A few days ago I took my two sons to see a movie called "Angry Birds." The movie is based on a video game app!
I had pretty low expectations of this movie. I'm not thrilled with children playing a lot of video games on handheld devices. When I checked a review site, most of the critiques were very unflattering. But at the time, we were visiting a small town for a performing arts festival, and we had a few hours free before our trip back home. This was the only movie available to see.
We ended up really enjoying it! I thought it was cute, charming, funny, and delightful. Maybe it was just the kind of light-hearted silliness I needed at the time.
One of the themes of the movie is about how it is possible to over-pathologize anger. It also pokes fun at therapeutic cliches. The main character, Red, has a short fuse, and frequently ends up having tantrums. The community he lives in is tranquil, peaceful, and happy. Red ends up getting into trouble, and gets sent to court-mandated "anger management therapy."
Yet, there are changes happening in the peaceful little community of birds. Red is the only one who seems to question what's going on. But his concerns are dismissed...
Finally, the story shows that Red's point of view should have been heeded and respected earlier--eventually, of course,he ends up saving the day, thanks to the very anger that he was initially sent to therapy for at the beginning of the movie!
Politically, I guess we could say Red represents a kind of militaristic position; he is a "hawk," so to speak. I'm not a fan of this position--I'm much more a fan of diplomacy and "dove-like" peacemaking.
But I am a great fan of free speech. I believe it is important to have the courage to speak out about something, even if you are the only voice of dissent in a crowded room, or in a community.
I have felt a little bit like "Red" myself this past year.
Part of my personal and family culture is of being gentle, calm, and reserved. Most people who know me would describe me this way. I have been very fortunate to have had a peaceful and mostly safe environment to live in, through the course of my life. I haven't had much to be angry about.
I also have a wonderful job, which I love very much. I hear many stories of terrible suffering, but I feel very lucky and honoured to get to spend time with my patients. It is a privilege and a joy to know them.
In mental health policy, and in working with my patients, I have some very simple principles which I hold dear:
Item 1
take the time to know your patients, to hear their stories, and to see them regularly if they desire it
Item 2
show kindness, gentleness, patience, compassion, humour, empathy, and open-mindedness. Be willing to listen. Learn from your patients before trying to teach them anything. These are the core elements of all therapeutic encounters.
Item 3
therapeutic tactics or advice (such as about CBT exercises, meditation, lifestyle changes, or medication) are important, but are far less important than items #1 and #2... unless items #1 and #2 are attended to very well, it is often the case that all the therapeutic tactics in the world will be unhelpful.
Item 4
resist the urge to use labels. Terms such as "depression," "OCD," "schizophrenia," or "borderline personality disorder" can sometimes be useful in a discussion about mental health or therapy, but I believe it is too easy to impose these labels upon someone, or to encourage people to impose them on themselves, even if this occurs in a well-meaning way. Here, I think a great insight comes from the genre of "narrative therapy," in which people are encouraged to create and mold their own terminology, rather than have a clinician impose it upon them. Therapeutic guidelines about helping people often focus upon labels of this type, followed by details about item #3, while barely mentioning items #1 and #2!
Item 5
see items #1 and #2 again!
I am saddened to contemplate a system which, in an effort to improve efficiency, would neglect items #1 and #2.
Tuesday, June 7, 2016
Wednesday, June 1, 2016
How to Spend Ten Million Extra Dollars per Year on Mental Health
Suppose that a community received a large infusion of money to spend on improved mental health. What would be the best way to spend this money?
The most common situation I see in my practice, which pertains to this issue, is of patients with severe or chronic symptoms, who do not have access to a therapist who is regularly available for them to see on an ongoing basis.
It is not uncommon for patients I've seen to have had a fairly superficial course of therapy with someone who didn't have time for them.
The money, in my opinion, should go towards immediately and directly helping such patients have the type of therapeutic care which they desire. This might be seeing a psychotherapist or psychiatrist regularly. In other cases, it might be finding a personal trainer, an art therapist, a massage therapist, or some other specific resource of the person's choice.
It is not necessary to spend money on new buildings, new office equipment, new computer networks, new meetings, etc. There are many therapists in the community who are skilled healers -- but who are underemployed. Extra money in a health care budget could help them survive and flourish.
I have long felt that public health care providers (such as MSP in BC) or private insurers should allow much more funding for psychotherapy from non-medical therapists. Problems with efficiency and collaboration could be addressed within this regime, without spending any of the budget directly on this.
Another simple alternative way to spend this extra money would be to simply hire more therapists, particularly if there was evidence in the community that there were fewer therapists per capita than in similar communities elsewhere.
Stepped Care
An evolving trend in mental health care is a system called "stepped care." Basically, this is grounded on a simple principle, of not "overprescribing" more involved or expensive care than is necessary for a given problem. This idea is a good one, necessitated by a therapeutic tradition over the past hundred years of prescribing intensive psychotherapy to almost any patient, regardless of the severity of their problems.
Yet, "stepped care" as a modern therapeutic philosophy is, to a large degree, a formalization of the obvious. In other areas of medicine, one would not, for example, visit a heart surgeon following a first bout of angina. There would be a rational sequence of steps, to be tried in order, to manage any health issue with the most satisfaction for you, and with the best use of resources for the system. The heart surgeons would have less time to operate if they were spending more of their time investigating angina! But in order for a stepped care system to work fairly, there should be strong input from all levels of the system, including the heart surgeons, to determine the appropriate levels of care.
One difficulty with a stepped care idea is a subtle one: mental health care isn't exactly analogous to cardiac health care. There are some similarities, such as dealing with clearly defined levels of severity. In cardiac health care, a mild concern would be low exercise tolerance; a moderate concern would be angina; a severe concern would be an acute MI (a heart attack). In mental health care, a mild concern could be feeling stressed before a test at school; a "moderate" concern could be dealing with a loss; a "severe" concern could be a manic episode or active suicidal ideation.
