The emphasis is on persistent symptoms

It’s been a quiet week, blog-wise. It’s been a very busy week, work-wise. I am glad of that, because it indicates that I am quite functional, which a good place to be at. I haven’t had much time for anything other than working, getting a little exercise, and then coming home to make supper, watch television, and go to bed. But that’s okay.

For now.

Ideally, I’d like to have my work and the rest of my life be more balanced out. I’ve got some other things I’d like to do with myself besides complete tasks for my employer. A 40-hour work week might be nice… but I’m not sure when that’s going to happen. So, I am looking for other ways to think about my job, other than it being just a job.

Anyway, I’ve been thinking on and off about the Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms, with the emphasis on *persistent*. On Page 6 of the document, they talk about

Common Symptoms of mTBI

Physical

  • Headache
  • Nausea
  • Vomiting
  • Blurred or double vision
  • Seeing stars or lights
  • Balance problems
  • Dizziness
  • Sensitivity to light or noise
  • Tinnitus

Behavioural/Emotional

  • Drowsiness
  • Fatigue/lethargy
  • Irritability
  • Depression
  • Anxiety
  • Sleeping more than usual
  • Difficulty falling asleep

Cognitive

  • Feeling “slowed down”
  • Feeling “in a fog” or “dazed”
  • Difficulty concentrating
  • Difficulty remembering

It’s a short list, compared to the “batch” of 84 ways TBI can make your life really interesting I catalogued several years ago and have used as a guideline in my own recovery. But it’s a list, nonetheless. And they can cause a whole truckload of hurt. mTBI can really mess with your head in all sorts of ways, even if medical imaging can’t pick it up. Indeed, the ONF Guidelines say:

Computed Axial Tomography (CAT) and conventional Magnetic Resonance Imaging (MRI) usually fail to detect evidence of structural brain abnormalities in mTBI. However, reviews of recent advances in the biomechanical modeling of mTBI in humans and animals conclude that mTBI leads to functional neuronal disruption, and at times structural damage

Yeah – what they said: “functional neuronal disruption, and at times structural damage”.

Now, I don’t want to go all worst-case-scenario on you and start going on about brain damage and whatnot. My point is that even if mild traumatic brain injury can’t always be recorded in medical imaging, over the long term, it can lead to problems, even structural damage.

Researchers are still learning a lot about mTBI/concussion, and they have a ways to go before they fully understand all the mechanics and impacts of it. But at least they’re starting to “get” that this is a real problem for real people, and it’s to be taken seriously. They’re making the important distinction that

In most cases, patients who experience mTBI will recover fully, typically within days to months. The concern is that, as the Centre for Disease Control (CDC) notes, “up to 15% of patients diagnosed with mTBI may have experienced persistent disabling problems” (CDC, p.3). The consequences for these individuals may include reduced functional ability, heightened emotional distress, and delayed return to work or school (MAA NSW, 2008). When symptoms persist beyond the typical recovery period of three months the term post-concussion syndrome or disorder may be applied.

So, while the majority of people do recover on their own from concussion/mild TBI within days or weeks or months, the fact remains that there are a whole lot of people who don’t. And those people who don’t can be disabled by their symptoms and the issues that surround them.

And here we come to the domain of post-concussive disorder/syndrome — that twilight zone where things get all jumbled up for no apparent reason, and a whole lot of stuff stops making sense, and you start to hear things like…

“It’s been months, even years, since your TBI — why aren’t you better yet?”

“You look fine — why are you pretending to be sick?”

“This should be easy for you — why are you having such a hard time with it?”

Everybody seems to think that recovery from concussion is a given, but sometimes it’s not. Sometimes the symptoms last for years and years, and even the people closest to you, the people who you’d expect to understand that you’re not exactly the same as you used to be, can’t seem to get their heads around the fact that you need more sleep, or you need to think things through more slowly, or you need to have more routine, than the “average” person. And they judge you for it. Sometimes they give up on you. Which is — sorry — total bullshit.

Can I tell you, the last one — “This should be easy for you — why are you having such a hard time with it?” — is probably the toughest for me — and it’s especially hard hearing it from inside my own head. I swear, there are a whole lot of things that I am certain should make a whole lot more sense to me, than they do — there are things I hear that I feel I should understand, directions I receive that I feel I should get, and there are things I’m tasked with that I should be able to complete with no problem.

