Recipes for Madness



This article is a trailer for a longer text which will appear on IP’s website – “We’re all in the Madhouse Now! DSM-5 and the real domination of capital.”

In May 2013, the American Psychiatric Association (APA) published the fifth version of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with around a thousand pages of definitions of insanities to be used by the psychiatric professions worldwide, by health insurers and by the global pharmaceutical industry. Why is this important? Well, the latest manual is published at a time when humanity has been experiencing a widespread upsurge (often described as an epidemic) of mental illness; so, in the eyes of the APA, its appearance might be considered timely. But, what should we think it represents for the state of humanity?

Madness is not new, nor is it constant; the conditions of its generation and expression vary over time. So, how to define madness? You might as well ask how to define saneness. You can put words together for dictionary definitions but these are always circular: one is what the other is not. How the mad are socially defined and viewed, the relationships the insane have with the sane in a given social setting, and especially with those who categorise and deal with them: these also vary over time. In other words, insanity has its socio-historical dimensions. How, then, should we link them to the appearance of DSM-5?

To prepare an answer to that question, it is worthwhile to look at how madnesses and the associated therapeutics have developed over the long term as this makes it easier to see where we are today in the evolving processes. Every culture has developed its own approaches to dealing with the insane; and indeed in some historical periods ruling classes have used madness as a component of repression. In this article, we confine ourselves to the main pathways that have led to today’s globalisation of defined psychopathological experiences and to the associated psychiatric diagnoses and treatments offered. Many diverse and important aspects of the history of psychiatry have had to be by-passed so as to focus on those most closely related to today’s intensification of capital’s domination over all aspects of our mental life; one that is nothing less than a major onslaught on our psyches in the interests of expanding the terrain for the valorisation of capital.

Madness of Old

Healing has always been a preoccupation of human societies. A division of labour long ago developed between empirical and physical approaches to damage to bodies and what today might be regarded as psychological healing applied to mental distress. We can see the differentiation on 5th Century BCE Kos where the priests at the temples of Asklepieion dealt with maladies of the soul and where Hippocratus medicalised what he could – into his theory of the humours. We might regard the ways of the shaman as precursors of temple priests, who focussed on the expulsion of adverse influences, and the ways of Hippocratus as precursors of the physicians.

The Christianising of European madness introduced a profoundly different explanation of its symptoms. Surrounded by supernatural hordes, each human soul was a battleground for the unceasing conflict between the Holy Ghost and the Devil and, while it could be divine, madness was for the most part considered to be of diabolical origin and spread by witches and heretics. Syncretism was pursued in all aspects of social behaviour for the strengthening of Christian domination over non-orthodox beliefs. Thus, for example, the (originally shamanic) expulsion of influences was transformed into the Christian rite of exorcism.

Enlightenment thinkers tended to follow Locke in his view of madness: As the human mind was a tabula rasa, shaped by sense impressions and education, it followed that insanity developed from wrongly associated ideas from which the delusional could be re-educated. This Enlightenment rationalist view was not unchallenged: later, in the Romanticist movement, an oppositional current appeared positively linking art to madness.

By the end of the 18th Century, the secularisation of madness was largely complete. On a theoretical level, spirits were expelled and it was widely argued that the study of insanity should be based on a philosophy of mind. On a practical level, Mesmer (and other ‘animal magnetisers’) drove into public use techniques of what was later termed hypnotism to replace the exorcism of the priests.

Where the early Greeks had the Gods throw madness into men’s minds, the later Greeks recognised man’s own inner self and its conflicts; where the Christians saw the conflict between the diabolical and the divine, the Enlightenment saw erroneously associated ideas. Where shamans extracted disease-objects, the priests exorcised demon possession, and the animal magnetisers hypnotised the afflicted into health. In many cultures, anthropologists have found a respect for those ‘touched’ by spirits; in mediaeval times, the words and music of Abbess Hildegard of Bingen were revered because God spoke directly to her. At other times, the mad could be the personification of The Other as Michel Foucault has pointed out. (1) Such anecdotes exemplify how the expressions, explanations and treatments for insanity all have their historicities, shaped by manifold social dynamics – as do all other processes in human social life. We must remember this when we look at the generation of new categories of insanities in more modern times. A priest now listening to a member of his parish, who wants to obey voices in his head, would likely refer the individual to a psychiatrist rather than exorcise him; even mystics bow to medical science today.

