I often hear good white people ask why people of color must make everything about race, as if we enjoy considering racism as a motivation. I wish I never had to cycle through these small interactions and wonder: Am I overthinking? Am I just being paranoid? It’s exhausting.
The link is to “Understanding Psychosis and Schizophrenia: a critique by Laws, Langford and Huda”. And that tweet made me wonder, as I often do in discussions about mental help, if I am in a parallel universe. As did this:
Really? All I need? From a site that seems to know that there is only one “psychological model”?
And what is “the medical model”? Could dr Huda and The Mental Elf please define it for me?
And do some of the participants really think that mental help professionals are locked in an ongoing battle between science and dangerous pseudoscience?
From where I stand, way behind the back of beyond in Norway, I see people who have opinions. And sometimes they have research to support their opinions, and sometimes the discussions about research resemble discussions about how many angels can dance on the head of a pin.
And I see some people who seem chained to hierarchic trees of knowledge, and some people who are connected to networks … people to whom service users, for example, are relevant sources of information.
And I see some people who are stuck in frames of cognition, and others who know that there are many different frames.
And I find it strange that professionals can have vehement arguments about something as vague as “the medical model” and “the psychological model”, or suggest that they are complementary. But maybe indirectness is needed in discussions like the one going on in The Mental Elf?
Here is a 10-minute talk on direct and indirect speech:
If you are pressed for time, you can start at 7.45, when Steven Pinker begins to discuss the difference between individual knowledge and mutual knowledge, and then goes on to retell the story of the emperor’s new clothes.
What he doesn’t mention is the sales pitch of the crooks who duped the emperor: They offered him a new suit of clothes that was invisible to people who were unfit for their positions, stupid, or incompetent.
Has “science” become an invisible suit of clothes in the mental help professions, both psychiatric and psychological? Is fear of being thought unscientific, unfit for their positions, stupid and incompetent keeping mental help professionals from asking critical questions? (I’m asking, I don’t know)
“At the Nordic Cochrane Centre, we have researched antidepressants for several years and I have long wondered why leading professors of psychiatry base their practice on a number of erroneous myths. These myths are harmful to patients. Many psychiatrists are well aware that the myths do not hold and have told me so, but they don’t dare deviate from the official positions because of career concerns. Being a specialist in internal medicine, I don’t risk ruining my career by incurring the professors’ wrath and I shall try here to come to the rescue of the many conscientious but oppressed psychiatrists and patients by listing the worst myths and explain why they are harmful.”
I do know that …
My perspective is that of one who grew up between continents, cultures, languages and belief systems. I am not anti-science, neither am I spiritually inclined; I am pro choice, diversity, evaluating authority, and “sceptically interrogating the universe with a fine understanding of human fallibility”.
I am also an abject failure at accepting that something is true because an authority says so. Which has caused huge problems for me in the mental help system, and drove me to the brink of suicide 24 years ago.
And I have no affiliations in the MH field, so I’ll say this explicitly:
I am looking very hard for evidence that, in discussions about mental help, the words “science”, “evidence-based” and “knowledge” do not conceal compliance, orthodoxy, and fundamentalism.
As a child I had to deal with a constant barrage of different social rules, rights and wrongs, knowledges and authorities, and I knew about frames long before I had a word for them.
I learned that some people were stuck in boxes where they owned THE TRUTH. One was a British teacher in a British school in Darjeeling in 1957, who invaded my experience of being a Norwegian schoolkid with information about Norwegian schoolchildren in an ancient British geography book. That story is in THE CERTAINTY OF NORMLIGHTS.
Luckily the child I was also met many people whom I thought of as “real people” … people who knew that there are different beliefs in different social and cultural boxes, and that “reality” is relevant only if it applies everywhere. That led to knowledge about the concept of networks, long before I had a word for them.
At 6.00 Manuel Lima describes how “the internet has changed the paradigm of looking at social structures from a hierarchic point of view”. His conclusion:
Even more than the idea of representing these complex systems is the need for a new way of thinking. And this new way of thinking is about this pluralistic way of thinking that everything is interconnected, everything is interdependent.
We are almost going back to the polymath, the Renaissance man mentality that it’s not just about being a specialist in one area, you need to know a little bit of everything. Or at least create outbound ties that you are able to learn from other disparate areas.
