Social Contagions and Iatrogenic Harms in Psychology

While with some new heterodox friends, I was describing my area of research and interest, I framed a number of my interests as being social contagions and harms in the world of therapy.

I mentioned the following as social contagions related to iatrogenic harms: the Satanic Panic, the multiple personality epidemic, the repressed memory epidemic, and the memory wars. I mentioned how some of these problems continue today, but how people have seemed to lose interest in these areas.

I also mentioned other types of iatrogenic harms as laid out in Abigail Shier’s new book, Bad Therapy. In that book, the social contagion of over-diagnosis in other areas of clinical psychology and an all too quick reflex to refer children to therapy is discussed quite brilliantly. Perhaps most importantly, Shrier points out that therapy always comes with some risk of harm, whether it be estrangement from parents or partners, or increased depression and anxiety from a therapist getting a client to ruminate on negative emotions. A couple of days later, one of my new friends, an academic who had been put through an awful harassment campaign in relation to a new social contagion, asked me to send her some of my work that relates to what I was talking about. I have many articles and encyclopaedia entries to send, but I realized that I have rarely framed all of the things I research using the words “social contagion,” and that I needed to fix that in a Substack article. I have used the words for many years since my doctoral social psychology training—in conversation, teaching, in my Trauma, Memory, and Law book, and probably a few times in articles too.  I connect the dots between social contagion and my areas of interest here in this essay.

In this Substack essay, I will talk about several past social contagions of which I have written about before, and give links to my past works, and also at the end talk about perhaps the newest social contagion that resulted in the harassment of my new friend. As I write I will also point out a few themes that connect them all, such as their tendency towards authoritarian enforcement (and harassment), a lack of falsifiability mixed with unmeasurable constructs, a holier-than-thou almost religion righteousness in believers, and of course a kind of viral social contagion of these ideas. Join me in a discussion through these topics in perhaps a clearer and more direct way than found in peer-reviewed journal articles.

1.      The Salem Witch Trials Social Contagion

I will organize this article chronologically, and start with the precedents of worst branch of modern psychodynamic therapy. Namely, let me describe how treatments for mental disorders evolved from exorcisms, to Mesmerism, to hypnosis, to recovered memory therapy and beyond. But first let’s start with an instructive case of social contagion that is somewhat related to the next section on exorcisms, that of the Salem Witch Trials.

The Salem Witch Trials has long been a staple used to explain the social contagions in my area of repressed memory epidemics. For decades, the writings of skeptics (both generalist skeptics and repressed memory skeptics) have described the Witch Trials to very successful effect. It is difficult to not learn valuable lessons from it.

The Salem Witch Trials of 1692 in Massachusetts is a chilling reminder of how societal fear and suspicion can spiral into mass hysteria and unjust persecution. At its core, the Salem Witch Trials was a terrible case of social contagion, wherein irrational beliefs and accusations spread rapidly through a community, fuelled by a belief in invisible constructs, confirmation bias, and a lack of critical thinking.

It all began with a group of young girls in Salem Village purportedly experiencing mysterious fits and symptoms that defied explanation. Whether these symptoms were real, and whether they were caused by psychological or physical (e.g. toxins) is not entirely known. In a community where superstition and belief in the supernatural were deeply ingrained, these occurrences were interpreted as being related to witchcraft and perhaps demonic possession. Unable to understand or control these purported phenomena, the villagers sought supernatural explanations, setting the stage for the ensuing hysteria.

As accusations of witchcraft surfaced, fear and suspicion permeated Salem Village. The initial accusations, driven by the afflicted girls, quickly spread beyond them, encompassing other villagers. Social interactions, rumours, and community gatherings became fertile grounds for the dissemination of these accusations, creating an atmosphere of paranoia and distrust.

Once someone was accused of being a witch, confirmation bias took hold, leading villagers to interpret any behaviour deemed suspicious as evidence of guilt. This reinforced the belief in the accused's witchcraft and led to further accusations.

The Salem Witch Trials also exemplify the power of mobbing and harassment. Fearing ostracism or worse, individuals felt compelled to conform to the prevailing beliefs and accusations. Those who dared to question or challenge the accusations risked becoming targets themselves, further intensifying the hysteria. Does any of this sound familiar from 2017 to 2024?

