|Fixing Health Care|
What Role Will Therapists Play?
By: William Doherty
Remember 1994? For those of us who could use some help pinpointing that year's events, on the political and economic scene, it was the year Richard Nixon died, Newt Gingrich became Speaker of the House, and the trade gap hit a six-year high, yielding a $108.1 billion deficit (chicken feed compared to the estimated $400 billion deficit for 2007, which will be added to the total public debt of $8.7 trillion). Hope flourished in Africa with the election of Nelson Mandela as the first president of South Africa, and was promptly dimmed by massacres in Rwanda. In the arena of popular culture, some of us were transfixed by the attack on iceskater Nancy Kerrigan and the slo-mo spectacle of the police chasing O. J. Simpson's white Bronco, while others were heartbroken that the World Series was cancelled for the first time ever because of a players' strike. It was also the year in which Congress deliberated on Hillary Clinton's health care plan, and there were high expectations that the nation's fractured health care system would be overhauled, expanded to include everyone in the country, and generally fixed.
On a cold January day in 1994, I sat in front of the huge, two-story fireplace in the living room of Wingspread, a Frank Lloyd Wright–designed house-turned-conference-center in Racine, Wisconsin. I was talking excitedly with a dozen other therapists, physicians, and health care administrators who, like me, had convened for The Wingspread Conference on Collaborative Health Care. We were plotting a radical new way to take care of sick people—one that married modern medicine with the interpersonal skills of psychotherapy for improved outcomes at lower costs—and it seemed that the revolution was upon us.
As a trained psychotherapist, I'd been working with primary care physicians since the late 1970s. In fact, I'd helped develop medical family therapy, an approach incorporating family systems thinking and interventions into medical treatment, with Susan McDaniel, Jeri Hepworth, and other family therapy colleagues. In crossing the ocean from family therapy to the land of primary care medicine, I'd discovered something that never came up in my training—people have bodies. I knew of course that people came with penises and vaginas (sex therapy was a required course), and I vaguely knew about brains. But other organs, like livers, lungs, and hearts—well, these never came up in my Ph.D. program. When I did family genograms, I documented every cutoff and enmeshment known to Murray Bowen, but left off the cancers and heart attacks passed down through the generations. In short, I never met a medical diagnosis in school or my early practice.
The second shock I got from working in a medical setting was that patients often don't get better, no matter what the treatment. I recall a case I worked on with a frustrated resident, in which we helped a young woman with serious Crohn's disease handle her disease more constructively and develop a better relationship with her family. Ultimately, she did get along better with her family and she did take better care of herself, but she died anyway. I remember my dismay when her mother called me to give me the news. I felt like a failure until the mother told me that the last months of her daughter's life were the most peaceful she'd spent in many years, thanks to our work, and that she and her husband were grateful that their frayed relationship with their daughter had healed before she died. I was relieved to hear all of this, and yet I couldn't stop thinking about that old line: the surgery succeeded, but the patient died. Nonetheless, I became a different therapist that day, a humbler one. Until then, I'd thought that therapy, especially systems therapy, could "cure" anything; school-refusing kids would go to class, a depression would lift for good, and a couple would find sustained happiness.
The Benefits of Collaborative Health Care
From the beginning of my work as a medical family therapist, there were clear benefits to considering ailments from a mental and physical perspective. I recall a 9-year-old boy with severe headaches, who'd had every diagnostic test in the world without discovering the cause. I met with his parents and physician to explore the context of his attacks. It turned out they came on when he was worried or frustrated within his peer group. I could feel the tension leaving the room with this revelation. I gave them a few tips about how the son could notice and manage his feelings and how the parents could help him talk about his inner experience so he didn't have to communicate through headaches, and that's all it took for his headaches to disappear. Jay Haley would have been proud! But this was a rare, uncomplicated case.
Most people who frequent medical clinics live with problems that are permanent companions, not episodic visitors easily banished. Along the way, they pick up a gaggle of health care providers who are often frustrated because these patients don't take care of themselves well enough, take up too much time, and cost too much money. I learned that the biggest thing I could do for patients was to help them live better with the hand of cards they'd been dealt, and the biggest thing I could do for physicians was to help them understand their common humanity with their patients, which meant not trying to shape patients to their own will.