Mental Health as an Educational or Developmental Process
But part of mental health care is different. It can be analogous to an educational process. And it can be analogous to a developmental or relational process. Here, a therapist can in some ways be similar to a university professor, or to a parent. A good university professor does not only spend time with students in the class who are having the most severe difficulties. Part of an efficient process in education is of nurturing all students, and offering special, personalized time and attention to all students, according to the students' wishes for dialog. And an "efficient" process in parenting is of always being present and nurturing, not only in times of severe distress. Such a process is not only healthy for students in a classroom, or for children in a family, but it is also healthy for the morale and overall well-being of the professors and parents.
The Process of Budgeting in Health Care
The process of budgeting is a political negotiation. Here are some steps typically taken to plan changes in health care expenditure:
Consultants
"Hire a consultant." Data could be gathered. Interviews of different groups ("stakeholders?") could take place. Evidence could be presented about how other health care systems operate elsewhere in the world.
One of the issues with consultancy has to do with the biases inherent to the group which is hired to do this type of task. Is there a particular political or philosophical agenda which the group brings, despite posing as a neutral assessor?
In the summer of 2015, I was asked to be part of a "consultancy" team of a sort, to evaluate the mental health care at a large North American university.
I expect that most consultancy groups charge quite high fees for their services. A first question I would have about spending a new health care windfall on consultants is "how much is their fee?" The fees should be transparent, evident to all those who are involved in the process. Is this type of money well-spent? Who will do the "consultancy" about the consultants themselves?
The fee I was paid for my role as a "consultant" was zero dollars. My travel expenses were covered, though not the cost of missing most of a week's work, plus the time spent afterwards helping to write the report. I suspect that similar fees are not the norm in the consultancy world.
Consultants can be a little bit like family therapists. In most cases, the reports are likely to contain very similar themes: "communicate better!" -- "collaborate better!" -- "encourage self-care!" -- "keep up with technology & cultural trends!"
Optimism Bias
Once a particular plan is put into place, there is another psychological bias which comes into play. Part of this is motivated by etiquette, and part of this is motivated by a natural process to relieve cognitive dissonance. One can see this phenomenon at weddings, at funerals, and at political rallies, once a new leader or plan of action has been chosen. Basically, we tend to say very positive things, about the newlyweds, about the deceased, or about the new political plan! It would be quite rude to say something negative about the newlyweds at a wedding!
But when a major policy change takes place, we can see leaders in the process, in a reflexive rhetorical habit, tending to be excitedly positive or complimentary about the new changes, even before the changes have even started. You might hear comments such as
"what an excellent new model we have!"
or
"Our hard work has really paid off--this is an exciting time of success and change as we implement and operationalize our new ideas!"
This can serve to boost morale, and help the changes to take place more effectively. But it can also serve to stifle important critical questioning or debate. Examples of this type are especially alarming in political movements, and we do not need to look far in the world's political history to see examples of harmful changes in a population moving forward at at an alarming pace, fueled by the reflexive excitement and enthusiasm of the citizens, with dissenting voices being suppressed or discouraged.
To prevent this phenomenon, it is important to always encourage a devout, reverential respect for the notion of free speech. Dissent and questioning should not only be allowed, it should be sought out and encouraged as a core part of our value system in a free, healthy society.
Population Surveys about Mental Health
I am particularly wary of consultants in the mental health area who claim to have surveyed the population, through interviews and similar data collection.
Quite a few of the most severely affected patients in a mental health population would be unwilling or unable to participate in such a survey!
Others might be willing, but are less apt to be aware of the presence of a consultancy group doing interviews. Interviews of this sort are already biased, due to the very mental health concerns that the consultants are intending to address.
I think the viewpoints of many of my own patients would be valuable to consider in such a consultancy process. As a specialist, my patients are analogously comparable to the patients of a heart surgeon, in a discussion of cardiac health (when I say this, I do not mean to say that my patients' problems are necessarily more "severe," nor do I claim that I am any more an "expert" than anyone else, but it certainly is true that it was harder for most of my patients to have found me, usually after being on a wait list and seeing various other counselors--just as patients of a heart surgeon have usually waited and seen other caregivers before). If one were conducting a survey about the goodness of cardiac health care, it would be severely remiss to only have open surveys of the general population, without talking to patients who had seen the surgeon!
The need for humility in consultancy reports
The report generated by my own group last year had a remarkably striking resemblance to other reports generated by other consultancy groups in similar situations, perhaps with some specific infusions of pet interests among the individual members of our group.
My own two pet interests, which I felt were most important to include in the report, were these:
1) I felt it was not possible to adequately understand the dynamics of a place after only a brief assessment period. I thought it was a bit like visiting a new country, or a new culture, spending a few days there, then presuming to write a report about what you think is wrong with how the place runs! This is also similar to a psychiatric consultation with a new patient -- the obligatory report generated after spending an hour or two with a person you've just met must be offered with deepest humility about its limitations, especially if the report is making categorical pronouncements about who the patient is as a person, or about "what is wrong."
It is therefore necessary to be very humble about reports of this nature, to acknowledge their limitations, and the limitations of its authors. Humility is key. It shows respect for the people and the institution you are visiting. It is perhaps less compelling to read a report in which the authors admit their own limitations. But it is more honest. It is just like seeing a therapist. Many people want clear, decisive advice from a therapist. Sometimes it is possible to give such advice. But a therapist's response to a suffering patient is much, much more powerful if it is patient and humble. Some advice can be given right away, but in most cases a promise to work together, to learn more, to promise to understand,to empathize, and to admit your limitations, is far more effective.
Empathic dedicated human contact as a foundation of care
2) I believe the foundation of care comes from empathic, dedicated human contact. It should never come from treating people like numbers, or like cogs in a system. Efficiency is important, but personal care must always be the transcendent value.
The wisdom and helpfulness of a family therapist (or consultant) does not come from the report generated from the "assessment." The assessment is likely to contain bland generalities, which, however, might be framed in assertive or rhetorically engaging ways. Furthermore, the ensuing interpretation or application of such a report, must not occur in a narrow or dogmatic way.
In family therapy, the helpfulness or positive impact comes not from the report which advises communicating -- but from actually communicating, possibly with the help of the therapist as mediator!
