Over the last decades, psychiatry has gone through a phase of significant transformations.
On the clinical side, the neurobiological, morphological and genetic studies, which have initially encouraged an enthusiast reductionist approach to the issue of understanding and managing mental illness, so far have failed to provide exhaustive and specific explanations for both the nature of psychiatric syndromes and the effectiveness of psychopharmacological treatments (Deacon 2013). On the nosological side, the use of more reliable systems of diagnostic reasoning and classification has yielded a still controversial picture of the diagnosable illnesses (Parnas 2015; Jablensky 2016; Kendler 2017). Substantial research efforts in neuroscience, neuroimaging and genetics have not led to clear patterns that match up with the diagnostic categories (Cohen 2016; Kendell and Jablensky 2003), and this absence of biologically validated nosological entities has left the modern diagnostic categories like a sort of empty containers, only defined by syndromal criteria of co-occurring symptoms, signs and courses. In addition, the systematic exclusion – in the name of reliability – of the subjective qualities of psychopathological experience has limited the possibility to match the diagnostic categories to meaningful psychopathological unities derived from in-depth clinical investigations. The exclusive reliance on diagnostic criteria has deprived the clinical process of its richness and does not reflect the complex thinking that underlies clinical decision making in psychiatric practice (Fava et al. 2012) and the relationship between psychopathology and meaning (Guidano 1987). Finally, the almost unchallenged confidence in the discriminating power of the structured diagnostic interviews, thought by many to be suitable for being used even by non-professional health workers, has de facto devalued the psychiatrist’s psychopathological and relational expertise, confining it to the role of an inessential – when not disturbing – factor in the diagnostic process (Andreasen 2007; Schultze-Lutter et al. 2018).
Many scholars have taken into consideration this problematic situation from different points of view (McGorry 2013; Nagar et al. 2018); among them, a number of philosophers and psychopathologists have identified the main problem with the disregarding of the epistemological issue inherent to the psychiatric discipline (Fuchs 2010; Berrios 2013; Nordgaard et al. 2013; Parnas et al. 2013; Parnas 2015). It has been acknowledged that the growing collection of new empirical findings and clinical observations risks – in the absence of a thoughtful and epistemologically rigorous framework – to turn into a set of unconnected and scarcely significant data. In particular, some authors have pointed out the need of redefining the nature of the psychiatric object and indicated on several occasions the role of phenomenology as a pivotal ally for psychiatry in this process (Parnas and Zahavi 2002 ; Parnas et al. 2013).
Indeed, over the past two decades phenomenology has given an essential contribution to some fundamental epistemological problems for psychiatry and to how to address them, working on two essential questions: how can we describe the normal and the altered structures of the human subjective experience? And which are the tools we could use to investigate those structures? (Gallagher and Zahavi 2008; Fuchs 2010, 2015). So far, the main clinical applied outcome of this contribution has been the development of psychometric instruments explicitly embedded in the theoretical framework of phenomenology, the so-called phenomenological scales, which are suitable for exploring the distortions of the structures of patient’s subjectivity, with a particular focus on the schizophrenia spectrum disorders since their early stages. The spread of these instruments has constituted a valuable opportunity to introduce phenomenological insights in psychiatric practice, even though most such instruments require both a good knowledge of phenomenological psychopathological concepts and an ad hoc training.
Our research can be situated in the field identified by the second epistemological question, that we could translate as “how can we know the patient’s subjective world?”, and it aims at specifically investigating the intersubjective dimension in the course of psychiatric assessment. The first step in this work has been the development of a new psychometric instrument, based on a phenomenological theoretical framework but designed to be used by all psychiatrists, regardless of their theoretical background. The focus of our work is intersubjectivity as it unfolds during the clinical encounter and in particular during diagnostic evaluation, which is a highly specific kind of human encounter, characterized by the active effort of one (the clinician) to understand and define the other’s (patient’s) mental suffering.
In this paper, we present in detail the theoretical background and the methodological reflection which were at the basis of the development of the instrument named Assessment of Clinician’s Subjective Experience (ACSE), together with a critical reflection on the problem of managing subjective data in empirical research.
Intersubjectivity and the clinician’s subjective experience during the psychiatric encounter
From the concept of diagnostic feeling to the phenomenological reflection on the second-person understanding
Many scholars along the history of psychiatry have claimed that the clinician’s subjectivity has a specific role in the diagnostic assessment (Lanzoni 2006; Noll 2018; Moskalewicz et al. 2018). About a hundred years ago, for example, the North American neuropsychiatrist Elmer Ernest Southard wrote about what he called the “empathic index” (Southard 1918), a sort of diagnostic test able to specifically discriminate between morbid entities, in particular between schizophrenia and cyclothymia. The empathic index was presented by the author as a form of naïve understanding of the patient, based on the feeling of the psychiatrist and similar to the medical concept of “general impression”. Almost at the same time, in Europe, Karl Jaspers was speaking about Einfühlung (empathy) as a specific way to reach “a personal, non-verbalizable and non-communicable understanding” of the patient (Jaspers 1913). On his account, empathy was an essential guide for a thorough examination of the suffering person, even though he did not explicitly assign to it a discriminating diagnostic power, preferring the well-known concept of cognitive (not empathic) “incomprehensibility” (Luft and Schlimme 2013).
