Neurobalm: the pseudo-neuroscience of couples therapy

soothingsyrup1Special thanks to Professor Keith Laws, blogger at LawsDystopiaBlog and especially the pseudonymous Neurocritic for their helpful comments. But any excesses or inaccuracies are entirely my own responsibility.

 

You may be more able to debunk bad neuroscience than you think.

In my last blog post, I began critically examining whether emotionally focused couples therapy (EFT) could be said to sooth the brains of wives who had received it.

Claims were made in a peer-reviewed article available here and amplified in a University of Ottawa press release that EFT was a particularly potent form of couples therapy. An fMRI study supposedly demonstrated how EFT changed the way the brain encoded threatening situations.

True love creates resilience, turning off fear and pain in the brain

OTTAWA, May 1, 2014— New research led by Dr. Sue Johnson of the University of Ottawa’s School of Psychology confirms that those with a truly felt loving connection to their partner seem to be calmer, stronger and more resilient to stress and threat.

In the first part of the study, which was recently published in PLOS ONE, couples learned how to reach for their lover and ask for what they need in a “Hold Me Tight” conversation. They learned the secrets of emotional responsiveness and connection.

The second part of the study, summarized here, focused on how this also changed their brain. It compared the activation of the female partner’s brain when a signal was given that an electric shock was pending before and after the “Hold Me Tight” conversation.

The experiment explored three different conditions. In the first, the subject lay alone in a scanner knowing that when she saw a red X on a screen in front of her face there was a 20% chance she would receive a shock to her ankles. In the second, a male stranger held her hand throughout the same procedure. In the third, her partner held her hand. Subjects also pressed a screen after each shock to rate how painful they perceived it to be.

Before the “Hold Me Tight” conversation, even when the female partner was holding her mate’s hand, her brain became very activated by the threat of the shock — especially in areas such as the inferior frontal gyrus, anterior insula, frontal operculum and orbitofrontal cortex, where fear is controlled. These are all areas that process alarm responses. Subjects also rated the shock as painful under all conditions.

However, after the partners were guided through intense bonding conversations (a structured therapy titled Emotionally Focused Couple Therapy or EFT), the brain activation and reported level of pain changed —under one condition. While the shock was again described as painful in the alone and in the stranger hand holding conditions (albeit with some small change compared to before), the shock was described as merely uncomfortable when the husband offered his hand. Even more interesting, in the husband hand-holding condition, the subject’s brain remained calm with minimal activation in the face of threat.

These results support the effectiveness of EFT and its ability to shape secure bonding. The physiological effects are exactly what one would expect from more secure bonding. This study also adds to the evidence that attachment bonds and their soothing impact are a key part of adult romantic love. Results shed new light on other positive findings on secure attachment in adults, suggesting the mechanisms by which safe haven contact fosters more stability and less reactivity to threat.

You can find my succinct deconstruction of the press release here.

I invite you to carefully read the article or my last blog post and this one. This shouldhold me tight prepare you to detect some important signs this press release is utter nonsense, designed to mislead and falsely impress clinicians to whom EFT workshops and trainings are marketed. For instance, where in the procedures described in the PLOS One article is there any indication of the “Hold Me Tight” conversation? But that is just the start of the nonsense.

The PLOS One article ends with the claim that this “experiment” was conducted with a rigor comparable to a randomized clinical trial. Reading the article or these blog posts, you should also be able to see that this claim too is utter nonsense.

In my last blog post, I showed a lack of compelling evidence that EFT was better than any other couples treatment. To the extent to which EFT has been evaluated at all, the studies are quite small and all supervised by promoters of EFT. Couples in the EFT studies are recruited to be less martially dissatisfied than in other couples therapy research, and there is some evidence that improvement in marital functioning does not persist after therapy ends.

I called attention to the neuroscientist Neurocritic’s caution against expecting fMRI studies to reveal much about the process or effectiveness of psychotherapy that we do not know already.

Of course, we should expect some effects of psychotherapy to be apparent in pre-post therapy fMRI studies. But we should also expect the same of bowling or watching a TV series for equivalent amount of time. Are we really getting much more than what we what we can observe in couples’ behavior or what they report after therapy to what we can find with an fMRI? And without a comparison group, studies are not particularly revealing.

The larger problem looming in the background is authors intentionally or unintentionally intimidating readers with glib interpretations of neuroscience. Few readers feel confident in their ability to interpret such claims, especially the therapists to whom author Susan Johnson’s workshops are promoted.

This blog post could surprise you.

Maybe it will reassure you that you possess basic critical faculties with which you can debunk the journal article –if you are willing to commit the time and energy to reading and rereading it with skepticism.

I would settle, however, for leaving you thoroughly confused and skeptical about the claims in the PLOS One article. There are lots of things that do not make sense and that should be confusing if you think about them.

Confusion is a healthy reaction, particularly if the alternative is gullibility and being persuaded by pseudoscience.

I begin by ignoring that this was specifically an fMRI study.  Instead, I will look at some numbers and details of the study that you can readily discover. Maybe you would have had to look some things up on the Internet, but many of you could replicate my efforts.

In the text below, I have inserted some numbers in brackets. If you click on them, you will be taken to a secondary blog site where there are some further explanations.

The 23 wives for whom data were reported are in unrepresentative and highly select subsample of the 666 wives in couples expressing an interest in response to advertisements for the study.

With such a small number of participants–

  •  Including or excluding one or two participants can change results [1]. There is some evidence this could have occurred after initial results were known [2].
  • Any positive significant findings are likely to be false, and of necessity, significant findings will be large in magnitude, even when false positives [3].

The sample was restricted to couples experiencing only mild to moderate marital dissatisfaction. So, the study sample was less dissatisfied with their marriages, i.e.,  not comparable to those recruited by other research groups for couples intervention studies.

Given the selection procedure, it was impossible for the authors to obtain a sample of couples with the mean levels of marital dissatisfaction that they reported for baseline assessments.

They stated that they recruited couples with the criteria that their marital dissatisfactionyour sample sizes are small initially be between 80-96 on the DAS. They then report that initial mean DAS score was 81.2 (SD=14.0). Impossible. [4]

Yup, and this throws into doubt all the other results that are reported, especially when they find they need to explain results that did not occur as expected in differences between pre and post EFT fMRI, but only in a complex interaction between pre/post fMRI and initial DAS scores.

