapist works collaboratively with the client to examine and modify the dysfunctional cognitions that give rise to the concerning behavior and troubling emotional output. Shifting the client's thought process to one that is rational and reality-based is at the heart of the therapeutic mission.

A central challenge of cognitive therapists is working with clients whose capacity for logical thought is weak or who, for various reasons, are reluctant to engage in rational analysis of their cognitive schemas and automatic thoughts. People who have been cognitively enhanced are likely to have a greater capacity for logical thinking than ordinary humans.

Depression and anxiety, both widespread psychological disorders, are examples of how a cognitive-based intervention program is made to order for clients who bring strong critical thinking skills to the therapeutic process. Beck began his work with depressed clients and treating that disorder is still the showcase for this therapeutic modality. Depressed clients exhibit a cognitive triad of negative views about self, the world, and their future (Beck and Weishaar 1989, p. 304; Beck 1995, pp. 166–92). The self is inadequate, defective, and/or worthless; the world is without pleasure or gratification; and the future is hopeless. The therapist helps the client see that these interpretations are not, for the most part, based in an accurate assessment of reality. All things being equal, enhanced humans with superior intellect would be more able to accurately dismantle this negative cognitive triad.

In Beck's program, anxiety arises from a perception of danger. Pathological anxiety by definition is anxiety that is not appropriate to the real situation. The error in thinking is overestimating the probability or severity of the feared event or underestimating the coping resources (Clark 1986). As with depression, presumably anxious clients able to utilize advanced critical thinking skills will be better equipped to correct these cognitive errors.

So, a central task of the cognitive therapist is to teach the client logical thinking and assist the client to apply that thinking to the schemas and automatic thoughts that give rise to dysfunctional behavior and troubling affect. Errors in thinking include arbitrary inference (i.e., jumping to conclusions), dichotomous (i.e., all-or-nothing) thinking, overgeneralization, selective abstraction, catastrophic thinking, minimization, and emotional reasoning (Mercer 2009, pp. 139–41). These deeply ingrained cognitive errors can be very hard to overcome, having taken root early in life and practiced regularly for years. A cognitively enhanced person, however, would have the intellectual arsenal to combat these errors. The therapist would not need to expend time teaching critical thinking skills.

To illustrate cognitive therapy, here is an example of a cognitive subsystem presented by Beck (Beck et al. 1979, pp. 250–51). As a therapist, I often saw versions of this pattern.

Affect: depression or anger

Automatic thought: I caused my husband to behave badly

Schema: If I'm nice, bad things won't happen to me.

In this case, early in life the client generated the schema, "If I'm nice, bad things won't happen to me." This schema, as with all maladaptive ones, includes cognitive errors, in this case arbitrary inference and all-or-nothing thinking. The schema is not reasonable, but a young child, perhaps fearful, might very well draw this conclusion in an anxiety-producing situation from her family of origin. The schema gets embedded deep in the psyche and provides a ready explanatory model when something bad happens in adult life. In essence, the adult is operating with an interpretative outlook generated as a child.

As a further explanation of this process, the notion of "hot cognition," used in but not peculiar to cognitive therapy, is relevant here (Roiser 2013). A hot cognition is an affect-laden, affect-led thinking process, as distinguished from cold cognition, which is more likely to be driven by and characterized by logic. Again and again, in my clinical practice, an adult client's dysfunctional schema could be traced to an origin in childhood during some emotionally stressful situation. While understanding the schema's origin could be helpful, the critical factor in treatment progress was the client's ability to think critically and exhibit motivation to do that.

#### *2.3. Unconscious Factors and Family of Origin Minimized*

Cognitive therapy is in contrast to those psychotherapeutic approaches that give considerable attention to unconscious motives and impulses and to family of origin issues. For example, psychoanalysis, stemming from Sigmund Freud, sees the person as driven by an array of buried unconscious impulses emanating in large part from one's early family experiences. It is true that cognitive therapy pays attention to family of origin to some

degree, in helping the client understand the origin of their schemas, likely in terms of a "hot cognition," explained in the last section of this article. But extensive interrogation of complicated childhood issues is not needed; the cognitive therapist concentrates on helping the client adjust dysfunctional thinking in their present life circumstances.

Enhanced humans would have a childhood and family of origin. However, clients who are cognitively enhanced are probably less likely to be influenced by those early years than ordinary people for the following three reasons.