Subsequently, a number of phenomenologically-oriented European authors have dealt with the issue of the clinician’s ability to grasp the patient’s psychopathological essence through an immediate feeling. Almost all of them situated this feeling into the specific – intersubjectively-determined – atmosphere of the encounter. In their view, the patient’s peculiar way of being-with-others directly reverberates in the clinician’s experience, mostly in a pre-reflective way, and this reverberation can be translated in a sensitive diagnostic feeling. This view has been comprehensively expressed by Henricus Cornelius Rümke, who in 1941 stated that the “praecox feeling”, i.e. the peculiar feeling arising in the psychiatrist during her first encounter with schizophrenic patients, is often the essential guide for making diagnosis (Rümke 1941; Neeleman 1990). In particular, the author identified the failure of the clinician’s attempt to establish a human interpersonal exchange with the patient as the most influential phenomenon affecting the clinician’s experience of the interaction (Pallagrosi and Fonzi 2018). Similar conclusions have been drawn by Binswanger (1924) (Diagnosis through feeling), Minkowski (1927, 1933) (Diagnosis through penetration), Wyrsch (1946) (Diagnosis through intuition), and Tellenbach (1968) (Atmospheric diagnosis). Even Schneider, while emphasizing the diagnostic value of a number of symptoms that came to be considered by many clinicians and researchers as a sort of diagnostic test (Picardi 2019), underscored the importance of the doctor-patient relationship for making the diagnosis of schizophrenia: “This is in workaday psychiatry usually the method of diagnosis. It concerns what is referred to as rapport or contact. Here the relevant fact is that schizophrenics seem to occupy another, alien space” (Schneider 1936).
Even the psychoanalytic thinking, which historically took a cautious position on the clinical value of the analyst’s feelings (Freud 1910), have subsequently articulated a sophisticated view of the intersubjective phenomena of the therapeutic encounter as perceived by the therapist. Concepts like counterstransference (Albarella and Donadio 1998), projective identification (Spillius and O’Shaughnessy 2012) and empathy (Bolognini 2002) have been studied extensively in the effort to account for the understanding potential of the clinician’s sensitive immersion into the emotional pre-reflective atmosphere of the interaction (Tansey and Burke 1989).
Phenomenology, on its part, has devoted much space to the concept of intersubjectivity and to the reflection about the human process of knowing and understanding others (Zahavi 2001, 2014; Fuchs and De Jaegher 2009; Fuchs 2017). Thus, it is not surprising that a close dialogue exists between the phenomenological proposals and the above-mentioned clinically derived concepts or, more generally, between the phenomenological account for human interaction and the psychiatric account for the diagnostic process (Stanghellini 2007; Fuchs 2010; Varga 2013; Galbusera and Fellin 2014; Gupta et al. 2019).
Even though an extensive discussion about the phenomenological concepts of intersubjectivity and human knowing processes falls outside the aim of this paper, a few aspects are worth to be briefly introduced. From a phenomenological perspective, interpersonal understanding is thought to be grounded essentially in an embodied, perceptual, pre-reflective, dynamical and circular process (Fuchs and De Jaegher 2009; Zahavi 2014). It is assumed, therefore, that human beings know others primarily through an implicit, emotional and gestaltic engagement, that phenomenologists – although through slightly different definitions – would identify with the notion of empathy: namely, a distinct form of other-directed intentionality which allows to experience others’ behaviours as expressive of their minds (Zahavi 2014, 2019a). The reflective, representational and cognitive dimensions of the knowing process arise only afterwards, implying an active effort to go “beyond what is directly available” through empathy (Zahavi 2014). On the other hand, the phenomenological account for interpersonal understanding acknowledges a second-person perspective, pointing out that the knowing process is embedded in a mutual preverbal attunement and in an active co-construction of narratives (Fuchs and De Jaegher 2009). In other words, every human encounter is regarded as a situation in which two subjectivities are involved in a process of implicit or active reciprocal interaction and generation of meanings. Within this perspective, the psychiatric assessment itself could be intended as a second-person encounter in which “it is necessary to explore the experiential perspectives of both the patient and the interviewer” (Fuchs 2010, emphasis added).