Couples therapy was continued until some vaguely defined clinical goal had been achieved.  None of the details were presented that one would expect a scientific paper for how it was decided that this was enough therapy.

We were not told who decided, by what criteria, or with what interrater reliability the judgments were made. We do know Susan Johnson, CEO of the nonprofit and profit-making companies promoting EFT supervised all therapy and the study.

Basically, Dr. Johnson was probably able to prolong the therapy and the follow-up fMRI assessment until she believed that the wives responses would make the therapy look good. And with no further follow-up, she implies that “how the brain processes threat” had been changed without any evidence that whether changes in fMRI persisted or were transient.

This might be fine for the pseudo-magic of a workshop presentation, but is unacceptable for a peer-reviewed article for which readers are supposed to be able to arrive at an independent judgment. And far removed from the experimental control of a clinical trial in which timing of follow up assessments are fixed.

Randomized clinical trials take this kind of control away from investigators and put it into the design and the phenomenon being studied so that maybe investigators can be proved incorrect.

The amount of therapy that these wives received (M= 22-9, range =13-35) was substantially more what was provided in past EFT outcome studies. Whatever therapeutic gains were observed in the sample could not be expected to generalize to past studies. [5]

Despite the therapy that they had received and despite the low levels of marital dissatisfaction with which they had begun, the average couple finishing the study still qualified for entering it. [6]

There is no explanation given why only wives data are presented. No theoretical or clinical rationale is given for not studying husbands or presenting their data as well [7]

A great deal is made of whether particular results are statistically significant or not. However, keep in mind that there was a very small sample size and the seemingly sharp distinction between significant and nonsignificant is arbitrary. Certainly, the size of most differences between results characterized as significant versus nonsignificant is not itself statistically significant. [8]

And, we will see, much is being made of small differences that did not occur for all wives, only those initially with the lowest marital satisfaction.

The number of statistical tests the conducted was many times number of women in the study. The authors do not indicate all the analyses they conducted and selectively reported a subset of the analyses conducted, but there was considerable room for capitalizing on chance.

cherrypickingMultiple statistical tests in  a small sample without adjustment for there being so many tests is a common complaint about small fMRI studies, but this study is a particularly bad example. Happy cherrypicking!

The article and Johnson’s promotional materials make much of differences that were observed from fMRI data collected before and after therapy. But the article never reports results for actually testing these differences.This is an important discovery. Let’s stop and explore it.

The article leads off its presentation of the fMRI results with

The omnibus test of EFT and handholding on all voxels activated in the original Coan et al. handholding study indicated a significant interaction between EFT, handholding and DAS, F (2, 72.6) = 3.6, p= .03 (Alone x EFT x DAS b= 10.3, SE =3.7; Stranger x EFT x DAS b = 2.5, SE =3.3).

What is oddly missing here is any test of the simple interaction between EFT (before versus after therapy) and handholding, i.e., EFT x handholding. The authors do not tell us whether the overall effects on hand holding (partner versus alone versus stranger) were different from before versus after completion of EFT (partner versus alone versus stranger), but that is the difference they want to discuss.

Basically, the authors only report interactions between EFT and handholding as qualified by level of initial marital satisfaction.

So? The authors proposed the simple hypothesis that receiving EFT will affect fMRI results in a situation involving threat of pain. They are about to do a very large number of multiple statistical tests and they want to reassure the reader that they are not capitalizing on chance.

For reassurance, they need an interaction between EFT and handholding in the omnibus test. Apparently they did not get it. What they end up doing is going back and forth between whatever few statistical tests are significant from the well over 100 tests that they conducted for pre-/post-fMRI findings. When most of those tests proved nonsignificant they went to a more complex interaction between fMRI results qualified by wives’ level of marital satisfaction.

NThis  is a classic fishing expedition with a high probability that many of the fish should be thrown back as false positives. And the authors do not even have the fishing license that they hoped  significant omnibus results would have provided.

The article makes repeated references to following up and replicating an earlier study by one of the authors, Jim Coan. That study involved only 16 women selected for higher marital satisfaction, so much so, they were called “supercouples” in press coverage of the study. You can find Neurocritic’s critique of that study here.

The levels of marital satisfaction for the two small samples were discontinuous with each other—any couples eligible for one would be disqualified from the other by a wide margin. Most of the general population of married people would fall in between these two studies in  level of marital satisfaction. And any reference, as these authors make, to findings for women with low marital satisfaction in the Coan study are bunk. The highly select sample in the Coan study did not have any women with low marital satisfaction.

The two  samples are very different, but neither study presented data in a way that allowed direct comparison with the other. Both studies departed from transparent, conventional presentation of data. Maybe the results for the original Coan study were weak as well and were simply covered up. That is suggested in the Neurocritic blog post.

But the problem is worse than that. The authors claim that they are preselected the regions of interest (ROIs) based on the results that Coan obtained with his sample of 16 women. If you take the trouble to examine Table 1 from this article and compare it to Coan’s results, you will see that some of the areas of the brain they are examining did not produce significant results in Coan’s study. More evidence of a fishing expedition.

It is apparent that the authors changed their hypotheses after seeing the data. They did not expect changes in the stranger condition and scrambled to explain these results. If you jump to the Discussion section concerning fMRI results for the stranger condition, you get a lot of amazing post-hoc gobbledygook as the authors try to justify the results they obtained. They should simply have admitted that their hypothesis was not confirmed.

j figure 2.pone.0079314.g002

Figure 2. Point estimates of percent signal change graphed as a function of EFT (pre vs. post) by handholding (alone, stranger, partner) and DAS score.

The graphic representations in Figures 2 and 4 were produced by throwing away two thirds of the available data [9].  Yup. Each line represents results for two wives. It is unclear what interpretation is possible, except that it appears that after throwing away all this data, differences between pre- and post-therapy were not apparent for the group that started with higher marital satisfaction. It is nearly flat in the partner condition, which the authors consider so important.

We do not want to make too much of these graphs because they are based on so few wives. But they do seem to suggest that not much was happening for women with higher marital satisfaction to begin with. And this may be particularly true for the responses when they were holding the hand of their partner. Yikes!

aPLOS Johnson EFT-1

Click to enlarge

In looking at the graphical representations of self-report data in figure 1 and the fMRI data in figures 3 and 5, pay particular attention to the bracketing +/- zones, not just the heights of the bar graphs. Some of the brackets overlap or nearly so and you can see that small differences are being discussed.