First, cognitive enhancements will not occur independent of other enhancements, such as those that extend the number of years of life. In other words, by the time robust cognitive enhancements are achieved, advancements that significantly extend healthy human life may very well have also arrived. Enhanced individuals living 130 years, just to pick a superlongevity number, will have had, for much of their lives, so many more years of life experience that the distant family of origin is likely to be less of a factor than with someone living the traditional fourscore and ten.

Second, by the time cognitive enhancements come, advanced affective enhancements may very well help address any family of origin issues in ways that minimize dysfunctional behavior and distressful emotions stemming from early childhood. Psychedelic-assisted therapy is one relatively new approach that looks promising (Marks and Cohen 2021).

Finally, the advanced cognitive abilities of enhanced people will give them the intellectual tools to cut through illogical schemas derived from hot cognitions in childhood. Cognitive therapy attends to present thinking patterns and their impact on affect and behavior and would be, therefore, an appropriate and effective intervention that would not require involved exploration of the early years.

#### *2.4. The Key Role of Collaboration*

The cognitive therapist is an active participant with the client in the psychotherapeutic process. There is no doctor treating patient, but, rather, a therapist engaged with the client in dialogue designed to challenge errors in thinking that lead to dysfunction. The client is presumed to have or be capable of learning the tools necessary to accomplish this.

A collaborative model seems appropriate for therapists working with cognitively advanced clients, who may not respect the therapist and his or her methods and who may be reluctant to cooperate with a therapist who thinks of themselves as doctor fixing the patient. A superiority complex is a psychological mechanism that serves as a defense against feelings of inferiority, to pick one possible cause. If the client is advanced due to some technological intervention, then the client may very well actually be superior in various ways to a therapist who is ordinary i.e., not enhanced. This disparity in abilities between therapist and client is likely to be one of the issues—perhaps a big one—to be addressed in therapy of the future. In any case, assuming a good therapeutic relationship can be achieved, a cognitively advanced client experiencing psychological difficulty may find it helpful to collaborate with a cognitive therapist with wisdom and experience derived from years of practice. The client's intellect may be superior to that of the therapist and should be respected and utilized by the therapist in the therapeutic partnership to accomplish treatment goals.

In the collaborative model fostered by Beck's program, cognitive therapists have always been keen to learn about and work with the client. As noted earlier, cognitive therapists, working with an enhanced population, will be learning things about their clients that are not found in the standard psychopathology textbooks. The usual paradigms may help, but the therapist will need to be nimble and creative in this unfolding frontier. The cognitive therapy collaborative model is made to order for this situation, where the therapist and client with advanced cognitive abilities work together to educate each other and forge a productive path forward. I can envision a situation where the roles of client and therapist are reversed during the therapeutic process, due to the advanced capabilities of the client, generating a therapeutic situation that would need to be addressed.

One of the goals in this article is to generate a discussion about addressing the mental and spiritual health needs of enhanced humans. If (perhaps when) significantly enhanced people begin to populate our communities, including faith communities, they will come with a variety of profiles depending in part on the kind and degree of enhancement. Over time a body of clinical and pastoral literature will grow that addresses the needs of these different categories of enhanced clients and enhanced persons of faith. The cognitive collaborate model is well positioned to help understand and develop the expertise needed.

#### *2.5. Spiritual Care and the Cognitive Model*

As noted earlier, pastors, chaplains, lay ministers, and pastoral counselors respond to people of faith seeking help for their spiritual distress and challenges. Spiritual caregivers get training from a range of sources, depending, e.g., on the particular religious tradition.

Secular psychotherapeutic approaches can influence spiritual care providers (Frederick 2009). The Association of Clinical Pastoral Education (ACPE 2020) is one notable organization devoted to providing that training in theological schools, hospitals, and other settings. Caregiving promoted by the ACPE recognizes that pastoral approaches draw from the behavioral sciences, working to integrate those psychological models with theological and pastoral insights (e.g., https://acpe.edu/programs/cpe-educator-certification; https://acpe.edu/education/cpe-students/faqs, accessed on 10 April 2022). Cognitively oriented psychotherapy, adjusted to fit spiritual care needs, has been explored for its usefulness with clients identified in the literature as "religious/spiritual" (e.g., Bingaman 2015; Carlson and Gonzalez-Prendes 2016).

