Conceptualization of mental illness within Arab cultures: Meeting challenges in cross-cultural settings July 31, 2007
Posted by in : health , add a commentKeywords: Arab, interpreters, cross-cultural, conceptualization, mental illness.
For the families of Arab patients psychological treatment primarily entails pharmacotherapy.
Using the aid and expertise of a doctor practising psychological science is seen as a sign of weakness (El -Islam, 1998; Okasha, 2000) or a shameful event that might bring disgrace to the family and the tribe. This may be attributable to rigidity in perception, rather than to a distorted misattribution of what constitutes treatment. These elements, mainly existential in nature, are traditionally relegated to a more “specialized” individual who often employs nonmedical, nonpsychological, noncultural bound methods of healing (Lefley, 1994). The traditional healer or Sheikh or Matawaa, in the typical Arabic dual acceptance of the two seemingly contradictory ways of dealing with mental illness, is considered the one who would drive the “evil spirit” and “evil eye” away. Family members may assume the role of guardians so that the patient may not reveal family secrets in sessions, which accounts for the triad configuration in many psychotherapeutic encounters with Arab patients. This may present a challenge for therapists who employ psychodynamically informed techniques. Needless to say, in such a therapeutic configuration some factors would be present that are not related to the therapy process, and which lend themselves to attenuation of the transference/countertransference paradigm leading in turn to dilution of transference that would be antitherapeutic for those clinicians subscribing to psychodynamically informed therapy. It may, in some extreme cases, lead the person present in the therapy room to develop some psychological problems himself/herself, due to repeated exposure to the traumatic material presented in the therapy session, especially if the person accompanying the patient has certain vulnerabilities, and there is a total immersion in the patient’s affairs.
This transference psychosis according to Meissner (2001a) occurs when “failure of reality testing leads to loss of self-object differentiation and diffusion of self and boundaries….such mirroring may reflect an attempt to re-fuse with an omnipotent object as a defense against underlying fear of vulnerability and powerlessness” (p. 199).
THE USE OF INTERPRETERS AND TRANSLATORS IN PSYCHOTHERAPY OF ARAB PATIENTS
The following case study illustrates the difficulties one would encounter when Arab patients are treated in a psychodynamically informed milieu. In addition to difficulties outlined by Meissner, (2001a & 2001b) regarding issues of alliance and transference, a complication arises from using interpreters and translators in the therapy sessions.
The relationship between companion and patient can cause role confusion for the companion who also acts as an interpreter in an individual psychotherapy process. It can be confusing and awkward to both companion and patient if the companion is more like a therapist in one setting, and a friend in another. At times, however, the companion may feel pulled into the role of patient as his or her charge needs to discuss his/her relationship in psychotherapy. When using a companion as an interpreter, the therapist in the triad may have to work in an unfamiliar modality that has elements of individual therapy, marital therapy, group therapy, and cotherapy. The presence of a companion in psychodynamic psychotherapy adds complexity in other ways. These include two additional relationships (i.e., companion-patient and companion-therapist), companion as transference object, companion’s countertransference, and the therapist’s countertransference to the companion. The following case illustrates the phenomenon of having a companion in a psychodynamically informed psychotherapy process:
A program to assist people with severe mental illness in formulating realistic life goals - Formulating Realistic Life Goals
Posted by in : health , add a commentA review by Spencer, Davidson, & White (1997) indicated several clinical approaches for helping individuals develop hope for the future. These approaches include goal setting, goal attainment, examination of change in an individual’s occupational configurations over time, and qualitative interviews about life history. It was reported that rehabilitation professionals used purposeful activities to help individuals develop goals during the recovery process (Howard & Howard, 1997).
A longitudinal study (Harding & Zahniser, 1994) demonstrated that people with serious mental illness can recover as evidenced by their successful employment and meaningful lives. A case study by Stern and Drummond (1991) illustrated that individuals with persistent schizophrenia changed from being `unwilling to be discharged’ to `willing’ when appropriate strategy was used. Steams (1998) measured the change in hope of 13 individuals with mental illness after receiving a three-month Lowa rehabilitation program. Significant differences in pre and post measures of the Herth Hope Scale were noted.