And, oh, the neuroscience….

It is helpful to know something about fMRI studies to go much further in evaluating this one. But I can provide you with some light weaponry for dispensing with common nonsense.

First, beware of multiple statistical tests from small samples. The authors reassure us that their omnibus test reduced that threat, but they did not report relevant results and they probably did not obtain the results they needed for reassurance. And the results they expected for the omnibus test would not have been much reassurance anyway, they would still be largely capitalizing on chance. The authors also claim that they were testing regions of interest (ROIs), but if you take a careful look, they were testing other regions of the brain and they generally did not replicate much of Coan’s findings from his small study.

new phrenologySecond, beware of suggestions that particular complex mental functions are localized in single regions of the brain so that a difference for that mental function can be inferred from a specific finding for that region. The tendency of investigators to lapse into such claims has been labeled the new phrenology, phrenology being the 19th century pseudoscience of bumps. The authors of this study lead us into this trap when they attempt to explain in the discussion section findings they did not expect.

Third, beware of glib interpretations that a particular region of the brain is activated in terms of meaning that certain mental processes are occurring. It is often hard to tell what activation means. More activity can mean that more mental activity is occurring or it can mean the same mental activity requires more effort.

Fourth, beware of investigators claiming that changes in activation observed in fMRI data represent changes in the structure of the brain or mental processes (in this case, the authors’ claim that processing of threat had been changed). They are simply changes in activity and they may or may not persist and they may or may not be compensated by other changes. Keep in mind the brain is complex and function is interconnected.

Overall, the MRI results were weak, inconsistent, and obscured by the authors’ failure to report simple pre-post differences in any straightforward fashion. And what is presented really does not allow direct comparison between the earlier Coan study and the present one.

The authors started with the simple hypothesis that fMRI assessments conducted before and after EFT would show changes in wives’ response to threat of pain relative to whether there hand was being held by their partner, a stranger, or no one. Results were inconsistent and the authors were left struggling with findings that after a course of EFT, among other things, the wives were more comfortable with their hands been held by a stranger and less comfortable being alone. And that overall, results that they expected to be simply a result of the wives getting EFT actually were limited to wives who got EFT, but who had the lowest marital satisfaction to begin with.

We could continue our analysis by getting into the specific areas of brain functioning for which significant results were or were not obtained. That is dubious business because so many of the results are likely to be due to chance. If we nonetheless continue, we have to confront post-hoc gobbledygook efforts to explain results like

In the substantia nigra/red nucleus, threat-related activity was generally greater during stranger than partner handholding, F (1, 47.4) = 6.5, p = .01. In the vmPFC, left NAcc, left pallidum, right insula, right pallidum, and right planum polare, main effects of EFT revealed general decreases from pre- to post- therapy in threat activation, regardless of whose hand was held, all Fs (1, 41.1 to 58.6) > 3.9, all ps < .05.

Okay, now we started talking about seemingly serious neuroscience and fMRIs and you are confused. But you ought to be confused. Even a neuroscientist would be confused, because the authors are not providing a transparent presentation of their findings, only a lot of razzle dazzle designed to shock and awe, not really inform.

Magneto, the BS-fighting superhero summoned by Neurocritic

Magneto, the BS-fighting superhero summoned by Neurocritic

In an earlier blog post concerning the PLOS One study, Neurocritic detected nonsense and announced that Magneto, a BS-fighting superhero was being summoned. But even mighty Magneto was thwarted by the confused presentation of ambiguous results and the absence of knowledge of what other results had been examined but were suppressed because they did not support the story the authors wanted to tell.

I’m not sure that I understand this formulation, or that a dissociation between behavioral self-report and dACC activity warrants a reinterpretation of EFT’s therapeutic effects. Ultimately, I don’t feel like a BS-fighting superhero either, because it’s not clear whether Magneto has effectively corrected the misperceptions and overinterpretations that have arisen from this fMRI research.

Some of you may be old enough to recall Ronald Reagan doing advertisements for Generalconfused-man Electric on television. He would always end with “Progress is our most important product.” We have been trying to make sense of neuroscience data being inappropriately used to promote psychotherapy,and have had to  deal with all the confusion, contradictory results, and outright cover-up in an article in PLOS One. To paraphrase Reagan, “Confusion is our most important product.” If you are not confused, you don’t sufficiently grasp what is being done in the PLOS One article and the press coverage and promotional video.

Category: Couples therapy, neuroscience, Uncategorized | Tagged , , , , , | 3 Comments

Soothing psychotherapists’ brains with NeuroBalm

Promoters of Emotionally Focused Psychotherapy offer sciencey claims with undeclared conflicts of interest, cherry picked evidence, and bad science.

The temptation exists for researchers and clinicians to search for the strongest and most provocative version of their knowledge, which will create greatest publicity. The appeal is great; oversell and over-dramatize the result and attention will follow. — Jay Lebow, Editor, Family Process

amygdalaPity the poor therapists. They want to do the best for their clients. They are required to get CE credits for licensure and renewal. But how do they choose their CE courses? With workshop promoters hawking approved courses in thought field therapy and somatic experiencing therapies, therapists can understand that professional organizations’ approval is no guarantee that what they will learn is evidence- supported or that it will mostly help, rather than hurt their clients.

Worse, few therapists have the research background minimally necessary to interpret the sometimes wild claims made promoters of workshops. They are unprepared to evaluate impressively sciency claims that are being made for treatments. And what is more sciency than neuroscience?

Psychotherapy is an inherently uncertain, subjective process. Isolated in sessions with clients, therapists do not have ready ways to monitor what is going on with confidence and decide moment to moment if it is helpful. Even when psychotherapy is manualized, done by the book, there is lots of uncertainty as to what is to be done when, to whom, whether it is done effectively, and how to follow-up.

Neuroscience seems to hold the promise of reducing some of that uncertainty. Exploitative hucksters make lots of money from therapists and their clients with claims that they can use neuroscience to monitor and direct the process of psychotherapy with precision. The hucksters play on the belief that changes in neural functioning can somehow serve to get more at what is “really” going on in therapy, beyond and, if necessary, in sharp contradiction of what therapists observe and clients report.