While secular models, such as cognitive therapy, can influence spiritual caregiving approaches, many and perhaps most spiritual care providers (e.g., pastors, lay ministers) will not have had specialized training in any therapeutic model. However, the four elements of the cognitive model highlighted above (i.e., cognition, collaboration, and minimal attention to unconscious factors and family of origin) could be valuable features of the care provided by any spiritual caregiver for the same reasons those features would be relevant for psychotherapists working with cognitively enhanced clients.

In seeking care from spiritual providers, cognitively enhanced humans who are also persons of faith will bring advanced intellectual abilities. How theological schools, denominations, and other religious institutions train spiritual caregivers to respond is beyond the scope of this article. However, the cognitively enhanced congregants, patients, and clients will probably seek out, indeed insist on, spiritual care providers who provide that care in cognitively oriented, collaborative, and other ways that best meet their particular needs.

#### **3. Psychological and Spiritual Challenges of Cognitively Enhanced Humans**

Cognitively enhanced humans are human and so will present with a range of psychopathology. Two issues being discussed by scholars working on human enhancement include physicality and inclusion into community. Concerns about either of these can lead to emotional distress, e.g., anxiety and depression.

#### *3.1. Physicality*

In this new world of enhancement, the significance and role of the body has been a topic of much debate among religion scholars (e.g., Thweatt-Bates 2012, pp. 67–84, 149–68; DeBaets 2015; Mercer and Trothen 2021, pp. 149–53, 165–70) and may very well constitute an important category of needed psychological and spiritual attention. Significant adjustments to the human body that evolution has to date bequeathed us may be on the way. Enhancements to the body could involve tissue engineering, cell therapies, biomanufacturing, 3D printing, and other biomedical technologies. So, people who are cognitively enhanced may also be enhanced in other ways, such as greater strength, better eyesight, and superior hearing. Changes like these and others to their body may entail emotional distress.

Psychologically, the body can play a role in pathology beyond overt body-related disorders, such as anorexia nervosa, bulimia nervosa, and body dysmorphic disorder. Patients who now must adapt to prostheses foreshadow enhanced humans who must grow accustomed to significant changes in their body. For cognitively enhanced people experiencing emotional distress, engaging their concerns from a reality based rational framework is likely to be more helpful than being served by therapeutic approaches that focus on early childhood and unconscious factors, for reasons already discussed in the section on the Beck model of therapy. Enhanced people, identifying as spiritual, may experience emotional distress at understanding and relating to their enhanced body and how their body fits into their theological framework and/or spiritual journey. Spiritual care providers, who follow a cognitive model, likewise will be better equipped to address their cognitively enhanced clients or parishioners.

#### *3.2. Inclusion in Community*

A second challenge people with advanced intellectual abilities will almost certainly face is how they fit into the larger community of persons, to pick one example which may have psychological fallout needing therapeutic attention. Scholarly discussions are already underway about the challenge of a new ism that could aggravate social inequality (Bostrom and Sandberg 2009; Mercer and Trothen 2021, pp. 57–59, 84–87). Along with racism, sexism, classism, and others, we will likely face differences and divisions between the "enhanced" and ordinary people or "normals," those who choose not to partake of the technologies or do not have access for any number of reasons. James Hughes' (2004) book title, *Citizen Cyborg: Why Democratic Societies Must Respond to the Redesigned Human of the Future*, makes the point that these differences will have societal and political implications.

Community here can be neighborhood, civic club, country, and others. Several factors could come into play with regard to enhanced individuals feeling integrated into community, with each type of community presenting its own challenges. One factor is the percentage of enhanced humans who constitute a particular community. Social pressure, feelings of alienation, communication challenges, and attitudes of superiority might show up differently, depending on the size of the enhanced population of the community. A competent therapist, in addressing the particular distress with which the client presents, will consider all these and other factors. Family issues that arise from one or more members of a family being enhanced constitute another whole domain of mental health need and possible intervention.

In addition to fitting into communities of ordinary humans, enhanced individuals may also struggle to relate well with other people with enhancements similar to or maybe quite different from those of the client. As with other isms that challenge society, people with advanced abilities may tend to isolate from ordinary humans, aggravating problems about how enhanced people relate to each other. My modest goal is not to detail the many possible therapeutic situations that might arise with an enhanced client working on relationship concerns with other enhanced people. Rather, I contend that a cognitive model would be an effective therapeutic approach for a cognitively enhanced client in a problematic relationship with other enhanced people.