But for some reason I can’t. It’s like my brain isn’t working. I usually end up soldiering on and just having a go at it — giving it my best shot and keeping on trying till I get it right. But I swear to GOD, it is maddening. You would think that after all this time, I would be able to get my act together.

In a way, I think I’ve kind of given up trying to get everything back in place the way I want it to be, the way it’s comfortable for me. I guess I’ve made peace with the fact that I am probably not going to get a lot of things right the first time, but I need to just keep trying. There are so, so many things that I have thought I was doing right, then I found out I was doing them all wrong… then I’d look back, six months later, and wonder why the hell it was so hard for me. It just makes no sense. But learning new things — even refining old things — takes what feels like an eternity for me, sometimes.

Still, I can’t let it get me down. If I keep my energy up and keep myself reasonably healthy and engaged in my life, I can just keep going… just keep going… till I figure things out. I just need to keep moving, keep rethinking things, keep my spirits up and keep trying. And if I treat this as an adventure and a chance to explore and learn new things about myself, it puts my experience in a very different light.

And that’s a challenge, because over the years, my anxiety has gotten to the point where a part of me HAS TO HAVE EVERYTHING COMPLETELY UNDER CONTROL, or it freaks out. A part of me craves order and predictability, it relies on routine, and being able to plan and anticipate and properly respond to my life situations. It’s that part that helps me get my routines in order, helps me keep going, helps me keep fit for work and life. But that part of me is constantly frustrated, constantly thwarted by the other parts of me that have gotten rewired and turned around over the years. So, it’s a constant source of tension for me.

A creative tension, really.

And when I think about it, it’s not all bad… there are some good parts to that tension. It spurs me on to do better, to make positive changes in my life and in the lives of others. It moves me to improve. And it moves me to explore.

The most important thing is keeping an open mind — that’s what transforms my situation from a terrible, awful burden, to an opportunity to learn and grow. It’s when I don’t cut myself slack, when I forget that the issues I’m having are because of what happened to my brain, not what my own inherent self-worth is, not what others think my problem is, and NOT because there is anything wrong with me… that’s when things start to get dicey.

In a way, acknowledging that my issues are neurological is both a blessing and a curse. A two-edged sword. But for now, for today, I’m going to focus on the blessing part.

Because I can.

 

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mTBI Guidelines and Persistent Symptoms – the scope of the work

Click the image to download the guidelines (156 pages - PDF)

I’m back to reading the PDF Guidelines for Mild Traumatic Brain Injury (MTBI) and Persistent Symptoms from the Ontario Neurotrauma Foundation, and I’m taking my time, because I want to really understand what they’re saying.

What’s jumped out at me right off the bat is that:

  1. They take mild traumatic brain injury seriously. This is really important, because in the world of brain injury, attaching the word “mild” to the injury can make it seem like it’s minor. I’ve been told that using “mild” in describing brain injury is falling out of use, however, in the medical establishment, I don’t think that’s going to change anytime soon — the degree of injury at the time of the accident/assault/event determines what sort of immediate care you receive, so that gets on your chart and your medical record for all time, and in a way that’s kind of “who you become” in the eyes of the healthcare workers who deal with you from that point on. Even so, the ultimate complications may turn out to be way more than “mild”. Hence, it’s important to start out saying “We’re talking about ‘mild’ injuries, people, and yes they are serious and can have some pretty impactful long-term effects” — at one time, they are acknowledging the relative “mildness” of the initial injury and also setting the context for future discussion. In fact, using that apparent contradiction/paradox as a basis, might actually help to get their message across even more.
  2. They emphasize the long-term effects and actually talk about them in terms of being immediately responsive and pro-active in how healthcare professionals address mild TBI. They acknowledge that there is literally no “best practice” clearly defined for treating folks who do not experience spontaneous recovery from mild TBI. And then they go on to use the sense that God gave them — they set about looking for an approach to “screen for and identify patients that are at high-risk of persistent symptoms” and also develop a management plan for the symptoms that are commonly associated with these symptoms. Pretty amazing… they actually intend to develop “clinical guidelines is to improve patient care by creating a framework that can be implemented by health professionals to effectively identify and treat individuals who manifest persistent symptoms following mTBI”.