Similarly to some newer contagions, the legal and religious authorities of the time lent legitimacy to the trials, accepting dubious evidence such as spectral testimony and dreams. This facilitated numerous convictions and executions, perpetuating the cycle of fear, injustice, and conformity.

As the hysteria began to wane, people reflected on the events and the injustices that had occurred. The trials were eventually recognized as a tragic episode of mass hysteria, driven by social and cultural factors. The Salem Witch Trials serve as a cautionary tale about the dangers of social contagion and the importance of critical thinking, skepticism, and intellectual courage. Perhaps the most important thing to note is that humans will likely create similar contagions going forward, and it may be for younger generations to be ready for them in decades to come.

2.      Exorcisms, Mesmerism, and Hypnosis Social Contagions

Before the end of the 18^th century in Christian Europe it was not unusual for unexplained psychological disorders to be treated with exorcism. The going model in some were that demonic possession may be causing the psychological or physical symptoms. One might also speculate that some individuals without symptoms may have been volunteered for exorcism by those who imagined them possessed. Similar to the repressed memory craze I will discuss later, I worry that many people treated by such harmful treatments did not even need any therapy (or exorcism). Nevertheless, some patients may indeed have had symptoms—perhaps caused by disease, lead or food poisoning, malnutrition, or many other hazards of those times. Exorcism never worked, of course, but if done with a conviction that a devil resides within, it would have done great harm in the hands of a brutal and brainwashed exorcist. Notice here we are dealing with the beginnings of modern day therapy—the forebears of a pattern of clients with problems seeking out an expert figure for a cure. The placebo effect both then and now likely effected the wonderful testimonials that exorcists could extract from clients.

Towards the end of the 18^th century, the old exorcism model was replaced by a new model of treatment: Mesmerism. Anton Mesmer took ideas from the emerging science of the times and proposed that diseases were related to fluid flow and magnetism within the body. This was utter claptrap and pseudoscience, and was readily debunked by scientists of the time (see the Franklin Commission of 1784, in France), and even more debunked since then. To emerge from Mesmerism were some ideas that survive to this day—ideas such as a trance-like state might be curative, and that the presence of expert therapists in sessions might be curative as well. Other aspects of Mesmerism, such as animal magnetism, was happily put into the dustbin of history in the century that followed.

But some of the errors of Mesmerism, such as the idea of curative trance in the presence of a paid physician, were retained as Mesmerism evolved into hypnosis in the early and mid-1800s. It is in this time period in which the first hypnotists introduced folklore into European culture that still pollutes the literature today. In the mid-1800s, the idea that hypnotic trance could be curative was perpetuated, as was the new idea that people lose time (i.e. forget) during hypnotic trance sessions. But this got even worse and perhaps even more iatrogenic in the 1880s to 1900, as hypnosis evolved to incorporate ideas of trauma and dissociation. In my view, the evolution from Mesmerism to hypnosis and to trauma-related hypnosis is little more than a cultural and social contagion phenomena in which each successive generation is just unable to throw out the old ideas no matter how unscientific their beginnings were.

In the 1880s, two French schools of hypnosis (Nancy and Paris schools) began to incorporate more ideas about trauma into existing hypnosis theory.  To be fair, a few of the physicians in these schools did identify the problem of suggestion and what they then called “pseudomemories” in these schools (especially Hippolyte Bernheim; note that we now call “pseudomemories” false memories). Nevertheless, some hypnotist-physicians created more pseudoscience and perhaps started the most harmful branch of psychology to date—a trauma-dissociation centric approach to hypnosis and psychodynamic therapy.

Jean Martin Charcot was pivotal in birthing the trauma-centric approach to hypnosis, with his ideas in the 1880s that trauma may cause what he called “hysteria.” His student, Pierre Janet, towards the end of that decade had coined the word dissociation—a concept still polluting ideas in psychology to this day. Dissociation, as Janet described it, involved the splitting of consciousness and memories, and was invented as an attempt to explain why memories under hypnosis were not readily available to a client’s memories outside of hypnosis. Even the birth of this concept is problematic: Janet was likely wrong to credulously believe that hypnosis split individuals. In fact, in 2024, there is no good evidence that hypnosis creates two consciousnesses with split memory systems. It is beyond me why we still believe in this claptrap as a profession. But we do to some extent, as I explain in later sections.