Enter workshop promoter Susan Johnson.  As told in the New York Times, she claims her emotionally-focused therapy (EFT)

can help couples break out of patterns, “interrupting and dismantling these destructive sequences and then actively constructing a more emotionally open and receptive way of interacting.” She aims to transform relationships “using the megawatt power of the wired-in longing for contact and care that defines our species,” and offers various exercises to restore trust.

Wow! If we could only monitor that interrupting and dismantling and the megawatt power of the “wired-in longing” with neuroscience.

In this blog post I discuss an article in PLOS One in which psychotherapist Johnson teams up with neuroscientist Jim Coan to claim they can do just that.

Ultimately, our handholding paradigm has provided a unique opportunity to test some of the proposed mechanisms of social support in general, and EFT in particular, all at the level of brain function, in vivo.

It is a terrible article, starting with its undisclosed conflicts of interests: Johnson is using the article to promote her psychotherapy products. And when we get past that, the article is shamelessly blatant cherry-picked evidence and poor psychotherapy research. We can learn from it as such.

Click in text for video

Click in text for video

But wait, hold on! Think of me like the greeter at the local Kanuka_BalmMacy’s department store who sprays you with free cologne or maybe rubs your hands with a soothing balm. Before we get into discussing the article, you can get a free sample of the Neurobalm right here that is being used to promote this psychotherapy product. See, no, feel for yourself. This is best appreciated wearing high-quality earphones to do the wonderful soundtrack justice.

Disclaimer: As you can already tell, I find this article outrageous and I am just getting warmed up in explaining how and why.  I am a PLOS One Academic Editor and I have gone on record insisting that promoters of psychotherapy be held to the same standards as the pharmaceutical companies in having to disclose apparent conflicts of interest. And now I have encountered an undisclosed conflict in the very journal where I work for free to provide a small bit of the oversight of the quality and integrity of what readers find there.

Oversight of conflicts of interest is far from perfect, especially when it depends on author disclosure. And oversight of the 24,000 articles published in PLOS One last year cannot be expected to be perfect.  But PLOS One has numerous tools to be self-correcting, especially when faced with undisclosed conflicts of interest. Unlike the journals Prevention Science and Clinical Psychology Review that I have been recently complaining about, PLOS One asks every author about potential conflicts of interest and every article published in PLOS One has an explicit declaration. And unlike these other two journals, PLOS One has explicit, orderly procedures for responding to apparent non-disclosures. An editor like myself, just like any reader, can make a complaint, and PLOS One will evaluate whether an inquiry to authors is necessary in order to decide what further action to take.

disclaimerThe opinions I am going to express here are my own, and not necessarily those of the journal or other members of the editorial board. Thankfully, at Mind the Brain, bloggers are free to speak out for themselves without censorship or even approval from the sponsoring journal. Remember what happened at Psychology Today and how I came to blog here.

The full text of the open access article is available here.

Abstract

Social relationships are tightly linked to health and well-being. Recent work suggests that social relationships can even serve vital emotion regulation functions by minimizing threat-related neural activity. But relationship distress remains a significant public health problem in North America and elsewhere. A promising approach to helping couples both resolve relationship distress and nurture effective interpersonal functioning is Emotionally Focused Therapy for couples (EFT), a manualized, empirically supported therapy that is strongly focused on repairing adult attachment bonds. We sought to examine a neural index of social emotion regulation as a potential mediator of the effects of EFT. Specifically, we examined the effectiveness of EFT for modifying the social regulation of neural threat responding using an fMRI-based handholding procedure. Results suggest that EFT altered the brain’s representation of threat cues in the presence of a romantic partner. EFT-related changes during stranger handholding were also observed, but stranger effects were dependent upon self-reported relationship quality. EFT also appeared to increase threat-related brain activity in regions associated with self-regulation during the nohandholding condition. These findings provide a critical window into the regulatory mechanisms of close relationships in general and EFT in particular.

Before co-authoring this PLOS One article with Susan Johnson, Jim Coan published a closely related 2006 study in Psychological Science. Coan received lots of press coverage, even before the article was available on the Internet. The blogger Neurocritic critiqued the press coverage and then followed up with a blog post critiquing the present PLOS One article.

Neurocritic provides some generally useful wisdom concerning interpreting statements about neural imaging, psychotherapy, and relationships. I think most neuroscientists would agree with him. If you are a therapist, you might want to bookmark his blog post for future reference when you feel slathered with Neurobalm from psychotherapy workshop gurus.

An extended excerpt from Neurocritic

Can neuroscience illuminate the nature of human relationships? Or does it primarily serve as a prop to sell self-help books? The neurorelationship cottage industry touts the importance of brain research for understanding romance and commitment. But any knowledge of the brain is completely unnecessary for issuing take-home messages like tips on maintaining a successful marriage.

In an analogous fashion, we can ask whether successful psychotherapy depends on having detailed knowledge of the mechanisms of “neuroplasticity” (a vague and clichéd term). Obviously not (or else everyone’s been doing it wrong). Of course the brain changes after 12 sessions of psychotherapy, just as it changes after watching 12 episodes of Dexter. The important question is whether knowing the pattern of neural changes (via fMRI) can inform how treatment is administered. Or whether pre-treatment neuroimaging can predict which therapy will be the most effective.

However, neuroimaging studies of psychotherapy that have absolutely no control conditions are of limited usefulness. We don’t know what sort of changes would have happened over an equivalent amount of time with no intervention. More importantly, we don’t know whether the specific therapy under consideration is better than another form of psychotherapy, or better than going bowling once a week.

Problems start  with the article’s title

Soothing the threatened brain: Leveraging contact comfort with Emotionally Focused Therapy.

This title titillates the unwary but triggers an alert among even open minded skeptics.

Some of you may recall that in the tips I gave for writing titles in the Colon Theory of Titles. I suggested that if you reserve one side of the colon in a title for keywords, you might use the other side to have a little fun attracting interest in your article.

Coyne, J. C., & van Sonderen, E. (2012). The Hospital Anxiety and Depression Scale (HADS) is dead, but like Elvis, there will still be citings. Journal of Psychosomatic Research, 73(1), 77-78.