The social transformation from feudal to capitalist socio-economics in Europe was experienced not only at the level of economics or of functionality at the point of production but ramified through all aspects of social and personal life and into mental life and its associated external behaviours. New norms brought new deviances; new social experiences brought new categories of well-being and malady.

Madness in Modern Times

By the 19th Century the relentless strengthening of the industrial revolution was becoming one of main drivers of social change throughout Europe. Along with the accumulation of immense social wealth were developments of new sciences and technologies, new social institutions along with new ideologies, beliefs and rationalisations. The growth of the new classes and the ethos of competition would ensure continuing social turmoil and consequent social and psychological stresses. Within this world were the circumstances that would create the psychiatry that entered the 20th Century: the development of the asylum industry, the development of psychiatry as a profession inside the broad surge to professionalize science, medicine and other technical categories. Inside the profession would come the theoretical constructions that brought conflicting views as to the functioning of the mind and its pathologies.

The asylum industry grew rapidly as it offered financially attractive business opportunities in the fast–growing service sector that accompanied the industrial production of goods. The concentrations of the insane so created fertilised other developments. There was a growth in professional institutions focussed on the management of the insane; from their work came the professional bodies of today (such as the APA and the UK’s Royal Psychiatric Association). The insane became a category of study, an interest that fitted into the mushrooming of scientific researches so marked at this time. Within the context of charitable endeavours, systematic treatments and therapies were pioneered and tested by physicians such as Philippe Pinel in France and taken through Europe and the United States. The asylums were also sources of statistics which were becoming a staple for the state bureaucracies which, through the century became progressively more absorbed by measuring the state of their economic and military power; they were interested in strength as well as the weaknesses represented by what they called in French statistical returns, Les misérables.

Psychiatry was absorbed into the medical profession where it developed institutionally in various locations – such as clinics, universities and private practice. The raw material – the insane – was found in asylums, prisons and in open society in the evolving circumstances of life. The industrialising world generated new sources of injuries – not only in factories but outside. For example, terrible and frequent railway accidents were spawning not only physical injury but also bizarre behaviours in the uninjured – ‘railway spine’ being one. It was recognised that these behaviours were akin to those of hysterias which had previously been thought to be the preserve of women.

Transient mental illnesses were also seen, isolated in time and location. For example, in the context of the social anxiety following the events in 1870 France, there was an epidemic of fugue among young men (a kind of dissociation from external reality manifest by physically leaving one’s normal social environment and subsequently displaying post-episode confusion and amnesia); it was almost unknown elsewhere. (Such behaviours were harbingers of what was to follow in 20th Century warfare.)

Psychiatry was brought into the legal system and established itself as the source of expertise regarding an accused’s responsibility for his actions; some high-profile court confrontations over mental responsibility led to the integration of psychiatric theories into law. Its theories also contributed to the developing imperialist national ideologies which were being interwoven with Social Darwinism. Sections of the German ruling class were concerned about the need for racial purity to strengthen its population. After its defeat by Germany in 1870 and the subsequent events in Paris, sections of the French ruling class were preoccupied by theories of degeneracy in its population.

By the end of the century, there were two main organising concepts in psychiatry – one, the psychodynamic view epitomised by Janet and Freud in which the life experience of a sufferer was to be analysed and, second, the view of Emile Kraepelin and others that mental pathologies were the products of biological and genetic malfunctions. Kraepelin devised a nosology (disease classification system) that mimicked botanical classification systems. These two perspectives have since co-existed – sometimes peacefully and pragmatically, and at other times with considerable hostility. The first half of 20th Century psychiatry was strongly Freudian; but in the second half of the century Kraepelin’s approach was to be strengthened in unexpected ways.

(It’s also worth noting that the asylum industry declined, as the institutions were turned into dumping grounds for the incurably sick, the syphilitic and the elderly, rendering useless what had been effective treatments. The asylums then had reduced attraction to the psychiatric profession as a source of pathological case studies.)