To give an example of one religion, Christianity has a particular focus on community as the church, the body of Christ. Societal divisions are reflected in the church (Lipka 2014), and the emergence of enhanced congregants alongside "normals" would present their own set of challenges. Those challenges could include, but not be limited to, controversies about a variety of topics, such as inclusion into the congregation, taking leadership positions in the church, administering sacraments, and ordination. Pastoral care that gives emphasis to reason and critical thinking, even when thinking through theological issues of community, could be a useful way to work with cognitively enhanced Christians on these and other matters.

#### **4. Further Considerations**

#### *4.1. Psychometric and Spiritual Distress Assessment*

The focus in this article is on psychotherapeutic intervention for people who have been enhanced cognitively and perhaps in other ways as well and who exhibit mental and spiritual health distress or dysfunction. An important related topic is the diagnostic question.

Mental health professionals trained in psychometric testing have an array of instruments to measure intelligence, personality, aptitude, attitude, behavior, and a host of other things. Such instruments could include tests measuring different kinds of intelligence (e.g., the Wechsler Adult Intelligence Scale or WAIS series), the Minnesota Multiphasic Personality Inventory (MMPI), the Beck Depression Inventory, and projective tests such as the Rorschach inkblot, Thematic Apperception Test (TAT) that uses enigmatic pictures, and projective drawings.4 Brain scanning and genome sequencing will undoubtedly play increasingly important roles in clinical work. Although they vary in reliability and validity, a battery of tests can yield valuable information for the therapist in formulating a diagnosis and treatment plan. While not as developed, other instruments assess spiritual development and distress (Hill 2013; King et al. 2017; Lucchetti et al. 2013).

#### *4.2. Enhanced Therapists and Spiritual Care Providers; AI Therapists and Spiritual Care Providers*

Thus far in this article it is presumed that the therapist and spiritual care provider are "normals," i.e., not cognitively enhanced. It is possible, perhaps likely, that a cognitive approach will be used also by therapists and spiritual caregivers who are cognitively enhanced, maybe leveling the caregiver-client relationship in helpful ways.

Another possibility is that the therapist will be an AI agent or robot. Artificial intelligence is already widely used in the healthcare field to both support human decisions about diagnosis and treatment and generate such decisions (Jordan and Mitchell 2015). ELIZA was a 1960s natural language processing program that attempted to mimic Rogerian client-centered psychotherapy, mainly by feeding back what the client says (Shun et al. 2018). Particularly relevant for this article about cognitively enhanced clients, Woebot, developed at Stanford, is a talk therapy chatbox that operates with cognitive behavioral protocols, assisting users to adjust their negative thoughts (Fitzpatrick et al. 2017; Young 2019).

Woebot is not alone. Today, AI virtual and robotic agents are at work in the mental health field (Fiske et al. 2019). They execute lower-level comfort and social interaction as well as higher level interventions that include, e.g., providing empathetic-type responses to clients (Inkster et al. 2018); sensing, analyzing, and expressing emotions (Robinson 2019); and addressing mood and anxiety disorders (Rabbitt et al. 2015).

We are now in the early stages of attempts to include a spiritual component into AI agents, some of which are being utilized in palliative care. Spirituality is a core dimension of palliative care, although often overlooked by medical professionals. So, researchers at Northeastern University and Boston Medical Center designed a touchscreen tabletbased "virtual conversational palliative care coach" that could test the receptance of and effectiveness of different degrees of spiritual engagement and from several faith traditions. The controlled study found that older adults were comfortable talking with the agent about end-of-life issues and in a conversation that included a spiritual dimension tailored to the patient's background (Utami et al. 2017; Young 2019).

#### **5. Concluding Reflections**

It is certainly possible, some would say likely, that we will see significantly enhanced humans resulting from the vast array of powerful technologies and therapies under development. Given the many research programs addressing it, cognitive enhancement could be a sizable part of human enhancement. Cognitively enhanced people will surely come with mental health and, for persons of faith, spiritual health needs and concerns. Two psychological challenges with religious dimensions and import, which could be faced by individuals as a consequence of their cognitive enhancements, are concerns about physicality and fitting into community with ordinary humans and other enhanced humans. I have

proposed Aaron Beck's cognitive therapy as a model appropriate for serving the mental and spiritual health needs of cognitively enhanced humans.

In my Himalayan trek, I thought about the first explorers who confronted the wild, unpredictable landscape. Their exciting journey forward was fraught with danger and uncertainty, but also opportunity. The enhanced human psychological terrain is also a frontier vast, unpredictable, and maybe dangerous, but also exciting and filled with possibility. Unlike standing before a Himalayan mountain, when these cognitively enhanced populations arrive, we will not have the luxury of avoiding the frontier. The sooner we begin readying ourselves for that trek, the better.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The author declares no conflict of interest.