The concept of dissociation came to mean a syndrome of symptoms that are suspiciously similar to hypnosis phenomena that were believed in the 1800s, namely the idea of lost time (amnesia), the feeling of depersonalization, and absorption. It is unsettling that the inaccurate idea that time was lost, or that memories were partitioned, during hypnosis, transformed into the idea of dissociative amnesia (a travesty of an idea now forever embedded into the influential Diagnostic and Statistical Manual for Mental Disorders). It is unsettling that the idea that consciousness is altered and fragmented in hypnosis transformed into the idea of fragmentation due to trauma. That absorption and suggestibility to hypnosis transformed into a symptom of trauma-induced dissociation is also rather credulous. That the “findings” of these pseudoscientific musings in French hypnosis schools is still the foundational pattern by which psychologists understand trauma and dissociation has got to be the weakest branch of psychology. It is terrible science, and that it became embedded into psychological theory was probably aided by the foolish inclusion of a chapter on dissociation in William James’ 1890 textbook Principles of Psychology (an otherwise excellent book, from an otherwise excellent psychologist/philosopher).

The social contagion of hypnotic theory has not abated even now, although there has been some weeding of that particular batch of land. Even some skeptics, and some of my colleagues and allies, hold onto some hypnotic theory and legitimacy, as well as treat dissociation with some respect as a proposed construct. I do not, this nonsense has gone on for too long, and there is a wonderful scientific side of psychology we could get back to once we debunk the nonsense.

3.      The Repressed Memory Social Contagion Before 1980

Sigmund Freud actually attended some of Charcot’s and Janet’s teachings at the Paris School of hypnosis, and it inspired his invention of the concept of repression that he put forward between 1893 and 1895 (with Breuer). Freud churned out some utter pseudoscience during this time, including the idea that emotions are stored after traumas, thus needing release in a kind of reliving therapy (catharsis theory). Hand in hand with catharsis theory was the idea that early traumas are stored, and that the memories can be repressed (or suppressed) from conscious awareness. Thus the idea, the deeply harmful idea, of repressed memories was popularized by the thousands and then millions of people who would read Freud in the twentieth century. It is still an idea that will not die. It spread around the world over the decades like a viral meme, and has infected almost every single country in the world at the time of writing.  Perhaps there is a tribe or two out there who are lucky enough not to be affected by this social contagion.

As pointed out by his fellow Austrian, Karl Popper, Freud’s theories are not falsifiable, at least in Freud’s way of theorizing and defending they are not. So we are dealing with invisible entities that cannot be measured in Freud’s theories (e.g., repression, id, ego, defence mechanisms, etc) much in the same way that demonic possessions involve invisible entities, or animal magnetism and fluids were also invisible entities in Mesmer’s theories. Another common theme in these viral ideas is that they can become somewhat authoritarian to preserve the bad ideas. Freud’s inner circle was notorious for isolating and expelling non-believers if they strayed from Freud’s lead (e.g., Carl Jung, Otto Rank). There was also an unseemly rivalry between Freud and Janet over who came up with the idea of dissociative amnesia or repression first. It seems obvious now that Freud caught the social contagion from Janet and Charcot, but none of them should have been proud of such poor science.

Perhaps the most important thing to say about Freud is that he did not actually cure his patients in the way in which he wrote in his books. Letters between Freud and his friend Fleiss revealed that much, and much more. See Frederick Crews’ writings and book for more on this (Crews, 2017: Freud: The Making of an Illusion).

Freud’s nonsense idea of repression has inspired a smorgasbord of iatrogenic trauma-centric therapies—some of those occurring before 1980 are documented in Patihis and Younes (2015). This social contagion of an idea seems to have inspired early Dianetics and Scientology therapy groups to believe they were recalling recovered memories of sperm and egg meeting. Perhaps the idea even inspired attempts to remember other aspects of Scientology folklore as well. The madness of Grof’s LSD therapy in the 1960 was similarly influenced by the idea of recovering repressed memories—much to the iatrogenic harm of countless human guinea-pigs. In the 1970s, the madness spread to Dr Arthur Janov’s primal therapy where many a victim of iatrogenic therapy came to believe they has extraordinarily painful trauma that had been gated away from consciousness. The thousands of lives the idea of repression had trashed even before 1980s was a deep tragedy.

