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Papers by Richard Almond

Psychiatry MMC, Nov 1, 1973

Psychoanalytic Dialogues, Feb 5, 2008

ABSTRACT Although psychoanalysis is by its nature a social process, conceptualizations of the pro... more ABSTRACT Although psychoanalysis is by its nature a social process, conceptualizations of the process have not acknowledged that the two participants function within social roles. The resistance to understanding the way that these subtle role structures affect clinical process is illustrated by the discussants' responses to a paper delineating the analytic role and the patient's role. The author suggests that although psychoanalytic language is increasingly relational, resistance to a social view stems from the persistence of monadic models in analytic thinking and discourse. This tendency, in turn, stems from the vantage point of the clinical theorist, which is as observer of either self or patient. It is difficult to observe the interaction itself. The contribution of the concept of role in the analytic relationship is a beginning effort at providing some terminology for such conceptualization.

Journal of the American Psychoanalytic Association, Oct 1, 2013

P sychoanalytic discourse often describes an ideal course of analy-sis, one that then becomes a n... more P sychoanalytic discourse often describes an ideal course of analy-sis, one that then becomes a norm for analysts and analytic discus-sion. It is well to remind ourselves that this ideal, or norm, developed first when Freud was conducting analyses in six months or a year, and believed that familiarity with unconscious process would be curative. Our idea that an analysis has a predictable course, a completeness in address-ing conflict, and a decisive termination stems from these early days. Contemporary discussions of crises and impasses in treatment, along with recognition of enactments and countertransference in general, have enriched our picture, just as Freud did in “Analysis Terminable and Interminable ” (1937). Investigations of the actual course of patients in and following analysis through follow-up has added further to creating a real understanding of where analytic experience may fit into patients’ lives (Schachter 2009; Wallerstein 1986). A recent invitation to report on my experience with psychoanalytic patients who returned for more treatment later on, and the lessons I

Psychoanalytic Dialogues, May 4, 2015

Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectiv... more Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectivity, and mutual influence. The area that has been explored least in this two-person appreciation of psychoanalytic process is the effect of the psychodynamics of the therapist in a wide sense-that is, how the therapist brings a whole psychology, with a wide array of potential transferences, to each treatment. Triggered by the unexpected announcement of a patient's expecting a baby, the author reviewed his practice and found that a large portion of his women patients ages 30-45 had become pregnant during therapy or psychoanalysis. The particulars were varied: how much the patient wanted a baby, whether the treatment was psychotherapy or psychoanalysis, the patients' personality structure. Was the analyst's psychology a common factor? The paper presents three quite different case examples and examines whether and how the author's developmental and inner experience of women, sexuality, pregnancy could have contributed to a dyadic process that, in turn, could lead to pregnancy. If such effects happen, then it is important to look beyond and behind "anonymity" and "neutrality," as well as momentary countertransferences, to the real-life effects that we have in our treatments. 1 A very rough review of my practice suggests that more than one third of the patients in the possible group got pregnant during treatment, and another third had a child subsequently (letting me know), for a total of two thirds of the total. My impression is also that this proportion increased to roughly half, as my practice continued, and I saw more women in the latter part of the child-bearing years (ages 30-45). As a baseline comparison, the average child-bearing rate for the age group 30-45 in recent years is 5.5%/year. If my treatment contacts averaged 5 years in length, the "control group" rate would be 28%. My patient population tended to be in the 35-to 45-year-old range, where the "control" rate would be 17%.

Journal of the American Psychoanalytic Association, Mar 1, 2003

As multiple theoretical models contend on the American analytic scene, the holding function of th... more As multiple theoretical models contend on the American analytic scene, the holding function of theory emerges as a unifying theme. In addition to supplying an intellectual superstructure for the working analyst, theory provides a psychological presence—a sense of conviction, affective stability, reassurance, and self-esteem— that makes effective analytic work possible from the analyst's side. Ideological passions and differences arise from the vital need for the holding function in an intense and inchoate engagement like psychoanalysis. To show how adherents of different models use theory in practice, three clinical cases are reviewed, one from Betty Joseph, one from Lewis Aron, and one from the author. The last example reconstructs the analyst's subjective experience of treatment both in the selected hours and in terms of the analyst's preconscious use of theory.