And I think this is the most beautiful aspect of knowledge that we can take into consideration by looking at this networked thinking. It’s more important even that we make that mental shift because I think there is immense benefit that can come from this network outlook of the world itself
And the reason for this longwinded introduction is that discussions on mental help often seem to take place between people who own THE TRUTH and people who have opinions; people who cleave to hierarchic trees of knowledge and people who are connected to networks.
Here is an article about the report from “the dangerous pseudo-scientists”:
Chartered Psychologist Angela Gilchrist reports from the launch of ‘Understanding Psychosis and Schizophrenia’
This is a critical moment in mental health history: never have so many decision makers wanted things to change. That’s according to the National Clinical Director for Mental Health, Dr Geraldine Strathdee, speaking last week at the launch of ‘Understanding Psychosis and Schizophrenia’, a report from the British Psychological Society’s Division of Clinical Psychology.
Angela Gilchrist’s article is free, but you have to register to get the full text. First she quotes the National Clinical Director for Mental Health, Dr Geraldine Strathdee.
Dr Strathdee said mental health issues would not go forward unless more voices were heard. ‘We need government to act to do things about mental health. We need brave people to speak out. We need the voice of every psychological therapist in the room to get louder’, Dr Strathdee said. She added that there were ‘prevailing myths’ about mental health that needed to be countered. These myths included the idea that people were born with mental health problems, that there were no treatments for them and that they were always long-term conditions. (…)
Maybe Dr Geraldine Strathdee is a dangerous pseudo-scientist?
Service users who had lived experience of psychosis contributed a quarter of the 175 pages of the report, which sets out to demystify psychotic experiences in everyday language. Speaking loudly to the psychological and social aspects of psychotic experiences, the crux of the document is that thinking of psychosis as an illness is not the only way to view these phenomena, said Ms Cooke.
The emphasis is mine, and I’ll repeat: Anne Cooke did not assert that thinking of psychosis as an illness is not a way to view these phenomena. She did not dismiss it. She said that thinking of psychosis as an illness is NOT THE ONLY WAY!!!
And yes, I’m shouting. And virtually jumping up and down and waving a virtual banner:
Is Anne Cooke a dangerous pseudo-scientist?
One of the most moving testimonies of the day came from survivor and activist, Jacqui Dillon, who spoke in mythic terms of her own struggle with psychosis and subsequent healing. Other speakers, including Psychiatric survivor and Clinical Psychologist Dr Rufus May, pointed to the meanings in psychosis and how these need to be understood and integrated. Service users and ‘voice hearers’ such as Rai Waddingham from ISPS UK, Mind in Camden and the Hearing Voices Network, spoke of their recovery journeys and how they had learned to live alongside voices and use these as a resource for their lives.
Maybe Jacqui Dillon, Rufus May and Rai Waddingham are dangerous pseudo-scientists?
What about the chair of the Schizophrenia Commission and a fellow of the Royal College of Psychiatrists? Is professor Sir Robin Murray a dangerous pseudo-scientist? He …
(…) said it was time for Clinical Psychologists to do more than ‘look after their own patch’. He had ‘no doubt’ that psychological approaches such as CBT benefitted patients. This approach had altered the way in which psychiatrists thought about psychosis, he said. Professor Murray added that he would have been proud if the RCP had produced the report.
The next tweet strengthened my sense of parallell universes:
So … two completely different interpretations of the same text. The first tweet seems to come from a hierarchic tree of knowledge, and the last two strengthen my resolve to not give up.
Sam Thompson’s oil looks good to me, and I hope it’s OK to reproduce it so extensively:
While these battles for the soul of psychiatry rage on, we offer a practical suggestion that all mental health practitioners can get along with in the meantime. In clinical practice, try as far as possible, to let the service users themselves identify the conceptual frame (ie, biological, psychological, social, or any combination thereof) within which their difficulties are understood. Some people find it helpful to think of themselves as having an illness like any other, a chemical imbalance, or a brain disease. Others find seeing their disorders as stemming from a difficult upbringing or traumatic life events more useful. Some might prefer explanations that have cultural or religious significance. The job of the clinician is not to use their innately powerful position to impose a particular perspective (eg, “unfortunately, you have an illness called schizophrenia”). Rather, the clinician’s job is to listen to how the service user understands his or her experience, join them in a process of collaborative sense-making, and be honest about the inherently speculative and socially constructed nature of all diagnostic and formulatory endeavours.
