Atheist nurse's fight against mandatory AA will go before B.C. Human Rights Tribunal

Belz... said:
Of course it can.

But you'd rather it couldn't, because whenever it is, it fails. So you prefer to focus on individual reports of success, as if that means anything.
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A rather detailed discussion of studies can be found in the thread 'Are vaccines as safe as can be?'

It's interesting to see the opposite wrong arguments being made here on why AA can't be studied, as the wrong arguments there on why vaccines should have better studies.

In the vaccine thread, there is a call for studies that would force people not to be vaccinated, just like here saying a study would force people out of AA to be a control.

It's fascinating set of bookends. Very educational.
 
Belz... said:
Of course it can.

But you'd rather it couldn't, because whenever it is, it fails. So you prefer to focus on individual reports of success, as if that means anything.
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Have you noticed that I'm the one person on this thread who is quoting from and posting links to thet peer-reviewed medical literature?
 
whoanellie said:
Have you noticed that I'm the one person on this thread who is quoting from and posting links to that peer-reviewed medical literature?
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That show the benefit of peer support, which is the only consistent element of different 12 step groups and non 12 step groups included in the peer-reviewed medical literatue.
 
The Greater Fool said:
That show the benefit of peer support, which is the only consistent element of different 12 step groups and non 12 step groups included in the peer-reviewed medical literatue.
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The study I cited above, Moos and Moos. J Clin Psychol. 2006 June ; 62(6): 735–750, is clearly focused on participation in AA, not "peer support" in general.
 
The Greater Fool said:
A rather detailed discussion of studies can be found in the thread 'Are vaccines as safe as can be?'

It's interesting to see the opposite wrong arguments being made here on why AA can't be studied, as the wrong arguments there on why vaccines should have better studies.

In the vaccine thread, there is a call for studies that would force people not to be vaccinated, just like here saying a study would force people out of AA to be a control.

It's fascinating set of bookends. Very educational.
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Hey, Vancouverite here, associated with BC Humanists. (previously a director of BC Skeptics). My perspective is as follows:

I think the challenge specifically for this claimant is that he offered to go to a secular support group and also offered to continue the pharmaceutical treatments that had helped him up to now, but was told by his employer that no, only demonstrated AA attendance will qualify him to return to work because that's policy. Since he has buy-in with the secular one and no buy-in with AA's "higher power" mandatory capitulation, he feels the employer's policy is arbitrary and/or prejudicial against Atheists and a human rights violation. He did not refuse attendance - he refused to agree to the step in question during a meeting and this was reported to the employer as a refusal to participate, so he can't go back to work.

Personally, I think he has a good point. I agree that the benefits of group support carry a plausible mechanism for success despite unclear/jumbled study results, and that participant buy-in is critical. The barrier to his return to work is not necessarily his refusal to participate in a group process, but rather, specifically AA because of its Higher Power mandate.
 
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whoanellie said:
The study I cited above, Moos and Moos. J Clin Psychol. 2006 June ; 62(6): 735–750, is clearly focused on participation in AA, not "peer support" in general.
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AA is peer support. When I read the moos & moos, it talked about groups and AA after in/out patient treatment. Then they seemed to shorten it to simply AA, probably because AA is the gorilla in the room. But sure, let's say it's ONLY AA...

As you say, every AA meeting is different. Which AA did Moos & Moos study? Where does it show whichever AA they studied is more or less successful than peer support generally?
 
blutoski said:
Hey, Vancouverite here, associated with BC Humanists. (previously a director of BC Skeptics). My perspective is as follows:

I think the challenge specifically for this claimant is that he offered to go to a secular support group and also offered to continue the pharmaceutical treatments that had helped him up to now, but was told by his employer that no, only demonstrated AA attendance will qualify him to return to work because that's policy. Since he has buy-in with the secular one and no buy-in with AA's "higher power" mandatory capitulation, he feels the employer's policy is arbitrary and/or prejudicial against Atheists and a human rights violation. He did not refuse attendance - he refused to agree to the step in question during a meeting and this was reported to the employer as a refusal to participate, so he can't go back to work.