#### **Notes**

#### **References**

Beck, Judith S. 1995. *Cognitive Therapy: Basics and Beyond*. New York: Guilford.

Hughes, James. 2004. *Citizen Cyborg: Why Democratic Societies Must Respond to the Redesigned Human of the Future*. New York: Basic Books. Hummel, Friedhelm C., and Leonardo G. Cohen. 2005. Drivers of brain plasticity. *Current Opinion in Neurology* 18: 667–74. [CrossRef]


**1. Introduction**

It is undeniable that non-financial information produced by companies has gained an increasing interest in the research sphere of accounting and sustainability in recent years [1–5]. The reporting of this sustainability information is prepared through information on corporate social performance (CSP), sustainability strategy, and goals evaluated by ESG factors [6]. This increase in reporting of nonfinancial information originates from increased societal attention and demand on how firms operate, with society questioning how firm activities affect the environment [1–5]. This need for transparency from larger stakeholders leads to the need for comparable non-financial information to assess company sustainability performance [7]. The inclusion of sustainability reports includes information related to emissions, waste, human rights, and corporate governance factors that are not captured in financial reports [2,3,5]. Sustainability reports target a wider audience of users, from governments to investors, customers, suppliers, and employees [4]. ESG disclosure scores are practices that can be used to satisfy investors' information needs requirements. At a firm level, an increased level of non-financial information mitigates risk and can increase corporate financial performance from risk mitigation due to the reduction of the cost of capital by disclosing more non-financial information [8]. As suggested by Ioannou and Serafeim, the disclosure of ESGs varies between firms and countries [9]. Therefore, this

**Citation:** Helfaya, A.; Morris, R.; Aboud, A. Investigating the Factors That Determine the ESG Disclosure Practices in Europe. *Sustainability* **2023**, *15*, 5508. https://doi.org/ 10.3390/su15065508

Academic Editor: Eduardo Schiehll

Received: 12 January 2023 Revised: 14 March 2023 Accepted: 16 March 2023 Published: 21 March 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

research will further this investigation to determine factors that affect ESG disclosure practices in Europe. Within the Europe region, European managers view ESG practices in a different way. Influenced by country-level factors such as cultural systems, the differences in ESG disclosure practices create an interesting discussion and analysis. The absence of the standardization of ESG reporting requires an investigation into why firms disclose ESG information and what factors play a mediating role in this disclosure [8].

In light of this, the study aims to investigate the determinants that affect higher levels of ESG disclosure. In this research paper, we investigate the impact of the CSR orientation of the board, the CSR strategy of the board, the GRI and the country–culture dimensions on the level of ESG disclosure practices of firms in Europe. When analyzing board characteristics, we expect there to be a link between board orientation and its three components, the presence of an audit committee with financial expertise, board independence, and if there is gender diversity in the board, captured by the works of Liao et al. [10]. Previous studies by Shaukat et al. have suggested that these three board attributes increase firm CSR activities and their environmental performance [11]. Further research on the orientation of the CSR board from Helfaya and Moussa suggests that a strong level of board orientation is more likely to be more environmentally responsible. Therefore, ESG scores have become a key component of CSR [12,13]. Additionally, Shaukat et al. use the board CSR strategy score and find that firms with a more clear and comprehensive CSR strategy lead to higher environmental performance due to long-term orientation. This long-term orientation means that ESG areas are considered [10]. In recent years, numerous studies have measured and evaluated the impact of both firm (i.e., micro-level) and country (i.e., macro-level) factors on ESG disclosure practices. However, these micro and macro factors that jointly affect such levels of ESG disclosure remain unexplored, as there are an increasing number of factors that affect such levels, especially in cross-country studies. Alternatively, disclosed ESG information can affect the value of the firm if investors see such information as greenwashing risks faced by the firm [5]. Cucari et al. highlights the importance of CSR influences, such as the role of the CSR committee and the number of women on the board, having influence on ESG scores in an Italian context [12]. Toumi et al. explore the region of origin of the director for CSR disclosure linking with its cultural context by separating the representation between Anglo–American and European directors in France [14].