What about Economics & Evidence-Based Science?
It is very difficult to conduct a good scientific study demonstrating a superior way to allot a large sum of money. One could plan to do follow-up studies to measure health outcomes, but this actually proves much less than it seems! For example, if the entire extra mental health budget was spent on building and maintaining a new ice rink, or a new flower garden, or on free trips to tropical resorts, I would expect that we could see improvements in some mental health outcomes! Surveys of people using the ice rink would most likely show that people were quite happy with the new facility! This would appear to justify the expenditures.
If the money were spent on a new health care centre, we could generate numbers showing large numbers of people using the service, and perhaps symptom score data showing that people were experiencing relief of symptoms after visiting the centre.
But even larger numbers of people could have been seen, with even larger symptom score improvements, if we had simply given the money directly to the patients, to use as they saw fit, such as with the many struggling, underemployed private therapists in the community.
A core problem with this issue is the difficulty of conducting a controlled prospective study of different budgeting choices.
The bigger question is about spending wisely, with a view to improving health care in the short term and the long term, with the biggest possible improvements from each dollar spent.
Heart Surgery
I have often thought of cardiac health as an analogy to mental health. How should we best divide up a budget windfall to help improve cardiac health?
We could correctly observe that the best improvements in cardiac health come from fostering good lifestyle habits in the population: to eliminate smoking, to encourage healthy nutrition, and to encourage regular exercise. So we could spend most of the extra budget on quit-smoking clinics, improving access to vegetables, and improving affordable gym facilities.
The thing is, these lifestyle changes were already possible without spending any extra money! Gyms are actually not needed to encourage more exercise!
I would not oppose building more gyms, or building a better communication infrastructure, or planning regular meetings between cardiologists, surgeons, dieticians, and fitness instructors...but imagine it was known that the the heart surgeons in the community were under tremendous strain, were having long waiting lists, were having trouble finding available time in operating rooms, and were having declining morale, yet were being told to see more people in a more time-efficient way...
In this situation, I would not want to send the surgeons away to have more planning meetings...I would hope that the surgeons could be given the opportunity to do their work, with the basic resources which they and their patients needed or desired.
The most common situation I see in my practice, which pertains to this issue, is of patients with severe or chronic symptoms, who do not have access to a therapist who is regularly available for them to see on an ongoing basis.
It is not uncommon for patients I've seen to have had a fairly superficial course of therapy with someone who didn't have time for them.
The money, in my opinion, should go towards immediately and directly helping such patients have the type of therapeutic care which they desire. This might be seeing a psychotherapist or psychiatrist regularly. In other cases, it might be finding a personal trainer, an art therapist, a massage therapist, or some other specific resource of the person's choice.
It is not necessary to spend money on new buildings, new office equipment, new computer networks, new meetings, etc. There are many therapists in the community who are skilled healers -- but who are underemployed. Extra money in a health care budget could help them survive and flourish.
I have long felt that public health care providers (such as MSP in BC) or private insurers should allow much more funding for psychotherapy from non-medical therapists. Problems with efficiency and collaboration could be addressed within this regime, without spending any of the budget directly on this.
Another simple alternative way to spend this extra money would be to simply hire more therapists, particularly if there was evidence in the community that there were fewer therapists per capita than in similar communities elsewhere.
Stepped Care
An evolving trend in mental health care is a system called "stepped care." Basically, this is grounded on a simple principle, of not "overprescribing" more involved or expensive care than is necessary for a given problem. This idea is a good one, necessitated by a therapeutic tradition over the past hundred years of prescribing intensive psychotherapy to almost any patient, regardless of the severity of their problems.
Yet, "stepped care" as a modern therapeutic philosophy is, to a large degree, a formalization of the obvious. In other areas of medicine, one would not, for example, visit a heart surgeon following a first bout of angina. There would be a rational sequence of steps, to be tried in order, to manage any health issue with the most satisfaction for you, and with the best use of resources for the system. The heart surgeons would have less time to operate if they were spending more of their time investigating angina! But in order for a stepped care system to work fairly, there should be strong input from all levels of the system, including the heart surgeons, to determine the appropriate levels of care.
One difficulty with a stepped care idea is a subtle one: mental health care isn't exactly analogous to cardiac health care. There are some similarities, such as dealing with clearly defined levels of severity. In cardiac health care, a mild concern would be low exercise tolerance; a moderate concern would be angina; a severe concern would be an acute MI (a heart attack). In mental health care, a mild concern could be feeling stressed before a test at school; a "moderate" concern could be dealing with a loss; a "severe" concern could be a manic episode or active suicidal ideation.
Mental Health as an Educational or Developmental Process
But part of mental health care is different. It can be analogous to an educational process. And it can be analogous to a developmental or relational process. Here, a therapist can in some ways be similar to a university professor, or to a parent. A good university professor does not only spend time with students in the class who are having the most severe difficulties. Part of an efficient process in education is of nurturing all students, and offering special, personalized time and attention to all students, according to the students' wishes for dialog. And an "efficient" process in parenting is of always being present and nurturing, not only in times of severe distress. Such a process is not only healthy for students in a classroom, or for children in a family, but it is also healthy for the morale and overall well-being of the professors and parents.
The Process of Budgeting in Health Care
The process of budgeting is a political negotiation. Here are some steps typically taken to plan changes in health care expenditure:
Consultants
"Hire a consultant." Data could be gathered. Interviews of different groups ("stakeholders?") could take place. Evidence could be presented about how other health care systems operate elsewhere in the world.
One of the issues with consultancy has to do with the biases inherent to the group which is hired to do this type of task. Is there a particular political or philosophical agenda which the group brings, despite posing as a neutral assessor?
In the summer of 2015, I was asked to be part of a "consultancy" team of a sort, to evaluate the mental health care at a large North American university.
I expect that most consultancy groups charge quite high fees for their services. A first question I would have about spending a new health care windfall on consultants is "how much is their fee?" The fees should be transparent, evident to all those who are involved in the process. Is this type of money well-spent? Who will do the "consultancy" about the consultants themselves?