Personally, I think he has a good point. I agree that the benefits of group support carry a plausible mechanism for success despite unclear/jumbled study results, and that participant buy-in is critical. The barrier to his return to work is not necessarily his refusal to participate in a group process, but rather, specifically AA because of its Higher Power mandate.
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Of course he has a good point. AA is a religion, no two ways about it. The 12 steps are faith statements, with or without god. The 12 steps are pulled from forms of Christianity that were floating around at the time. The 12 steps don't even mention alcohol, and aim for spiritual awakening.

We got into the current thread because of AA folks claiming AA is not religion.
 
The Greater Fool said:
I'll leave it with impotent positive thoughts. :o
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Thanks. I don't mind arguing though ;)

whoanellie said:
I wish you the best Minoosh. I've valued your contributions to this thread.
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I know I'll find support when (not if) I get there. Have been dabbling.

Steve said:
Agreed on both counts. I don't agree with some things Minoosh has posted but his(?) comments have been useful none-the-less.
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I'm a her.

blutoski said:
He did not refuse attendance - he refused to agree to the step in question during a meeting and this was reported to the employer as a refusal to participate, so he can't go back to work.
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Do you have a link to those details? The OP article just said he refused to go.

I've never heard of a meeting where they make you do the steps and report to your employer if you don't :eye-poppi !!!

There is secular AA in Vancouver; I wonder if that was an option.
 
whoanellie said:
The study I cited above, Moos and Moos. J Clin Psychol. 2006 June ; 62(6): 735–750, is clearly focused on participation in AA, not "peer support" in general.
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And did they provide a control group with a peer support system that was not AA, no they did not.
So it could be peer support and not AA that is effective, that is the point that was raised.

"Compared with individuals who remained untreated, individuals who obtained 27 weeks or more of treatment in the first year after seeking help had better 16-year alcohol-related outcomes."
 
A little more background:

Is It Fair to Be Fired for Not Attending AA Meetings?

In the spring of 2014, Wood decided to hit up a residential treatment program in Ontario, and became concerned with the rehab’s methodologies.

Wood attended the program in Ontario in the spring 2014, staying for five weeks, though he took issue with their hardcore 12-step approach.

"If I questioned the 12-step philosophy or tried to discuss scientific explanations and treatments for addiction, I was labelled as 'in denial'," Wood said. "I was told to admit that I am powerless, and to submit to a Higher Power. It was unhelpful and humiliating. There was a mentality among staff that addiction is a moral failing in need of salvation. We were encouraged to pray." ...

After returning to BC from Ontario, he refused to attend the three mandatory AA meetings per week as required by his employer and his nursing union in order for him to keep his job.
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Minoosh said:
Thanks. I don't mind arguing though ;)

I know I'll find support when (not if) I get there. Have been dabbling.

I'm a her.
Do you have a link to those details? The OP article just said he refused to go.

I've never heard of a meeting where they make you do the steps and report to your employer if you don't :eye-poppi !!!

There is secular AA in Vancouver; I wonder if that was an option.
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I thought I might have been wrong. Thanks for the correction.
 
BStrong said:
If a friend or loved one is an addict/alcoholic and expresses a desire to attend AA, do you inform them of the programs' limitations and the reliance on a higher power or do you give them a ride to the meeting?
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If a friend or loved one is suffering from depression and expresses a desire to use homeopathic medicine for treatment, do you inform them that homeopathy is ******** or do you buy them sugar pills?

The answer to both, of course, is to take them to a professional for professional help, e.g., medical help with withdrawal symptoms, psychiatric help with therapy, medications proven to be effective in helping people with depression, etc.

As others have said, if AA works for someone that's great, but at best it's a support group and at worst it's a social club where you hang out with people who won't stop talking about alcohol. Support groups have their place, but if someone is physically addicted to a substance they need more, and a friend/loved one deserves more.
 
I have never attended any rehab or AA in my life. But I have been in "serious" situations where demonstrated catholic faith was a requirement. I have none. Never bothered even faking it.

I got married in a Catholic church and had to look like I was praying. I said your if the prayer said my when referring to a belief. I was encouraged to say in english as the priest thought it might help. More than he knew.
I faked it, made my goal and got on with life. Other situations came up with my mil, she hated atheist, and just barely playing along made her happy.

This nurse in the thread could possibly have just played along, said the right words and not ruffled so many feathers. He took a higher road and seems like he is out of work. Honorable and all trying to point out something is wrong, but it really helps to hold a position of power going in. He didn't.
Now he is uncooperative and they don't want to change the system.