Most of us working in medical family therapy in those days had the luxury of being in academic centers, somewhat buffered from the financial constraints of everyday medicine. In this hothouse environment, we knew we'd developed a great new way of working in collaboration with medical and nursing professionals, but often wondered whether it could succeed in the real world. After seven years in academic family medicine residency programs in Iowa and Oklahoma, I moved to Minnesota, where I met C. J. Peek, a pioneer in the world of HMOs. A big, bearded health psychologist with a penchant for engineering-related metaphors, he was the best systems thinker I'd ever met. He introduced me to the "three-world view" of mental health care, in which innovations that stick have to meet the demands of three perspectives: the clinical world (the innovation has to be good therapy), the operational world (it has to be logistically feasible), and the financial world (it can't break the bank).
At the HealthPartners HMO in Minneapolis, Peek and his psychiatrist colleague Richard Heinrich were building the scaffolding of a collaborative, integrated-care system in which teams of physicians, nurses, and therapists worked closely to deliver medical and mental health care to the same patients. Peek was a master of pithy pearls of wisdom, such as this rationale for scheduling team meetings on difficult cases: "More time early in a case can save time later in the case."
By the mid-1990s, when Peek came to the Wingspread conference, this collaborative, integrated-care model was ready to go mainstream in all HealthPartners' primary care clinics, because it had been so successful on so many levels where it had been introduced. Patients already in the system were going to the hospital less frequently—which pleased the financial people—the medical providers were feeling less stressed because there were therapists around to help with the emotional aspects of care, and the therapists liked being part of a bigger team. But for therapists to thrive in such a setting, they had to view themselves as health care providers, not just mental health providers. They had to care about the patient's diabetes and headaches, not just the patient's depression and anxiety.
At the Cooperative Care Clinic of the Permanente Medical Group in Colorado, other pioneering work was underway in the late '80s and early '90s to replace traditional doctor–patient visits with "group medical visits," which included a number of patients with the same chronic illness (such as diabetes, asthma, and fibromyalgia) and provider teams consisting of a physician, a nurse, and a therapist. Patients loved this more informal, group-oriented way to get care. They learned to manage their chronic conditions better, probably because of peer support, the fact that they were getting regular reinforcement to take their medications and follow the rest of their regimen, and the sense that they were helping others stay healthier.
In these and other local initiatives across the country, the future was already here in 1994. We were creating a new combination of steel and soul—joining the dazzling technologies of scientific medicine with the more nuanced power of behavioral and family systems approaches. Many of the beneficiaries were patients whose chronic problems—diabetes, cancer, obesity, asthma, chronic pain, and fibromyalgia—straddled the threshold between the physical and emotional worlds. Others faced terminal illnesses and, there, too, the evidence was mounting that psychosocial interventions could improve physical health. We knew, for example, about research at Johns Hopkins showing that a family intervention improved blood pressure control and reduced mortality. We knew about a Stanford University study showing that women with metastatic breast cancer who participated in group therapy survived twice as long as women who got medical treatment alone.
Armed with this hard-earned knowledge, we now had good reasons to hope for major changes, which would extend far beyond our own limited experiments with integrated care. It was becoming increasingly obvious that the technology-driven, highly medicalized system as it existed was badly broken. Health care costs were inflating by double digits per year in the early 1990s, yet nearly 40 million people had little or no access to basic medical health care, and another 70 million had inadequate insurance. Individual citizens were spending about 14 percent of their income on health care—up from 9 percent in 1970, and nearly twice what citizens of other developed countries were spending. America was spending the most for medical care of any developed country without showing greater benefits in key indicators, like infant mortality and life expectancy. There seemed to be a consensus that our "health care system"—an unsystematic, partially regulated hodgepodge of government programs, private insurance, and free market anarchy—was cracking under the weight of high costs and fragmentation. Democrats and Republicans agreed on the need for an overhaul, and two months before our conference at Wingspread, Hillary Clinton's health care bill was presented to Congress on the last day of its session. Significant national change was on the way.