A corollary of this idea would be acknowledgment of a service user’s right to reject a diagnosis if they do not believe it characterises their experience in a helpful way. Similarly, they have the right to reject any other kind of formulation, case-conceptualisation, analytic interpretation, and so on. Such rejections should not be regarded as evidence of lack of insight or denial, but as a failure by the clinician to enter the service user’s world empathically and sensitively.
As I understand this, Sam Thompson is calling for cooperation between different opinions, suggesting that mental helpers set aside their innate power in order to work constructively with autonomous individuals who need help, meeting them where they are.
Misquoting Kierkegaard here:
In these words of Sam Thompson, dr Fulli found “a miracle cure for anosognosia”. And she despairs for the future:
My opinion is that many patients with psychosis might die by suicide to go to prison& many carers will suffer from this report. @Mental_Elf— Ivana Fulli (@DrFulli) December 4, 2014
I suggest that dr Fulli and others who share this opinion take a look at #whywedontengage in Twitter.
I appreciate dr Fulli’s directness. She says things explicitly in public space that I have only heard indirectly in public and explicitly in closed therapeutic situations.
I also appreciate her willingness to engage in discussion instead of blocking me, like other scientific mental help professionals have done on Twitter when I ask questions.
And I do not doubt dr Fulli’s sincere wish to to help people. I do not doubt that she has professional knowledge and experience.
I do doubt that what she has learned and experienced is the only way of helping people. And I doubt it’s the best way:
And I wonder … Where has dr Fulli learned to tell people that “life is unfair”?
Does she realize how much suicide, imprisonment and suffering there already is within the existing mental help system? Does she see how the concept of “anosognosia”, which to her is real and maybe even scientific, can harm people?
The Understanding Psychosis report is not perfect, and I would have been sceptical if it was presented as such.
But in following the hashtag on Twitter, I have seen that co-authors of the report retweet critical articles about what others see as missing from it.
I hope the report will become an extension of a network of information – partly evidence-based and partly based on knowledge and experience that cannot be counted – where “more voices are heard”, and no mental help professionals are stuck in hierarchic trees of knowledge.
And all I want for Thingymas this year, is more knowledge of frames and networks in discussions about mental help. And, of course, more explicit language.
And I suggest that professionals stop seeing discussions on mental help as a war between science and superstition, as the two other co-authors of this critique seem to do:
“… show me and I will believe” sounds eminently logical and scientific. And sometimes “science” can become a frame that filters out relevant information.
“Frames are cognitive shortcuts that people use to help make sense of complex information. Frames help us to interpret the world around us and represent that world to others. They help us organize complex phenomena into coherent, understandable categories. When we label a phenomenon, we give meaning to some aspects of what is observed, while discounting other aspects because they appear irrelevant or counter-intuitive
I am keeping an open mind about this, and I am looking for evidence that “science” in a context of mental help is open-minded enough to use hypothetical-deductivereasoning, and to factor in the strength, resilience, complexity, unmeasurability and tangled squalor and beauty of human existence.
One of the arguments of anti-vaxxers is that vaccines are not scientifically proven to be effective: there have been no randomized double-blind trials, so no evidence. The fact that vaccines work does not count.
“No evidence” also seems to be a scientific argument in the field of mental help, for example in the discussions around the “Understanding Schizophrenia ” report. And service user narratives about what works for them does not seem to count.
I have learned a lot from reading James Coyne’s analyses of research, and I was (perhaps naively) surprised when I read this:
Evidence? How does one measure listening, empathy, understanding and choice?
Are “narratives” and “testimonials” synonymous in Coyne’s frame?
This is a superb and a thorough takedown of the 200 pages or so, of a shamelessly retro book put out by British Psychological Society for its Division of Clinical Psychology. One of the shameful actions of the BPS is that many of the authors of this book are identified as “service users.” But there was no procedure for sampling adequate range of service user opinion. I’m confident that many, perhaps most service uses would not identify with the voice is being given to them. This is not just a matter of just a methodology, but of ethics. I highly recommend this blog post, but don’t recommend the book unless you’re drunk and stoned, like some of the psychologists who contributed to might have been.
I had not really expected a reply to this question. Neither had I expected to be blocked. Which I was.