I don't fix all that is wrong I see other folks do. Results will be their problem and not mine. They take the losses. I don't point out poor thinking, even when a guy was here saying the sun will burn out so maybe he should be buying lots of candles. He forgot about it or seen the light, either way he didn't buy any candles.
I watch paranormal shows with the kids and point out obvious tricks and psych games these fools use. After a year the kids propose their ideas on how it was faked, sometimes they are dead on. But I am invested in those kids being able to think.
 
8enotto said:
I have never attended any rehab or AA in my life. But I have been in "serious" situations where demonstrated catholic faith was a requirement. I have none. Never bothered even faking it.

I got married in a Catholic church and had to look like I was praying. I said your if the prayer said my when referring to a belief. I was encouraged to say in english as the priest thought it might help. More than he knew.
I faked it, made my goal and got on with life. Other situations came up with my mil, she hated atheist, and just barely playing along made her happy.
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That's a conundrum. One could take a stand against lying (playing along) but is it worth it if it will make your spouse unhappy? Probably not.
 
Minoosh said:
Thanks. I don't mind arguing though ;)

I know I'll find support when (not if) I get there. Have been dabbling.

I'm a her.

Do you have a link to those details? The OP article just said he refused to go.
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No, source is local, skeptics in the pub. The lawyer is Humanist-friendly and attends.




Minoosh said:
I've never heard of a meeting where they make you do the steps and report to your employer if you don't :eye-poppi !!!

There is secular AA in Vancouver; I wonder if that was an option.
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He offered to go, but was told no, only AA qualifies. This is partly why BCHA is involved, as they host the secular alternative.
 
theprestige said:
I wonder what his own proposal would have been, for treating his addiction and returning to work.
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He offered to continue to use the pharmaceutical prescriptions and/or attend a secular addiction group therapy that was designed to be an alternative to AA called Secular AA, since these had been working for him.

ETA: the other local secular alternative that was rejected was attending Secular Sobriety, which uses what's called "SMART Program" instead of the AA styled 12 step model.
 
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blutoski said:
No, source is local, skeptics in the pub. The lawyer is Humanist-friendly and attends.
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blutoski said:
No, source is local, skeptics in the pub. The lawyer is Humanist-friendly and attends.
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Attends your pub group, or attends AA? If the latter, I'm surprised he would talk about what a specific person said or did in a meeting.

I can't imagine someone in a community AA meeting reporting to this guy's employer about what an attendee says/does in meetings. I know that's an argument from incredulity, but it runs very counter to AA tradition.

Another oddity is that he filed this complaint in 2015 and a hearing was supposed to be held that year.

A story I read from 2016 said,

That decision [to allow his complaint to be heard despite untimely filing] noted that the health authority, the College of Registered Nurses of B.C., and the union all denied that they were made aware of Wood’s religious concerns.

"The BCNU denied that it forced the complainant to resign," tribunal member V.A. Pylypchuk wrote. "The BCNU asserted that, had it known about the complainant’s religious objections, it would have investigated."
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I wonder why this has dragged on for so long.
 
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blutoski said:
He offered to continue to use the pharmaceutical prescriptions and/or attend a secular addiction group therapy that was designed to be an alternative to AA called Secular AA, since these had been working for him.

ETA: the other local secular alternative that was rejected was attending Secular Sobriety, which uses what's called "SMART Program" instead of the AA styled 12 step model.
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If it's not inconvenient, do you have a source for the rejected programs above?

Every article I can find is basically the same story told in different sequence, with no details of the rejected programs. The reason I am interested is I wanted to look at the programs to see if perhaps they were rejected for valid reasons other than not being 12 step.
 
Babbylonian said:
If a friend or loved one is suffering from depression and expresses a desire to use homeopathic medicine for treatment, do you inform them that homeopathy is ******** or do you buy them sugar pills?

The answer to both, of course, is to take them to a professional for professional help, e.g., medical help with withdrawal symptoms, psychiatric help with therapy, medications proven to be effective in helping people with depression, etc.

As others have said, if AA works for someone that's great, but at best it's a support group and at worst it's a social club where you hang out with people who won't stop talking about alcohol. Support groups have their place, but if someone is physically addicted to a substance they need more, and a friend/loved one deserves more.
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Alcohol and/or drug addiction is a completely different animal than depresion. There are many individuals suffering with addictions that may also be suffering from clinical depression, but that disease is treatable fairly easily, and in fact if we're talking about alcoholism, stopping the drinking sometimes has a positive effect on depression.