At the Wingspread conference, we were ebullient. Those of us who'd worked for years at the interface of medicine and psychotherapy were sure a new age was dawning. Not only would we soon see a new kind of system emerge—universal and integrated, patient- and family-centered, delivered by teams of therapists, physicians, nurses, and other professionals—we'd also help end the stifling, insurance-dominated approach to healing that combined the disadvantages of capitalism with socialism's lack of competition, cost controls, and accountability. Our new model, we were sure, would keep people healthier—and at a far lower cost—than before. I remember Lyman Wynne, a founder of family therapy, saying at the final session of the conference, "I haven't felt this way since those first conferences in the 1950s where family therapy was being created." It all made perfect sense, and it was bound to sweep away all the obstacles in its path. I have never left a meeting higher, before or since.
The Rude Awakening
And then we had our pie-in-the-face moment. By September 1994, Hillary Clinton's health care-reform plan, fashioned by the best and brightest minds in health care and mandating universal coverage through the private sector, had crashed and burned. The debate had been extensive and extreme, with supporters like Rep. Rosa DeLauro (D-Conn.) contending "The Health Security Act will guarantee every American a comprehensive benefits package that can never be taken away" and opponents like Rep. Martin Hoke (R-Ohio) stating, "The Clinton health care-reform plan will create over 350,000 bureaucratic jobs to replace 350,000 private sector jobs and 100 new bureaucracies nationwide. It is going to cost over $700 billion and limit the health care choices of every American." And then, of course, there were the infamous Harry and Louise ads, developed for the health insurance industry's lobbying arm, the Health Insurance Association of America (now called America's Health Insurance Plans), which eroded the public's support for the proposed reform. In his post mortem, Paul Starr, a key developer of the plan, summed up the roller-coaster experience: "It was one year from euphoria to defeat. The collapse of health care reform in the first two years of the Clinton administration will go down as one of the great lost political opportunities in American history."
In November 1994, the Newt Gingrich Republicans swept into Congress with a perceived mandate to limit government and turn as many problems as possible over to the genius of the unregulated marketplace. Right in step, HMOs and managed care companies threw their energies into cost containment, separating, as always, mental and physical health. Instead of folding mental care into physical care to create an entirely new and effective healing system, the health industry outsourced—or "carved out"—mental health care to control costs. Mental health care was increasingly defined by payers as a nice, but not strictly necessary, frill, which might improve quality of life or enhance the marriages or personal growth of those who could afford it, but it certainly didn't have much to do with real, life-and-death medical matters, like liver transplants, dialysis, or the amputation of the gangrenous limbs of diabetics.
Physicians, particularly primary care physicians who don't make money on tests and procedures, became increasingly embattled and discouraged. They abandoned private practice when large health systems made them offers they couldn't refuse. Physicians' incomes lost ground to inflation, while expectations for "productivity" (patients per hour) increased. Starting in the mid-1990s, all but one family practice group in Minneapolis sold itself to a larger care organization because they couldn't sustain the expenses of practice in an era of reduced compensation. I consult with the only independent practice group left—and they're the only happy group of practitioners I know.
Meanwhile, people with chronic diseases continued to get expensive, high-tech, but often subpar care. Their medical illnesses like diabetes were often accompanied by depression and "problems of compliance": they didn't change their diets, monitor their blood sugar, and make other changes that their doctors recommended. Typically, these noncompliant patients became depressed, continued to eat badly, watched their blood sugar skyrocket, started to lose their toes, and finally were referred out to therapists who might help with the depression but knew nothing about managing diabetes. The result of this piecemeal care was that patients might feel less depressed, but their diabetes usually got worse, eventually costing the care system and the economy tons of money in progressive surgeries, heart attacks, amputations, and intensive treatment for eyes going blind.
All of this has led to higher health care costs and to further efforts to curtail costs in the system, especially for the poor, by cutting services. The uninsured remain out in the cold entirely, until they show up in emergency rooms with severe, sometimes terminal, and always costly complications from their undertreated or entirely untreated chronic condition.
With the federal government on the sidelines, the pharmaceutical industry has become the dominant player in health care, without, by the way, producing much in the way of true innovation. In their 2005 book, Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients, Ray Moynihan and Alan Cassels joined a chorus of critics arguing that in looking for ways to maximize markets, pharmaceutical companies "redefine more and more people as sick. There's an informal alliance between the drug companies and aspects of the medical profession and aspects of the patient advocacy world."