To date, hospital-based treatment protocol to help individuals with mental illness in setting realistic life goals has been scant. Bauer & McBride (1996) developed a five-session psycho-educational program designed to help in-patients with affective disorder develop life goals, improve their social and occupational functioning and improve self-management skills. The program however, was not suitable for individuals with persistent schizophrenia as individuals with this disorder are usually detached from reality and have poorer prognosis than individuals with affective disorder. Structured protocol to assist the development of life goal for individuals with severe mental illness has rarely been documented. A clinical protocol (Goal Attainment Program, GAP) (Ng, 1999) was therefore designed and piloted to in-patients with severe mental illness in Hong Kong (a Special Administrative Region of China). This paper aims at describing the theoretical framework and reporting the findings of the pilot study regarding the effectiveness of the GAP.
Framework of the Four-stage Cyclic Model of Goal Attainment
The framework for planning the Goal Attainment Program was based on the Mezirow (1981) learning cycle (adult learning theory) and a planning model for change (Rantz and Miller, 1987). Mezirow’s adult learning theory (1981) provides a framework to guide individual mentoring processes which was found useful in integrating Chinese scholars into Canadian culture (Morales-Mann & Higuchi, 1995). The adult learning theory was used as guideline for the program in this study because it emphasizes self-examination and relates one’s experience to others. It is consistent with the approach of life history review during counseling sessions. The adult learning theory also encourages building competence and confidence in new ways of acting, which is one of the objectives for the Goal Attainment Program. As in-patients with severe mental illness have often adopted a maladaptive passive life pattern, encouraging them to view life with a new perspective may facilitate change. Finally, the reintegration into society as the final step of adult learning theory matches the ultimate goal of the Goal Attainment Program.
Mental illness in the workplace - Manager’s Workshop
Posted by in : health , add a commentMany workers are simply not taking advantage of the health-care insurance programs and EAPs available in many companies either because they are unaware of the available help or because of the social shame still attached to seeking out mental health care. Sadly, many workers conceal and hide their disorders rather than seek assistance. And many employers don’t have established screenings that would support workers to seek out help in a private, confidential environment.
As a result, workers with mental disabilities do not have the same opportunity to contribute and to achieve their potential because of barriers they face when trying to obtain competitive employment. In the United States, the unemployment rate for individuals with psychiatric disabilities is between 80 to 90 percent.
Psychologists often write about the emotional state of the American workforce. And, sooner or later, managers peer into these findings hoping to adapt them to their own particular work-a-day world. But a recent report conducted by the Pfizer Pharmaceuticals Group and the National Mental Health Association found that 25 percent (about 28 million) of the US, workforce suffers at least one mental or substance abuse disorder each year. That’s a staggering one out of four workers!
About 66 percent of that 28 million have never been diagnosed, and just 14 percent have received treatment in the past year. Unfortunately, the myth is that if you are at work you are healthy, but this is simply not the case.
The most common mental disorders among American workers aged 18-54 are alcohol dependence, major depression and social phobia.
The report also found that companies pay more than $17 billion a year in unproductive wages to workers with mental disorders: $5 billion for missed workdays and $12 billion for lost productivity. Employers aren’t the only losers. Workers with mental disabilities earn on average 22 percent less than those without them.
The first of its kind, this large-scale study and its findings will certainly be analyzed and questioned for a long time to come.
For many Americans, working provides a sense of self-worth and a source of self-esteem. Work offers many benefits besides a means to pay the bills. It provides a sense of purpose, social interaction and an opportunity to contribute to the community.
Understanding mental illness is every manager’s responsibility.
SOURCES: Robin Hertz, Ph.D., senior director, population studies, Pfizer Pharmaceuticals Group, New York City; Mary Graham, senior policy advisor, National Mental Health Association, Alexandria, Va., Pfizer Pharmaceuticals Group study, 2002.
Police contact with mental illness in mid-sized city - Inner City Health
Posted by in : health , add a commentThe study of patterns of contacts between police and people with serious mental illness in southwestern Ontario confirms that police officers do not have the resources to appropriately assist this population. Research supports that most of the needs of the seriously mentally ill are best met outside a hospital setting. However, appropriate resources need to be in place in the community to ensure that this population receives the best possible range of treatment options.
