Tuesday, March 6, 2018

Depression Treatment Guidelines

I encourage having a look at the September 2016 issue of The Canadian Journal of Psychiatry, which summarizes treatment recommendations for major depressive disorder, based on a thoughtful review of the evidence available at the time.  The authors spent many hours of careful work preparing this authoritative set of articles, and I think they did a good job. 

Here is a brief summary:

1) Various antidepressants are beneficial for treating depression.  They may help with an acute episode, and may help prevent relapses if continued.  Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices.    Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.

2) Various types of psychotherapy are beneficial for treating depression.  These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation.  CBT has particularly strong evidence for being effective. 

3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured. 

4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.

I am concerned that there was not a lot of critical debate about these claims.  Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view.   It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.

There are some useful specific pointers:  for example, there is a lack of evidence that combining two different antidepressants is consistently helpful.  But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence. 

In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.

Here are some ideas of my own to add about "treatment guidelines":

A very thorough understanding of a person's history is most important for care.  In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history.  Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms).  Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc.  It takes time and a good therapeutic relationship to know a person's story.

There is some question about the validity of "major depressive disorder" as a construct.  Eiko Fried has a good summary of this issue on Twitter: https://twitter.com/EikoFried/status/935098850439847937
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme).   It is therefore limited to focus only on the treatment of depression alone.  I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically.  But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need. 

There are many pathways towards nurturing mental health.  Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits.  Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness.  Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone.    There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.

In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:

1) love:  0 times.  The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness:  0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times

While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis.  These issues include compassion, meaning, love, and patience.  Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure.  Algorithms and guidelines tend not to help very much with this existential struggle.    Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.   

I prescribe a lot of medication.  In some cases the medication appears to be incredibly helpful.  In many other cases, there is a small but significant benefit.  And in others still, there is not much benefit at all despite many, many trials of different medication.  And in a few cases, the medications are harmful.   Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research.   But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training.   Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles.    Review articles of this type are  authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.

My therapeutic style has included more and more ideas based on CBT, over the past 15 years.   Many of my patients work on structured CBT elsewhere as well.  As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others.  Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered.   In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them.  This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care.  It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus,  and a lack of someone to speak the language with on a regular, long-term basis.

Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis.  It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs.   Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol.  Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles.    Some psychiatrists have a particular expertise and interest in medication management.  Most research protocols do not look at this issue in groups or systems.  These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other.  For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.

Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.

Wednesday, October 11, 2017

Mindfulness: is the evidence exaggerated?

Mindfulness-based techniques are now mainstream in psychotherapy.

A recent review and look at the evidence, published by Nicholas Van Dam et al. (Perspectives on Psychological Science, October 10, 2017, doi 10.1177/1745691617709589) is worth reading.   This article is discussed by Bret Stetka in Scientific American Mental Health today.

I believe there are very important points to consider:

1) Mindfulness itself could mean different things to different people.
2) People are earning a lot of money from mindfulness education, groups, books, etc.

We come to a theme that I have often found, in so many other areas of life, and specifically in psychiatry:  "dogma."

In a therapeutic encounter, or in a long-term course of therapy, the patient or client may feel better.   In the process of this therapy, the client or patient may adopt new ideas, habits, or beliefs, based on the subject matter of therapy.  We see this in CBT, in psychodynamic therapy, and in meditation-based therapies.  In other areas of life, such as in religion, in exercise training, in education, and in nutritional change, we also see people adopt new ideas, habits, or beliefs.  The benefits of these experiences are often attributed to the specific changes in ideas, habits, or beliefs.

But I believe that in many cases, the specific ideas, habits, or beliefs are less important (sometimes totally unimportant, or at worst even harmful) than the process.

In meditation, people adopt a quiet behavioural habit, which is then practiced diligently.  Time and effort is committed to learning the skill, perhaps paying money take lessons, and to meet others who share the same practice.

The process here is of diligent commitment, daily behavioural practice which differs from the status quo, and often different social affiliation.

The actual theory or literal practice of the meditation might sometimes not be important at all.  These details are part of the dogma of the practice, and may not be required for the practice to be helpful.  Yet, we humans can become more committed to a practice if we believe there is some strong theoretical foundation behind it.

I see this phenomenon in other therapeutic styles.   CBT has a strong theoretical foundation, yet I have to wonder if much of the benefits from CBT occur irrespective of the theory, but rather simply because of the diligent practice of exercises.  Psychodynamic theory features many dogmatic beliefs (such as about the impact of certain childhood events), but yet the process of the therapy (of warmth, communicative freedom, invitation to reflect) is probably the key factor in its benefits, irrespective of the theoretical dogma.