I’m going to deliberately overlook the fact that the medical establishment has, up to this point, not felt it was important enough to actually do this before. Let’s not dwell on that maddening fact.

Let’s focus instead on the fact that someone is doing it now, and they are off to a good start, from what I can tell from the first 10 pages of the PDF. And they are coming from a medical standpoint, so the general practitioners of the world who are seeing all these folks who had a car accident or sports concussion six months ago and still aren’t getting any better, won’t be left out in the cold wondering WTF?!, when it comes to these types of patients.

That said, now it’s on to the next paragraph — on page 5, the Scope of the work. (I’m adding my own emphasis below)

The present guidelines are appropriate for use with adults (≥ 18 years) who have experienced mTBI. The present guideline is not appropriate for use with patients who have incurred penetrating brain injuries, birth injuries, brain damage from stroke or other cerebrovascular accidents, shaken baby syndrome, or moderate to severe closed head injuries. The guideline addresses early management to only a limited extent because the purpose of this document is to provide guidance on the assessment and treatment of persistent symptoms. Nonetheless, because early management can influence the development and maintenance of persistent symptoms, the most critical issues regarding early management have been incorporated. For more comprehensive guidance on prehospital and acute care, readers are directed to the Motor Accidents Authority of NSW ‘Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury’ (MAA NSW, 2008,
http://www.maa.nsw.gov.au/default.aspx?MenuID=148). The present document targets healthcare professionals providing service to individuals who have experienced mTBI, including health care providers, neurologists, physiatrists, psychiatrists, psychologists, counselors, physiotherapists, occupational therapists, and nurses. (p5 “Scope”)

More good stuff. They’re clear about who this is for. It’s for adults who are least 18 years of age or older, who have experienced mild traumatic brain injury. This is an important distinction because the more we find out about mTBI and concussion, the more we realize that kids are affected differently than adults — small children are affected differently from teens and adults, and teens are affected differently from small children and full developed adults. I wonder if the 18-year cutoff might be a little controversial, since I’ve read/heard that the brains of males are not fully mature until age 24 or so. I’ve heard that all young adults have still-developing brains. So, I wonder if there might be a gray area around the ≥ 18 years qualifier. And I wonder if this isn’t going to spur more research and similar guidelines for teens and small children.

Anyway, the main point is that it’s a start at differentiating between adults and non-adults, and yes, that piece of information is important, too, because too many people — doctors and other healthcare folks included — aren’t fully up to speed on the differences. It’s also significant to me because in the world of mild traumatic brain injury/concussion, when adults are impacted and cannot get adequate care, everyone is affected — their spouses/partners, their kids, their own parents, their employers, their co-workers, everyone they interact with in the adult world. Their difficulties affect our whole system — our economics, our politics, the social fabric of our culture — in ways that kids’ issues simply can’t. So, coming up with guidelines for treating adults can have far-reaching benefits and consequences throughout the whole of society.

The next important distinction is that this “guideline is not appropriate for use with patients who have incurred penetrating brain injuries, birth injuries, brain damage from stroke or other cerebrovascular accidents, shaken baby syndrome, or moderate to severe closed head injuries.” This is an important distinction because mild TBI has its own set of “exciting” complications that don’t necessarily translate to other sorts of acquired or traumatic brain injuries. mTBI is in a class of its own — and yet, it can have confusing and frustrating overlaps and similarities with other brain conditions, such as stroke or birth injuries or penetrating brain injuries like gunshots or Phineas Gage’s much-studied case.

Mild Traumatic Brain Injury is in a class of its own, as so many of us can attest. And its initial complications can mutate into a whole host of other problems on down the road. Not taking it seriously, or trying to apply treatment/coping mechanisms to it that are really developed for other kinds of brain injury can be terribly frustrating and counter-productive. It’s important to acknowledge that this is a condition that stands on its own and needs to be considered and treated as a distinct condition.