4.      The Satanic Panic Social Contagion of the 1980s

As far as I can tell, it got even worse in the 1980s, with several social contagions all emanating from the idea of repression. The Satanic Panic of the 1980s and beyond came directly from attempts to recover memories in psychotherapy. In this madness that resembled the Salem Witch Trials, those therapist that also tended to have a religious bent, steered memory recovery towards their worst fears and beliefs—often their Christian influences leading to false memories of Satanic cult rituals. In the late 1980s and early 1990s, after many years of searching, no Satanic cults that engaged in abusive rituals had been found, and that is still true to this day, in 2024. There are a few Satanic churches in existence today, but they did not engage in the kind of ritualistic abuse that was falsely being remembered in some therapies in the 1980s (and beyond).

The Satanic Temple in fact, appears to have been set up in 2014 partially to debunk the Satanic panic (how wise or effective the choice to antagonize with such a name during this debunking is open to question), and appears to have some altruistic tenets. Anton LeVay’s Satan’s Church, which was set up in the 1960s, appears more unsettling hedonistic than the Satanic Temple, but again did not appear to advocate for any law-breaking or abuse. Both Satanic organizations, of course, are antagonism turned up to 11, but such expression of rebellion happen in free societies. In one of these groups, I even get a sense of mild cultic-ness, a proneness to wokeness, a certainty of correctness, and a lack of understanding of trade-offs, in the followers, though not necessarily in the leadership. Suffice to say, despite rumours to the contrary, there has been precisely zero organized Satanic ritualistic abuse in the United States and the United Kingdom (yes, the social contagion spread to the UK in the 1980s, with a predictable few years of delay).

5.      The Multiple Personality Social Contagion that is Reborn on Social Media

The 1970s and 80s also spawned another massive iatrogenic social contagion: the rise of multiple personality disorder diagnosis and therapies that ruined countless numbers of lives. As mentioned a bit earlier, multiple personalities as an idea was inspired by Pierre Janet’s theorizing of splitting of consciousness initially in the 1880s. Janet passed on his idea to Harvard psychologist Morton Prince, and it was Prince’s dreadfully unscientific article and book (1905/1906) that documented the first patient with purported multiple personalities. This led to a few decades with very rare diagnosis of the condition. In the 1950s, a book and a film called the Three Faces of Eve, told a supposedly real life story of a patient with multiple personalities. That film influenced a rise in diagnosis, but still the diagnosis was fairly rare. It was not until the release of a book called Sybil (1973), and then the film Sybil a few years later, that we saw the social contagion about multiple personalities truly take off. Within a few years, diagnosis had increased manyfold, and even the consultants on the Diagnostic and Statistical Manual of Mental Disorders were caught up in the virality—they created a diagnosis section called multiple personality disorder in the DSM III (1980), and the illegitimate disorder has been legitimized ever since. The 1980s marked a tragic ruining of thousands of people’s lives as they succumbed to beliefs about multiple personalities, often transferring their live savings to their therapists, doctors, or hospital bills in the process.

The memory wars of the 1990s, including brilliant litigation by lawyers such as Christopher Barden, saw quite a few multiple personality clinics closed down. Nevertheless, the hope that changing the name to Dissociative Identity Disorder (DID; in the DSM-IV in 1994) would help mitigate the belief that people actually had multiple personalities was short lived. That name change did not work: therapists continued to do similar therapy, often using alternative labels for personalities such as parts, and the harmfulness of these therapies was just as bad as before. Today, social media has prompted s new wave of social contagion, through the publication of hundreds of online videos purportedly educating people about DID, and videos made by purported sufferers of DID explaining how the disease works, and often showing themselves “switching” from one alter to another.

The iatrogenic harm done to young teenagers and young adults is likely enormous. This harm manifests in a few ways: 1. Young people come to believe they have repressed trauma; 2. Estrangement from parents and whole families can occur; 3. The creation of false memories can happen, some of which are horrific in their detail to match the theory; 4. The creation of a belief system that they have multiple personalities; 5. Leading to a possible lifetime of disability status and unemployment, often with prescribed pharmaceuticals and sometimes with a worsening of symptoms as clients remember more false memories over time. Even today, with other more novel social contagions dominating the culture wars, the DID medical malpractice going on in the US and Europe is horrendous by any standards.

