I entered graduate school for clinical mental health counseling pretty much on a whim. Since earning my undergraduate degree in the early nineties, I had worked in various positions in higher education. At the end of 1999, I found myself in a job I really disliked and wondering what was next. My co-worker and friend, knowing I was interested in holistic health and deeming me “a good listener,” thought I should consider the counseling field. She even had a school in mind with a holistic concentration.
While I had spent many hours researching the purchase of my current car, no research whatsoever went into my decision to apply to grad school and to enter the mental health field. In fact, I knew very little about the field and, frankly, had never given it much thought. Sure I knew that people could be depressed and anxious, but I had never viewed those as illnesses. I just figured life happens, and for some it does in very bad ways. Of course, there were those eccentric folks who could be seen walking the streets of my hometown exhibiting bizarre behaviors, and who “probably” had what I and many others thought to be the brain disease of schizophrenia. But beyond that, the idea that many suffered from a variety of mental illnesses had never crossed my mind. Despite all of this, my friend’s idea caught my interest.
In the early nineties I had been introduced to the concept of the mind-body connection through my participation in a twelve-week pain management program. I had been enthralled by all I learned and at the end had inquired about how I might go about becoming a facilitator for such a program.
The response was that I would need to attend graduate school. This was not an appealing thought at the time, given that I had just finished my bachelor’s degree a year or two prior. I did not enter into formal study at that time, but throughout the following years I did continue to educate myself about what it meant to be healthy in mind, body, and spirit. Thus, a counseling program with a holistic specialization was very appealing and I thought it would provide me with the education and the degree needed to help people as I had been helped years ago.
In the spring of 2000, I attended the open house, completed my application, and waited to hear if I had been accepted. I had applied to no other schools, nor did I have a Plan B. I also did not do any research into the field while I waited. The acceptance letter arrived and I entered my weekend intensive orientation to the program in August of 2000.
I felt at home upon walking through the doors that first day, and confident in what now seems to have been a somewhat impulsive decision. I have also never regretted making it. I loved and excelled in my classes. My professors took a client-centered approach to counseling and the focus was on empowerment rather than disease. In my psychopathology class I was taught to diagnose mental disorders using the DSM-IV and discussions often centered on the difficulty of having to label people and how to best treat them.
Cognitive behavioral therapy (CBT) is listed throughout my notes from that class as being an effective treatment, as is recognizing a client’s strengths and resources. In none of my notes is there a mention of a biological basis for these disorders or the need for medication to cure them. In fact, according to my class notes, I was informed that the DSM is “a theoretical document” and “that we should keep asking the question, ‘What’s the norm for whom?’” Additionally, my professor said that it is “a document based on what happens outside the people and that there is no language to address the subjective experience and no place for thinking about the person themselves.”
The questions begin.
In reviewing other classes I took, nowhere was I taught that mental disorders are an illness arising from a chemical imbalance which needs to be treated with medication. If my university professors did not teach it, then where did I learn it? The answer lies in working in the field itself and hearing it from supervisors and other colleagues. But where did they learn it? Was it from their professors and their training? Or have we all been so well “educated” by those ubiquitous television ads which show us how our brain does not “work” when our neurotransmitters are not “balanced” that we have come to accept this as truth? Have the medication providers with whom we work also promoted this myth because they too are prescribing based on the false education received by the pharmaceutical companies? Even insurance companies suggest that we speak with clients about taking medication to improve their symptoms. Why do we to continue to blindly go along without questioning whether or not any of this makes sense or is helpful?
About a year and a half ago I had stumbled upon a documentary about the history of psychiatry which led me to begin further questioning the disease model of mental health and the use of psychiatric drugs. I soon found myself listening to podcasts and watching videos with interviews of Peter Breggin, MD, the Harvard-trained psychiatrist who has written extensively about the dangers of psychiatric drugs, and who has been an expert witness in FDA hearings and trials against the makers of those drugs. The interviews of others included Mad in America’s Robert Whitaker and Britain’s Joanna Moncrieff, MD, author of The Myth of the Chemical Cure. I also began reading their books.
The research backing up the assertions made by Breggin, Whitaker, Moncrieff, and others validated much of what I had originally thought about so-called mood and anxiety disorders. For whatever reasons, I failed to further question the status quo until recently.