Madness in the Trenches

The national bourgeoisies, the military and state bureaucracies were taken aback by the outbreak of the war neuroses in the early months of the First World War. Indeed, in the British Army, by December 1914 it was estimated that up to 10% of officers and up to 4% of other ranks were casualties of shell-shock as the condition was first labelled . After the Battle of the Somme (July 1915) the Army was almost paralysed by the epidemic of psychiatric casualties (40% of the total) whose effects were compounded by the logistical problems generated by sending them home for treatment during the battles. In the following years, doctors, the military high commands of all forces, newspapers and others argued over the medical cause – especially since the symptoms were rarely seen in the seriously physically wounded and were seen in soldiers who had never been in battle.

It became clear to the military doctors that, although the term continued to be used, shell shock was a misnomer and, as all the original suggestions as to its somatic origins were groundless, the medical view was formed that it was a neurotic condition. The scale of the psychiatric problem continued to alarm the British High Command which was innervated by the approaching Battle of Passchendaele to reduce it. Distilling from experience, instructions were drawn up to implement acute management strategies for handling shell-shocked soldiers. These included acute front line treatment and then returning them to the fighting, with evacuation reserved for only the most severe cases. The statistics showed the effectiveness of the measures: at Passchendaele in 1917 the overall figure for shell shock fell to 1%.

After the end of the War, an investigation into the whole experience was set up and its conclusions were published in the Report of the War Office Committee of Enquiry into ‘Shell Shock’ (1922). The report highlighted the contagious nature of these neuroses, in which there was reckoned to be a strong (iatrogenic) effect from the mode of treatment received, and the introduction of pensions for the psychiatrically disabled. Indeed, all belligerent governments and states were horrified by the size of the pension bills they had created to deal with the urgencies caused by these neuroses, and from this time on financial factors were to become a continuing motif in the history of psychiatry.

Madness in Total War

The 1938 Munich crisis concentrated minds inside the British state which was preparing for renewed conflict with Germany. The Ministry of Pensions took the initiative: it reviewed the work of the 1922 Committee of Enquiry and brought together those with medical experience into conferences held in the summer of 1939. In anticipation of heavy aerial bombardments of cities the issue was broadened to deal with the entire population. Arguments as to the cause of war neuroses were still live; nevertheless, a compromise set of operational principles was drawn up : (2) not to use quasi-medical words like ‘shell-shock’ either to the patient or in the media; not to pay pensions for ’war neurosis’; to keep psychotherapy to a minimum and rely on social pressure; and to use personnel selection to keep vulnerable people out of the forces.

The bureaucrats recognised that contagion of the psychopathologies, of war neuroses, was potentially as virulent as an infection of plague. And efficacy of treatment, containment of contagion, required strong management of those showing symptoms. This was a philosophy of ‘tough it out’ imposed on society, and not only soldiers. It was recognised openly in this wartime ideology that fear and distress were natural emotions in such circumstances and that everyone felt the same. The social expectations of that time provide us with a benchmark against which current ideology can be compared; they also provide input into our understanding of why it changed.

Capitalism’s development during the 19th Century created many new stressors in society – not just at the point of production but throughout social life – and generated psychopathologies that were categorised in new ways by the psychiatrists who studied them. Their perspectives percolated through society. In the first half of the 20th Century capitalism was characterised largely by the orgies of killing in massive industrialised general warfare and the psychopathologies generated worked against military effectiveness. The second half of the 20th Century brought huge changes to the structure of capitalism and its psychological stressors and these were to have a great impact on society, insanity and the pursuits of psychiatry.

Post-1945: New Bible Trails and ‘Magic Bullets’

In 1943, the US army issued Technical Bulletin Medical 203 as a guide for its psychiatrists and this was used after the war by the demobilised psychiatrists when they went back to civilian life.

The “international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use” according to the World Health Organisation ( WHO ) is its International Classification of Diseases and Related Health Problems (ICD) whose origins go back to the 1850s. The ICD is the standard in all WHO Member States – including the US. In ICD-6, published in 1949, there was included for the first time a section on mental disorders which the APA noted was similar in nomenclature to Medical 203. Nonetheless, the APA decided that it should compile its own manual to be used alongside the ICD. Thus began the DSM series, based on Medical 203, DSM-I appearing in 1952 and DSM-II in 1968. The philosophy of these first two Manuals continued the tradition of a psychodynamic conceptual organisation of mental illness diagnosis, with strong psychoanalytic content.