Based on a sample of 784 European firms during the period of 2011 and 2020, this paper makes several contributions to the literature. Although this previous literature on ESG disclosure is a highly researched field, we argue that the use of country–culture dimensions based on Hofstede's cultural dimensions dummy variables, adapted from Li et al.'s classifications of Hofstede's 2010 descriptive values, adds a new contribution to the literature, as previous studies use index numbers [15]. Second, the relationship between our impacts on CSR characteristics and ESG disclosure scores further expands the theoretical contribution of the CSR literature to the CSR strategy and orientation within CSR research [14].

Our results indicate that effective CSR-orientated firms that consider long-term strategies and promote a high level of board CSR orientation and a high level of CSR strategy led to a positive effect on the quality of ESG disclosure. Furthermore, the existence of a firm that follows the GRI guidelines has a significant effect on the level of ESG disclosure within our sample. Within this research, we further present the study not only with ESG as a whole component but within the individual pillars. We find that ESG disclosure is intricately linked to these internal characteristics that are linked to CSR-orientated directors creating such a positive link. Within the cultural element of this research, our results indicate that firms headquartered within cultural dimensions that exhibit feminine with long-term collaborative concern for social and environmental issues see an increased level of ESG disclosure scores. This research also further strengthens the link between firm and country-level attributes and ESG quality disclosure scores. These results support the theories of legitimacy, stakeholder, signaling, agency, and institutional. Thus, this paper extends the predicative power to these overlapping theories. Our research findings provide

a link between both firm-level and country-level factors that affect the level of European ESG disclosure practices.

The remainder of this paper is structured as follows. Section 2 presents the relevant review of the literature, followed by a discussion of the theoretical framework and the development of the main research hypotheses in Section 3. Section 4 describes the research methodology. Section 5 discusses our empirical results, followed by concluding remarks in Section 6.

#### **2. Literature Review**

The term 'ESG' was introduced in 2004 in 'Who Cares Wins' and was introduced to find ways to incorporate the aspects of ESG into the capital market [16]. From this point on, ESG is seen as an extension of traditional CSR and socially responsible investment (SRI) [1,2]. The growing public awareness of corporate recognition of actions toward the planet has led to this increase in the implementation of sustainability strategies. Within this, an increasing number of firms have now revealed their ESG information to the public [8]. The concern around ESG issues has grown into the realm of climate change, concern over poor working conditions such as safety violations, etc. [17]. Interest in ESG is also seen from the corporate perspective, identified by the Governance and Accountability Institute. For example, in their 2018 report, the institute found that 86% of the S&P 500 companies released sustainability reports [18]. These figures reflect the increase in sustainability reporting growth and how disclosure of ESG has become a tool for communicating sustainability activities [5,9]. This increase in the number of standalone sustainability reports published and/or CSR sections in annual reports is not only seen by investors and corporate management [18]; Helfaya and Whittington note that disclosure of ESG is desirable both from a private and public perspective. From a theoretical point of view, the link between the integration of the ESG strategy and cultural values can be seen [19]. From a theoretical point of view, the link between the integration of the ESG strategy and cultural values can be seen. Toumi et al. note that the cultural system within the country has effects on managerial decision-making processes [14]. This is further examined by Baldini et al. note that culture affects voluntary and mandatory disclosure of sustainability information [20]. Ioannoi and Serafeim note that within countries operating with a low level of social cohesion and unequal distribution of opportunities, managers feel a greater obligation within key stakeholders to enforce key increase in corporate disclosure through ESG reporting [9]. There are motivations behind reporting on ESG practices, within the capital markets; such disclosure is seen as effective risk management tool [1].


**2.3. Forensic hospitals**

**2.2. Prisons**

54 Occupational Therapy - Therapeutic and Creative Use of Activity

periods of time [3].

Prisons are classified as high, medium and low security institutions that are typically used for convicted criminals who have been sentenced to at least a year of imprisonment in U.S. Federal Bureau of Prisons. In addition, depending on the severity of the crime, some individuals are sentenced to either state or federal prisons. However, compared to jails, prisons offer a far more stable environment for the inmates and restrict their interaction with society for longer

The primary purpose of prisons is to ensure public safety and the security of inmates. In addition to incarcerating criminals, prisons offer them programs to address their criminogenic needs related to education, substance abuse, employment and transition to the community. Basic services in prisons involve intake and screening of psychotropic medicines and to provide occupational therapy services. Those services are substantially provided for prisoners to decrease their social isolation and increase their problem solving and adaptation skills, self-efficacy and self-esteem. The occupational therapy services also promote emotional regulation abilities and social and emotional skills in order for the inmate to deal with prison life and take this opportunity to improve on self-efficacy and occupational engagement [15].