Big Pharma has made money in two other ingenious ways: keeping drugs on patent by changing a molecule or two of an old formulation, then slapping a new name on them, and by direct-to-consumer advertising of prescription drugs. Remember the early ads for the "purple pill" with the woman dancing around with the purple scarf? Well, the purple pill Prilosec (for acid reflux) soon became one of the top three prescription drugs in the country. Or the hunky-looking middle-aged guys in TV ads improbably suffering from erectile dysfunction and craving Viagra? Not to mention the threefold increase in psychotropic prescriptions for preschoolers during the early 1990s. By 2002, 4.8 percent of children ages 6 to12 were on some type of stimulant medication, with rates for boys nearly 2.5 times higher than for girls. Nearly 4 percent of adolescents were on antidepressants. With most mental health treatment occurring in primary care medical offices, time-starved physicians were reaching for the prescription pad when in doubt about how to respond to the complex behavioral problems of children and adolescents. As the old saying goes, when your only tool is a hammer, you see a lot of nails.
Thus did the counterrevolution win out before the first shot was fired. Economist and columnist Paul Krugman and his colleague Robin Wells summed the situation up recently: "Thirteen years ago Bill Clinton became president partly because he promised to do something about rising health care costs. Although Clinton's chances of reforming the U.S. health care system looked quite good at first, the effort soon ran aground. . . . The evidence clearly shows," they write, "that the key problem with the U.S. health care system is its fragmentation." Diagnosis clear, commitment to treatment uncertain.
A Dream Reborn
The promise we felt at the1994 conference at Wingspread lived on in small pockets around the country, and is now rising again like the proverbial phoenix from its ashes. The big difference today is that marketplace forces are calling for change. An unmistakable signal of change occurred in 2005 at a small meeting of HMO leaders, state officials, and business executives in Seattle, Washington. At this meeting, sponsored by the Collaborative Family Healthcare Association (the organization launched at Wingspread), a benefits executive from Starbucks told the group, "This year we spent more for health care than for coffee beans." My head went back and I heard suppressed gasps in the room from everyone except the other benefits officers in attendance, who were nodding in agreement. Instead of being defensive, the HMO leaders concurred that their costs were out of control. The state officials were as unhappy about the situation as the Starbucks executive because they seemed to be throwing taxpayer dollars down a rat hole.
What was remarkable wasn't the collective moaning, but that all present agreed about the main problem: a care system that carves up people into pieces that separate professions or institutions are expected to treat, combined with a massive tilt toward expensive medical treatments. They also agreed that the large number of uninsured Americans was unconscionable, on both ethical and economic grounds, but that simply universalizing a flawed health care system won't solve the deeper problems.
Since then, I've been reading about companies like General Motors that are pleading with Republican lawmakers for help with out-of-control health care costs, so they can compete with industries in more enlightened countries with national health insurance. Employers, it turns out, never signed on to be the pack mules carrying skyrocketing health care costs; it happened almost by accident in the early years of World War II, when a few companies got around mandated wage freezes by offering health insurance to their employees. The trend established in those years hasn't reversed until now, when blue states like Massachusetts and red states like Tennessee are experimenting with universal health care, this time in a much simpler form than the Clinton plan. Just this year, Arnold Schwarzenegger put California on the path to universal health care. In February 2007, Wal-Mart CEO Lee Scott and Service Employees International Union President Andrew Stern held a press conference calling for the virtual scrapping of the employer-based health care system by 2012, accompanied by the development of a universal health care plan. Not even the most diehard idealist would have predicted this development a few short years ago!
It isn't just private business and states worrying and agitating for change. The federal Medicare program faces a crisis acknowledged by liberals and conservatives alike. Joseph Antos of the conservative American Enterprise Institute told Congress that "the impending retirement of 78 million baby-boomers . . . will rapidly escalate demands on Medicare's finances" and bring the system down unless there are reforms. This tsunami is just offshore: the baby-boom generation begins to turn 60 this year, while the fastest-growing age group in the country is those 85 and older. Medicaid, administered by federal and state governments, is heading for major problems because of long-term care of the elderly.