Psychoanalytic Dialogues, Feb 5, 2008

Who we are depends on the situation we are in. Psychoanalysis, like any other recurrent social ac... more Who we are depends on the situation we are in. Psychoanalysis, like any other recurrent social activity, is conducted under the influence of implicit social roles. Our technical emphasis on free association and other unstructured aspects of the analytic setup tends to minimize awareness of the degree to which both analyst and patient orient around role expectations. The analyst's role is the result of enculturation during training and after; the patient's role is a product of character, transference, and analytic influence. This paper explores the way in which the alternation and tension between role and nonrole aspects of the psychoanalytic relationship is at the center of therapeutic process and change. The author illustrates the way in which role and nonrole aspects of process appear in a case study, both over longer stretches of time and in particular moments. Understanding the importance of analytic roles clarifies some dilemmas and contradictions in older discussions of technique and modern relational theory.

Psychoanalytic Psychology, 2004

Journal of the American Psychoanalytic Association, Apr 1, 1999

The psychoanalyst's expectations of the patient are complex and crucial to the work of an... more The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the `microstructure` of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.

Journal of Psychiatric Research, May 1, 1974

Journal of the American Psychoanalytic Association, Apr 1, 1995

Recognition of the analyst's subjective involvement has led to profound reconsideration of th... more Recognition of the analyst's subjective involvement has led to profound reconsideration of the nature of mutative process. How is it that the analyst can be personally involved in an unconscious way, yet also be an “objective” participant in the relationship? The paper proposes that the analyst's subjectivity is mediated by his or her role. The analytic role conditions how the analyst listens, experiences, and behaves, leading to interactive outcomes different from that expectable from unmodified subjectivity. The paper describes the analytic role in terms of contributions from metapsychology, clinical theory, and tactics. Each affects the function of the analyst-at-work in a different way. The analytic role, learned during training, is maintained by a combination of internalization and ongoing involvement in psychoanalytic activities. A clinical illustration demonstrates how a typical transference-countertransference enactment is influenced by the analytic role. The vignette suggests ways in which the concept of role modifies the effect of subjectivity. Three recent viewpoints-those of Renik, Ehrenberg, and Hoffman-that challenge previous theories of mutative process are discussed in terms of the analytic role. In each case, consideration of role clarifies the nature of the innovative technique or view, and seeming contradictions between it and existing clinical theory.

Journal of the American Psychoanalytic Association, Dec 1, 2015

Journal of the American Psychoanalytic Association, Feb 1, 2015

J ay Greenberg’s “Therapeutic Action and the Analyst’s Responsibility” uses the idea of “fictions... more J ay Greenberg’s “Therapeutic Action and the Analyst’s Responsibility” uses the idea of “fictions” or “controlling fictions” to develop a number of significant points in the ongoing discussion of psychoanalytic pluralism: What is the epistemological status of our theoretical models? Greenberg’s answer: they are powerful fictions, shared among communities of believers, controlling our thought and action. These fictions contend as equals in the marketplace of ideas. We value our fictions because they tell us how to act with patients—though there is always a tension between our preferred fiction and the immediate press of an actual patient. Ultimately, psychoanalytic experience is so dense that we cannot hope to know which is best, more “right,” among contending fictions. I will look at Greenberg’s theses in the context of our current literature and my experience. My discussion will demonstrate the heuristic value of Greenberg’s paper, though I have strong disagreements regarding his conclusions, and with his view of the state of psychoanalytic knowledge. Greenberg’s ideas about psychoanalytic fictions are powerful and in some ways familiar statements about psychoanalytic theory and process,

Psychiatry MMC, Aug 1, 1969

Psychoanalytic Dialogues, May 4, 2015

The target paper had the purpose of drawing attention to something “beyond countertransference”—t... more The target paper had the purpose of drawing attention to something “beyond countertransference”—the impact of the therapist’s psychology on the treatment, not in reaction to the patient, but as desires and defenses that operate throughout. The illustrative issue was a speculation that my development and analytic engagement carried elements that led me to interact with women patients in a way that increased the likelihood of their conceiving. The respondents reacted differently to the provocative aspect of this idea, but have in common a recognition of the analyst’s desire as an important part of the relationship. A further case vignette is introduced in this reply to examine some of the points raised by the respondents, in particular how the analyst’s desire may be expressed in a form that is modulated by the analytic role and at the same time has an impact on the patient’s life decisions. In sum, we are players in the drama of analytic work, and the more we think about what and how we are ourselves in treatments, the more informed our inevitable impact will be.