**1.** High-security units: Individuals classified as high risk to public safety have been sentenced to life imprisonment and are receiving long term treatment, are housed in high-security prisons. The physical environment in these facilities consists of a number of physical and structural barriers between the facilities and the external environment of the institution. In high-security prisons with highest number of staff, and both multiple and single cells, criminals remain in their cells or in an outer cage in the facilities' yard. Each cell is equipped with a toilet, screwed to its floor, and prisoners are permitted up to three 10-min showers per week. Movement is firmly restricted and activity within the cellblock does not occur without other constraints, such as handcuffs, leg irons and corrective officer escorts [3]. Orientation can be considered as essential because it gives the staff the chance to be acquainted with the prisoners. The ward program focus areas, such as improving awareness of self, others and the environment; orientation to time, place and situation; probing cognitive abilities and teaching of new skills to improve leisure time use and psychomotor

**2.**  Medium-security prisons, where prisoners' accessibility to prison gardens and exercise areas, libraries, showers and health services are high, offer far more opportunities in terms of interaction, movement and activity inbetween prisoners [3]. Medium-security prisons usually have a wide diversity of workoriented and treatment programs. Parole is more frequently granted in medium-security prisons and may be classified as supervised (always less than 1 h), limited (sent to wards for only 1 or 2 h), occupational therapy parole (join structured activities or subcontract work) and unlimited parole (mostly on weekends and during the week when they do not

activation, should be maintained after discharge [16].

join specific rehabilitation activities).

Forensic psychiatric settings are generally located in secure units that rehabilitate individuals deemed unfit to stand trial or not criminally responsible. Those inmates pose a serious threat to either themselves or others because of severe mental illness. A forensic psychiatric setting provides treatment-based approaches with a view to rehabilitating patients while keeping the public safe. Patients, temporarily transferred from correctional facilities or incarcerated environment, are assessed and treated for mental illness in the facility that consists of secure, closed and open common units [17].

Forensic psychiatric hospitals reintegrate patients systematically into the community with well-equipped and specialized clinical services, as well as an exhaustive range of vocational and rehabilitative programs. Treatment is typically long-term, in order to improve and safely stabilize patients' mental well-being.


**4. Digital differential protection**

Many digital algorithms have been used so far after the invention of the computer. These algorithms do the same job with different accuracy and speed. The acceptable speed according to IEEE standard for transformer protection is 100 msec. All modern algorithms are faster than this IEEE standard. Nowadays, there are some algorithms performs their function in less than 10 msec. In this chapter, a fast algorithm is introduced. Its speed is in the range of 1 to 15 msec. This algorithm is based on the Fast Fourier algorithm (FFT). This algorithm is not new, however, significant changes has been introduced to make it much faster.

The proposed digital differential relay is designed using a simulation technique in Matlab Simulink environment. The design is implemented to protect the power transformer against internal faults and prevent interruption due to inrush currents.

This algorithm is built on the principle of harmonic-current restraint, where the magnetizing-inrush current is characterized by large harmonic components content that are not noticeably present in fault currents. Due to the saturated condition of the transformer iron, the waveform of the inrush current is highly distorted. The

$$\mathbf{f(t)} = \frac{\mathbf{a\_0}}{2} + \sum\_{\mathbf{k=1}}^{\infty} \mathbf{C\_k} \cos(\text{kwt}) + \mathbf{S\_k} \sin(\text{kwt})$$

$$\mathbf{C\_{k}} = \frac{2}{\mathbf{N}} \sum\_{\mathbf{n=1}}^{\mathbf{N-1}} \mathbf{x(n)} \cos \left(\frac{2\mathbf{kwt}}{\mathbf{N}}\right)$$

$$\mathbf{S\_{k}} = \frac{2}{\mathbf{N}} \sum\_{\mathbf{n=1}}^{\mathbf{N-1}} \mathbf{x(n)} \sin \left(\frac{2\mathbf{kwt}}{\mathbf{N}}\right)$$

$$\mathbf{F\_k} = \sqrt{\mathbf{S\_k^2} + \mathbf{C\_k^2}}$$

In the meantime, the harmonic calculation is performed. If the percentage value of the second harmonic amplitude is in the range of (0.3 to 0.6) of the fundamental component amplitude, then the logic (0) occurs, that means recognition of inrush current. Otherwise, the logic (1) takes place, which indicates a detection of an internal or external fault.