I look at the question the same way that you'd approach an individual with catastrophic physical injury.

You don't tell the victim how serious their wound(s) are or that they're dying, you stay calm, keep the victim conscious if possible and keep telling them to stay with you and help is on the way.

Bad thing - sometime it's a flat out lie. Good thing - the individual may survive.

I'll take the lie over the truth.

As an aside, anyone that believes that individuals out of control w/ drug or alcohol use are susceptible to logical argument and an appeal to self care hasn't lived with the consequences of addiction.

The best example that I can cite is from the autobiography of Greg Boyington, WWII Marine ace, Medal of Honor recipient.

He was a full blown alcoholic even before he flew with the Flying Tigers in China. While in captivity after being shot down by the Japanese, he was put in charge of warming sake for the camp guards and he found himself alone with the sauce.

He believed that if he drank, the best possible outcome would be a quick death via decapitation. He had witnessed the brutality of his captors and knew they were capable of the worst.

He drank anyway, to the point he blacked out. The guards woke him with a good beating, and Boyington was surprised that he hadn't been killed.

More modern examples of addiction under extreme circumstances:

https://www.nbcmiami.com/news/local...ys-Miami-Crack-Cocaine-Pursuit-511200292.html

A Florida man told officers he ingested crack cocaine while police chased him from Miami to the Upper Keys, sheriff's deputies said.

Mark Edward Welch, 50, of Lake Worth, was arrested Tuesday night and faces charges of DUI, fleeing and eluding, and possession of cocaine and drug paraphernalia, according to the Monroe County Sheriff's Office.

Florida City police started pursuing a black Jeep Liberty involved in hit-and-run crashes on the mainland. Welch drove from Miami to the Upper Keys and kept driving even after running over tire spikes, officials said.


http://www.fox2detroit.com/news/loc...-during-chase-smokes-crack-pipe-before-arrest

"In this job, you can never say you've seen it all," said Macomb County Sheriff Anthony Wickersham.

The suspect, 36-year-old Kristi Rettig of Eastpointe, now faces several charges including fleeing and eluding, assault with a dangerous weapon, and possession of a controlled substance.

"I think she truly believed she was going back to prison and figured she'd get one more hit of crack cocaine before she does her time," Wickersham said.

The passenger, 28-year-old Alexandra Weed of Melvindale, was also charged with possession.

The Macomb County sheriff wants to use this case as an example that it's never too late to join the "Hope Not Handcuffs" program which helps people get sober -- without fear of getting arrested.

The well intentioned folks here that believe an addict/alcoholic is basing their decisions about their addiction based on facts and statistics doesn't understand the subject matter.

To that demographic, anything that may give that person a leg up on beating their addiction - even snake oil or magic - is worth a hell of a lot more than statistics or discussions of higher-power this or that. None of these people ended up where they are be making good informed decisions. Expecting that these people will somehow begin making good decisions because that what's what you'd do under the same circumstances completely misses the point.
 
BStrong said:
Alcohol and/or drug addiction is a completely different animal than depresion. There are many individuals suffering with addictions that may also be suffering from clinical depression, but that disease is treatable fairly easily, and in fact if we're talking about alcoholism, stopping the drinking sometimes has a positive effect on depression.



I look at the question the same way that you'd approach an individual with catastrophic physical injury.



You don't tell the victim how serious their wound(s) are or that they're dying, you stay calm, keep the victim conscious if possible and keep telling them to stay with you and help is on the way.



Bad thing - sometime it's a flat out lie. Good thing - the individual may survive.



I'll take the lie over the truth.



As an aside, anyone that believes that individuals out of control w/ drug or alcohol use are susceptible to logical argument and an appeal to self care hasn't lived with the consequences of addiction.



The best example that I can cite is from the autobiography of Greg Boyington, WWII Marine ace, Medal of Honor recipient.



He was a full blown alcoholic even before he flew with the Flying Tigers in China. While in captivity after being shot down by the Japanese, he was put in charge of warming sake for the camp guards and he found himself alone with the sauce.



He believed that if he drank, the best possible outcome would be a quick death via decapitation. He had witnessed the brutality of his captors and knew they were capable of the worst.