In practice neither DSM-I nor DSM-II was much used as the American psychiatrists tended to compile their own mix of diagnoses and psychotherapies (largely Freudian) to deal with their patients. However, there were many changes taking place in the environment: changes in the American health industry after 1945, changes in reimbursement processes, professional changes including a propagation of talk-therapy services with an uneasy relationship to psychiatry whose market was expanding to medicalise all kinds of life problems having little to do with mental illnesses. Furthermore, from the early 1950s the pharmaceutical companies were starting to develop ‘magic bullets’.

Chlorpromazine, developed in France, was the first. Investigated in the course of a search for compounds toxic to the microbes that caused fly- and worm-borne illnesses, it was found to ‘disconnect’ various brain functions. Indeed it was suggested in 1951 by a surgeon experimenting with the drug that it may have a psychiatric use as it ‘produced a veritable medicinal lobotomy’. In the following year, its use spread across European asylums as a means of quietening wards and facilitating patient management; it was described as a neuroleptic because it seized hold of the nervous system. It crossed the Atlantic, to be marketed in the US as Thorazine.

To begin with, Thorazine was used to relax patients and make them accessible to treatment; as the New York Times put it, they were “adjuncts to psychotherapy, not the cure.” Yet by the end of the decade, it was claimed that new psychiatric drugs, such as anti-depressants, “may be compared with the advent of insulin, which counteracts symptoms of diabetes.” By 1963 the National Institute of Mental Health (NIMH) endorsed the rebranding of the neuroleptics as antipsychotics, muscle relaxants became mood normalisers and the psychic energisers, anti-depressants. The introduction of neuroleptics into the witches’ brew of health industry bureaucracies, reimbursement processes, pharmaceutical marketing, and professional rivalries, could only elevate the toxicity.

Sea Changes: DSM-III and the ‘Victory for Science’; DSM-IV and Trauma

Robert Spitzer was appointed to lead the task force preparing the new version of DSM for publication in 1980. He was animated by the debacle over the change to the homosexuality designation in DSM-II; the cultural prejudice that had defined homosexuality as a mental disease had been knocked out in the seventh printing in 1974 – not by medical or scientific research – but by political protest. This undermined the claim to scientific validity for DSM. To counter this, Spitzer looked for a more supposedly scientific framework and found it in a group of neo-Kraepelinians with whom he produced a set of specific criteria to be used for psychiatric diagnosis. Out went the Freudian legacy and in came Kraepelin’s. (Although, as a sop to the psychoanalysts, the word neurosis was put in parenthesis after the word disorder throughout the document.) It was a putsch; and what enables a putsch to be successful is a clement context and a favourable alignment of forces. The descriptive nature of the document harmonised with so many needs: of institutions, of legal processes, of the pharmaceutical industries and the blurb (oral and written) used to ‘scientise’ the ideologies and products of self-serving snake oil merchants.

DSM-III was heralded as a ‘victory for science’. Yet DSM-III was no more immune from political pressures than its predecessor had been; I cite only one example here. Against the resistance of many on the task force who argued against its adoption, DSM-III included the new diagnostic category – Post-Traumatic Stress Disorder (PTSD). “… [T]he events … allow us to see elements of the routine politics of diagnosis and disease in an especially clear light. PTSD [was] in DSM-III because a core of psychiatrists and veterans worked consciously and deliberately for years to put it there They ultimately succeeded because they were better organized, more politically active, and enjoyed more lucky breaks that their opposition.” (3) The inclusion of PTSD opened a channel for widening the concept of trauma.