I’ll continue to read Coyne’s articles on research, keeping in mind that he seems to be stuck in a frame of information that can be counted, where he seems to discount the experience of people with mental problems. Also keeping in mind that when it comes to lucrative psychological products, critical research is vital. I know that there are people who feel comfortable in the frame of “mental illness”. And I and other people with experience of psychosis and other mental problems do not.
I can’t speak for anyone but myself, but I am incapable of believing that something is true because an “expert by knowledge” says so. The expert information has to fit my life, what I have seen and experienced … and it if doesn’t, why should I believe it?
In my belief system, the collective stories of our surroundings drown out the stories of individuals. Some people, the so-called normal ones, are better able to adapt to collective stories, and the so-called mentally ill ones have problems adapting, for many different reasons. And “mental illness” is in itself a powerful and invasive story.
Dr Fulli is undoubtedly an expert by knowledge. Has she really learned that she practices medicine and stops suffering by dismissing grief with “life is unfair”?
I still wonder: Who are experts by knowledge? What knowledge, and how is it acquired?
The knowledge that dr Fulli brings to bear on people “with the unexpected dying of a loved one”, I consider a belief system. She knows it works. Evidence?
In my experience, what works is not fearing or avoiding grief, but allowing it, accepting it, being in an individual process of grieving, letting it run its course. That has worked for me, I know it has worked for others, and I would not presume to state that it works for everyone.
Are the narratives and opinions of people with personal experience of psychosis and other mental problems only relevant if they have degrees in … what? Psychiatry, psychology, neurobiology?
Are the opinions of people with such degrees only relevant if they are evidence-based?
Last Rt content is quite a mystery to my mind: How can one think it is OK for both antipsychiatry CPs &psychiatrists to use service users?— Ivana Fulli (@DrFulli) December 11, 2014
How can professor Coyne and dr Fulli not know that people with experience of mental problems are autonomous entities, capable of thinking critically and deciding independently what works for them and what does not? They seem to be in a frame that is so different from mine that I doubt we can find common ground. And I thank them for stating their opinions so explicitly.
I haven’t really understood what “evidence-based” means in the field of mental help until I read their reactions to “Understanding Psychosis”.
In my frame, this is not about “consumer testimonials”, antipsychiatry/psychiatry or about service users being used by anyone. Quoting the National Clinical Director for Mental Health in the UK, Dr Geraldine Strathdee:
“We need brave people to speak out.”
Framing the narratives of people who speak out as “testimonials”, and dismissing and psychopathologizing the opinions of people with experience … from where I stand, this is caused by very unscientific prejudice. I choose to assume that such patienting is not deliberate, so it could also be called “microaggression”:
Microaggression theory is a social theory that describes social exchanges in which a person says or does something, often accidentally, and without intended malice, that belittles and alienates a member of a marginalized group.
Would it be OK if I constantly referred to dr Fulli as “that prolific French psychiatrist tweeter”? She is French, she is a psychiatrist, she does tweet a lot when she feels strongly about something, but I don’t think so.
It would place a label between us that would filter out information from her.
She deserves better: She is who she is and she writes what she writes, and I use her name to remind me of that.
Would it be ethical and OK if medical specialists referred to people they disagreed with in a somatic health care discussion as “diabetics”? And assumed that their opinions were caused by their diabetes, and defended this assumption because the persons blogged about diabetes?
I don’t think so, and I suggest that similar behavior from mental help professionals on Twitter gets hashtagged #GoldwaterRule:
What did Professor Laws, who has a long history of lashing out at SUs on Twitter, feel about this fierce defense of his professional honour? What will the @rcpsych do about “hate tweets” from “BPDBloggers”?
I would really, really like to know what “completely different set of moral issues” dr Fulli is thinking of. The article in The Lancet Psychiatry brings up issues that are vital in any discussion on mental help. Inserting some bits here, with comments:
The first is to assume the best of one’s opponent: that their argument proceeds not from self-interest, financial interest, or wilful ignorance, but from genuine curiosity and a desire to improve the lives of people with mental health problems.
And please, please do not assume that the arguments of people with service user experience proceed from their diagnoses. Instead, assume first that they are persons, autonomous entities who can reason and think critically. You can always reassume if they demonstrate that they cannot.