Psychoanalytic Study of The Child, 1989

JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, ha... more JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, has as a major theme the process of psychological change. I will compare Austen's depiction with the psychoanalytic process to help identify universal features of how people change. This approach can be seen as the inverse of that of Spence (1982), who suggests that psychoanalysis can be understood as a process in which analyst and patient strive to interpret the "text" of the analytic dialogue in the manner of literary criticism. As they develop their romantic bond, the novel's lovers, Elizabeth Bennet and Fitzwilliam Darcy, move from one psychological position to another. They each have some difficulties; they encounter traits and attitudes in themselves that prevent their development. To become partners each must change. This change does not occur in isolation; one serves as a foil for the other, like parent and child or patient and therapist. In psychoanalysis we observe and participate in a powerful and change-inducing experience. Analysts differ significantly in their opinions about how change comes about (

The Psychoanalytic Study of the Child, 1989

JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, ha... more JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, has as a major theme the process of psychological change. I will compare Austen's depiction with the psychoanalytic process to help identify universal features of how people change. This approach can be seen as the inverse of that of Spence (1982), who suggests that psychoanalysis can be understood as a process in which analyst and patient strive to interpret the "text" of the analytic dialogue in the manner of literary criticism. As they develop their romantic bond, the novel's lovers, Elizabeth Bennet and Fitzwilliam Darcy, move from one psychological position to another. They each have some difficulties; they encounter traits and attitudes in themselves that prevent their development. To become partners each must change. This change does not occur in isolation; one serves as a foil for the other, like parent and child or patient and therapist. In psychoanalysis we observe and participate in a powerful and change-inducing experience. Analysts differ significantly in their opinions about how change comes about (

Research publications - Association for Research in Nervous and Mental Disease, 1969

Journal of Psychiatric Research, 1971

ABSTRACT The interrelations of a variety of outcome measures are reported for a series of 65 cons... more ABSTRACT The interrelations of a variety of outcome measures are reported for a series of 65 consecutive admissions to a milieu therapy inpatient psychiatric unit. Correlations between various outcome variables were found to be suprisingly low, except when the variables were derived from the same time and the same evaluator-patient relationship. Findings were interpreted as reflecting the fact that no single criterion of ‘outcome’ is sufficient, and that a more differentiated view of the impact of treatments must be considered.

Psychiatry MMC, Nov 1, 1973

Psychoanalytic Dialogues, Feb 5, 2008

ABSTRACT Although psychoanalysis is by its nature a social process, conceptualizations of the pro... more ABSTRACT Although psychoanalysis is by its nature a social process, conceptualizations of the process have not acknowledged that the two participants function within social roles. The resistance to understanding the way that these subtle role structures affect clinical process is illustrated by the discussants' responses to a paper delineating the analytic role and the patient's role. The author suggests that although psychoanalytic language is increasingly relational, resistance to a social view stems from the persistence of monadic models in analytic thinking and discourse. This tendency, in turn, stems from the vantage point of the clinical theorist, which is as observer of either self or patient. It is difficult to observe the interaction itself. The contribution of the concept of role in the analytic relationship is a beginning effort at providing some terminology for such conceptualization.

Journal of the American Psychoanalytic Association, Oct 1, 2013

P sychoanalytic discourse often describes an ideal course of analy-sis, one that then becomes a n... more P sychoanalytic discourse often describes an ideal course of analy-sis, one that then becomes a norm for analysts and analytic discus-sion. It is well to remind ourselves that this ideal, or norm, developed first when Freud was conducting analyses in six months or a year, and believed that familiarity with unconscious process would be curative. Our idea that an analysis has a predictable course, a completeness in address-ing conflict, and a decisive termination stems from these early days. Contemporary discussions of crises and impasses in treatment, along with recognition of enactments and countertransference in general, have enriched our picture, just as Freud did in “Analysis Terminable and Interminable ” (1937). Investigations of the actual course of patients in and following analysis through follow-up has added further to creating a real understanding of where analytic experience may fit into patients’ lives (Schachter 2009; Wallerstein 1986). A recent invitation to report on my experience with psychoanalytic patients who returned for more treatment later on, and the lessons I