In this post, I am not meaning at all to be critical of meditation-based techniques.  I actually think that meditation could be quite a wonderful and transformative practice.  But I do encourage people to question the theoretical dogma.  Your own personal version of meditation may be equally effective or better than some other formally prescribed method, provided you are engaging with it in a way which feels comfortable, meaningful, useful, and enjoyable.

Another implication is that positive disciplined activity can be very therapeutic, but perhaps we can be free to choose the specifics according to our interests and proclivities.  So it may be that a Tango class or art lessons or nature photography or horseback riding could be more therapeutically "meditative" than an actual mindfulness or yoga class.  But others might prefer the mindfulness class.  I encourage us to be open-minded.  I also encourage us to have a little bit of healthy skepticism about therapeutic trends, especially when there is a lot of money and salesmanship involved.

Wednesday, June 14, 2017

Twitter in mental health

I wanted to learn a little bit about Twitter recently, so I started a Twitter account (@DrGarthK).

In past years I assumed that the Twitter format would be very limiting, and would tend to favour very superficial chatter.

But despite this issue, I have found Twitter to be an interesting way to connect a little bit with people in the world whose ideas and wisdom you admire.   There are leading theorists, researchers, poets, authors, therapists, and scientists who contribute to Twitter regularly.  Of course, there are political leaders as well (one of my favourite contributors is the Dalai Lama, @DalaiLama).  

The very brief format of tweets does constrain expression very much, but on the other hand there can be a sort of concise poetry to them, at their best.  Furthermore, it is possible for your tweets to introduce a piece of lengthier writing.

Positives about Twitter

Here are some of the positives with Twitter I have discovered so far:

1) Interesting to hear what some famous people or great scholars are saying or doing.  It's possible to actually participate in a conversation with them, and give feedback about their ideas.

2) It is easy to engage with Twitter over a very short period of time, such as during a break.

3) The 140-character limit makes you practice framing ideas in a brief, concise manner.

4) It is interesting to appreciate Twitter as an art form, which some people have done very creative things with.

Negatives about Twitter

Here are some of the negatives or problems I have seen:

1) Even some famous people or leaders in a scholarly community contribute posts which can be rambling smalltalk, ranting/complaining, or disparaging other people, which I think is less enjoyable and makes less of a positive impact.

2) I realize that Twitter is commonly used for self-promotion, but an overtly self-promoting agenda comes across like an unwelcome sales pitch.  I find it a bit tiresome to see a lot of  tweets trying to market a new book or seminar etc.  I think I'd be more interested in someone's book if it wasn't advertised so directly.

3) Twitter, like many other forms of social media or electronics, can have an "addictive" quality, which might make you spend more time on it than is healthy for you.  Also the brevity of the content may condition people to expect morsels of knowledge or conversation that only require a few moments of attention.  I worry that this would make people gradually more impatient with a deeper, lengthier conversation.

 Uses of Twitter for mental health:

There are many people who post psychoeducational material, affirmations, meditations, encouragements, testimonial accounts about recovery and healing, etc.  In many cases, a person with psychological symptoms may have only the time or attention to spend reading something very brief.  So it is good that there is a medium favouring such brevity.


So far, after using Twitter for a few weeks, I am not quite sure if it has been worthwhile.  There's been some interesting content and discussion about things, but I have had a tendency to check it a little too often, at the expense of reading more substantial things...  Maybe a little too much time spent absorbed on a device, instead of enjoying the present moment, going outside,  or enjoying the scenery.

But it's been a learning experience, and I may continue to use it a little bit, in moderation.

Monday, March 13, 2017

Helping Patients with Schoolwork

In my clinic, I mainly see university students.  I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.

Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."

I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:


In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time.   University students often spend thousands of hours studying, writing, and thinking about academic subjects.  Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning.  For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops."   In many cases, a student's academic work is a reflection of health status (both mental and physical),  For many students, academic performance affects self-esteem:  low grades can cause a person to feel like a failure.  Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.

In order to understand another person's emotional life, it is very important to learn about how he or she is spending time.   Is the schoolwork a meaningful life pleasure?  Is it only a chore, a burden, or a stress?

It deepens understanding of this issue to explore it in more than a superficial way.  I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit.  Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.

Shared Interest

Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level.  But sometimes, they have almost no social conversation about their studies, with a person who shows interest.  The academic study becomes an insular, lonely experience, rather than a source of potential social interest.  Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this.    Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.

Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise.  It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.


All mental health issues affect cognitive functioning and academic performance.  A direct discussion about academic matters is relevant to the assessment of overall mental health.  Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative.  In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.

What do Notes Look Like? 

The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health.    Are notes tidy, meticulous, or disorganized?  Do the notes fluctuate a lot from one week to the next?  Are the notes clear for someone else to read and understand?  Are there gaps where notes are missed entirely?  Is writing fluent once started, but just difficult to start?  Is there evidence of tremor or other neurological symptoms manifest in handwriting?

Cognitive Testing

If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with.  A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems.  It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work.    A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum.    Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.

Practical Therapy

Cognitive therapy is a type of "academic" process:  it requires note-taking, reflection, analysis, and homework.  Many students might not have time for diligent cognitive therapy.  But they do have time for their schoolwork!   Cognitive therapy can take place while doing schoolwork!  It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time.   A creatively constructed regime of cognitive therapy could involve combining it with academic study.

Behaviour Therapy for performance anxiety

Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc.  The therapy session is a chance to directly practice these things, in a supported setting.  It is a simple CBT exercise!

Therapy for Procrastination

Procrastination is one of the most common problems faced by almost all students.  This is often much worse when there are other mental health issues going on.  The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms.  Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully.    The core necessity in treating procrastination is to do the procrastinated thing as soon as possible!  In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately!   It is an incredibly simple way for a therapy hour to be directly helpful.  Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse!   If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.

Study Techniques

Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health.  Discussion and practice of better studying techniques is directly relevant to mental health therapy.  I like to discuss various memory and time-management techniques with patients, and try them out right in the session.  These ideas are applicable to other life activities, including CBT exercises.

Reading and Oration

It has been remarkably common to find students who have trouble reading.  Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school.  But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study.  Reading textbooks becomes a gruelling chore.   Reading out loud, or giving presentations, can become a source of dread.

The most effective therapies for reading difficulties are very similar to therapies for mental health issues:  it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth.    Reading out loud is very literally an exercise to strengthen one's voice.  Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy.  Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.

Study as Mood Therapy

I believe that studying and other intellectual work can be intrinsically therapeutic for mood.  It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense.  But some students have study practices which are far from meditative.  The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."

Oliver Sacks

I am reminded of the famous neurologist, Oliver Sacks.  He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind.   Part of his technique was to always engage deeply with his patient's work and study interests.   In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to.   I would hope to be a clinician more like him.

Other Work (not just study)

I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired.  I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.

Benefit for the therapist

If a therapist takes sincere interest in a patient's work, study,  and other activities, it is also beneficial for the therapist.  What a delight it is to vicariously be part of an educational journey!   The therapist's health will therefore also be better.  This, in turn, will improve care within the system as a whole.  And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.

Wednesday, March 8, 2017

Biases in Psychotherapy Research

Biases in Research 

Pharmaceutical Research

We are much more familiar these days with biases in pharmaceutical research studies.  A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer.  This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers.  There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved.  But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.

Alternative Medicine

This same critical eye is very much needed for looking at research evidence regarding alternative treatments.  There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies.  For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.

Psychotherapy Too! 

We may assume that studies of psychotherapy would be relatively free of these biases.  After all, there is no big company that is profiting from psychotherapy!

But we must maintain a critical eye even for studies of psychotherapy.  Here are some reasons:

1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors.  A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications.  A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors.   This career advancement is analogous to direct financial gain.

2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique.  Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it.  You could imagine that you might have a bias in favour of the technique that you had studied all those years.  You would really want to show that it works!  If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career!  In Cialdini's terms, this bias would have to do with "consistency."   If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable.   Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions.  You might have frequently attended conferences devoted to your area of specialty.  You might have even taught students the technique, who appreciated your help and mentorship.  This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.

3) There is more and more direct financial gain related to therapy techniques.  We see a lot of books, self-help guides, paid seminars and workshops, etc.  Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.

4) In the psychotherapy research community, CBT is the most common modality.  CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited.  CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific.  There is nothing intrinsically wrong with this , but it leads to more bias in the research.  Therapy styles other than CBT are studied less frequently.  Therefore there will be fewer positive studies of other styles.  This gives the impression that CBT is best.  It is not because comparative studies have actually shown it is best.   New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best.  The research study becomes an advertising tool for those who have designed the technique.


I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful.  We should all learn about them, and make use of some of their principles.  But I do not think that any one style is necessarily "best."  We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.

I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.

Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills.  I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.