6.      Repression Today

As I and others documented in Patihis et al., (2014), and since, the belief about Freudian repression is deeply embedded into US and British society. Most people believe it is a real phenomenon—that it is possible to completely repress traumas, and then recover those memories in therapy in great detail. So much so, some misguided people think these recovered memories are reliable enough to be used in court (they are not). Others have shown similar majorities in European countries too—most non-researchers believe in the archaic concept of repressed memory (or dissociative amnesia). In actual fact, there is absolutely no credible scientific evidence that traumas are repressed in this way. The consequences of these beliefs are thousands (perhaps millions) of false memories in psychotherapy in the twentieth and twenty-first centuries (and countless false beliefs of abuse, without memories). The harm done to families is so enormous, and it continues.

In fact, in Patihis and Pendergrast (2019) we surveyed over 2000 Americans, and estimated through extrapolation that a few million Americans have probably recovered repressed memories of abuse in therapy, of which very many of these recalls being either false memories or memory distortions. It was quite an eye opener that even in therapy that was commenced from 2015 onwards, quite a lot of clients reported recovering repressed memories. This concurs with some legal cases I have consulted on since that time. In my experience, it appears that repressed memories are being exhumed in some therapies (e.g., Eye Movement Desensitization Reprocessing; EMDR therapy) by some therapists (but not all). Some of these cases are going to court, and some people are being wrongly convicted as a result. Still today, in the 2020s.

7.      Abigail Shrier’s Bad Therapy and Dennis Hayes’ The Dangerous Rise of Therapeutic Education

I would be neglectful if I were not to point out the many other ways in which psychotherapy can be harmful. As Abigail Shrier points out in her new book Bad Therapy (2024), psychotherapies always come with some element of risk of side effects. One such side effect, she notes, is the possible damaging of relationships. The risk being, says Shrier, that the therapist might suggest a parent might be difficult or to blame, and that in turn leads to a rift in relationships.

In Patihis et al. (2019) I led experiments that found that even non-suggestive questions about a parent can lead to reappraisals of that parent. In our research, we simple asked participants to write out a few sentences about recent examples in which their mother had either been shown generosity (or a lack of in another condition), and other attributes in other sentences. These simple non-suggestive led to the participant’s current evaluations of their mother to  change according to the group they were randomly assigned to. The knock on effect was that current feelings of love changed accordingly with these reappraisals. Perhaps most surprisingly to the uninitiated to memory research, participants’ childhood recollections of the love they once felt towards their mothers changed as well. This is one of the most important studies I have ever done, and eventually it’s significance may be picked up by the field.

Abigail Shrier also warns about the use of therapy with children as well, arguing that parents should not assume that handing over their children to therapists comes with no risks. As well as the risk of damaged relationships, getting children to focus on negative emotions can also lead to increased depression and anxiety. Teaching children to reevaluate past difficulties with parents as “trauma” also comes with tremendous risks to the family, including worsened symptoms.

Shrier was not the first to point out the dangers of therapy when directed towards children. The brilliant Kathryn Ecclestone and Dennis Hayes wrote about this in the book The Dangerous Rise in Therapeutic Education (2008). They discussed how therapeutic ideas from popular culture dominated social thought and social policies and offer a diminished view of human potential. Ahead of the current controversy about therapy in education (E.g., in social emotional learning; SEL), Ecclestone and Hayes discuss how schools undermine parental confidence and authority by fostering dependence and compulsory participation in therapeutic activities based on disclosing emotions to others. They discuss how higher education had already at that time adopted therapeutic forms of teacher training because many academics had lost faith in the pursuit of knowledge.

This section serves to show the possibility of iatrogenic harm is broader than my own areas of focus, and how these also usually involve some degree of social contagion that spreads through the therapy community as they become fashionable and profitable.  There is also no denying that a deep sense of empathy, sometimes too much empathy to the point that it becomes pathological, are drivers of the communication from one therapist to another, and from client to another.

8.      How this Relates to New Social Contagions

I wrote this article with a new friend in mind who was bullied mercilessly in a British University, and who recently won a legal case against the university. She asked me to send her some of my work on social contagion in my areas, and it occurred to me that in my actual peer reviewed articles I often had to hold back from calling my areas of interest social contagions. Due also to the direction of my career going more towards cognitive psychology, I realize that I have not yet fully used social psychology framings of the cultic-ness of the repressed memory areas as much as I had planned to when I chose a social psychology doctoral program with social psychology comprehensive exams. I do tend to mention the social influence aspects of my areas more so in my teaching and my book Trauma, Memory, and Law, than I have yet in my articles.