He drank anyway, to the point he blacked out. The guards woke him with a good beating, and Boyington was surprised that he hadn't been killed.



More modern examples of addiction under extreme circumstances:



https://www.nbcmiami.com/news/local...ys-Miami-Crack-Cocaine-Pursuit-511200292.html



A Florida man told officers he ingested crack cocaine while police chased him from Miami to the Upper Keys, sheriff's deputies said.



Mark Edward Welch, 50, of Lake Worth, was arrested Tuesday night and faces charges of DUI, fleeing and eluding, and possession of cocaine and drug paraphernalia, according to the Monroe County Sheriff's Office.



Florida City police started pursuing a black Jeep Liberty involved in hit-and-run crashes on the mainland. Welch drove from Miami to the Upper Keys and kept driving even after running over tire spikes, officials said.





http://www.fox2detroit.com/news/loc...-during-chase-smokes-crack-pipe-before-arrest



"In this job, you can never say you've seen it all," said Macomb County Sheriff Anthony Wickersham.



The suspect, 36-year-old Kristi Rettig of Eastpointe, now faces several charges including fleeing and eluding, assault with a dangerous weapon, and possession of a controlled substance.



"I think she truly believed she was going back to prison and figured she'd get one more hit of crack cocaine before she does her time," Wickersham said.



The passenger, 28-year-old Alexandra Weed of Melvindale, was also charged with possession.



The Macomb County sheriff wants to use this case as an example that it's never too late to join the "Hope Not Handcuffs" program which helps people get sober -- without fear of getting arrested.



The well intentioned folks here that believe an addict/alcoholic is basing their decisions about their addiction based on facts and statistics doesn't understand the subject matter.



To that demographic, anything that may give that person a leg up on beating their addiction - even snake oil or magic - is worth a hell of a lot more than statistics or discussions of higher-power this or that. None of these people ended up where they are be making good informed decisions. Expecting that these people will somehow begin making good decisions because that what's what you'd do under the same circumstances completely misses the point.
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well said
 
BStrong said:
To that demographic, anything that may give that person a leg up on beating their addiction - even snake oil or magic - is worth a hell of a lot more than statistics or discussions of higher-power this or that. None of these people ended up where they are be making good informed decisions. Expecting that these people will somehow begin making good decisions because that what's what you'd do under the same circumstances completely misses the point.
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Wrong.

As you say, people in crisis grab for anything. This is why we as a society try to ensure that what people in crisis grab for actually has a chance of helping and not causing additional harm. This is why we rational folks are constantly working to outlaw quackery, snake oil, homeopathy, magic, etc. so that people in crisis don't grab for them, and grab for something that can actually help.
 
BStrong said:
Alcohol and/or drug addiction is a completely different animal than depression.
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Different, yes, but both diseases. One of the problems with AA is that it has marketed itself as "The Solution" to addiction. There is no other path to a better life but AA, and only an addict in denial would say otherwise.

I think this has hampered efforts to find other treatments. I can't point to any evidence for that, but I have seen anecdotal evidence referring to people who have addiction problems just need to get back to AA. A bit like Weight Watchers in their heyday.

I hope further study of the disease of addiction can get us to better solutions than AA or other current treatments. I think recognizing the limitations of AA and other current treatments is a big part of that.
 
The Greater Fool said:
Wrong.

As you say, people in crisis grab for anything. This is why we as a society try to ensure that what people in crisis grab for actually has a chance of helping and not causing additional harm. This is why we rational folks are constantly working to outlaw quackery, snake oil, homeopathy, magic, etc. so that people in crisis don't grab for them, and grab for something that can actually help.
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AA isn't an addict/alcoholic version of quack cancer cures or "psychic surgery," it's a bunch of folks in the same boat making an effort towards solving their addictions. I see no harm in it. Whether it works or not can be debated forever but making the perfect (self realization and positive action in abstaining from the DOC) the enemy of the good (12 step and similar programs) doesn't save anybody's life.
 
BStrong said:
AA isn't an addict/alcoholic version of quack cancer cures or "psychic surgery," it's a bunch of folks in the same boat making an effort towards solving their addictions. I see no harm in it. Whether it works or not can be debated forever but making the perfect (self realization and positive action in abstaining from the DOC) the enemy of the good (12 step and similar programs) doesn't save anybody's life.
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Argument from Ignorance.Which is why we study. And, unlike AA, improve.