The fee I was paid for my role as a "consultant" was zero dollars. My travel expenses were covered, though not the cost of missing most of a week's work, plus the time spent afterwards helping to write the report. I suspect that similar fees are not the norm in the consultancy world.
Consultants can be a little bit like family therapists. In most cases, the reports are likely to contain very similar themes: "communicate better!" -- "collaborate better!" -- "encourage self-care!" -- "keep up with technology & cultural trends!"
Optimism Bias
Once a particular plan is put into place, there is another psychological bias which comes into play. Part of this is motivated by etiquette, and part of this is motivated by a natural process to relieve cognitive dissonance. One can see this phenomenon at weddings, at funerals, and at political rallies, once a new leader or plan of action has been chosen. Basically, we tend to say very positive things, about the newlyweds, about the deceased, or about the new political plan! It would be quite rude to say something negative about the newlyweds at a wedding!
But when a major policy change takes place, we can see leaders in the process, in a reflexive rhetorical habit, tending to be excitedly positive or complimentary about the new changes, even before the changes have even started. You might hear comments such as
"what an excellent new model we have!"
or
"Our hard work has really paid off--this is an exciting time of success and change as we implement and operationalize our new ideas!"
This can serve to boost morale, and help the changes to take place more effectively. But it can also serve to stifle important critical questioning or debate. Examples of this type are especially alarming in political movements, and we do not need to look far in the world's political history to see examples of harmful changes in a population moving forward at at an alarming pace, fueled by the reflexive excitement and enthusiasm of the citizens, with dissenting voices being suppressed or discouraged.
To prevent this phenomenon, it is important to always encourage a devout, reverential respect for the notion of free speech. Dissent and questioning should not only be allowed, it should be sought out and encouraged as a core part of our value system in a free, healthy society.
Population Surveys about Mental Health
I am particularly wary of consultants in the mental health area who claim to have surveyed the population, through interviews and similar data collection.
Quite a few of the most severely affected patients in a mental health population would be unwilling or unable to participate in such a survey!
Others might be willing, but are less apt to be aware of the presence of a consultancy group doing interviews. Interviews of this sort are already biased, due to the very mental health concerns that the consultants are intending to address.
I think the viewpoints of many of my own patients would be valuable to consider in such a consultancy process. As a specialist, my patients are analogously comparable to the patients of a heart surgeon, in a discussion of cardiac health (when I say this, I do not mean to say that my patients' problems are necessarily more "severe," nor do I claim that I am any more an "expert" than anyone else, but it certainly is true that it was harder for most of my patients to have found me, usually after being on a wait list and seeing various other counselors--just as patients of a heart surgeon have usually waited and seen other caregivers before). If one were conducting a survey about the goodness of cardiac health care, it would be severely remiss to only have open surveys of the general population, without talking to patients who had seen the surgeon!
The need for humility in consultancy reports
The report generated by my own group last year had a remarkably striking resemblance to other reports generated by other consultancy groups in similar situations, perhaps with some specific infusions of pet interests among the individual members of our group.
My own two pet interests, which I felt were most important to include in the report, were these:
1) I felt it was not possible to adequately understand the dynamics of a place after only a brief assessment period. I thought it was a bit like visiting a new country, or a new culture, spending a few days there, then presuming to write a report about what you think is wrong with how the place runs! This is also similar to a psychiatric consultation with a new patient -- the obligatory report generated after spending an hour or two with a person you've just met must be offered with deepest humility about its limitations, especially if the report is making categorical pronouncements about who the patient is as a person, or about "what is wrong."
It is therefore necessary to be very humble about reports of this nature, to acknowledge their limitations, and the limitations of its authors. Humility is key. It shows respect for the people and the institution you are visiting. It is perhaps less compelling to read a report in which the authors admit their own limitations. But it is more honest. It is just like seeing a therapist. Many people want clear, decisive advice from a therapist. Sometimes it is possible to give such advice. But a therapist's response to a suffering patient is much, much more powerful if it is patient and humble. Some advice can be given right away, but in most cases a promise to work together, to learn more, to promise to understand,to empathize, and to admit your limitations, is far more effective.
Empathic dedicated human contact as a foundation of care
2) I believe the foundation of care comes from empathic, dedicated human contact. It should never come from treating people like numbers, or like cogs in a system. Efficiency is important, but personal care must always be the transcendent value.
The wisdom and helpfulness of a family therapist (or consultant) does not come from the report generated from the "assessment." The assessment is likely to contain bland generalities, which, however, might be framed in assertive or rhetorically engaging ways. Furthermore, the ensuing interpretation or application of such a report, must not occur in a narrow or dogmatic way.
In family therapy, the helpfulness or positive impact comes not from the report which advises communicating -- but from actually communicating, possibly with the help of the therapist as mediator!
What about Economics & Evidence-Based Science?
It is very difficult to conduct a good scientific study demonstrating a superior way to allot a large sum of money. One could plan to do follow-up studies to measure health outcomes, but this actually proves much less than it seems! For example, if the entire extra mental health budget was spent on building and maintaining a new ice rink, or a new flower garden, or on free trips to tropical resorts, I would expect that we could see improvements in some mental health outcomes! Surveys of people using the ice rink would most likely show that people were quite happy with the new facility! This would appear to justify the expenditures.
If the money were spent on a new health care centre, we could generate numbers showing large numbers of people using the service, and perhaps symptom score data showing that people were experiencing relief of symptoms after visiting the centre.
But even larger numbers of people could have been seen, with even larger symptom score improvements, if we had simply given the money directly to the patients, to use as they saw fit, such as with the many struggling, underemployed private therapists in the community.
A core problem with this issue is the difficulty of conducting a controlled prospective study of different budgeting choices.
The bigger question is about spending wisely, with a view to improving health care in the short term and the long term, with the biggest possible improvements from each dollar spent.
Heart Surgery
I have often thought of cardiac health as an analogy to mental health. How should we best divide up a budget windfall to help improve cardiac health?