Or the more outrageous

Krauth, S. J., Coulibaly, J. T., Knopp, S., Traoré, M., N’Goran, E. K., & Utzinger, J. (2012). An in-depth analysis of a piece of shit: distribution of Schistosoma mansoni and hookworm eggs in human stool. PLOS Neglected Tropical Diseases, 6(12), e1969.

Fair fun. But the problem with Soothing the Threatened Brain is that many of the therapists think there is something more profound about ‘soothing the brain’, rather than soothing the wife or her heart or her emotions. And this target audience is all too ready to believe that there is something special about promoters of emotion focused therapy claiming it soothes the threatened brain. EFT is better than other marital therapies because it works on the wife’s brain, not just a couple. Other therapies only do relationships or wives but EFT does brains.

If you think I am being too tough on therapists, you can do an informal experiment. Strike up conversations with a few therapists about how they understand the abstract and title of this article or the dramatic video is based on the study. I tried this, and though some expressed some skepticism, they really did not feel competent to argue with a peer-reviewed article or a video of a fMRI assessment.

undeclaredAppearance of conflict of interest

Competing interests: The authors have declared that no competing interests exist.

Funding. This research was supported in part by the International Centre for Excellence in Emotionally Focused Therapy (ICEEFT), a not-for-profit corporation whose mission includes the scientific evaluation of EFT. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Additional funding was provided by a National Institute of Mental Health grant, Award Number R01MH080725, awarded to JAC. No additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

This does not ring true. The website of the International Center for Excellence and Emotion Focused Therapy lists Susan Johnson as founder and director. Not only did Susan Johnson design the study and interpret the data, she provided supervision of the therapy and somehow decided the particular time point at which women who had received the intervention would get fMRI assessment. As psychotherapy research, this is bizarre and breaks down any benefits of experimental control — the investigator with strong allegiance to her treatment gets to pick when outcome assessments are done rather than having preset times of assessment.

The website for Johnson’s for-profit Ottawa Couples and Family Institute indicates that it shares the same physical space and administrative staff as ICEEFT. The nonprofit corporation serves a number of marketing functions, including maintaining a referral list of therapists who have completed sufficient trainings to obtain the certification, as well as granting permission to otherwise unqualified persons to participate in workshops and get certification so they can practice in the community, often without licensure. Depending on the country or state, people who attend trainings can offer EFT for a fee without having a license or any regulation as long as they do not adopt a title that is regulated and licensed in that particular jurisdiction. This can be a matter of calling themselves a coach or counselor, depending on the jurisdiction.

This is a rather standard arrangement in the therapy training business, whereby profit-making activities are from ostensibly nonprofit certification that extends the market for trainings.

If readers were informed of financial interests at stake….

If a candid conflict of interest statement had been provided, readers would have been more prepared to independently and skeptically evaluate claims starting in introduction and colorful and on scientific language throughout.

For instance, the authors declare in the introduction

Early research suggested that EFT was superior to behavioral marital therapy [20], and a more recent meta-analysis [21] concluded that 70–73% of couples who undergo EFT are no longer relationally distressed at the end of therapy – at an average effect size of d= 1.3.

The evidence of superiority [20] refers to a 1986 study with 15 couples each assigned to EFT or behavioral marital therapy. It was a small underpowered study that can be discounted by its high risk of bias, including the developers testing their own therapy.

Let us get real. Accumulated psychotherapy studies suggest that it is quite unrealistic to expect that a comparison of 15 couples receiving a particular therapy versus 15 couples who were on a waiting list will yield a significant finding. There are also lots of studies suggesting only modest differences between credible, active, structured therapies like EFT versus behavioral marital therapy. It is highly unlikely that such findings would be obtained by honest and transparent reporting of well-done psychotherapy research by anyone without a dog in the fight.

The “more recent meta-analysis [21]” refers to a 1999 poor quality review and meta-analysis also conducted by developers of EFT.

The meta-analysis is worth a look. You can click on the table to the right and see the 7 table EFT meta-analysis 1999-1studies included. All were done by developers of EFT or as a dissertation under the supervision. Three studies are nonrandomized trials, one with only seven couples. All of the randomized trials have 16 or fewer couples assigned to EFT,  and so have less than 50% probability of detecting a positive result if it is present. All of the articles identified as positive studies.

Essentially this is a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab. The meta-analysis lacks many of the formal features of meta-analyses including forest plots and assessments of risk of bias. The overall effect size of 1.31 is improbably high in the failsafe N of 49 studies being unpublished to unseat a positive evaluation EFT highlights the absurdity of invoking that statistic. If we took failsafe N seriously, we would have to accept that there would have to be almost as many unpublished null trials as there are couples in the published studies.

It is instructive to compare the assessment of the EFT from its developers to a more detached consideration about the same time by a group organized by American Psychological Association to evaluate the evidence-supported status of psychotherapies.

The APA group tell you things that somehow get missed in this review of EFT in PLOS One.

It is important to note that the interventions were restricted to moderately distressed couples because the investigators were concerned that EFT might not be optimal for extremely distressed couples.

Promoters of a psychotherapy rarely lose a comparison between the intervention they are rooting for and a rival comparison-control, particularly in a grossly underpowered study. However, that is exactly what occurred in one of the studies included in the meta-analysis were EFT was bested by strategic therapy in follow-up. This led the APA group to declare systemic therapy “possibly efficacious.” I doubt this kind of upset has ever happened in formal evaluations of psychotherapy research. Of course, the APA group’s rules are kind of loopy and I would not give this evaluation too much credence. Nonetheless, the APA group goes on:

This difference between treatments resulted from the couples in the EFT treatment experiencing significant relapse during the follow-up period. The investigators noted that couples in this study were much more distressed than couples in the Johnson and Greenberg study, which might account for the differences seen in the two studies at follow-up. They cautioned that, with severely distressed couples, time-limited EFT might not be powerful enough to create sufficient intimacy to maintain posttest gains.

Compare this to what Susan Johnson says in the PLOS article:

 Moreover, EFT treatment gains realized among distressed couples at high risk for relapse are stable over two- and three- year assessment periods [22,23]. *

Art Garfunkel’s Mr Shuck ‘N Jive http://tinyurl.com/k7wbwo4

Art Garfunkel’s Mr Shuck ‘N Jive http://tinyurl.com/k7wbwo4

The discrepancy can be explained by picking and choosing particular timepoints for particular tiny psychotherapy follow-up studies with highly selected, on representative patients.  Come on Susan, you’re shucking us. This has little resemblance to finding best evidence, you are just finding evidence to sell your psychotherapy.