Having worked in the field for over ten years, I have come full circle. Looking back, I see clearly that for many of the clients with whom I have worked, particularly at a community agency in an impoverished city, the pills actually made things worse. I remember the clients who gained weight and developed diabetes because of the antipsychotics they had been taking. In my mind, I can see a man whose hands shook so badly he could barely hold onto anything. This side effect was thanks to the tardive dyskinisia which we knew to have been caused by an antipsychotic prescribed to help him sleep. I also remember a couple of clients who, after I had diagnosed them with major depressive disorder and referred them for medications, developed bipolar disorder. The explanation was that the bipolar disorder had been underlying the depression all along. All of these clients and others were on disability for their so-called psychiatric illnesses. It now seems obvious that the drugs were not improving their quality of life.
Many times during my years at the agency I found myself “educating” clients about the “chemical imbalances” from which they suffered, and informed them that they needed to take their medication as they would need to take a drug for any lifelong illness, such as diabetes. I said the words because I had been trained to do so, but saying them never made sense to me. The one exception to this was those symptoms related to psychotic episodes, which at the time I viewed as a true mental illness. However, my clients for the most part were people who came from—and continued to live in—poverty. They had been horribly and traumatically abused in a variety of ways, and/or were dealing with various multiple losses. These were disempowered folks with few healthy coping skills, in some cases with little-to-no familial or social supports, and limited resources. No amount of pills was going to make their lives alright.
Since leaving the agency and working in private practice, I have been slower than most to refer clients for medication, but have done so. I have made a conscious effort to talk with clients about depression and anxiety without using the terms of a chemical imbalance. However, in having to diagnose them with depression or anxiety, I feel I am placing upon them a label that need not be there. In previously telling people that they have a lifelong “disease” for which they will need to take medication, I have at the very least contributed to and in other cases outright caused more harm than good. While it was sincerely not my intention to do so, that is nonetheless the reality. Thus is my confession.
Here now is my dilemma.
While I have and will always support a client’s right to choose medication, I am now, with perhaps the rarest exception, extremely reluctant to agree with that decision. I feel that there should be fully-informed consent, with the client made aware of the actual risks of these drugs; something which is often missing or minimized by prescribers. Now, when the topic of medication does arise, I spend a good amount of time talking with clients about the real risks involved so that they are able to make the best decision for themselves. I talk with them about the myth of the chemical imbalance and continue to validate their life experiences which have led to them feeling depressed, anxious, or generally moody. Most seem to appreciate these conversations, which often resonate with their own views. Others are understandably skeptical, since I am providing information which often conflicts the views of their doctors and society at large.
I have clients who are on medication and would like to stop, but may not have a prescriber who is supportive of that decision. I know of no one to whom I can refer them. The best I can do at this time is to encourage them to assert themselves with their current prescriber and let them know that I am also willing to speak on their behalf. This lack of a network of prescribers who are fully aware of the risks, and who are willing to discontinue or minimize the use of these drugs, also means that I have no one to whom to refer clients who are on medication which is most likely worsening their symptoms.
The removal of the disease-model lens, and the desire to best help my clients without having the appropriate resources, has left me feeling professionally isolated. I know of no colleagues who have accessed similar information and have drawn the same conclusion. There is no one with whom to discuss the concerns and questions I have. A year ago, in conversation with a colleague when I merely raised the possibility that we were perhaps wrong in our approach of a disease model which required medication I was told that I was “starting to sound like Tom Cruise.” Most others with whom I have had talked have been dismissive or, understandably, skeptical. Some are interested, but seemingly not enough to do their own research. This, too, I understand as people are overwhelmed and busy. But we need to do better.
As a profession, it is time to return to a client-centered approach, rather than a disease-centered one. We need to empower clients to know that they do have some control and can make positive changes in their lives, despite how horrible their experiences. We need to let them know that they are not sick, but instead remind them that they are human and that being human, while emotionally messy at times, is not a disease state or something to fear. I cannot do this alone, but I also know that I am not the only one who feels this way. Will you join me?
Hi Tracey,
Welcome to MIA. As an FYI, if your clients don’t have support from a psychiatrist, you might refer them to this site:
http://survivingantidepressants.org/
There is a list of doctors who will support clients with a very slow tapering method which is what this site advocates which is 10% of current dose every 4 weeks. And many times, people are advised to go more slowly.