We could correctly observe that the best improvements in cardiac health come from fostering good lifestyle habits in the population: to eliminate smoking, to encourage healthy nutrition, and to encourage regular exercise. So we could spend most of the extra budget on quit-smoking clinics, improving access to vegetables, and improving affordable gym facilities.
The thing is, these lifestyle changes were already possible without spending any extra money! Gyms are actually not needed to encourage more exercise!
I would not oppose building more gyms, or building a better communication infrastructure, or planning regular meetings between cardiologists, surgeons, dieticians, and fitness instructors...but imagine it was known that the the heart surgeons in the community were under tremendous strain, were having long waiting lists, were having trouble finding available time in operating rooms, and were having declining morale, yet were being told to see more people in a more time-efficient way...
In this situation, I would not want to send the surgeons away to have more planning meetings...I would hope that the surgeons could be given the opportunity to do their work, with the basic resources which they and their patients needed or desired.
Monday, May 30, 2016
Rhetoric and Jargon in Health Care Policy, Part 2: "Evidence Based"
These days we often hear about how a new treatment, or program, or therapy style, is "evidence based." This gives the listener an impression that the new treatment must be superior in some way.
It is another language construct which has become much more common, especially in mental health care discussions. Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.
But was does "evidence based" really mean?
We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based." The implication of this statement is that other forms of therapy must not be "evidence based."
It should go without saying that most everything is "evidence based":
An individual's personal account of their experience is a form of evidence.
A randomized controlled prospective trial of therapy supplies another form of evidence.
An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another form of evidence.
Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter. It implies that the issue it is describing has already been decided upon.
In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy. But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.
I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change. There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.
But in mental health care, the evolving evidence is often much less robust than it seems. Most studies are of very short duration. Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present. Also, a great deal of evidence supports the efficiency of treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.
Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...
It is good to think carefully about evidence, and to be prepared to change our practice accordingly. But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking. Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.
It is another language construct which has become much more common, especially in mental health care discussions. Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.
But was does "evidence based" really mean?
We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based." The implication of this statement is that other forms of therapy must not be "evidence based."
It should go without saying that most everything is "evidence based":
An individual's personal account of their experience is a form of evidence.
A randomized controlled prospective trial of therapy supplies another form of evidence.
An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another form of evidence.
Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter. It implies that the issue it is describing has already been decided upon.
In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy. But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.
I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change. There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.
But in mental health care, the evolving evidence is often much less robust than it seems. Most studies are of very short duration. Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present. Also, a great deal of evidence supports the efficiency of treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.
Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...
It is good to think carefully about evidence, and to be prepared to change our practice accordingly. But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking. Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.
Monday, May 2, 2016
Rhetoric and Jargon in Health Care Policy, Part One: "Stakeholders"
Jargon bothers me. It reduces the enjoyment and engagement we have with language. It can be a barrier for others to even understand what is being said.
The term "stakeholder" is part of contemporary jargon in the area of policy development and corporate planning. According to the Google NGram viewer, this word was very rarely used before 1975. Since 1975, its frequency of use in printed language has increased by a factor of 10 000! The words "stakeholder" or "stakeholders" surpassed the prevalence of the word "honesty" in written language as of the year 2000, and since then the prevalence has almost doubled again!
Before 1975 "stakeholder" was primarily used as part of legal jargon, including one definition as follows:
The term "stakeholder" is part of contemporary jargon in the area of policy development and corporate planning. According to the Google NGram viewer, this word was very rarely used before 1975. Since 1975, its frequency of use in printed language has increased by a factor of 10 000! The words "stakeholder" or "stakeholders" surpassed the prevalence of the word "honesty" in written language as of the year 2000, and since then the prevalence has almost doubled again!
Before 1975 "stakeholder" was primarily used as part of legal jargon, including one definition as follows:
"A stakeholder is a person who is or may be exposed to multiple liability as the result of adverse claims."(McKinney, W. M. (1918). McKinney's Consolidated Laws of New York Annotated. West Publishing Company.)
Since 1975, the meaning has evolved to:
"a person or company with a concern or financial interest in ensuring the success of an organization or business" (Oxford English Dictionary)
The
etymology of the word "stake," relates not to its meaning as a sharp
wooden stick, but rather to another meaning, dating back to 1540, as
"the money risked on a game of dice." (Oxford English
Dictionary)
The honourable spirit of the word "stakeholder" has to do with respecting different groups, positions, and points of view while discussing an issue in an organization. It may invite a shared view of complex systemic matters, as though all the different interested individuals figuratively have "money risked on a game of dice." It invites group decision making, rather than a dictatorial approach.
My complaint about this word has to do with its reflexive use as part of jargon. There are connotations of a group of people gathered around in a betting game (which is literally where the word originates). There is an image of wealthy property-holders (with "stakes" in the land) debating about real estate dealings. Another unintended connotation is of a group of people holding sharp sticks, waiting to confront a vampire!
Finally, I wish that people in a discussion could simply be referred to as people, or by name, rather than as "stakeholders."
I believe
that the honourable spirit of respect, intended by using the word “stakeholder,”
is vitally important. But sometimes jargon brings us farther away, rather than closer, to this honourable
spirit. Many policy discussions can be so laden with this, as to be content-free, muddled doublespeak.
I invite us all to express ourselves in an articulate, engaging manner, while letting go of any need to use jargon. Jargon can be a divisive tactic in language and debate: many listeners become inured to it through repetition. The jargon becomes a short-cut to be persuasive, while not leading the listener with any new thought. It becomes "filler" in a dialog, which can distance and bore the audience. This type of rhetoric can fool an uneducated audience into believing that the speaker is bestowing more wisdom than is actually the case. It can also have a suppressive effect on a dissenting voice, therefore stultifying debate and free thinking.
In cognitive therapy, we see that our minds can create various types of "inner jargon," which can perpetuate anxious or depressive states. While cognitive therapeutic theory is laden with its own jargon, one healthy principle it encourages is to practice awareness of our "inner jargon," to "talk back" to it, and to create new, imaginative, constructive, mindful, and reasoned inner dialog or self-talk.
I believe that cognitive therapy doesn't tend to encourage one thing enough: to practice expressing our thoughts, or forming new inner dialogue, in a way which is rhetorically beautiful.