The APA group also noted some differences in the outcomes of a waitlist control group in behavioral marital therapy conducted by its originator, Neil Jacobson:

Whereas 50% of James’s [an EFT study done by a dissertation student] waiting list couples improved without treatment, the waiting list couples in the BMT studies reviewed by Jacobson et al. showed an improvement rate of only 13.5%.

So, even the waitlist control groups do better in the EFT versus BMT studies.

Johnson continues her overview of the literature in the PLOS One introduction.

EFT has also been successfully applied to couples in which one or both partners are coping with a history of childhood sexual abuse [28,29], major depression [30,31], and even breast cancer [32].

You are shucking us again, Susan. What constitutes being “successfully applied”? These are not randomized controlled studies. For instance, the application to breast cancer involved only to patients. You are hardly in a position to crow about this. Shame on you.

When I read an introduction to a scientific article, I expect a much more nuanced, balanced consideration of the existing literature in a way that leads up to the research question of a particular study. What we get in this introduction in no way resembles us. Rather, an author with undeclared conflicts of interest is shamelessly hawking her psychotherapy product.

But stay tuned. In Part Two of this blog post I will offer a detailed critique of the methodology and interpretation of the actual study. It would be great if readers read the open access PLOS One article ahead of my next post and were prepared with their own interpretations and maybe even to dispute mind.

*The EFT literature and apparently what is said in workshops provide strong claims about outcomes that are echoed in the advertisements of therapists who get certified in EFT. For instance, the website of a Philadelphia-based therapist claims

EFT ad

Click to enlarge

This is either an exaggeration or outright fraud if it is supposed to represent the likelihood of a positive outcome of a couple coming to this therapy.

conflict of interest

 

Category: Conflict of interest, evidence-supported, mental health care, neuroscience, psychotherapy | Tagged , , , | 4 Comments

Repost: The Latest and Greatest in Treatment for PTSD: Magic Bullets and Cutting Edge Innovation

June is PTSD awareness month.  In light of this, I am reposting a blog I wrote about “The Latest and Greatest in Treatment for PTSD.”  If you are interested in knowing more about PTSD please check out the NCPTSD website.

Also, below are links to other blog posts I have written about PTSD and related topics:

 

The Latest and Greatest in Treatment for PTSD: Magic Bullets and Cutting Edge Innovation

I am frequently asked to talk about PTSD to professional audiences and, without 2012-04-05-ptsd1exception, always get a post talk question asking about my experience with some experimental intervention that someone read about somewhere in a newsmagazine or heard about from the T.V.

Internally, I always groan.

Having just spent 60-90 minutes pouring over carefully crafted PowerPoint slides that contain information about the evidence base for the treatments of PTSD and what best practices consist of, why I am always confronted with a zealous audience member who is obsessed with the new, the innovative, or the magic bullet?

In the interest of full disclosure, I have to share my viewpoint as being that of a health services researcher.  I approach PTSD treatment with a basic belief that we already have pretty good treatments, and the issues with getting better outcomes for PTSD lie more in how we implement those treatments, the limitations of the systems that provide care, massive issues of access to care (i.e. those who need care the most simply can’t access it for a myriad of reasons), and healthcare disparities (that an individual’s outcomes for PTSD are more likely linked to their zip code as opposed to their genes/neurotransmitters).

In short, I usually have a healthy skepticism toward the experimental or magic bullets type of treatments for PTSD, which often get a lot of media attention and can be very seductive to the brain of a researcher or clinician who spends their days trying to help individuals who live with PTSD.

 

Still, today I am curbing my skepticism and with much enthusiasm am writing about some of the hottest ideas for innovation in the treatment of PTSD.

 

Please note: MANY of these approaches are still considered EXPERIMENTAL, and I am listing them in no particular order of importance.

1. Mind – Body Practices for PTSD

Image Credit: Cornelius383

Mind Body practices are increasingly used to offer symptom reduction for PTSD.  Approaches such as Yoga, Tai Chi, Mindfulness Based Stress Reduction, Meditation, and Deep breathing are some examples.  There are about 16 rigorous studies that have been done to date, most of which have small sample sizes.  Whilst early findings suggest such practices can have a beneficial impact on symptoms like intrusive memories, avoidance, and increased emotional arousal, there is insufficient evidence to support their use as standalone treatments, though they can be recommended as an adjunctive treatment.

 

2. Cervical Sympathetic Blockade and Stellate Ganglion Block for PTSD 

In 2008, reports started to emerge about a minimally invasive manipulation of sympathetic nerve tissue in patients with PTSD that relieved their anxiety.  The procedure consisted of injecting a local anesthetic into sympathetic cervical nerve tissue at the C6 level and was apparently accompanied by immediate relief by the patient.  In 2012, a case series was reported where treatment resistant veterans with PTSD were given a stellate ganglion block and also a pre and post intervention CAPS. After the intervention, 5/9 of the patients experienced significant improvement; these benefits diminished over time and the benefits were not universal.  Controlled trials are currently underway to investigate this intervention further.

 

3. Virtual Reality Exposure Therapy

Virtual Reality exposure therapy utilizes real time computer graphics, body tracking devices, visual displays, and other sensory input devices to give the patient the experience that they are immersed in a virtual environment. It is an enhanced version of the imaginal exposure typically utilized as a part of trauma-focused psychotherapies. In 2001 an open clinical trial of Virtual Reality exposure therapy yielded promising results. It is currently being studied under controlled conditions.

 

4. D-Cycloserinemanypills

D-Cycloserine is a partial agonist of the NMDA receptor (a brain receptor that plays an essential role in learning and memory). It has been used to treat social phobia and panic disorder and to enhance the effects of psychological therapies for those disorders.  Preliminary data suggests it can be a useful adjunct in addition to evidence-based psychotherapies for patients living with severe PTSD.

 

5. Ketamine

Ketamine is a non-barbiturate anesthetic and antagonist at the NMDA receptor that is typically administered intravenously.  It has been used for years for patients with severe burns and it was, in this use, that its dissociative properties became apparent.  Retrospective studies show that those who received Ketamine after a traumatic event were less likely to develop PTSD.  It has been postulated that Ketamine may disrupt the process via which traumatic memories are laid down. A 2014 JAMA study reported on a RCT which demonstrated a rapid reduction in symptom severity following Ketamine infusion in patients with chronic PTSD.