Now granted, it is not run my medical professionals but then again, so many of them are clueless as to how to advise people to taper and many times, advocate way too fast taping methods which put people in danger.
Welcome aboard.
Thank you, AA.
I absolutely agree there should be a client centered approach, not a disease centered one, especially since the DSM disorders are neither scientifically valid nor reliable. And as one who was put on a “safe smoking cessation med” / aka dangerous mind altering antidepressant, in conjunction with a “safe pain killer” / aka dangerous mind altering synthetic opioid, and a NSAI due to a “bad fix” on a broken bone.
And since all the doctors I went to claimed that these “safe” drugs could never cause odd dreams, thoughts, and brain zaps / have mind altering effects. These mind altering effects were DSM-IV-TR misdiagnosed as the “life long, incurable, genetic” “depression caused by self” (by a therapist who, unbeknownst to me at the time, wanted to cover up the abuse of my child for some friends of hers), “paranoid schizophrenia” (by a paranoid PCP whose husband, also unbeknownst to me at the time, had been the “attending physician” at the “bad fix” surgery), and “bipolar” (by 2 deluded psychiatrists) within a few weeks.
I’m glad you’re waking up to the awe inspiring stupidity of your industry’s theology, and the harm your industry is committing against the decent and innocent people of the world, especially the million plus American children who were also DSM-IV-TR misdiagnosed as “bipolar.” I hope the psychiatric industry does soon overcome their delusions, and realizes that their “wonder drugs” are actually nothing more than toxic “torture” drugs that actually create the symptoms of the DSM disorders. And that they wake up to the reality that the antipsychotics create the negative and positive symptoms of “schizophrenia,” including “psychosis,” via neuroleptic induced deficit disorder and anticholinergic toxidrome.
It is truly sad there are so few American psychiatrists today who will wean people off the toxic, psychiatric torture drugs.
Totally totally agree. Well said. When I got medicated there were virtually no mention of risks. Bravo.
Thanks Randall. And not only was there no mention of ADRs and withdrawal symptoms, there was outright denial, and still is 15 years later, despite the fact I’ve since sent most my former doctors the medical proof ALL my symptoms were completely iatrogenic. And an ethical pastor confessed to me that this literally is the “dirty little secret” way the medical community and religions have been covering up their easily recognized medical errors and child abuse for decades, or longer.
Tracy, forgive me, I did not mean to come across as discourteous, welcome to MiA. I really just wanted to point out that even “psychosis” is not proof of a “real” (non-iatrogenic) “mental illness.” And I believe it’s really important for the psychiatric industry to realize that if you put a person, who is suffering an adverse reaction to an antidepressant, on to an antipsychotic. By claiming “bipolar” was really underlying their “depression,” which was malpractice according to the DSM-IV-TR, but no longer is in the DSM5. You run a high risk of making that person “psychotic,” via anticholinergic intoxication syndrome, aka anticholingeric toxidrome.
https://en.m.wikipedia.org/wiki/Toxidrome
I’m obviously fully aware of the fact those writing the DSM are intentionally deluding the rest in you industry, by encouraging this type of “psychosis” creation. However, I do appreciate your truth seeking and enlightened new views. Perhaps, you can win a psychiatrist or two over to the realm of the decent with this little medical fact? The symptoms of anticholinergic intoxication syndrome are almost identical to the symptoms of “schizophrenia” today, the only difference is “inactivity” vs “hyperactivity.”
Overcoming the staggering magnitude of the betrayal – being it medical or educational – does take time, though. Best wishes.
I should correct that, the central symptoms of anticholinerginic intoxication syndrome ….
Someone Else,
No need for the apology, as I can understand your frustration. I have also begun to question psychosis as a mental illness and have come to believe that there are many other factors that result in such a presentation. Certainly, medications do cause it, as your experience shows. I appreciate your feedback.
-Tracey
Tracey: In my personal life: I was institutionalized in 1989 and 1990’and diagnosed with manic-depression which later morphed into bipolar.’I find it difficult to drop under 1.5 mg. of Zypreza and I also take .5mg. of clonipin. 20 plus years of lithium damaged my kidneys. I am none to happy about this.
In my professional life I work as a youth worker and a substitute teacher. So
the subject of psychiatric medications comes up from time to time. This puts me in a bit of a quandary. I have logged my concerns about psychiatric drugs with the youth agency and was told to refrain from talking about it in the log.