In cognitive therapy, we are encouraged always to garner the courage to offer a dissenting voice! In the case of cognitive therapy for depression, we must bravely speak back, in our thoughts, to a storm of negative, pessimistic, self-critical thinking. Let us make the "speaking back" full of eloquence, poetry, and beauty. Let us step away from using jargon or other forms of empty talk.
We are "stakeholders" of our own minds! Or, different points of view held in the mind are all "stakeholders" of self. But perhaps we can let go of the "stakes" and simply work with ideas, without using jargon, in a frank, articulate, compassionate dialogue.
In cognitive therapy, we see that our minds can create various types of "inner jargon," which can perpetuate anxious or depressive states. While cognitive therapeutic theory is laden with its own jargon, one healthy principle it encourages is to practice awareness of our "inner jargon," to "talk back" to it, and to create new, imaginative, constructive, mindful, and reasoned inner dialog or self-talk.
I believe that cognitive therapy doesn't tend to encourage one thing enough: to practice expressing our thoughts, or forming new inner dialogue, in a way which is rhetorically beautiful.
In cognitive therapy, we are encouraged always to garner the courage to offer a dissenting voice! In the case of cognitive therapy for depression, we must bravely speak back, in our thoughts, to a storm of negative, pessimistic, self-critical thinking. Let us make the "speaking back" full of eloquence, poetry, and beauty. Let us step away from using jargon or other forms of empty talk.
We are "stakeholders" of our own minds! Or, different points of view held in the mind are all "stakeholders" of self. But perhaps we can let go of the "stakes" and simply work with ideas, without using jargon, in a frank, articulate, compassionate dialogue.
Tuesday, April 26, 2016
E-Mental Health
The whole issue of e-mental health induces quite a bit of resistance in me, which causes me to pause and reflect.
The issue perhaps represents, somehow, a threat to the way I like to practice psychiatry. Therefore, I may be prone to some biases, and simple resistance to change.
On the one hand, I love gadgetry, and I love technological innovation. But I also love to practice psychiatry in a way which does not require any gadgetry of any sort. I like, quite simply, to see my patients regularly, in person. I am averse to a system which would make this type of practice less possible.
There is no personal financial reason why e-mental health would need to be opposed. Seeing patients in person, for an hour at a time, is financially disfavoured in the current system. E-mental health certainly does not need to pose any threat to the financial well-being of therapists. It may actually facilitate higher earnings for many therapists. In fact, if anything, there may be a bias towards using more e-mental health, as a therapist may be able to offer these types of services in a zero overhead environment, to large numbers of clients, therefore maximizing financial profit.
I have thought that various e-mental health resources are "impersonal," but I realize that I may need to be a bit more open-minded about this. I am reminded of my own experience in university, many years ago:
I can think of many examples of courses I took in university, even in medical school, in which attending the lectures was not effective for good learning. It was often a passive activity, involving a struggle to stay awake; many professors may have been great experts in their fields, but were not effective, dynamic, or interesting teachers. It would have been better for my learning to have skipped the lecture and just spent the time reading on my own. Maybe in-person psychotherapy can be like this, in some cases.
Nowadays, students often have opportunities to take courses entirely online. Also, many teaching resources, such as lectures (including those done at famous universities) are available online. While taking a course online could be less "personal" in many ways, it is not necessarily so. Personal interaction with a professor or classmates may in some cases be easier online than in an in-person lecture. It is only the medium which is different.
For many types of psychotherapy, there can be a sort of "curriculum" akin to the material presented in a university course. This is especially true in CBT (cognitive-behavioural therapy). In many cases, structured self-learning, possibly with an on-line "curriculum," could be more effective, engaging, and enjoyable than attending in-person appointments.
What are the variables that might determine this? Individual factors relating to personal needs are obviously relevant here--in many cases of depression or anxiety, it is the CBT-like "curriculum" which is the most important element to be mastered, in order to have relief of symptoms. It may not necessarily be the case that these patients have a particular need for interpersonal care from a therapist, at least not in an in-person setting. The optimal way, and even the most enjoyable way, for a person to benefit from this "curriculum" may, just like a student in a university course, be through taking a "CBT course" online. But, of course, in many cases, the "curriculum" does not really matter so much as the "therapeutic alliance" or the personal experience in a therapy setting.
Another variable is the therapist's personal style. This reminds me, once again, of professors I took university courses with long ago. In some cases, the courses were wonderful, meaningful, engaging, energetic, and delightful experiences, with a professor who was full of love for the subject, enthusiasm, and personal care for the students. This made the course a joy to attend, even if the subject matter might have been approachable in an on-line or indirect fashion.
I suspect a similar dynamic can occur in therapy--in order for a one-on-one therapy experience to be worthwhile, or superior to an on-line substitute, there would have to be a meaningful engagement with a therapist, whose style would suit the patient's interest, and kindle the patient's motivations.
Unfortunately, in today's therapy environment, personal sessions are often in short supply. Courses of therapy are often very time-limited. There is often, as a result, an excessive focus on simple, trite therapeutic advice, with very little time allowed to form an ongoing therapeutic connection. If this form of therapeutic encounter is compared with a computer app, I am not surprised that the app has similar effectiveness! I do see that this type of simple, brief, limited therapeutic encounter is indeed helpful for many people (e.g. with stress-related anxiety or mild, transient depression), but I also see that such an encounter would be very frustrating and ineffectual for many who have a more complex or difficult psychological history.
Here are some other dynamics to watch for:
1) "the Christmas gift effect." Sometimes, parents will buy expensive gifts for their children, during the Christmas season. These parents may not have had much time for the children during the year, and indeed the children may well have been asking for various expensive toys or gadgets. The expensive gifts are appreciated excitedly -- but they don't really help the children feel better! They are just more "stuff," and may even condition the children to become more materialistic. What the children may really desire is to have parents who spend more time with them, attending to them, playing with them, and caring for them. They don't really want gadgets -- they want care and love. But in the absence of the care and attention, the children may only identify a wish for more presents or gadgets. This is what Kahneman might call "miswanting," a distortion of identified desire caused by short-term materialistic reflexes, while longer term substantive needs are unmet.