Another impetus for change is that we're now seeing a public backlash against the biggest single source for escalating costs: Big Pharma, the most profitable business in America and the most profligate contributor to political campaigns. Ironically, when therapists finally came to accept the hegemony of the pharmaceutical industry (some therapists cover their insurance and liability butts by making sure their clients, including children, are on meds), the public has started to sour on the promise of a pill for every problem. The public's disillusionment with the pharmaceutical industry may have started because more people are becoming aware of how much they're being exploited for profit and have taken appropriate action. Note the discontinuation of hormone-replacement therapy for women following the revelation that the medicines were linked to breast cancer and the decline in SSRI prescriptions for children and adolescents after reports that they caused increased suicidal thinking. According to a Harris poll reported in the British Medical Journal, public confidence in drug companies has plummeted and is now in the same ballpark as our confidence in Big Tobacco and Big Oil.
The second monster wave on the health care horizon, in addition to the aging population, is the growing obesity problem among children and youth, with its devastating health consequences. According to the American Obesity Association, approximately 33 percent of children ages 6 to 11 are overweight, and 18.3 percent are obese. What used to be called "adult onset diabetes" is now becoming a disease of the obese young, with potentially grave consequences for their future health (potentially blindness, limb amputations, and kidney failure before they're middle aged). If we don't figure out a way to staunch the rise in obesity, our children could be the first generation in modern history to live shorter, less healthy lives than their parents.
Even if the old system is faltering and there's increasing support for dumping it, that doesn't mean we'll necessarily replace it with something better. After all, the consensus for change in the 1990s led to slash-the-costs managed care that turned professionals into lapdogs for utilization reviewers. And universal health care plans, vitally important for social justice, won't work well or efficiently if they only bring everyone into another version of the system we now have, which neglects whole persons in favor of their disparate parts.
This time, though, a new care-delivery model is on the table, not just a new payment model, called by various names—integrated care, collaborative care, and collaborative family health care, for example—and health care, government, and even a growing number of business leaders are now actively pushing for it, even if they don't entirely know yet what "it" will be.
Retooling for the New Health Care System
So how can an enlightened therapist hook up with the new promise for the health care system? It comes down to getting ourselves educated on the pressure points in health care —the intractable problems about which there's an emerging consensus that collaborative teams of medical and mental health professionals can make the kind of difference that may save the entire system—and then networking in our local communities. Here's my short list of pressure points in health care today:
Diabetes Mellitus Type II. This disease, which is growing at an alarming rate in young and old, debilitates people over time and will seriously strain the health care system if it isn't prevented and managed better. Diabetes management is mostly behavioral—an area that therapists know about—and the disease frequently engenders depression and family struggles.
Obesity. This is the leading cause of diabetes and a chief contributor to almost every other major ailment patients suffer, with childhood obesity offering an especially fertile ground for therapists who work with families. Medical professionals often don't know how to go beyond futile explanations and exhortations, but going deeper is what therapists do.
Alzheimer's disease. The aging of the population, combined with longer life expectancies, means that the majority of families will face this devastating illness in a loved one. Nearly 50 percent of those over 85 years old have Alzheimer's. Patients and families will need the help of therapists who, unlike most medical professionals, are trained not to run from powerful emotion and family conflict.
End-of-life care. You can be sure that the boomers aren't going to "go gentle into that good night." They'll want special help for themselves and their families. Medical professionals often feel powerless during the dying process and will value the work of therapists to assist with the final months of members of the most psychologically minded and therapy-familiar generation in history.
The genetics revolution. Genetic counseling will come to the fore on a large scale as advances in genetic testing allow more family doctors to inform patients that they've got a cancer gene and have passed it on to their child, or might pass it on to their unborn child. Someone on the health care team then will have to help people sort through intense feelings and make Solomon-like decisions. But to be effective, therapists will have to know something about genetics and how families make decisions about testing, as well as how to help them cope with distressing information. Family therapists Susan McDaniel and John Rolland are leading the way for other therapists to enter the arena of genetic counseling.
Cancer. Currently, most people diagnosed with cancer continue working during and after treatment and survive to live full lives. Most of the emotional adaptation occurs at diagnosis and after the intensive medical treatment ends, and many doctors know they lack the tools to help people manage the psychological and interpersonal stresses of cancer treatment. This is ideal territory for therapists who aren't afraid to talk about tumors and chemotherapy.
Health care for the underserved. If we get universal health care, there'll be a big need for therapists who can work with low-income families who come to clinics with medical problems, but whose needs extend far beyond. We'll need every bit of cultural competence we've struggled to learn if universal health care is to deliver on its promise of social justice and we're to engage underserved populations as agents of health care in their communities, not just as passive consumers of whatever services get doled out. My own work in "citizen health care" is an illustration what therapists might do.