Under the DSM-IV task force whose manual was published in 1994, trauma was plasticised. To paraphrase one social anthropologist, (4) not only do encounters with death and injury affect people in different ways but also what constitutes a threat can be conceived in widely different ways in different people; furthermore, the stressor can not only be experiential but an account of the experience may be sufficient; and to round off the diagnosis the inability to remember the event – even 20 years later – is symptomatic of PTSD. And with widespread use, and progressive vulgarisation, PTSD can now appear anywhere. For example, a postal questionnaire sent to doctors attending victims of the 1998 bombing in Omagh, Northern Ireland, found that 25% of them had PTSD; the paper reporting this ‘finding’ even berated the doctors for not seeking treatment. (5) Furthermore, “by widening the definition of traumatic stressors to include the experience of learning the news that something bad has happened to someone to whom one is close: second hand shocks now count.” (6) In the UK, awards for psychological damages based on the diagnosis can be several times higher than, say, the £30,000 - £40,000 limit that the Criminal Injuries Compensation Authority applies for the traumatic loss of a leg.” (7)

Where psychopathologies were once regarded as problems by the ruling class, obstacles in the way of achieving their objectives, towards the end of the 20th Century insanities had become market opportunities, as we shall see...

Madness for the 21st Century: DSM-5

In contradiction to the ideology about the openness of the scientific process, the task force for DSM-5 has tried to cover its tracks by having members sign non-disclosure agreements, so we don’t know about all the political wrangling for this new round of scientific endeavour. I’ll give two examples of problems that confronted the task force.

First, in a keynote paper, The Conceptual Development of DSM-V written in 2009, they admitted a failure to provide a basic definition of a mental disorder, an inability to find separations between mental disorders, and confessed they were unlikely to find single gene underpinnings for most mental disorders – a crude and reductionist view in any case. Secondly, the field trials showed appallingly low levels of diagnostic reliability, so they instead set for themselves the goal of ‘managing expectations’ to condition their profession and other users to accept poor results. And we are supposed to believe that this is science?

Since the publication of DSM-5 in May 2013, old existential arguments about the future direction for psychiatry have been rekindled. Two recent documents are noteworthy. In one, a paper written by Kenneth Kendler, the role of the DSM-5 Scientific Review Committee is described (8) as a huge effort made to ‘scientise’ what was in essence a negotiation process, and is well worth reading to grasp how these people work. He draws lessons for the production of future versions of DSM and looks forward to many more of them. By way of contrast Tom Insel, the Director of the NIMH, blogged his assessment of the new Manual and emphasised “its lack of validity.” He declared the NIMH’s intention to re-orientate its research away from DSM categories and, as the NIMH is the world’s largest funder of research, this is no mean threat to the psychiatrists. After rubbishing some of the DSM methodology, he went on to say that it should continue to be used until something better comes along. The ‘something better’ will come as a result of “collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.” This is because, in the NIMH view, “mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behaviour.” Seems like the DSM categories weren’t such a victory for science after all. But, hey, the science is dead; long live the science.

Our Psyche and the Value-Form

The size of the current epidemic of mental illness diagnosis is grotesque. The absolute numbers of diagnosed sufferers in the US are breathtaking: for example, major depression affects 15 million adults, anxiety and manic depression 40 million adults of whom 14 million are designated severely impaired in their ability to function in society. Furthermore, the life expectancy of the seriously mentally ill has in recent decades has shrunk by between 15 and 25 years. And the epidemic isn’t confined to adults; children have become a major target group. At the end of the ‘80s, 1 in 250 children were taking an anti-depressant; by 2002 it was 1 in 40, a greater than six-fold increase.

With all the billions of dollars of pharmaceuticals pumped into the American patient population, what have been the long-term outcomes for the afflicted? The statistics can be found elsewhere, (9) but the general picture is given in the following headlines. With schizophrenia, the outcomes for un-medicated sufferers have remained roughly steady: about 70% of people suffering a first episode of psychosis were discharged from hospital within eighteen months with few returning over lengthy follow-up periods; today only 5% of medicated patients recover over the long term. Anxiety used to be considered to be a mild disorder; today it is the primary diagnosis for 8% of people on the benefit rolls because of psychiatric disability. In 1955 major depression had hospitalised 38,000 people with high expectations for remission; today it is the main cause of disability in the US for people between 15 – 45 years old. Bipolar disorder – previously known as manic-depression – was once rare with an 85% recovery rate; now recovery is down to approximately 33% and, over the long term, those who reliably continue on their medications can become almost as impaired as schizophrenics on neuroleptics. Such is the triumph of medical science and its magic bullets.