I am concerned that various examples of e-mental health are a bit like expensive Christmas gift gadgetry. Everyone is excited about it (not least the vendors who are selling the electronics required for it, or the researchers clamoring to publish journal articles about it), but in the midst of the fray, it may not be noticed that even less time, care, and attention is spent actually caring for patients directly. More time in front of computer screens, less time in front of other people.
2) The "curriculum" benefits of e-mental health could be obtained in a variety of other trivial ways. If CBT curricula were widely available online already (which is ever more the case) or if they were introduced as health care programs during childhood, etc., then e-mental health curricula may have much less measurable impact. It would be like taking the same university course (which you already passed) a second time. For this cohort, a more direct, personalized form of care may be even more important.
3) Hidden costs. While e-mental health ideas may indeed be effective in many situations, or may be equal in some measure of effectiveness to other established treatments, there could be hidden problems. For example, suppose a cohort of therapists who love providing personalized, direct therapeutic care are compelled to spend their time supervising e-mental health activities (for example, sitting alone in an office, in front of a computer screen) for an expanding proportion of their time. In this case, perhaps an equal (or greater) number of patients or clients could be seen and helped. But--those individual clients who would have benefited most by seeing someone in person would not have been seen and helped, because the therapist was sitting in front of a computer screen instead!
Another hidden problem is the detriment to morale caused by compelling people to spend even more time in front of a computer screen, instead of in front of an actual person. An effective psychotherapist (or teacher, or musician, or worker of any type) is one who feels joy and passion and excitement and personal connection for the work. Imagine seeing a therapist or a teacher who appears disconnected, distant, or absorbed with an electronic gadget instead of with a person! If joy of personal connection is deprived, through the use of supposedly efficient technology, then the effectiveness of the entire system is at risk.
Furthermore, there could be a selection bias evolving in a therapists' population if this trend continues, favouring those who can tolerate more impersonal interactions as a norm. Those who are most comfortable with simple personal connection, and less comfortable with technology, may feel more and more uncomfortable with entering into a therapy profession at all. Yet, those with the highest comfort for personal connection are arguably the most valuable and talented therapists!
The Golden Rule Question:
In trying to sort out this issue, I think we could ask ourselves a type of "Golden Rule" question: if it was you yourself, or if it was your partner, your spouse, your mother, your child, or your closest friend, who needed help for managing serious anxiety, depression, or some other psychological distress--how would you feel about an electronic resource being offered instead of a one-on-one therapist?
As I ask myself this question, I think that it ought not to be either/or. I suspect, for me, that I would appreciate using various electronic resources. And I suspect, for me, that it would also depend on the therapist who was available: would I like that person? Would that person seem compatible? Would that person have the time and the commitment to offer the help needed (possibly over a long period of time)?
If I was told that the use of e-mental health modalities would reduce the total amount of direct in-person time available for clients or patients, this might further demote my enthusiasm for them.
In a system which is already failing to attend to providing adequate personalized care, I would be worried about a strategy in which even more time, money, and attention was given to a gadget, rather than to a human relationship. The consequences of such movement away from personalized care affect not only clients or patients, but also the morale and health of the therapist community, and arguably the health of society as a whole.
But, if e-mental health simply expanded the accessibility of therapy, allowed people trapped at home or in remote locations to access care, allowed playful educational engagement, while still allowing clients and therapists to have direct, personal time in a therapeutic framework, then I think this technology could be embraced in a way which is healthy for all.
In subsequent posts on this subject, I would like to survey some of the literature on this. Much of the recent literature is very positive and enthusiastic about e-mental health. While I am curious, and am sometimes delighted, by some of the ideas, I am also wary about the lack of consideration for the issues described above. There is a long history in psychiatry, and in medicine generally, of big enthusiastic trends of practice, sometimes following political motives, leading in retrospect to regrettable decrements in care.
The issue perhaps represents, somehow, a threat to the way I like to practice psychiatry. Therefore, I may be prone to some biases, and simple resistance to change.
On the one hand, I love gadgetry, and I love technological innovation. But I also love to practice psychiatry in a way which does not require any gadgetry of any sort. I like, quite simply, to see my patients regularly, in person. I am averse to a system which would make this type of practice less possible.
There is no personal financial reason why e-mental health would need to be opposed. Seeing patients in person, for an hour at a time, is financially disfavoured in the current system. E-mental health certainly does not need to pose any threat to the financial well-being of therapists. It may actually facilitate higher earnings for many therapists. In fact, if anything, there may be a bias towards using more e-mental health, as a therapist may be able to offer these types of services in a zero overhead environment, to large numbers of clients, therefore maximizing financial profit.
I have thought that various e-mental health resources are "impersonal," but I realize that I may need to be a bit more open-minded about this. I am reminded of my own experience in university, many years ago:
I can think of many examples of courses I took in university, even in medical school, in which attending the lectures was not effective for good learning. It was often a passive activity, involving a struggle to stay awake; many professors may have been great experts in their fields, but were not effective, dynamic, or interesting teachers. It would have been better for my learning to have skipped the lecture and just spent the time reading on my own. Maybe in-person psychotherapy can be like this, in some cases.
Nowadays, students often have opportunities to take courses entirely online. Also, many teaching resources, such as lectures (including those done at famous universities) are available online. While taking a course online could be less "personal" in many ways, it is not necessarily so. Personal interaction with a professor or classmates may in some cases be easier online than in an in-person lecture. It is only the medium which is different.
For many types of psychotherapy, there can be a sort of "curriculum" akin to the material presented in a university course. This is especially true in CBT (cognitive-behavioural therapy). In many cases, structured self-learning, possibly with an on-line "curriculum," could be more effective, engaging, and enjoyable than attending in-person appointments.