Psychoanalytic Dialogues, May 4, 2015

Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectiv... more Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectivity, and mutual influence. The area that has been explored least in this two-person appreciation of psychoanalytic process is the effect of the psychodynamics of the therapist in a wide sense-that is, how the therapist brings a whole psychology, with a wide array of potential transferences, to each treatment. Triggered by the unexpected announcement of a patient's expecting a baby, the author reviewed his practice and found that a large portion of his women patients ages 30-45 had become pregnant during therapy or psychoanalysis. The particulars were varied: how much the patient wanted a baby, whether the treatment was psychotherapy or psychoanalysis, the patients' personality structure. Was the analyst's psychology a common factor? The paper presents three quite different case examples and examines whether and how the author's developmental and inner experience of women, sexuality, pregnancy could have contributed to a dyadic process that, in turn, could lead to pregnancy. If such effects happen, then it is important to look beyond and behind "anonymity" and "neutrality," as well as momentary countertransferences, to the real-life effects that we have in our treatments. 1 A very rough review of my practice suggests that more than one third of the patients in the possible group got pregnant during treatment, and another third had a child subsequently (letting me know), for a total of two thirds of the total. My impression is also that this proportion increased to roughly half, as my practice continued, and I saw more women in the latter part of the child-bearing years (ages 30-45). As a baseline comparison, the average child-bearing rate for the age group 30-45 in recent years is 5.5%/year. If my treatment contacts averaged 5 years in length, the "control group" rate would be 28%. My patient population tended to be in the 35-to 45-year-old range, where the "control" rate would be 17%.

Journal of the American Psychoanalytic Association, Mar 1, 2003

As multiple theoretical models contend on the American analytic scene, the holding function of th... more As multiple theoretical models contend on the American analytic scene, the holding function of theory emerges as a unifying theme. In addition to supplying an intellectual superstructure for the working analyst, theory provides a psychological presence—a sense of conviction, affective stability, reassurance, and self-esteem— that makes effective analytic work possible from the analyst's side. Ideological passions and differences arise from the vital need for the holding function in an intense and inchoate engagement like psychoanalysis. To show how adherents of different models use theory in practice, three clinical cases are reviewed, one from Betty Joseph, one from Lewis Aron, and one from the author. The last example reconstructs the analyst's subjective experience of treatment both in the selected hours and in terms of the analyst's preconscious use of theory.

Psychoanalytic Dialogues, Feb 5, 2008

Who we are depends on the situation we are in. Psychoanalysis, like any other recurrent social ac... more Who we are depends on the situation we are in. Psychoanalysis, like any other recurrent social activity, is conducted under the influence of implicit social roles. Our technical emphasis on free association and other unstructured aspects of the analytic setup tends to minimize awareness of the degree to which both analyst and patient orient around role expectations. The analyst's role is the result of enculturation during training and after; the patient's role is a product of character, transference, and analytic influence. This paper explores the way in which the alternation and tension between role and nonrole aspects of the psychoanalytic relationship is at the center of therapeutic process and change. The author illustrates the way in which role and nonrole aspects of process appear in a case study, both over longer stretches of time and in particular moments. Understanding the importance of analytic roles clarifies some dilemmas and contradictions in older discussions of technique and modern relational theory.

Psychoanalytic Psychology, 2004

Journal of the American Psychoanalytic Association, Apr 1, 1999

The psychoanalyst's expectations of the patient are complex and crucial to the work of an... more The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the `microstructure` of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.

Journal of Psychiatric Research, May 1, 1974

Journal of the American Psychoanalytic Association, Apr 1, 1995

Recognition of the analyst's subjective involvement has led to profound reconsideration of th... more Recognition of the analyst's subjective involvement has led to profound reconsideration of the nature of mutative process. How is it that the analyst can be personally involved in an unconscious way, yet also be an “objective” participant in the relationship? The paper proposes that the analyst's subjectivity is mediated by his or her role. The analytic role conditions how the analyst listens, experiences, and behaves, leading to interactive outcomes different from that expectable from unmodified subjectivity. The paper describes the analytic role in terms of contributions from metapsychology, clinical theory, and tactics. Each affects the function of the analyst-at-work in a different way. The analytic role, learned during training, is maintained by a combination of internalization and ongoing involvement in psychoanalytic activities. A clinical illustration demonstrates how a typical transference-countertransference enactment is influenced by the analytic role. The vignette suggests ways in which the concept of role modifies the effect of subjectivity. Three recent viewpoints-those of Renik, Ehrenberg, and Hoffman-that challenge previous theories of mutative process are discussed in terms of the analytic role. In each case, consideration of role clarifies the nature of the innovative technique or view, and seeming contradictions between it and existing clinical theory.