These aren't standard topics for continuing education of therapists, but the new health care system will pass us by if we don't move outside our comfort zone to learn about them. To be sure, our standard skills already give us a unique way to contribute. We may start out ignorant about medical issues, but when it comes to interpersonal communication, the average therapist's skills are dazzling to many medical professionals. We have crucial contributions to make at the intersection of medical care and mental health care—frequently termed "behavioral health"—a terrain still poorly served by our current system.
The big question for today's therapists is whether there'll be jobs in integrated health care outside of the handful of academic settings where many of the leaders of the discipline learned their skills. Here, too, the signs
There's action at the state level, too. All six New England states have launched early initiatives to integrate behavioral health and primary care. In the private sector, the American Psychological Association has made it a mission to put more psychologists into primary care clinics. The Collaborative Family Healthcare Association (CFHA) is pulling together regional stakeholders from business and government to explore ways they can work together on this issue. Blount is convinced the future is now: "The ship of integrated care has sailed," he said, "It's just that we're building it at sea."
Getting On Board
What can therapists do to prepare for the emerging opportunities? The first step is self-education. Getting connected to the emerging health care environment is like starting with a new client: you've got to find the pressure points—the areas of pain, discomfort, and motivation for change. Having identified them, you've got to know something about these pressure points to be a credible helper. If we retool ourselves, everything else we know and all our skills can be used to ameliorate these real and painful pressure points.
Second, we can look for opportunities to collaborate on cases with local physicians and other health professionals. Aside from traditional private practice, the future of psychotherapy lies in primary care medical clinics. Fortunately, we have a great resource in the CFHA literature about how to connect with primary care. We're beginning to see formal programs that'll train experienced therapists to make the transition from traditional therapy, with its relatively leisurely pace, to the fast-paced culture of primary care. Sandy Blount has launched the first national training program via distance learning from his Worcester setting. Other programs are likely to become available through consultation arrangements with the CFHA.
Third, you can simply find out who the primary care physician is for a current client with a chronic medical problem and get permission to call that physician to introduce yourself and talk about your work with this person. Everybody needs to eat, so you could take local doctors to lunch, describe what you do, and ask them how you might help them with their patients. You can talk to a local clinic about the possibility of renting office space parttime in order to better serve patients in that clinic. As you gain experience in working with medical professionals, you can look for opportunities to integrate your practice more fully into a clinic, so that you function as a full team member. And you can have your eyes open as opportunities open up in health care clinics funded by the federal or state government.
Every therapist I know who's joined an integrated team loves the work. Of course, they still treat a lot of people with depression and anxiety, because these problems appear so frequently in medical settings, but collaborative practice takes therapists beyond psychotherapy-as-usual into a stimulating environment, which focuses on helping people function better in their lives, whether or not they carry a DSM diagnosis. They get to work with people in the crucible of serious medical, psychological, and family problems. They get to help people who exasperate their providers, but respond to the skills of a therapist, particularly one who can work within multiple, overlapping systems. This is therapy on the front line of primary health care.
What happens if we don't retool ourselves for an integrated health care system? If we aren't seen as relevant to society's pressing needs in health care, will we be relegated to the backwaters? Health care innovators will create new professional job titles; indeed, they're already doing so in the form of "health counselors." When mental illness is being treated "in house" in medical clinics alongside chronic medical illness by "allied professionals" who don't carry our job titles or make our salaries, we'll definitely feel threatened. But that could be the future, if we don't go with the flow. We need to decide whether we're narrowly in the psychotherapy field—meeting with people with traditional mental health problems in our mental health offices—or we're in the health care field, adapting our skills to the changing priorities in the health of the nation.
Maybe I'm just as wrong about the opportunities emerging in health care as I was in 1994, but it's a gambler's bet for therapists that I'm right. In any case, learning about society's health care pressure points and developing collaborative relationships with medical professionals can't possibly hurt any therapist's practice. And it just might mean a new, flourishing career on the creative edge of our field.
William Doherty, Ph.D., is professor and director of the marriage and family therapy program at the University of Minnesota. Contact: firstname.lastname@example.org. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.