But sometimes clients and students beg the questions and I feel that I would be less than honest if I did not respond to their concerns.’At least two clients managed to avoid being ensnared into the psychiatric drugnet. Some staff have
also expressed reservations about ADHD medications. Above all else, I always
advise young people to avoid an abrupt cessation of the drugs. I also loaned my
direct supervisor a copy of Whitaker’s new book, but as of yet, I have received no feedback.
Tracey, thank you for the incite shown in your posting. I was once also a part of the mental health system and fell victim to the theory of the disease model approach to treating routine mental health issues. These include various so called anxiety disorders, grief, trauma and forms of mood disorders. I now see that almost all of these problems should be treated without medications or with only short term drug therapy. It has become apparent that those persons treated with many of these medications are now in crisis. My personal experience includes a shocking addiction to benzodiazepines and amphetamines. There was no warning of the dependence potential and no help in withdrawal. I also had a front row seat to the change over from a labor intensive therapeutic approach to treatment to the 15 minute drug check.
I pray that you and other mental health professionals remain so brave as to speak out. The current approach makes money for prescribers and drug companies, but causes great harm to clients and their families. I know from personal experience.
Hi Tracey,
Thank you for a very honest account of your experience.
This is a topic of much interest to me, I’ve been the person on the receiving end of the “chemical imbalance”, “take this medication for life”, “just like diabetes” message – except I received it in an involuntary inpatient setting which is infinitely more confronting.
I’m genuinely keen to understand – in your experience when you did counsel people on the “chemical imbalance” model (which it sounds like you never truly believed in) – why did you do this? What were the factors for thinking that this was a good/appropriate explanation to provide? Was it because you thought they would be more ready to accept medication if they thought this was true?
Not trying to be confrontational – I found it very damaging to find out that it wasn’t true, and am really interested to understand why clinicians or other MH practitioners would tell someone something that they themselves don’t think is true…
Hi Anonime,
Your questions are valid, so thank you.
There were a few factors which led to my “educating” clients the way that I did initially, despite what I felt to be true. I think the first one had to do with the transition from the classroom to working in the field. In the classroom, the focus was not on pathologizing as much as it was on empowering clients. However, in the field the focus does tend to be on pathologizing as doing so is the only way to be reimbursed by the insurance companies, who, as I’d mentioned in the blog, also suggest that clients be considered for medication.
The second piece was the result of having been new to the field. Rather than go with my gut, to which I now pay closer attention, I relied on those who had more experience than I. While I did question at times, I found it difficult to trust what I felt to be true when the opposite messages were louder.
Hopefully, this clarifies it for you.
-Tracey
Thanks for starting the ball rolling! I can now take a break in peace knowing profs are beginning to be come aware! See you all later and keep safe.
Hmm. Very interesting, the part about being conditioned post-academia to adopt assumptions about biology and drugs you had never been taught in school. (By the way, if you check those ads for SSRIs, “bipolar” drugs and others, the “science” of how they “may” work is very sketchy and tentative; at no point do they make confident declarative statements but talk in terms of “some believe” and “this may explain such & such.”)
Be careful about people “choosing” so-called “medication.” No one ever expressed a natural desire for benzos, for example, before they were offered them and/or exposed to them via the same means you say influenced you to internalize the whole pseudo-biological narrative.
So, newfound consciousness entails newfound responsibility — but that shouldn’t include wallowing in guilt about what you didn’t previously understand. Use your knowledge wisely. 🙂
Hi Oldhead,
Thank you for the feedback.
I agree with you about the ads. However, when they are showing the cartoons about how the brain “works,” I think for many, the “may” and “some believe” get overlooked.
I also agree with you that, had folks never been exposed to these medications, they would not choose them. However, the sad truth is that most have been exposed and that for many people, an MD still represents the highest/best opinion/knowledge. So, if I am advising a client against taking medication and their doctor is advising them to take it, the doctor’s advice often wins, so to speak. I do and will continue to educate people, but, at the end of the day, I have to respect their right to choose what to put into their bodies. I don’t, however, have to agree with it.