There is a view that so-called punching up to perceived figures of authority is justifiable and necessary, but punching up is still punching someone. There is always potential in the discussion of mental health issues to trigger distress, as everyone, patient or professional, has an unseen personal history and sensitivity.
What I am addressing now, is the prevalence of punching down by mental help professionals on Twitter.
Punching is punching, of course, whatever the direction, but psychopathologization is one reason for punching up: When opinions are derailed with patienting, calm and reasonable dialogue is impossible.
And let’s not forget the imbalance of power between mental help professionals and people with experience:
The final point is to ensure that those whose voices are not listened to enough are given the space and opportunity to be heard. Their numbers include individuals such as mental health nurses and social workers, who provide a large amount of care but who are given little time compared with psychologists and psychiatrists. Most important, the voices of patients must be “airtime” respected in all their diversity.
“Psychiatrists aren’t helpful when they flatter seemingly hypomanic blogger telling she is always right”
It would be helpful to be able to invoke #GoldwaterRule on this type of response, especially now, when patienting in the debate around “Understanding psychosis” can restrict the open dialogue that I have found so interesting.
… and I have a heavy workload at the moment, so it must be done in installments. The first one will be on “knowledge and experience and hazardous gurus”. I have collected dr Fulli’s replies in screenshots. They are in reverse chronological order, so if you want to read them you should begin at the end:
Jan 26: some personal stiff snipped, to be used in another context.
an article by Sanda Kaufman, Michael Elliott and Deborah Shmueli
Frames are cognitive shortcuts that people use to help make sense of complex information. Frames help us to interpret the world around us and represent that world to others. They help us organize complex phenomena into coherent, understandable categories. When we label a phenomenon, we give meaning to some aspects of what is observed, while discounting other aspects because they appear irrelevant or counter-intuitive.
As I see it, ignorance about frames is one cause of miscommunication and dehumanisation in mental help. Mental helpers can – with the best of intentions, of course – be so stuck in their professional frame that they discount crucial information about people they are helping.
This sketch illustrates the framing problem from an engineering point of view:
I am not an engineer, but therapists, both psychiatric and psychological, have expected responses from me that are as meaningless in the context of my life as “seven red lines, perpendicular, some drawn with green ink and some with transparent ink, one in the shape of a kitten”.
How did “low and moderate use” become “NOT antipsychotics lead to higher mortality in psychosis”? This interchange reminds me of the story by Hans Christian Andersen about how a feather became five hens:
The drug-centred model focuses our attention on the impact that drugs have on the body and the brain, and on all the possible consequences that drug-induced alterations can have on how people think, feel and behave. It is a necessary starting point for the sensible, cautious and safe use of drugs in mental health services.
YEAYYYY for “sensible, cautious and safe use of drugs”!
How did the people in the study who had no exposure to antipsychotics live?
Were they left to neglect themselves to death? Did they receive constructive treatment without drugs?
And … what does the fox say?
The British Medical Association is not a fox nor a wooly-headed coven of deluded antiscientists, and here is something that it says, via The council for evidence-based psychiatry:
Professor Peter Gøtzsche has won first prize in the 2014 BMA book awards in the Basis of Medicine Category with his most recent book, ‘Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare’, published by Radcliffe Publishing. Peter is Director of the Nordic Cochrane Centre and a member of CEP.
The BMA reviewer commented as follows:
‘I would say that this book should be compulsory reading for medical students and junior doctors to make them aware of these issues…
The author’s long experience in the field leads to a clear and authoritative view on the failings of the pharmaceutical industry. However he is clear that doctors, their organisations, journals and policy makers also have a role in these failings. I was particularly interested in the entanglement between doctors and the pharmaceutical industry. The use of clear language – fraud, corruption, and criminality – helps show what we would call this behaviour in any other sphere of life. It also refocuses our minds on the impact this behaviour has on patients – medication being the third largest cause of death…
“Noel Hunter: Madness and Meaning in the Human Experience:A clinical psychology doctoral student, Noel explores the link between trauma and various anomalous states and the need for recognition of states of extreme distress as meaningful responses to overwhelming life experiences.”