And now we come to the proposed management strategy — They say they’re going to talk about early management only a bit, because they’re really talking about long-term issues that don’t resolve. It’s a good place to come from — being clear like that. At the same time, they do say they’re going to talk about early management, because it “can influence the development and maintenance of persistent symptoms, the most critical issues regarding early management have been incorporated.” So, I could see this document serving two uses:

  1. To teach healthcare folks how to understand, treat, and manage long-term mTBI issues, to teach them to take it seriously — and also give them tools and information they can use to improve their medical practice.
  2. To heighten awareness about all the crap that can go wrong, if you don’t manage the injury properly at the start — a kind of wake-up call for the healthcare folks who dismiss concussion and mild TBI as something that “takes care of itself”. 10-15% of mild traumatic brain injury survivors don’t spontaneously recover — and I wonder how much that might change, if the injury were properly managed from the get-go.

And then they give us a link to more comprehensive guidance on prehospital and acute care which is great – I checked it out and there is a lot of information there. Too much for me to get through right now. Since I’m working on my focus and not getting distracted, I’ll focus on the ONF pdf before I go wandering off to other things 😉

So, whom do they intend to educate with this document?

  • healthcare professionals providing service to individuals who have experienced mTBI, including health care providers
  • neurologists
  • physiatrists
  • psychiatrists
  • psychologists
  • counselors
  • physiotherapists
  • occupational therapists
  • and nurses

That’s a pretty comprehensive list, and I have my own individual hopes for how this document can shape the perceptions and approach of each. Here’s my wish list:

  • For healthcare professionals providing service to individuals who have experienced mTBI, including health care providers — I hope that they gain a heightened awareness of the issues that mTBI survivors can deal with on a daily basis, and that they stop writing us off as malingerers and fakers, and start taking our issues seriously.
  • For neurologists — I hope that they can find a common nomenclature, a common conceptual framework within which to place mild TBI. I also hope that they will stop dismissing us because our injuries were “mild” and that they’ll gain a greater long-term view of the consequences of their actions at the start of the injury management. Mild TBI is not an injury that always “just clears up” — when it doesn’t, the choices made and actions taken at the start, can have dire long-term consequences, which result in untold, needless, and often avoidable suffering.
  • For physiatrists, physiotherapists and occupational therapists— I hope that, like neurologists, they gain a greater appreciation of the impacts that mTBI can have on a person, and connect the dots between the different aspects of the injury – physical, mental, emotional, and yes, spiritual. Being in rehab, it’s also so important for them to not fall into cookie-cutter responses to mTBI survivors, because our symptoms and issues can shift and change over time. Plus, at times, our issues can seem to be improving, when they’re really not — we may be able to better manage the pain and confusion and sensitivities, but they are still very much there and very much a part of our experience. So, please don’t dismiss them because we seem to be doing so much better.
  • For psychiatrists, psychologists and counselors — I hope that they come to see that there can — and will — be physiological reasons for and connections with mental health issues that some of their clients have. I truly hope that they can somehow learn to see the physical aspects of mental health, and to acknowledge the neurological basis for many issues. Rather than trying to address certain problems at a psycho/spiritual level, it can be a whole lot more effective to address them at their physiological roots and foster better mental health by encouraging things like getting good sleep, exercising, and eating right. Acknowledging the neurological and physiological basis for some mental health issues is not caving in to the competition or losing ground to the “hard sciences” — it’s identifying concrete things that can be addressed through behavior modifications and support and focused intention — and in solving issues at the root level, you can get out of the business of constantly talking people back from the ledge, and helping them to live truly full and amazing lives. I honestly can’t imagine why a counselor wouldn’t want to get out of the “mental health maintenance” business and take on more of the work of true life transformation. Seriously — wouldn’t it be amazing if you went to work everyday and saw your clients doing amazing things with their lives, instead of just trying to stop them from screwing up, time and time again?
  • And for nurses — I hope that this document helps raise awareness — just as it could for doctors and neurologists — only on a much more thorough-going basis. I had a relative, years ago, who was in a terrible car accident and sustained a brain injury in the process. But the nurses on staff treated her like she was being uncooperative on purpose. She literally could not speak properly anymore or lift/move her hands and body, but the nursing staff treated her like she was a cranky old lady who was coming off long-time Valium use — they treated her like a junkie going through withdrawal, when she had really been brain injured and was not receiving proper rehabilitative care. It wasn’t until a trauma doctor happened up on her and told everyone that she was in fact brain injured, that she started to get proper help. I don’t fault the nurses — they had every reason to believe it was antidepressant withdrawal that was causing the problems. But it wasn’t — it was a brain injury. And I spent every Tuesday and Thursday nights (after work) and most of the day Saturday for the next six months or so, sitting and working with and helping her to restore her ability to interact and relax and think and express herself, watching her improve each week. I really believe in the work that nurses do, and I really believe that if they were given the right information and properly trained about mild TBI, they could play a hugely important role in diagnosing and treating brain injury. I also believe they might be able to mitigate some of the conditions that exacerbate the effects of TBI. Just a higher awareness and also a genuine caring about what mild TBI can do to a person’s body, mind, heart, and sense of self, might make a real difference in the world.