Service problems and solutions for individuals with mental retardation and metal illness - 2001 NRA Graduate Literary Award Winner
Posted by in : health , add a commentBackground Information
The case described above reveals how difficult it can be to provide services to individuals with a dual diagnosis of mental retardation and mental illness. In fact, this population still remains widely unrecognized, and professionals who do recognize it often refer to this combination of diagnoses as the “other dual diagnosis,” because the term, “dual diagnosis,” is often assumed to refer to the combination of mental illness and substance abuse (Bongiorno, 1996, p. 1142). Along with the difficulty in recognizing this population, the services to people with mental retardation and mental illness still remain separate and continue to diverge considerably (Nezu, 1994). Without proper recognition and collaboration from both systems, necessary treatment is not possible.
Historical Beliefs
Problems providing services to individuals with mental illness and mental retardation began as a result of previously held beliefs of professionals. For instance, little distinction is often made between mental retardation and mental illness, and individuals with mental illness and/or mental retardation are treated as a single population (Nezu, 1994). In addition, some professionals believe that individuals with mental retardation are immune to emotional and psychological problems as a result of the retardation. Fletcher (1988) reported, “The mildly retarded have been characterized as worry-free and thus mentally healthy. The severely retarded have been considered to express no feelings and therefore do not experience emotional stress” (p. 255). These beliefs have prevented individuals with both mental retardation and mental illness from receiving appropriate services.
Current Beliefs
Recent research has revealed that professional beliefs, such as those described above, are not valid. Individuals with mental retardation can indeed experience emotional and psychological problems. In fact, it is now typically mandated that people with mental retardation receive appropriate medical assessment, diagnosis, and follow-up treatment (Szymanski, 1994). As a result, fewer individuals with a dual diagnosis of mental retardation and mental illness go unnoticed.
Pathology and Pharmacology of Mental Illness, The
Posted by in : health , add a comment0-7487-5321-4
pp 238, L25.00
As a lecturer working with a wide range of mental health professionals I have often wished that there was an up-to-date text book that clearly explained the actions of medication used in the contemporary treatment of clients suffering from mental health problems and also related the pharmacology to the neurobiology. So it was delightful to come across this book.
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in Health
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in Health
The authors state that the book is aimed at professionals who are working with people who are suffering from mental health problems. Throughout, all the biological content is presented in an accessible manner even if the reader does not have a particular background in biological sciences. The language is clear and jargon kept to a minimum with unusual terms explained without the authors appearing to patronise the reader in any way. The use of highlighted key points and self-assessment questions make this a particularly good study aid.
The book is divided into eight chapters. The first chapter gives an overview of the use of medication in mental health treatment and includes information about drugs and the law as well as the biological facts of how drugs work to control or treat mental health problems.
The next six chapters each have a specific focus, for instance, schizophrenia or disorders of sleeping and eating. In each chapter the authors give an introduction to the disorder and the problems associated with it. They go on to explain the neuro-biological aspects and then discuss in detail, a range of pharmacological treatments. The action of that particular group of drugs is discussed and attention is paid to the possible side effects and contra-indications.
The final, and very useful, chapter entitled ‘The Mind-Body Link’ deals with a wide range of physical disorders that may result in mental health problems including organic brain disease and the effects of endocrine disorders.
Each chapter is very much evidence-based and each is well referenced. The authors indicate online journals and useful websites where appropriate. I tried a number of these and each gave access to more useful and focused information.
The use of small vignettes/case studies were used throughout the book though sometimes the focus of these was the management of the patient/client rather than the pharmacological treatment.
The strength of this book is the clarity of writing, the strong evidence base and the style where key points are highlighted. The index is well compiled and I found no difficulty finding information about particular disorders or treatments just using the index, not always true of all books alas.
It is unlikely that someone would read this book from cover to cover; it is very much a ‘dipping in’ text book.
The main criticism I have is the line drawings. Some look like the sketches made at lectures and seem to give a certain ‘home made’ quality to the book. The exact meaning of the diagrams is not always clear. For instance, looking at the diagram labelled the ‘blood brain’ barrier, the reader could be forgiven for thinking that hormone changes only happened in the occipital area of the brain. Given the price of the book and the excellent technical/biological drawing that is available at present, I feel the illustrations let the book down.
However, I must stress that this is very much a minor point when considering the book overall. I have already found myself referring to it for information for lectures and I do feel that it is a well written and useful resource that many practitioners who work with or care for those with mental health problems will value in the future.