#### **Step 3.** Taking the final decision:

If the logic cases received from both cases (a & b) in step two are both (1), that indicates a detection of an internal fault. Then a trip signal is released to stop the simulation.

For the other logic options of (0,1) means an external fault, (1,0) means an inrush current, or (0,0) indicate an occurrence of an inrush current or an external fault, and the simulation goes back to step two to start the calculation again for the next sample.


6. Weight and PCO

4. Androgens and PCO

26 Debatable Topics in PCOS Patients

PCOs more than obese PCOs women [40, 41].

hyperandrogenic skin symptoms [45].

5. Inflammation and PCO

to men.

About 10–12% of women in reproductive age suffer from androgen excess sign and symptom. It can be caused by androgen overproduction (from ovary or adrenal gland) or secondary to increased sensitivity of pilosebaceous unit (with normal level of androgens). Hyperandrogenemia is another hallmark of PCOs; mainly by ovarian resource and less by adrenal. In PCOs women, 60% of serum androstenedione and testosterone (T) are secreted by ovary. Surprising, ovarian androgens will not prominently affect LH production, thus an elevation in free testosterone or androstenedione will not decrease ovarian synthesis of these androgens in women, contrasting

As mentioned before, in PCO women, insulin in a solitary manner or with synergetic effect of LH induces androgen production by ovaries. Even in lean PCOs women with normal metabolic insulin sensitivity and insulin levels, decline of insulin secretion with diazoxide (like metformin) prominently reduce levels of free T and androstenedione and meaningfully increased SHBG [36]. In these women, hyperandrogenemia is seen because of augmented sensitivity of their androgenic pathway to insulin and dysregulation of steroidogeneses enzymes based on genetic predisposition [37]. Therefore, even in PCOs patients with normal insulin metabolic and without clinical approved IR, local resistance in the ovaries increased androgens production [38].

Androgen excess or hyperandrogenemia (HA) in PCOs women contribute in exacerbation of metabolic abnormalities, such as insulin resistance in adipose tissue and skeletal muscle and elevation in lipid metabolism in visceral fat, decreased lipolysis in subcutaneous fat, increased low-density lipoprotein cholesterol (LDL-C) levels decreased HDL-C levels. Besides that, androgens may be involved in possible direct vascular action [39]. There are some studies, in which hyperandrogenemia was accompanying with metabolic syndrome (MetS) in non-obese

Hyperandrogenemia or androgen access clinical signs are mainly cutaneous manifestations: hirsutism, acne, androgenic alopecia, acanthosis nigricans (AN), and seborrhea. In one study, their prevalence in PCOs women was: 78, 48, 31, 30, and 29% (in mentioned order) [42]. In another study, the prevalence of acanthosis nigricans in obese PCO was 42.5% compared to 28% in non-obese [43]. One published paper shows that AN is a marker of hyperinsulinemia in both obese and non-obese PCO patients rather than a sign of androgen excess and the only sex steroid associated with histological AN is dehydroepiandrosterone sulfate (DHEAS) [44].

Pharmacological management of hyperandrogenic skin symptoms has two targets: firstly, decrease the level of circulating androgens, and secondly prevent their effect at tissue level. Cyproterone acetate/ethinylestradiol has beneficial effect in non-obese PCO women with

There are many published studies about proinflammatory or inflammatory situations in PCOs woman. Increased level of circulatory inflammatory markers like C-reactive protein (CRP), Even in lean PCO women, we can see higher waist to hip ratio, greater intra peritoneal and visceral fat, and percentage of body fat in comparison with BMI matched non-PCO women. Accumulation of small subcutaneous abdominal fat in those patients shows spoiled adipogenesis and hyperandrogenism [53]. Also, abnormal gene expression in stem cell of subcutaneous abdominal fat in normoandrogen and ovulatory lean PCO women display abnormal vacuolization and angiogenesis, which may reflect metabolism alter in those women [54]. From another side, adiponectin, a protein which is involved in regulating glucose levels and fatty acid breakdown, is produced by omental fat and dysregulated by high level of insulin; thus, even in lean PCOs women, inappropriate metabolism of glucose and lipid can be explained [55]. In respect with a new randomized controlled trial, arranged and regular physical exercise can ameliorate insulin sensitivity, hyperandrogenemia, and menstrual regularity in lean PCO women [56].