So, those are my hopes for the audience of this document.

Now, how to get it into the hands of those who are best served by it?

That, my friends, is the question.

But I digress. I’ve written a whole lot about this matter, and it’s time for me to get on with my day. I’ll be reading more and writing more — rest assured, as this is really great stuff to “chew on”.

Happy reading…

Perfect for Brain Injury Awareness Month

Happy, happy, happy... so far

I just started reading the PDF from the Ontario Neurotrauma Foundation about Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms. And I’m off to a great start.

These are

“guidelines that can be used by healthcare professionals to implement evidence-based, best practice care of individuals who incur a mild traumatic brain injury (mTBI) and experience persistent symptoms. Persistent symptoms are not an uncommon complication of mTBI; 10 to 15% of individuals who incur mTBI will continue to experience significant symptoms beyond the normal recovery period of three months (Iverson, 2005), which can include post-traumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue, and mood or affective disorders. With the high incidence of mTBI this potentially translates to a significant number of individuals who may experience associated disability.”

Currently, the best practice for treatment of those who do not experience spontaneous recovery is not clearly defined. Therefore, the following clinical questions needed to be addressed — Can an approach be devised to screen for and identify patients that are at  high-risk of persistent symptoms and, once identified, can a management plan be developed to treat the symptoms commonly associated with the disorder? Hence the purpose of developing the clinical guidelines is to improve patient care by creating a framework that can be implemented by health professionals to effectively identify and treat individuals who manifest persistent symptoms following mTBI. (p.5 of the PDF – emphasis mine)

Reading this feels completely %(*&*#$(*^ awesome. Can I just say, to hear a recognized foundation acknowledge the importance of this, and to acknowledge that 10-15% of mild TBI survivors experience serious issues which can literally disable us (for long or short term)… it’s pretty amazing. What a feeling.

I’m going to quell the impulse to rue my lost past, when so much was unknown, and the only explanation people could come up with was that I “wasn’t trying hard enough” or I was “lazy” or a “problem”. I’m going to be deliberately happy for everyone who can and will benefit from this — and I’m going to urge everyone in the strongest terms possible to please make sure your doctor has a copy of this, when you see them about your issues. After all, this information is only as good as the people it informs — the people with the power to make a difference.

Granted, I’ve just started reading, and there may be information in there that doesn’t square with my own views and experience.

But so far, we’re off to a good start.

You can download the full PDF from the Ontario Neurotrauma Foundation here.

Guidelines for Mild Traumatic Brain Injury (MTBI) and Persistent Symptoms

Click the image to download the guidelines (156 pages - PDF)

The Concussion Blog post Now This is a Possible Game Changer has just posted some pretty great news about recognizing and responding to TBI/concussion. The Ontario Neurotrauma Foundation has produced “comprehensive, evidence-based, set of recommendations that broach all four parts of a concussion: physical, cognitive, sleep, and social/behavioral”.

This is important. Because up till now a lot of folks have been talking about TBI solely in terms of the physical OR cognitive OR sleep OR social/behavioral issues. Rarely have I found a professional organization addressing them all in one place.

I’m also very hopeful because this information comes from a neurotrauma foundation — the kind of information source that doctors and other healthcare professionals may just take seriously, instead of blowing off patients who have a host of issues and “complaints” that make no sense to them on the surface.

I just downloaded the full pdf of the guidelines yesterday, so I haven’t had a chance to go through it all, but from my skimming last night, it looks like there might be some good stuff in there. I hope to spend some time this weekend reading and digesting and writing about what they have to say.