Fight for life: Janet Walton writes from her experience of mental illness—one of the few remaining taboos of our age - Living Issues
Posted by in : health , add a commentPsychotic illness is one of those strange enigmas people fear. They therefore discriminate against those who suffer from it. It is the worst of the worst. Worse than the big C or death itself. It epitomizes all we most fear–’losing our marbles’, losing control.
My grandfather suffered from a severe incurable mental illness and died in an asylum in 1916. It is uncertain whether my father carried a dominant or a recessive gene for this illness. He died aged 40 from Hodgkins Disease when I was only three and a half. I, his only child, carry the dominant gene for psychotic illness.
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in Reference
Science WorldCatholic New TimesAfrican American ReviewCollege Student Journal
Normal people are sometimes at the mercy of their sick and tortured thoughts or emotions. These can temporarily affect their brain chemistry. But we psychotics live at the mercy of changes in our brain chemistry, which can quite unpredictably zing us right out of gear–and may be connected to a change in the weather or diet or to exceptional events or to simple unavoidable everyday stress. These changes can affect our thoughts, emotions and behaviour, as by-products.
PENDULUM
We psychotics never–or hardly ever–lie back and give in and say what is actually so true, ‘We can’t help it.’ We gather the reins in our blistered bleeding hands to work on that frantic wild beast within. At times we resemble a raging lion, at times a meek mouse. If you can catch the pendulum as it swings you might get a glimpse of the amiable border collie which we perceive in our fellow human beings at their best.
Through weeks, months, years of torture I have learned to let the pool of sanity of God’s creative mind touch and circle my sick mind. Like a stone in a pond, the particle of sanity from Above radiates rings of illumination and sanity in the dark dingy pool. Mostly my mind is alone, cut off from God. But the more I perceive of him, the nearer middle age I reach, the more I stretch forth a calloused hand for a shoot of sanity.
Six years ago when I began to break out of severe psychosis, my anti-psychotic drug was reduced. As a side-effect, my blood pressure rose dramatically. I suffered a heart attack and a slight stroke, which unfortunately were wrongly diagnosed. The medication was reduced still further. There were times when I wanted to die, due to the complete debilitation which resulted.
Eighteen months ago I was taken off mood stabilizing and sleeping medication. As the sick chemistry drifted away from my brain, the physical struck where, unbeknownst to me, it had been threatening to strike for some 40 years. My blood pressure soared and I suffered two severe strokes and a life-threatening and frightening bout of pneumonia. My life was in jeopardy for seven weeks in hospital. For the first year at home I often lay at death’s door.
At the onslaught of pneumonia, one junior house officer in hospital said to me, ‘I wouldn’t bother to live with a prognosis like yours, Mrs W.’
‘Why?’ I said. ‘What is my prognosis, doctor?’
‘Well probably paralysed waist-down for life, and psychotic into the bargain,’ he said. ‘I know what I would do.’
‘Well, I have a husband to live for, doctor, and live I will.’
At one point I feared the pneumonia would take me: the hospital had left it to providence. They left me to struggle for my life, and struggle I did.
So I said to God, ‘What do you want me to do?’ The answer came back heart-to-heart, mind-to-mind, ‘Free will I give you, Janet.’
‘My will is to do your will, God,’ I said. ‘I submit my will totally and utterly to you.’
The reply came, ‘I need you alive. Rick needs you. Fight.’
So fight I did until after five more days I felt I could let go of the draining battle and rest and trust in God. He took over the strings of the marionette puppet.
‘TO LIFE’
The next day my husband asked if I had felt something different as if someone had prayed for me. He and my doctor, unbeknownst to me, had prayed in earnest. Their request–and mine–was answered. My chest cleared and my throat muscles began to work again. Richard and I toasted each other with a glass of water, ‘To life’. And life we have, and have it more abundantly.
Now a few months on I give thanks for what I have: partial sanity–it could have become total insanity–and partial paralysis–it could have been total. I have a home of my own–friends, family–and a very loving and wonderful husband. My singing voice has returned after five years of not being able to sing. I am able to read and write again after 30 years of fuzz and confusion. I compose and play my father’s piano.
My husband and I are joined in submitting our wills and minds–sick though they at times are–to God’s will. He is our light, our life and our way.