 

6. Increasing the Intensity of Treatments

In an experimentation with packaging, British researchers compressed versions of trauma-focused psychotherapies for PTSD into a seven day intensive treatment.  This was found to work as well as treatment as usual, which is the same treatment delivered once a week, over 12 weeks.  Such an approach was postulated to be more efficient and convenient and was associated with faster improvement in symptoms and lower dropout rates.

 

7. Memantine colorful-pills

Memantine is a non competitive NMDA antagonist that is thought to protect the glutamergic destruction of neurons and hence prevent the hypothesized neurodegeneration in the hypothalamus, which contributes to the memory issues related to PTSD.  In a 2007 open label small trial, Memantine was found to be associated with some encouraging outcomes.  Double blind placebo controlled trials are pending.

Category: alternative medicine, Commentary, mental health care, Psychiatry, PTSD, research | Tagged , , , , | 1 Comment

Did the FDA antidepressants warnings increased suicidality?

A new study just published in the BMJ makes this very point.

bmj-logo-ogChanges in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

The title makes two claims:

  1. That the  2003 black box  US Food and Drug Administration warning about a possible increased risk of suicidality with antidepressants lead to a change in antidepressant prescriptions.
  2. Further, that there were changes in suicidal behavior following the said US FDAwarning.

While the title does not indicate the direction of the changes, the study conclusions carry little ambiguity:

Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people.

This is obviously a big claim, with far reaching implications spreading from the level of primary care physicians who might consider changing their antidepressant prescription practices to the level of policy makers deciding on guidelines about antidepressants approvals and reimbursement.

In this post we will discuss some of the study limitations which, for unclear reasons, seem to have been all but ignored by the over-excited welcome that study received in the mainstream media.

Our goal here is to not discuss subtle academic limitations but rather obvious limitations which could have been picked even by a casual yet critical reader of the paper. We will then cursorily survey the media presentations of the paper and assess the quality of their review in terms of balance and fair criticism.

Let’s start with some of the study most overt shortcomings:

  1. The title is not entirely informative. The study reviews US data however the title seems to indicate world-wide findings.
  2. The study uses a quasi-experimental design assessing changes in outcomes after the FDA  warnings, controlling for pre-existing trends. However the reliability of the controls is not entirely convincing.
  3. Not much is known about the relationship (if any) between the individuals entered in the study because they were prescribed antidepressants and the individuals who took psychotropic overdoses.
  4. The study uses psychotropic drug poising data as a proxy for suicide but is that a good proxi?
  5. The study does not address the possibility that suicide has been on the raise for reasons having nothing to do with antidepressant prescriptions (such as the recent years economic crisis).

Big media enthusiastic welcome

prozac-mood-brightener-150

First the Washington Post (Dennis) reports:

As a result [of the FDA warnings] antidepressant prescriptions fell sharply for adolescents age 10 to 17 and for young adults age 18 to 29. At the same time, researchers found that the number of suicide attempts rose by more that 20 percent in adolescents and by more than a third in young adults.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

According to NBC News (Raymond) :

New research finds the warning backfired, causing an increase in suicide attempts by teens and young adults. After the FDA advisories and final black box warning that was issued in October 2004 and the media coverage surrounding this issue, the use of antidepressants in young people dropped by up to 31 percent.

Comment from a non-study affiliated expert? NO

How many limitations are discussed? NONE

Reuters (Seaman) reports that:

Antidepressant use decreased by 31 percent among adolescents, about 24 percent among young adults and about 15 percent among adults after the warnings were issued. At the same time, there were increases in the number of adolescents and young adults receiving medical attention for overdosing on psychiatric medicines, which the authors say is an accurate way to measure suicide attempts. Those poisoning increased by about 22 percent among adolescents and about 34 percent among young adults after the warnings. That translates to two additional poisoning per 100,000 adolescents and four more poisoning per 1,000 young adults, the researchers write.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? ONE (limitation #5)

According to USA TODAY (Painter):

Warnings that antidepressant medications might prompt suicidal thinking in some young people may have backfired, resulting in more suicide attempts, new research suggests.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

Forbes (DiSalvo) reports:

Antidepressant use fell 31 percent among adolescents and 24 percent among young adults after the FDA warnings, according to the study. Suicide attempts increased by almost 22 percent among adolescents and 33 percent among young adults in the same time period. Suicide attempts tracked in the study were largely the result of drug overdoses.

Comment from a non-study affiliated expert? NO

How many limitations are discussed? NONE

NPR (Stein) also reports on the story:

Antidepressant use nationally fell 31 percent among adolescents and 24 percent among young adults, the researchers reported. Suicide attempts increased by almost 22 percent among adolescents and 33 percent among young adults.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? ONE (limitation #5)

Finally, the Boston Globe (Freyer) concludes that

instead of declining as hoped, suicide attempts over the next six years showed a “small but meaningful” uptick among people ages 10 to 29, according to a study published Wednesday in the journal BMJ. That increase followed a substantial drop in the use of antidepressants.

Comment from a non-study affiliated expert? YES

How many limitations are discussed? NONE

A few observations

colorful-pills

To summarize: big media’s portrayal of the situation is straightforward. The FDA black box warnings were followed buy an almost 30% decrease in antidepressant use and an almost 30% increase in suicide rates for adolescents and young adults.The conclusion, while not stated directly, is implicit: antidepressants decrease suicide in this population.

The issue is that this conclusion is at odds with what the study really found:

1. The decrease in antidepressant prescriptions is not absolute but relative to a projected forward prediction of increased antidepressant use over the studied period. All is good if the prediction is accurate – but there in no way of actually assessing how correct these sort of predictions really are.

2. There is no absolute increase in suicides either. The increase rate is not for suicide for for psychiatric drugs poisoning, which might be an entirely different beast than suicide. Even if accepting the authors’ decision to use psychotropics poisoning as proxy for suicide the reported increase is again not absolute but relative to a predicted trajectory of in fact unknown accuracy for psychotropics poisoning.

3. Or maybe the suicide rate was on the raise anyway for reasons that have nothing to do with the FDA warnings or antidepressant prescriptions.  As discussed above the economic crisis of the last few years might have independently contributed to this state of affairs.