My areas of interest in social contagion, you will note, have several characteristics. First, they all involve invisible entities that are difficult or impossible to measure and test. Freudian repression, dissociation, and multiple personalities are essentially non-scientific constructs that set the stage for ideological-like belief systems. Second, you will notice, this often leads to iatrogenesis that both the doctor and the patient often stubbornly fail to recognize—though it is obvious to the outsider that harm is occurring. Third, there is often a cultic or authoritarian turn in those that believe in these theories relating to these invisible entities, and often they can dismiss individuals in ad hominem ways to protect their theories. Repression-believing therapists were, and are, for example, quick to point out the likely massive repression in any critic of their theory. This can be devastating if one is trying to exist in their domain, and much less painful if one is out of their circles.

So how does this relate to the bullying that Jo Phoenix and others received in the late 2010s and early 2020s? A number of legal precedents, including Jo Phoenix’s win against the Open University, have now vastly improved the free-speech atmosphere in the nation. The precedent that Jo Phoenix’s views are a protected category of beliefs and opinions is now replicated in a few legal cases and employment tribunals. The reader likely knows the terrain and the arguments for and against these views, so I will simply ask a series of questions about the parallels between other areas of controversy I have been following for decades, and this newer controversy.

One question might be: do novel controversies involve invisible entities that are unfalsifiable or difficult to measure? Is iatrogenesis an aspect that is present in the controversy? Do believers also appear blinded to seeing possible harms done by the treatment (and theory) itself? In addition, is there an unsettling authoritarianism or cultic-ness in this novel controversy that is reminiscent of that in the repression and multiple personality scandals? And finally, of course, is there any evidence of social contagion in the newer controversy? Does that include in young females, as in previous contagions (though not always)? I leave these questions with the reader, and I also refer to articles in Skeptic magazine by my social psychologist colleague Carol Tavris, (and a fellow skeptic of repressed memories).

9.      A Final Thought: The Stupidity of Humans and on Academics Retiring With Pride

Humans are prone to social contagions. Including me, and especially me before I learned some scientific skepticism tools. It is terrifying to think how much harm this has caused in the past, and will cause in the future. It was probably adaptive to be so wired towards contagion and conformity in evolutionary history. It remains to be seen whether those who are going along with social contagions and conformity will be more successful than the skeptics, but they may well be given the preferences shown in grant-funding, hiring, and promotion at the current time in universities. We only have to look at what happened to Socrates as a result of his founding of a skeptical branch of thought. We only have to compare the riches of those who conformed, to those that did not, in the decades to come. The conformists will likely have richer retirements, but they will have to try to forget how they bent their soul to agree with absurdities, and forget about the good people they ignored or excluded. While these conformists retire with wealth in a decade or two or three, they at least will not feel as proud as those, probably poorer and possible cancelled and expelled, who retire proud, active, and true to themselves.

Academics and therapists alike: make your choices now about how you want to feel about yourself when you retire. Money can be meaningless without freedom, truth, purpose, and goodness.

Further Reading

Most of my journal articles are listed on my CV here, and pdfs may be found here.

Patihis, L., & Pendergrast, M. H. (2019). Reports of recovered memories in therapy, informed consent, and generalizability: Response to commentaries. Clinical Psychological Science, 7, 32–36. https://doi.org/10.1177/2167702618804206

Patihis, L., & Younes Burton, H. J. (2015). False memories in therapy and hypnosis before 1980. Psychology of Consciousness: Theory, Research, and Practice, 2, 153–169. https://doi.org/10.1037/cns0000044

Patihis, L., Cruz, C. S., & Herrera, M. H. (2019). Changing current appraisals of mothers leads to changes in childhood memories of love toward mothers. Clinical Psychological Science, 7, 1125–1143. https://doi.org/10.1177/2167702619842468

Patihis, L., Ho, L. Y., Tingen, I. W., Lilienfeld, S. O., & Loftus, E. F. (2014). Are the “memory wars” over? A scientist-practitioner gap in beliefs about repressed memory. Psychological Science, 25, 519–530. https://doi.org/10.1177/0956797613510718