Mind swings - recovery from mental illness
Posted by in : health , add a commentI felt like a werewolf growing claws. A migraine headache generated blinding spots in front of my eyes. The rustling Florida palms outside the kitchen assaulted my ears as I tried to wash dishes. The year was 1994, and I was visiting my mother’s home near Tampa. She quietly asked me a benign question, but her words stabbed like a knife. In response I crashed a cast-iron skillet in the sink and turned the silverware into weapons of mass destruction against defenseless plates.
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in Home & Garden
My mother, a retired nurse, assumed the mask of a cool clinician, but bewildered eyes betrayed her confusion. She watched me edge toward my bedroom, one hand cupped around my temple and eye, trying to block the painful glare of the dimly lit room and the violent sound of near silence. I fell on my bed and lay for days in an all-encompassing somnolence.
Episodic mood swings were nothing new to me. Typically I was an extroverted whirling dervish of productive energy–sometimes to the extent that people asked, “What are you on? “I’m just on a natural high,” I happily responded, then spun away. But, from the age of 13, the seven to ten days before my menses were often distressing. Once a month I faced the possibility of metamorphosing into the thing with claws.
Occasionally, the onset of my period added an irritable, agitated kick to my euphoria and I verbally–sometimes physically–tried to mow down anything in my way. I did not realize then that these shifts were only partly due to premenstrual syndrome (PMS), which subtly masked a mood disorder that left untreated would become even more debilitating.
I was 16 the first time I put myself in therapy, and by 1994 I’d spent more than two decades swinging from various kinds of highs to increasingly crippling lows. It was the verdict of at least seven doctors I had consulted since high school that I was a Type A, overachieving, stressed-out-from-work woman with a traumatic family history. That may have been true, but as I got older, talk therapy failed to stop the exhausting highs and debilitating plummets. Despite long periods of stability, my body chemistry was awry, and it was more than the hormonal frenzy of PMS. The frequency of my mood changes, which worsened with age, convinced me of that. I couldn’t have PMS 24-7, 200 days a year.
As a journalist and author trying to fulfill a second book contract in 1995–and three years behind on the deadline–I was alarmed by a new inability to concentrate and write consistently. I would stare at my computer screen for eight, ten, twelve hours a day, in a sterile writer’s trance. My fogged brain grasped at jumbled thoughts that evaporated with each effort to nail them. At the end of a frustrating day, I fell into a sleep from which I was often awakened by pains that throbbed deep in my joints. Compelled to get up to go to the bathroom, I would linger in front of the mirror, intrigued by the hideous woman I saw there–her features a fun-house mirror distortion and her pinpoint pores, a particular preoccupation, cavernous. Staring at my image, I wanted to take a razor to my throat.
DIAGNOSIS: MANIC-DEPRESSION
Just after Thanksgiving in 1995, I dragged myself, in tears, to my internist, demanding that she refer me to a female psychiatrist. (I’d been completely alienated by the paternalistic male clinicians I’d seen previously. And I wanted drugs prescribed if necessary, something a psychologist cannot do.) At the department of psychiatry of the Washington University School of Medicine in St. Louis–a leader in the diagnosis of bipolar disorder–I met with Devna Rastogi-Cruz, M.D. I immediately felt at ease. “I feel so tired,” I said during our first appointment. Despite my fatigue, words tumbled from my mouth at emotionally jacked-to-the-max Energizer-bunny speed. “I’ve got to finish this book, but I’m years behind….” Then I backed up and gave Rastogi-Cruz the history she needed.
Every two or three years since I was about 13 years old, I would crash, I said, recounting the story I had told previous doctors. I would come down with a severe respiratory ailment and become irritable and withdrawn. Those episodes usually followed intense, exhilarating months of work and socializing. After my crashes I’d regain my equilibrium.
“I trained for years to be a musician,” I continued, “and sang on major concert stages before I was 18. Singing was all I ever wanted to do. But in the seventies I caught the tail end of the Black cultural-nationalist movement and embraced it zealously. I am often zealous. I abruptly abandoned music and changed my major to journalism. I decided I could have a greater political impact as a journalist than as an opera singer.” I stopped to look at the doctor. “You with me.?” Yes, she nodded.