Because as great as it is for there to be professional expansion on this, the fact remains that a whole lot of us folks “on the ground” don’t have access to good professional care, and sometimes the one hope/lifeline we have is online — the stories and information and interpretation of official information sources in language that we can actually understand. There’s a whole lot of science going on these days, but understanding it and getting what it all means is a different story. I hope to fill that gap a bit with my work on this site.

You can download the full PDF from the Ontario Neurotrauma Foundation here.

Truly excellent writing — and reading

This is a profoundly insightful and important blog post.

Could This Be The Reason Traumatic Brain Injury Is Misdiagnosed and Untreated?

What is the real reason traumatic brain injury is misdiagnosed, untreated or under treated?  Do we have enough rehabilitation centers in America to accommodate 1.7 million people every year?  Is this a national problem or local issue? I cannot believe they missed the most obvious of all … brain injury. I was the patient with all the issues…but the healthcare professionals still expect you have it all together to let them know what’s going on.  What one does know is most head injuries, strokes, and many diseases of the brain are not classic in any way.  The emergency room personnel look for only the classic obvious symptoms: one sided weakness, dropping of the facial muscles, slurred speech, and others.  These are not necessarily symptoms that appear with the 1.7 million traumatic brain injuries every year.

Really great stuff. Should be a must-read for all medical folks.

It’s a wake-up clarion call about the treatment of people with brain injuries, and it’s the kind of message you really have to read several times to fully digest. At least, I have to read it a few times 😉

Read the whole piece here >>

Good News For Rural Stroke Patients: Virtual Stroke Care Appears Cost-Effective

For those who have experienced stroke / brain injury… as well as their caregivers… you all know how lonely and isolating it can be, and getting help can be a real problem.

Just knowing you need help — what kind, to what extent, what to do… what to do?! — can be a problem.

Now, there’s a program called telestroke that has been tested. The results are promising. Read about it here.

Brain injury unfolds over months: study

Just found this news

Australian research has found the damaging effect of a traumatic brain injury, caused by a car crash or hard blow to the head, unfolds not over minutes or days but over months.

The study, conducted at the University of Melbourne, underscores the fragility of the brain but it has also uncovered a broad “window” in which effective treatment could improve a patient’s outcome.

“We have demonstrated that changes in brain structure and function after traumatic brain injury are dynamic, and continue to progress and evolve for many months,” said Professor Terry O’Brien, head of the university’s Department of Medicine.

“This opens up a window of opportunity to give treatments to halt this damage and therefore reduce the long-term neurological and psychiatric complications that many patients experience.”

Read the whole article here…

Stop saying PTSD (and TBI) is incurable

I came across a great post by Belleruth Naparstek over at Huffington Post about how well-intentioned professionals are running around saying that PTSD is incurable — an intractable condition.

Huh. How about that. Sounds to me like we’re all screwed, because a ton of people have PTSD, and it affects their families and friends and coworkers, and if it’s an intractable, incurable condition, we’re all stuck dealing with it for all time.

Which doesn’t sound right to me.

So, I’m glad Belleruth is talking about non-standard ways of dealing with it. And I have to think, also, about how I employ similar techniques to deal with the stresses of my TBI-related difficulties.

I strongly recommend the article. And the piece I’m taking away is:

[There are] consistent threads running through these approaches:
1. They first and foremost find ways to re-regulate the nervous system.
2. They destigmatize and normalize the experience by explaining PTS as the somatic and neurophysiologic condition it is.
3. They offer simple, self-administer-able tools that empower the end-user and confer a sense of mastery and control.
4. The interventions are cast as training in skill sets, not the healing of pathology.

They treat PTSD as a physical condition, first, and they teach people how to deal with that aspect of their lives.

I have found, in my own dealings with TBI-related stress, that this same kind of orientation helps a whole lot. I have to take seriously the physiological aspects of my condition, which tweak the psychological parts of me. And when I approach the situation with a physical orientation, the results really are like magic.

Except they’re not magic — they’re physiology. Which well-trained psychological professionals miss, because it all happens in realm of  a “frozen, primitive, pre-language experience – sensation, perception, emotion, images and motor reactivity – in the survival-based structures of the brain.”

I wonder… if people treated the stresses of TBI the same way that they treat the stresses of combat and other traumas, with this non-standard, non-talk-therapy approach, how much of a difference would it make? If I’m any indicator, that would be a whole lot of difference.