Journal of the American Psychoanalytic Association, Dec 1, 2015

Journal of the American Psychoanalytic Association, Feb 1, 2015

J ay Greenberg’s “Therapeutic Action and the Analyst’s Responsibility” uses the idea of “fictions... more J ay Greenberg’s “Therapeutic Action and the Analyst’s Responsibility” uses the idea of “fictions” or “controlling fictions” to develop a number of significant points in the ongoing discussion of psychoanalytic pluralism: What is the epistemological status of our theoretical models? Greenberg’s answer: they are powerful fictions, shared among communities of believers, controlling our thought and action. These fictions contend as equals in the marketplace of ideas. We value our fictions because they tell us how to act with patients—though there is always a tension between our preferred fiction and the immediate press of an actual patient. Ultimately, psychoanalytic experience is so dense that we cannot hope to know which is best, more “right,” among contending fictions. I will look at Greenberg’s theses in the context of our current literature and my experience. My discussion will demonstrate the heuristic value of Greenberg’s paper, though I have strong disagreements regarding his conclusions, and with his view of the state of psychoanalytic knowledge. Greenberg’s ideas about psychoanalytic fictions are powerful and in some ways familiar statements about psychoanalytic theory and process,

Psychiatry MMC, Aug 1, 1969

Psychoanalytic Dialogues, May 4, 2015

The target paper had the purpose of drawing attention to something “beyond countertransference”—t... more The target paper had the purpose of drawing attention to something “beyond countertransference”—the impact of the therapist’s psychology on the treatment, not in reaction to the patient, but as desires and defenses that operate throughout. The illustrative issue was a speculation that my development and analytic engagement carried elements that led me to interact with women patients in a way that increased the likelihood of their conceiving. The respondents reacted differently to the provocative aspect of this idea, but have in common a recognition of the analyst’s desire as an important part of the relationship. A further case vignette is introduced in this reply to examine some of the points raised by the respondents, in particular how the analyst’s desire may be expressed in a form that is modulated by the analytic role and at the same time has an impact on the patient’s life decisions. In sum, we are players in the drama of analytic work, and the more we think about what and how we are ourselves in treatments, the more informed our inevitable impact will be.

Psychoanalytic Study of The Child, 1989

JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, ha... more JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, has as a major theme the process of psychological change. I will compare Austen's depiction with the psychoanalytic process to help identify universal features of how people change. This approach can be seen as the inverse of that of Spence (1982), who suggests that psychoanalysis can be understood as a process in which analyst and patient strive to interpret the "text" of the analytic dialogue in the manner of literary criticism. As they develop their romantic bond, the novel's lovers, Elizabeth Bennet and Fitzwilliam Darcy, move from one psychological position to another. They each have some difficulties; they encounter traits and attitudes in themselves that prevent their development. To become partners each must change. This change does not occur in isolation; one serves as a foil for the other, like parent and child or patient and therapist. In psychoanalysis we observe and participate in a powerful and change-inducing experience. Analysts differ significantly in their opinions about how change comes about (

The Psychoanalytic Study of the Child, 1989

JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, ha... more JANE AUSTEN WAS AN ASTUTE OBSERVER OF HUMAN NATURE. HER BEST known novel, Pride and Prejudice, has as a major theme the process of psychological change. I will compare Austen's depiction with the psychoanalytic process to help identify universal features of how people change. This approach can be seen as the inverse of that of Spence (1982), who suggests that psychoanalysis can be understood as a process in which analyst and patient strive to interpret the "text" of the analytic dialogue in the manner of literary criticism. As they develop their romantic bond, the novel's lovers, Elizabeth Bennet and Fitzwilliam Darcy, move from one psychological position to another. They each have some difficulties; they encounter traits and attitudes in themselves that prevent their development. To become partners each must change. This change does not occur in isolation; one serves as a foil for the other, like parent and child or patient and therapist. In psychoanalysis we observe and participate in a powerful and change-inducing experience. Analysts differ significantly in their opinions about how change comes about (

Research publications - Association for Research in Nervous and Mental Disease, 1969

Journal of Psychiatric Research, 1971

ABSTRACT The interrelations of a variety of outcome measures are reported for a series of 65 cons... more ABSTRACT The interrelations of a variety of outcome measures are reported for a series of 65 consecutive admissions to a milieu therapy inpatient psychiatric unit. Correlations between various outcome variables were found to be suprisingly low, except when the variables were derived from the same time and the same evaluator-patient relationship. Findings were interpreted as reflecting the fact that no single criterion of ‘outcome’ is sufficient, and that a more differentiated view of the impact of treatments must be considered.