Karp, David A. The Burden of Sympathy: How Families Cope with Mental Illness - Book Review July 30, 2007
Posted by in : health , add a commentKarp chronicles the experiences of the family members of the mentally ill, and how they draw “boundaries of sympathy” to avoid being engulfed by the day-to-day suffering of a loved one. Working from sixty extensive interviews, the author reveals striking similarities in the experiences of caregivers: the feelings of shame, fear, guilt and powerlessness in the face of a socially stigmatized illness; the frustration of navigating the complex network of bureaucracies that govern the mental health system; and most of all, the difficulty negotiating an “appropriate” level of involvement with the mentally ill loved one while maintaining enough distance for personal health. Throughout the narratives, Karp sensitively explores the overarching question of how people strike an equilibrium between reason and emotion, between head and heart, when caring for a catastrophically ill person. The Burden of Sympathy concludes with a critical look at what it means to be a moral and caring person at the turn of the century in America, when powerful cultural messages spell out two contradictory imperatives: pursue personal fulfillment at any cost and care for the family at any cost.
Moving past what to how—the next step in responding to individuals with mental illness - Police Practice
Posted by in : health , add a comment[ILLUSTRATION OMITTED]
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in News
EbonyAdvocate, TheMilwaukee Journal…Independent, The (London)
Tulsa, Oklahoma, like most other communities across the country, has long experienced the difficulties of the increasing pressure on individuals with mental illness and their families as a result of state funding problems and constant changes in mental health care delivery systems. Most of the responsibility for providing services to those seriously ill or less able to pay for services has shifted from one agency to another, sometimes more than once. Because of this challenge, the Tulsa Police Department’s (TPD) apprentice police officer (APO) academy training has included a component similar to the “Memphis Model (1) since 1988. Integrating front-line mental health professionals into the broad, multidisciplinary training given to APOs for almost 15 years has helped TPD field officers become proficient in the task of responding effectively to individuals with mental illness.
To answer a growing need, the TPD resolved to go beyond refresher classes for incumbent officers and, instead, committed to developing an advanced mental health response officer school. The school was designed to help police and mental health professionals work in a collaborative partnership as both instructors and students. (2)
THE GUIDING PRINCIPLE
The guiding principle for the school’s development, the “operational triangle,” represents a model the TPD has used for many years to instruct APOs. The foundation of the operational triangle is safety. Ensuring safety is the first step in all interactions between officers and citizens. Only after this is established and maintained should an officer focus on using communication skills to form an effective relationship with a subject. Officers first must have a safe environment before they can apply interpersonal skills directed toward possible problem solving.
Once officers establish a state of safety, they are tempted to move directly to problem solving. Yielding to this temptation means skipping the middle section of the triangle and, often, results in ineffectiveness. Increasing officers’ confidence in their abilities to effectively use interpersonal communication skills improves the likelihood that they will incorporate each section of the operational triangle.
Over the last 20 years, the law enforcement profession has made huge strides in raising officers’ awareness and competence in the areas of citizen and officer safety. Agencies should devote attention to increasing officers’ awareness of the essential step between safety and problem solving. These human relation skills, like officer safety skills, improve with practice. Enhanced interpersonal skills will amplify the ability of officers to project a powerful influence with citizens they serve, especially those with mental health issues.
THE INSTRUCTIONAL OBJECTIVE
The school’s mission is to assist people in need of mental health services in a way that secures the safety of all concerned, respects the dignity of the person in need of attention, and increases the chances of a good outcome with mental health service providers following the law enforcement contact. This statement defines the instructional objective of maximizing the time spent conducting collaborative cross training between law enforcement officers and mental health professionals most likely to have direct contact with individuals in need of mental health services. Minimal time expended on reviewing mental health knowledge (e.g. facts, diagnostic categories, mental disorder descriptions) in lecture-type presentations allows instructors to spend more time on practical applications of interpersonal communication and intervention skills.
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CURRICULUM DEVELOPMENT
Various departments of the TPD and the mental health community designed the school’s 40-hour curriculum in the spring of 2002 over a 6-month period. Classes are limited to 20 police officers and 5 mental health professionals. Attendees are divided into smaller groups composed of four officers and one mental health professional with a TPD special operations team crisis negotiator acting as facilitator/instructor because of this person’s experience and expertise.
Upon completion of the school, sworn law enforcement graduates earn department certification as advanced mental health response (AMHR) officers. Further, mental health professional graduates are certified AMHR responders and can receive continuing education credits as well.
CURRICULUM
Day 1