Which leads us to an interesting conclusion

Somewhat paradoxically, it turns out that a study that tongue-in-cheek points to the media’s uncritical coverage of medical news as a possible contributor to a public health issue receives an almost universal and equally uncritical acclaim from the same media that it rightfully criticizes.

In a past analysis of medical news reporting I stated that

[...] my hope is that members of the media who cover [medical] debate[s] will realize that “first do no harm” is not only the duty of physicians; it is also the responsibility of anyone trusted with giving health information to the public at large.

More than 2 years later I found that this conclusion still stands.

For my Storify discussion of this story – I’ll see you here.

 

Category: antidepressants, depression, mental health care, Uncategorized | Tagged , | 4 Comments

The Vital Importance of Integrating Primary Care and Mental Health Care: How the VA Does It

For the better part of the last two decades I have practiced psychiatry in a variety of different American healthcare systems, and over these years I have, on numerous occasions, heard psychiatric services referred to in manner that imply (often subtly) that such services are not medical care.  These references come not only from patients, but nurses and doctors (including myself) too.

 

“Yes Mr. Jones you need to follow up with your regular medical doctor about that issue.”

Or

“Dr. Jain, I went to see my medical doctor and he told me my blood pressure was high.”

 

Yes, I have been guilty of propagating this false dichotomy myself, and I too end up colluding with this societal misperception that somehow psychiatric care is NOT medical care, but something separate or distinct from other medical services. I think I did it because, on a day to day basis, when I am busy in clinic it is easier to collude than to get into a debate about semantics.

 

Still, in today’s blog I want to highlight the fact that this artificial distinction between physical and mental health perpetuates much of the stigma and misperception that, we as a society, have toward mental illness. But, most importantly, I want to convey my belief that when mental and physical well-being are separated, healthcare becomes poor in quality.

 

When I did my medical school training in Great Britain, every single medical school student was required to complete a 3 month (minimum) rotation in psychiatry and, furthermore, psychiatry was one of the specialties that had to be passed, in clinical exams, at finals before your MD would be granted.  Why, might you ask, should a ENT surgeon/dermatologist/ER physician to-be  need to spend so much time training in psychiatry?

Firstly, the majority of British medical students become primary care doctors.  The system is set up that way, so there are relatively few spots for specialty training (e.g. cardiology or plastic surgery) and there is much more emphasis for medical students to become primary care doctors.  This is based on the premise that that is what the country needs so that is what medical schools should provide.

colorful-pillsIt’s well known that a significant percentage of patients seen in primary care have a mental illness/disorder as a primary problem.  In fact, most prescriptions for psychotropic medications are written in primary care, hence it is logical that every British medical graduate be well versed and adept in diagnosing, treating, and managing psychiatric disorders.

Secondly, if one looks at mental illness from a sheer epidemiological point of view, no physician can afford to not be well trained in the fundamentals of psychiatric practice.  I, as a psychiatrist, may or may not, in my career, treat a patient who also develops a testicular tumor, needs bypass surgery, or has a fractured hip, but epidemiologically speaking, my colleagues in urology, cardiology, and orthopedics WILL treat patients who have comorbid depression/anxiety or even severe mental illness such as Bipolar Disorder or Psychosis.  For this reason, it makes sense that these providers have some awareness or understanding of such disorders.

My experience with US healthcare is different; the business side of US medicine has a tendency to favor medical specialties that are procedure-based or that generate flash technologies that can be promoted and attract more market share.  Unfortunately, psychiatry often fares poorly when it comes to such business strategies.  Mental illness can be chronic, take time to treat, and there is rarely a quick fix or magic cure.  Moreover, mental illness can be associated with a downward drift, e.g. someone becomes psychotic, they lose their job, and then their health insurance etc. etc.

 

In the U.S. healthcare business the specialty of psychiatry is often not given a seat at the table.

 

I think this, in part, explains this nonsensical divide between “medical” and “psychiatric” that we often have in healthcare.  Of course, it is a fallacy. Mental health and physical health are intricately link on every level, from a cellular level to a more macro perspective of how human beings navigate their day to day life.  In my view, a sophisticated healthcare system should reflect this intricate relationship and integrate primary and psychiatric care, i.e. get rid of this false distinction or separation by physically placing both services in one clinic, side by side.

soldier-294476_640One American healthcare system has been a leader in integrating primary care and mental health care. That system is the Veterans Health Administration (VA). Unlike many other U.S healthcare systems (which place more emphasis on treating individuals), the VA is charged with taking care of a population, i.e. veterans. This mission guides where the VA places emphasis, so whatever the prevalent issues are for this population becomes the area where the VA will place emphasis and resources.

 

The VA aims to meet the needs of the population it is serving, and hence gives psychiatry a seat at the table.

 

With more than 1,000 outpatient clinics, the VA is the largest health care system in the United States, and it has a very clear sense of its population. Over the past 15 years, the VA has not only participated in some of the biggest studies of integrated care, but has made a commitment to provide patient-centered integrated care to its population.

For the last two years I have been in the role of medical director of the Primary Care-Behavioral Health Team at the VA Palo Alto Health Care System, and I spend most of my days right here at the interface between physical well-being and mental health.  Contrary to some of my previous experiences in healthcare, the last two years have taught me the following:

 

  • Our colleagues in primary care place very high value on psychiatric and psychological consultation from colleagues.

 

  • The clinical work is very rewarding and in many ways bypasses a lot of the frustrations we often feel as physicians working in fragmented health care systems.

 

  • As a specialist, your experience and knowledge can add enormous benefit in making health care more streamlined and patient-centric. There are many opportunities for psychiatrists to act as educators to both colleagues and patients about common misperceptions surrounding mental disorders and mental health care.

 

  • Being a consultant for and working closely with a team of professionals from various specialty backgrounds helps your own career development. It prevents you from getting rusty in areas of medicine other than psychiatry and keeps you on the cutting edge of how health care systems are evolving to meet the needs and demands of all stakeholders.

 

Integrated care is the way of the future, and I feel fortunate that I work in a system that is at the cutting edge of such innovation.

 

For more information about the integrated model at the VA Palo alto Healthcare System please follow this link.

Category: Commentary, mental health care, Psychiatry, Uncategorized | Tagged , , , , , | 4 Comments