Recent years have seen an influx of numerous studies providing an undeniable link between childhood/ chronic trauma and psychotic states. Although many researchers (i.e., Richard Bentall, Anthony Morrison, John Read) have been publishing and speaking at events around the world discussing the implications of this link, they are still largely ignored by mainstream practitioners, researchers, and even those with lived experience. While this may be partially due to an understandable (but not necessarily defensible) tendency to deny the existence of trauma, in general, there are also certainly many political, ideological, and financial reasons for this as well.
I do not have all the answers. But, I do ask why it is that mental health professionals do not start with just saying what they mean? We can talk about altered identity states, memory loss, feeling unreal, not knowing what is real or not, being terrified of others, etc. Mental health professionals can own the fact that “I do not understand this person” instead of taking this as equivocal evidence of some brain-diseased process of “psychosis.” Each of these experiences do not make a distinct disease. People are complex. People do not fit in nice, neat boxes. People suffer, and when they do this is not necessarily a disease. People adapt to unbearable life circumstances in a number of complex ways that cannot be categorized, no matter how much psychiatry insists that it can. And none of these labels can tell anybody much of anything about a person beyond the stereotypes and confirmation biases they elicit.
The sentence in Norwegian at the top of the next image belongs to another conversation, but fits in nicely: “You can realize that I am right or complain and be shown that I am right”. Said by the psychiatrist who borderlined me, in our first meeting.
Experts who “know” are wonderfully seductive. Whenever I attend a lecture by someone, usually a hospital specialist, who seems absolutely certain of the correct response to a patient in a particular situation, the temptation to take careful notes is enormous. Yet once I’m back in the consulting room the notes are never as useful as I had hoped they might be. Certainty seems to be born of pretending that things are very much simpler than they really are and in our consulting rooms things never seem simple. Yet there is a terrible certainty about much medical rhetoric and in much of what we say to patients.
Isaiah Berlin would recognise the expert who “knows”:
“Happy are those … who have, by their own methods, arrived at clear unshakeable convictions about what to do and what to be that brook no possible doubt. I can only say that those who rest on such comfortable beds of dogma are victims of forms of self-induced myopia, blinkers that may make for contentment, but not for understanding of what it is to be human.”6
As would Jose Saramago:
“assuming he has been wise and prudent enough not to believe blindly in what he thinks he knows, because this rather than ignorance is the cause of the greatest blunders”.7
The pursuit of certainty–the desire for certainty–what Hans-Georg Gadamer calls “the reduction of truth to certainty”8 affects the way we use words and language. So I want to explore the use and abuse of words within the interaction between doctor and patient, and examine the normative basis of power in story, language, and knowledge. I hope to show how easy it is for doctors to use these dimensions of power to constrain and limit our patients’ stories, consign many of them to stories of failure, and reduce their capacity to celebrate, or even recognise, achievement.9
4 Dec, 14 | by BMJ Evidence based medicine (EBM) should form the foundation of effective clinical decision making; however, growing unrest—and an awful lot of criticism—suggests the evidence bit of EBM is increasingly part of the problem, and not the solution.
“Carl Heneghan jointly runs the Evidence Live conference with The BMJ and is a founder of the AllTrials campaign.”
I am linking to this article because of the Twitter discussion on #understandingpsychosis – and other situations where the word “evidence” sometimes seems to trigger System 1 reactions that block off relevant information.
Distortion of the research agenda, mainly by commercial decisions, is leading to an ever increasing evidence base that doesn’t meet the needs of patients. With too much focus on the well, and not enough on the sick, the paradoxical situation has arisen whereby medicine is potentially harming the healthy through earlier detection and increasingly looser definitions of disease.
As an example, if you find yourself constantly late, disorganised, forgetful, and overwhelmed by your responsibilities—which could refer to all of us—you might have adult attention-deficit disorder. You will be pleased to know that there are at least four different medications currently available for this condition. You could argue that the pharmaceutical industry is becoming equally good, if not better, at manufacturing diseases as opposed to drugs.
While research publications continue to increase—to the point where the notion of keeping up to date is nigh on impossible—the quality is often very poor, if not sometimes outright pitiful. Although there has been a growth in research to promote implementation, my observations—note the low level of my evidence —have been that while clinicians are extremely good at responding to robust evidence, all too often the quality of the evidence is weak and unworthy of implementation.
Poor quality evidence arises when observational data are used to establish treatment effects; when outcome measures are unimportant to patients or, even worse, are meaningless for patient care; and also when simple factors to account for bias are not incorporated into the research design.