Development of the preliminary version of the Assessment of Clinician’s Subjective Experience (ACSE)
The project of developing a new psychometric instrument able to capture the clinician’s subjective experience during her interaction with patients stemmed from the above reflections, while addressing at the same time a clinical need. In fact, psychiatrists deal with the human situation of the diagnostic encounter in their everyday practice and are continuously permeated by its emotional, resonant and meaningful atmosphere (Sholokhova 2019). As we have seen, the clinical weight of such atmosphere cannot be eluded; rather, it is worth to be analytically examined as a valuable way of knowledge. Following the claim of a number of psychopathologists (Callieri 1985; Fuchs 2015; Van Duppen 2017), we are persuaded that the intersubjective dimension of experience is specifically affected in mental illness, and that its unfolding in the relationship with the other is a relevant target for psychopathological investigation.
Hence, the primary object of our investigation is the intersubjective dimension of the clinical encounter as captured by the clinician’s side. So far, research in phenomenological psychopathology has mostly focused on the patient’s first-person experience, and on her overall perception of both herself and the external world. In our case, the focus has been moved to the first-person experience of the psychiatrist, which is explored in relation to the specific situation of the encounter. Given that the clinician is driven by the will and the need to understand the patient’s subjective world, the clinician’s experience can be conceived as a sort of sounding board for the patient’s way of being and the subtle nuances of the interaction. In other words, our core assumption is that the clinician’s experience during the encounter can be seen as an embodied, pre-linguistic, linguistic and cognitive meaningful reaction to the patient’s state of mind and her intersubjective dimension.
The exploration of this dimension was carried out through the development of a self-report questionnaire to be filled by the psychiatrist after his first encounter with a patient (Fonzi et al. 2011; Pallagrosi et al. 2014). We have identified the first diagnostic encounter as the most suitable situation to be explored, since the clinician’s receptive attitude is usually high and the interaction is less influenced by preconceptions derived from previous knowledge. The first version of the questionnaire was created through the collection of a large number of psychiatrists’ experiences related to the clinical encounter, put into words in the form of simple descriptive sentences (e.g., “I felt unease during the encounter”, “I felt I lacked spontaneity”, “I had difficulties in identifying myself with the patient”). Two main sources were used: the feelings described by classical psychopathologists (Minkowski, Binswanger, Rümke, Wyrsch, Blankenburg, Callieri) and the everyday practice of a number of experienced psychiatrists and young psychiatry residents. The latter experiences, in particular, were collected through extensive free interviews, and then were grouped together with the former in an overall list of 104 items. A subsequent revision by 15 experienced psychiatrists, aimed at excluding items that were deemed redundant, reformulating those judged as unclear and ambiguous, or integrating new items, yielded a refined list of 65 items, which constituted the preliminary version of the instrument.
Our questionnaire was designed to probe a wide and heterogeneous selection of human experiences as they are lived by the psychiatrist, regardless of her own theoretical background and of patient’s characteristics (diagnosis, clinical severity, cultural factors, etc.). We did not define a priori discrete domains of investigation, preferring to explore the experiential field with a large number of different descriptors, and then to study their pattern of aggregation as it emerges from the mere observation. Thus, we did not use the method of the phenomenological interview and we did not preliminarily establish a grid for collecting the experiences. We have rather proceeded according to the traditional psychometric principles of scale construction (see below). The link between the development of the questionnaire and the phenomenological approach was kept at the level of the shared theoretical framework. In fact, different kinds of subjective experience were considered in the item list, in the effort to take into consideration both the cognitive, reflective dimensions and the embodied, pre-reflective ones. In particular, attitudes, thoughts, behaviors and also bodily perceptions (e.g., “I avoided eye contact with the patient”, “I felt awkward in my movements” or “I maintained a rigid posture”) were included, with respect to the embodied perceptual nature of the process of understanding.
We are aware of the inherently problematic nature of the relationship between the lived and immediate experience of the encounter and its subsequent verbal description. It is known that the act of self-reporting inevitably implies, for the clinician, a reflective process that encompasses a number of factors exceeding the pure experience of the interaction, such as the time-lag, the semantic translation, the worries about the coders’ opinion. Even if the clinician is asked to describe his experience immediately after the encounter and with the simplest words, he still runs the risk of intentionally hiding, forgetting, over-interpreting or unconsciously distorting feelings and perceptions, and the risk of misunderstanding the items. However, similar risks are inherent to all the psychometric scales exploring and objectifying human experiences, and, since even a rigorous statistical procedure cannot fully remove such risks (Berrios 2013), the most convenient strategy is to take them into account when interpreting the empirical results.