This description of today’s mental illness bears little similarity to an overview that might be made of 1950, or the years of world war, or at the end – or beginning – of the 19th Century, as the examples mentioned in this article illustrate. As I indicated earlier, mental illness has its historicity and that didn’t stop when psychiatry was invented. Medical pathologies have flowed along courses created by capitalism’s trajectory. These courses have created stressors that acted on society and generated the pathological effects apparent at different moments – be the fugues of late 19th Century France, the neuroses of 20th Century warfare, or the glut of depressions in 21st Century civilised life. Here is where the base/superstructural model of orthodox Marxism shows itself to be entirely inadequate to the task of explaining the historicity of psychopathologies. The centrality of the value-form to an understanding of capitalism does not translate to seeing it in purely economic terms. The value-form is the key social symbolic for capitalism – but it does not stand alone. It has to be considered in the context of all the social factors - such as authority, norms, beliefs, identities – that enable society to operate. Together, they enable the value-form to penetrate into the very subjectivisation of the human being in capitalist society. This is a dynamic process and it is imperative that its historical dimension be recognised.

So, at one time the state and its medical bureaucrats developed methods to manipulate and manage soldiers in warfare, and later extended their procedures into the civilian population as I indicated earlier. That such processes were developed to meet military needs when bourgeois states were at war is not surprising. What is astonishing is the way in which the PTSD created for DSM-III purposes has permeated so many areas of life. Now bourgeois society recognises trauma disorders in survivors of everything from tsunamis to child sex abuse, from the Holocaust to road accidents, from ethnic cleansing to just reading about it. We see the trauma culture growing through the definitions made by doctors, medical scientists and ancillary industries. Treatment offers come from a counselling industry equipped with all sorts of therapies and anti-depressants. Effectively, this commodifies victimhood. Are many of these people who go through appalling experiences very distressed? Undoubtedly so. But suffering from mental disorders?

Culturally, this promotes an entirely negative focus on mental pathology as a shared experience for humanity in the 21st Century. And rather than the result of a centrally-directed component of war policy, this focus is the outcome of all the interested institutions in capitalist society negotiating their way through the socio-economic pathways enabled by the value-form. The ‘boom’ of the last few decades has fuelled the lifestyle industries with their celebrities, magazines and TV talk shows. They all contribute to the interpretations and reinforcement of mental distress conditions, and maintain and extend the epidemics. These institutions all have their market niches and their profit targets, and their mutual reinforcements contribute massively to structuring receptivity to the spread of distress alongside their role of social diversion. TV programming, especially, dovetails into the globalisation of American culture, to play its role in spreading the fertiliser internationally.

This is but one facet of the reification processes in society. In addition to reification of the worker at the point of production, and of the consumer in the market place, capitalism is also reifying humanity’s soul, using the human psyche as yet another terrain for the valorisation of capital, for the deeper penetration of the value-form – intensifying working class atomisation and contributing to further market expansion.

The pressure is on to individualise the responsibility for insanity as something the individual owns. The individual has the malfunction, and the psycho-industries are going to find a cure for his broken brain. In so doing, attention is diverted from the real source of madness: the utter insanity of this socio-economic system.

Marlowe
October 2013


Notes

1. Michel Foucault, Madness and Civilisation, 1965.

2. These are Ben Shephard’s summary in his paper: The Rise of the Trauma Culture, ‘De Historie Vande Psychiatricais Basis Voor De Toekomst’, Je Havens & GJ Van Der Ploeg (eds), 2002.

3. See Wilbur J Scott, PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease, Social Problems, v37, no 3, August 1990.

4. Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder, 1995.

5. Jenny Firth-Cozens, Simon Midgley, Clive Burges, Questionnaire survey of post-traumatic stress disorder in doctors involved in the Omagh bombing, British Medical Journal v 319 no 7225 (Dec 18-25, 1999); p 1609

6. Derek Summerfield, The Invention of Post-Traumatic Stress Disorder and the Social Usefulness of a Psychiatric Category, British Medical Journal, v 322 no 7278 (Jan 13, 2001) pp 95-98.

(7) Ibid

8. K S Kendler, A history of the DSM-5 scientific review committee, Psychological Medicine, August 2013, pp 1-8.

9. See references in Robert Whitaker, Anatomy of an Epidemic: magic bullets, psychiatric drugs and the astonishing rise of mental illness in America, 2010. Part three – Outcomes.


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