What are the variables that might determine this? Individual factors relating to personal needs are obviously relevant here--in many cases of depression or anxiety, it is the CBT-like "curriculum" which is the most important element to be mastered, in order to have relief of symptoms. It may not necessarily be the case that these patients have a particular need for interpersonal care from a therapist, at least not in an in-person setting. The optimal way, and even the most enjoyable way, for a person to benefit from this "curriculum" may, just like a student in a university course, be through taking a "CBT course" online. But, of course, in many cases, the "curriculum" does not really matter so much as the "therapeutic alliance" or the personal experience in a therapy setting.
Another variable is the therapist's personal style. This reminds me, once again, of professors I took university courses with long ago. In some cases, the courses were wonderful, meaningful, engaging, energetic, and delightful experiences, with a professor who was full of love for the subject, enthusiasm, and personal care for the students. This made the course a joy to attend, even if the subject matter might have been approachable in an on-line or indirect fashion.
I suspect a similar dynamic can occur in therapy--in order for a one-on-one therapy experience to be worthwhile, or superior to an on-line substitute, there would have to be a meaningful engagement with a therapist, whose style would suit the patient's interest, and kindle the patient's motivations.
Unfortunately, in today's therapy environment, personal sessions are often in short supply. Courses of therapy are often very time-limited. There is often, as a result, an excessive focus on simple, trite therapeutic advice, with very little time allowed to form an ongoing therapeutic connection. If this form of therapeutic encounter is compared with a computer app, I am not surprised that the app has similar effectiveness! I do see that this type of simple, brief, limited therapeutic encounter is indeed helpful for many people (e.g. with stress-related anxiety or mild, transient depression), but I also see that such an encounter would be very frustrating and ineffectual for many who have a more complex or difficult psychological history.
Here are some other dynamics to watch for:
1) "the Christmas gift effect." Sometimes, parents will buy expensive gifts for their children, during the Christmas season. These parents may not have had much time for the children during the year, and indeed the children may well have been asking for various expensive toys or gadgets. The expensive gifts are appreciated excitedly -- but they don't really help the children feel better! They are just more "stuff," and may even condition the children to become more materialistic. What the children may really desire is to have parents who spend more time with them, attending to them, playing with them, and caring for them. They don't really want gadgets -- they want care and love. But in the absence of the care and attention, the children may only identify a wish for more presents or gadgets. This is what Kahneman might call "miswanting," a distortion of identified desire caused by short-term materialistic reflexes, while longer term substantive needs are unmet.
I am concerned that various examples of e-mental health are a bit like expensive Christmas gift gadgetry. Everyone is excited about it (not least the vendors who are selling the electronics required for it, or the researchers clamoring to publish journal articles about it), but in the midst of the fray, it may not be noticed that even less time, care, and attention is spent actually caring for patients directly. More time in front of computer screens, less time in front of other people.
2) The "curriculum" benefits of e-mental health could be obtained in a variety of other trivial ways. If CBT curricula were widely available online already (which is ever more the case) or if they were introduced as health care programs during childhood, etc., then e-mental health curricula may have much less measurable impact. It would be like taking the same university course (which you already passed) a second time. For this cohort, a more direct, personalized form of care may be even more important.
3) Hidden costs. While e-mental health ideas may indeed be effective in many situations, or may be equal in some measure of effectiveness to other established treatments, there could be hidden problems. For example, suppose a cohort of therapists who love providing personalized, direct therapeutic care are compelled to spend their time supervising e-mental health activities (for example, sitting alone in an office, in front of a computer screen) for an expanding proportion of their time. In this case, perhaps an equal (or greater) number of patients or clients could be seen and helped. But--those individual clients who would have benefited most by seeing someone in person would not have been seen and helped, because the therapist was sitting in front of a computer screen instead!
Another hidden problem is the detriment to morale caused by compelling people to spend even more time in front of a computer screen, instead of in front of an actual person. An effective psychotherapist (or teacher, or musician, or worker of any type) is one who feels joy and passion and excitement and personal connection for the work. Imagine seeing a therapist or a teacher who appears disconnected, distant, or absorbed with an electronic gadget instead of with a person! If joy of personal connection is deprived, through the use of supposedly efficient technology, then the effectiveness of the entire system is at risk.
Furthermore, there could be a selection bias evolving in a therapists' population if this trend continues, favouring those who can tolerate more impersonal interactions as a norm. Those who are most comfortable with simple personal connection, and less comfortable with technology, may feel more and more uncomfortable with entering into a therapy profession at all. Yet, those with the highest comfort for personal connection are arguably the most valuable and talented therapists!
The Golden Rule Question:
In trying to sort out this issue, I think we could ask ourselves a type of "Golden Rule" question: if it was you yourself, or if it was your partner, your spouse, your mother, your child, or your closest friend, who needed help for managing serious anxiety, depression, or some other psychological distress--how would you feel about an electronic resource being offered instead of a one-on-one therapist?
As I ask myself this question, I think that it ought not to be either/or. I suspect, for me, that I would appreciate using various electronic resources. And I suspect, for me, that it would also depend on the therapist who was available: would I like that person? Would that person seem compatible? Would that person have the time and the commitment to offer the help needed (possibly over a long period of time)?
If I was told that the use of e-mental health modalities would reduce the total amount of direct in-person time available for clients or patients, this might further demote my enthusiasm for them.
In a system which is already failing to attend to providing adequate personalized care, I would be worried about a strategy in which even more time, money, and attention was given to a gadget, rather than to a human relationship. The consequences of such movement away from personalized care affect not only clients or patients, but also the morale and health of the therapist community, and arguably the health of society as a whole.
But, if e-mental health simply expanded the accessibility of therapy, allowed people trapped at home or in remote locations to access care, allowed playful educational engagement, while still allowing clients and therapists to have direct, personal time in a therapeutic framework, then I think this technology could be embraced in a way which is healthy for all.
In subsequent posts on this subject, I would like to survey some of the literature on this. Much of the recent literature is very positive and enthusiastic about e-mental health. While I am curious, and am sometimes delighted, by some of the ideas, I am also wary about the lack of consideration for the issues described above. There is a long history in psychiatry, and in medicine generally, of big enthusiastic trends of practice, sometimes following political motives, leading in retrospect to regrettable decrements in care.
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