-Tracey
Good article, Tracey. It sounds like you’ve grown a lot over the years after a somewhat haphazard entry into the profession. Although, it sounds like wherever you are you’re surrounded by some pretty uninformed and close-minded therapists/psychiatrists, given that they still believe in the outdated disease model of mental illness and the necessity for medication.
If you’re not a member already, you might look into ISPS (www.isps.org) and ISEPP (psychintegrity.org), where you can find hundreds of mental health professionals who think similarly to you.
Regarding this: “I have clients who are on medication and would like to stop, but may not have a prescriber who is supportive of that decision. I know of no one to whom I can refer them. The best I can do at this time is to encourage them to assert themselves with their current prescriber…”
I think this may illustrate a possible misconception seen on MIA: the idea that the support or consent of a mental health professional is needed to taper off and discontinue psych meds. This notion is false. With careful research, patience, planning, and determination, it is possible to come off of psych meds alone or even against the wishes of a psychiatrist, as I did.
About 8 years ago, at age 22, I had been taking an antipsychotic, antianxiety (benzo), and antidepressant for about a year. None of them were helping; they were just making me feel dead and unable to work on my problems coming from an abusive childhood. At that time, I was still financially dependent on my parents; my father was heavily into the medical model and insisted on my being medicated for my “depression” by our psychiatrist. It was frustrating because I was also seeing a separate non-prescribing therapist, but had difficulty working well with them due to the effects of the meds.
I did my own research, reading authors like Peter Breggin, and realized that long-term use of psych drugs is a dangerous scam. One day, I decided I had had enough of these worthless pills and I was going to come off the meds myself, even though the psychiatrist and my father would not support it. The problem was, I still needed my father’s money to go to therapy.
So, over a period of several months I very gradually titrated off all 3 meds while continuing to tell the psychiatrist and my father that I was taking them. I did my research and realized how critical it was to step down very slowly over multiple several-week periods, and to monitor my mood closely each time I made a drop in dosage.
The anti-authoritarian side of me took great delight in misleadingly telling the psychiatrist how much the meds were helping me, right as I was coming off of them without his knowledge. He never knew what really happened, which was further evidence to me that psychiatrists don’t know what they’re talking about since they can’t tell when pills are “working” or not. Within a relatively short period after coming off meds, I was able to start working and supporting myself financially, and things really began to take off.
The moral of this is, psychiatrists are not gods, and people suffering with “mental illness” labels can and do come off meds alone. Psychiatrists can’t even validly define “mental illnesses”, nor do they know as much as they claim about how neuroleptics work, so why do people think psychiatrists’ oversight and consent is necessary to come off meds? In my case, I knew that secretly titrating myself off meds was a risk, but I wanted to take bold action and do what I felt was right for myself in the long term, rather than play it safe. If I went back in time, I’d do it all over the same way.
The interesting thing about psychiatrists is that they are easily fooled as long as you know what they believe in and what they want to hear. Once you learn that you can get them to believe just about anything. Since many of them have no empathy with and for people and since many of them know little or nothing about real therapy they can’t read people very well at all and don’t seem to catch on when people are lying to them. Many of the so-called “patients” are much more intelligent and wise than the psychiatrists treating them. It’s difficult to have real respect for this group of people.
Yes, I also was aware in my own case that the psychiatrist wanted to hear that the drugs are working, because it would confirm to him the myth that the prescribed pills were an effective treatment for “major depression” and “anxiety disorder”, and make him feel good about himself.
So it was even easier to deceive him. It probably never even occurred to him that this young guy was misleading him in order to not be damaged by the drugs and, more importantly, in order to get the money from my father I needed to get real help with my psychotherapist.
This experience was the first time I realized, “Wow, psychiatrists really have no idea whether their drugs work or not. They can only go on patient self-reports. There are no objective measures.” This keyed me on to the lack of reliability and validity behind “illnesses” like major depression and anxiety disorders, and the lack of biomarkers and tests, that is the Achilles heel of the field.
I have had to behave similarly at various points. Many people have to mislead psychiatrists to protect themselves and this is a prime example of why psychiatrists should not trust their own “clinical experience.”
I found telling my psychiatrist that the drugs made me sick just resulted in more, and / or different drugs. So, I too, learned pretty quickly you must mislead psychiatrists, and say the drugs are helping, in order to get weaned off of them. The whole experience was like dealing with delusional children (only they were adults claiming they were “doctors”). But I suppose you can’t convince healthy people they’re insane, unless the whole industry itself behaves insanely collectively, so they do.