It is not about the perfect being the enemy of the good, because we don't even know if AA is 'good'. AA has little evidence of success. Is it better or worse than simple peer support? We don't know. We do know it is a faith based approach, and we know that is a sword that cuts both ways.

I am advocating for evidence based approaches that change as more information is learned. By definition, this is not AA.

Being faith based, courts nor employers should be mandating AA. Courts and employers need better options.
 
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The Greater Fool said:
Argument from Ignorance.Which is why we study. And, unlike AA, improve.

It is not about the perfect being the enemy of the good, because we don't even know if AA is 'good'. AA has little evidence of success. Is it better or worse than simple peer support? We don't know. We do know it is a faith based approach, and we know that is a sword that cuts both ways.

I am advocating for evidence based approaches that change as more information is learned. By definition, this is not AA.

Being faith based, courts nor employers should be mandating AA. Courts and employers need better options.
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I think this gets to the crux of it. A lot of people have asked "If someone you knew wanted to go to AA, would you drive them to the meeting?" and similar questions. That's not really analogous to the OP situation, though.

The better question to ask is "If you knew someone with an alcohol problem, would you force them specifically to go to AA, regardless of what they wanted or other treatment options they might choose?"
 
The Greater Fool said:
Argument from Ignorance.Which is why we study. And, unlike AA, improve.

It is not about the perfect being the enemy of the good, because we don't even know if AA is 'good'. AA has little evidence of success. Is it better or worse than simple peer support? We don't know. We do know it is a faith based approach, and we know that is a sword that cuts both ways.

I am advocating for evidence based approaches that change as more information is learned. By definition, this is not AA.

Being faith based, courts nor employers should be mandating AA. Courts and employers need better options.
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While we're waiting for you to be satisfied with a proven treatment protocol for addiction, would you mind if the addicts/alcoholics in question attempt to work things out on their own?
 
BStrong said:
AA isn't an addict/alcoholic version of quack cancer cures or "psychic surgery," it's a bunch of folks in the same boat making an effort towards solving their addictions. I see no harm in it. Whether it works or not can be debated forever but making the perfect (self realization and positive action in abstaining from the DOC) the enemy of the good (12 step and similar programs) doesn't save anybody's life.
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Should it be debated or should it be studied as we study most other disease treatments?

We don't rely on debates to determine if a proposed drug is effective, we rely on studies. So far, AA has been rather resistant to studies.

Can you imagine a world where there was only one treatment for cancer and that treatment resisted most attempts to study whether it was effective or not? And yet the general consensus was that it probably was as good as you could get, so there's not much need to study cancer treatment anymore.
 
Hellbound said:
I think this gets to the crux of it. A lot of people have asked "If someone you knew wanted to go to AA, would you drive them to the meeting?" and similar questions. That's not really analogous to the OP situation, though.

The better question to ask is "If you knew someone with an alcohol problem, would you force them specifically to go to AA, regardless of what they wanted or other treatment options they might choose?"
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I'm OK with allowing the individual in question to decide if they want treatment or not.
 
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While I agree people should have options other than AA, I believe it does help some people.
Now what actually is the working factor is up to debate.

Working with MISA (Mentally Ill Substance Abuse) clients (funny I am one), our rules were solely one:

You can not express a desire fro active use while in group the caveat being you had to say you wanted to stop. But you were not allowed to attend if you sai 'Eff this I am getting drunk as soon as I get home"

The clinician who developed our program used a harm reduction model
1. Know why you don't want to use
2. Make plans to avoid use
3. Make an 'escape plan for when you were at risk of using or using
4. Make a plan to avoid use after a replase
4. Develop a life style on non-using behaviors, skills and support
 
whoanellie said:
The Greater Fool was attempting to move the goalposts also.
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No, you are trying to have it both ways. You claim every AA is different so can't be studied, then site a study about AA. Again, which AA was studied?

You yourself say the only consistent aspect of AA is peer support, so how can it be claimed more than that is being measured by Moos & Moos? Nowhere does Moos & Moos, or any study, address 12 step vs peer support. So, Moos & Moos do not prove any point about AA other than peer support seems to work.

Moving goalposts: AA doesn't have to be religious, AA is not treatment, AA is a social club. AA can't be studied. Here is a study.
 
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