“…so why do people think psychiatrists’ oversight and consent is necessary to come off meds? ”
BPD, it is great to hear that you were able to pull this off on your own, without the help of (or even in spite of) your former psychiatrist. And while it is totally understandable, human and perhaps even inevitable, to generalize from one’s experience (we all tend to do this to a degree), we must not minimize the risks and difficulties associated with withdrawal. You may have had an easier time because you figured this out quickly on your own and did not allow yourself to be trapped and immobilized by drugs for years. Everyone deserves a chance to be free of drugs; they are disempowering, exactly what a person who already feels powerless does not need. But let’s not minimize the difficulties of withdrawal. Forewarned is forearmed.
Thanks for your comment GetitRight. I agree that it’s probably harder for many people than it was in my case. I had certain advantages, including being young, healthy, physically large/strong, not on the drugs for many years, etc. that I think helped my body and mind be less vulnerable to the withdrawal effects.
I think given that it’s often not possible to find – or more importantly afford – a psychiatrist who will help you taper off drugs (something which is really just advice giving and monitoring) – and that doing it on your own has to be considered a valid option. It can be a risk worth taking, dependent on a lot of factors.
GetItRight,
It is important to warn people about the very real likelihood of a drug withdrawal induced super sensitivity manic psychosis. I suffered from this both times doctors weaned me off the drugs. Thankfully, mine were supportive “psychoses” / spiritual awakenings, so not particularly problematic for me personally. But I know some people can have very frightening withdrawal “psychoses.” And these almost always get labled a “return of the illness,” rather than properly classified as a common drug withdrawal symptom. “War is a racket,” and so is psychiatry.
Thank you Tracy for your article. I recently started a petition for patients, or rather, victim’s of our local Community Mental Healthcare facility’s to sign. I shared my horror story of community mental health with Paula J. Caplan, I haven’t shared it here because I too, live on disability from my diagnosis and can’t afford to pay to post here right now. I literally live month to month. The problem with our Community Mental Health facilities that I’ve been involved with for over 30 years is that they prescribe the drugs, and heavily, but they will never help us get off them. They informed me, after 10+ years taking Klonopin it was ‘just fine’ to stop with out providing any support what so ever. So I did. I trusted them, and there are not enough words to describe the horror, and mental torture I endured at home, alone, while going through this withdrawal. In fact, they didn’t even believe what I experienced, it wasn’t up for discussion with my then therapist, and I was blamed. Because it was my decision to get off Klonopin, not theirs, after overdose after overdose they didn’t deem important enough to address. I was afraid I was going to actually die one of these times. My therapist actually told me “Sandy, you wouldn’t have went through what you did if you wouldn’t have taken all your Klonopin in the first place.” They also said they were not responsible, at all, for anything I experienced during that withdrawal because I signed a simple, one-page consent form (and I did). I was a transfer from the pscyh hospital in horrible shape and I taking 4 other psychotropic medications. I was so mentally impaired when I signed ALL the ‘consent’ forms I had no idea what a benzodiazepine or an anxiolytic was. And from that consent form they said that was information enough to inform me of the 50 horrendous Klonopin withdrawal symptoms I was going to experience one year later. I can’t even begin to tell you what the rest of my psychiatric drug withdrawals were like. That’s when my world fell out from under my feet for another 5 months of suicidal and homicidal severe ideations. So please, if you recommend your patients take drugs, do you research thoroughly like I have now done to know what your doing to your clients. And for God’s sake, if they decide to come off their drugs for any reason. Help them taper. I didn’t have that luxury and it almost cost me my life.
I was very lucky that I had a psychiatrist who totally cooperated with my slow tapering plan even though initially, it was clear he thought it was the dumbest thing on earth. But to his credit, he did come around.
However, I never did feel comfortable sharing with him about the wd issues I was having as I feared if I did, he would state I was having a relapse and would pressure me to go back on the meds. Until the end of the taper, I had the sense he was waiting for me to fail so I didn’t give him any ammunition.
By the way, when I told other people in my area about my experience with this psychiatrist, they said I was very lucky and most psychiatrists would not have supported my withdrawal the way he did even though it was far from perfect. If that had been the case, I would liked to get the prescriptions I needed and simply continued the slow tapering method.