Subjective experience, objectivity and quantification
The question of “measuring” the subjective qualities of experience: The phenomenological scales
In his enlightening 2004 contribution, Dan Zahavi (2004) deals with the theoretical issue of how phenomenology could really collaborate with natural sciences in the study of subjective experiences. Since subjective experiences are given immediately – and explored phenomenologically – through a first-person perspective, and natural sciences usually describe the psychic processes according to a third-person perspective, researchers and clinicians face a problematic gap. In the author’s opinion, a possible strategy to combine the philosophical tools of phenomenology together with the scientific ambitions of empirical research consists in the phenomenological psychology approach, which applies phenomenological concepts to local regional-ontological investigations, integrating them into a natural approach. In this way the results of phenomenological philosophical research can be made available for empirical tests, to be carried out according to scientific methods.
This kind of reflection is at the base of the growing attempts to include phenomenological intuitions in psychopathological empirical research, the main example of which is the development of the standardized phenomenological interviews. To date, there is a general consensus among researchers about calling “phenomenological” a group of psychometric instruments that follows a phenomenological view of psychiatric illness and focuses on the first-person experience of the examined persons. The epitome of these instruments is the Examination of Anomalous Self-Experience (EASE), used since 2005 (Parnas et al. 2005) for the study of self-disorders in schizophrenia spectrum conditions (for a comprehensive review, see Nordgaard and Henriksen 2019). The EASE is based on a semi-structured interview exploring in detail the patient’s self-experience and collecting its characteristics into a standardized research form. It yields a quantifiable detailed description of anomalous self-experiences, that can be used for quantitative research on early detection or differential diagnosis of schizophrenia spectrum disorders, as well as for qualitative research on the subtle nuances of self-disorders themselves. Similar examples are the Examination of Anomalous World Experience (EAWE) (Sass et al. 2017) and the Examination of Anomalous Fantasy and Imagination (EAFI) (Rasmussen et al. 2018), which share with the EASE the formal structure and the clear reference to phenomenological concepts.
The development of phenomenological scales and their suitability for psychopathological investigations has some fundamental implications for the longed-for dialogue between philosophy and empirical psychiatry. First, it represents the first real attempt to make large empirical studies about psychopathology within a phenomenological framework, and constitutes a feasible operational model. The intriguing results of the widespread use of the EASE have indeed raised a number of questions for both clinical psychiatry (i.e., about early diagnosis and intervention in schizophrenia) and phenomenological studies (i.e., about the comprehension of self-disorders), launching a promising line of research. These questions are of particular importance, since there is still not a full consensus among philosophers about the appropriateness of calling “phenomenological” this kind of experiments and about their usefulness for philosophical advancements (Zahavi 2019b).
The encouraging findings from the studies using phenomenological interviews together with consolidated third-person instruments suggest that an integration between different epistemologies, if carefully handled, is not only feasible but also profitable. As it is argued in a recent empirical paper on the use of the EASE and EAWE for the evaluation of schizophrenic patients, “the addition of an ‘observed’ dimension to the EASE and EAWE scales […] could enhance the overall understanding of the person, providing insight derived not only from the experiential narrative of the patients but also from the way that the patients are experienced in their social or behavioral comportment.” (Englebert et al. 2019). In the authors’ opinion, the novel challenge for the phenomenologically oriented researchers is indeed that of integrating the clinical external observation into studies focused on the first-person perspective, promoting a substantial paradigm shift. According to the latter, the first-person and the third-person data should be considered as parts of a single complex picture, and should be accepted and held together with respect to their constitutive and epistemological peculiarities. Currently, within the psychiatric field this view is not taken for granted, and the idea that scientific knowledge should be pursued through the complete exclusion of any subjective element is still appealing for several researchers (Berrios 2013).
From the preliminary version to the final instrument: The validation process of the ACSE
Similarly to the EASE and the other phenomenological interviews, our questionnaire was derived from the clinical experience of several psychiatrists and from the examination of the relevant psychopathological literature. However, while the former instruments have been specifically designed to capture well-established experiences clustered in predetermined domains, the ACSE questionnaire was designed to cover a wide range of experiences without postulating a priori a structure for them. In fact, our aim was to investigate the dimensions of the clinician’s subjective experience as they emerge within the context of the everyday clinical practice.
Following the traditional procedure for scale development, we administered the preliminary list of 65 items, rated on a 5-point Likert scale, to a sample of 13 psychiatrists who saw overall 527 new patients, with a mean of 40.5 ± 29.5 patients per clinician. For each item, we examined the range of responses, the stability over time, and the suitability to be included in a coherent factor solution (Pallagrosi et al. 2014). To be kept in the final version of the scale, each item was required to show an acceptable variance, which suggests it describes an experience that clinicians could acknowledge and quantify, and to show stability over time provided that the patient’s clinical condition did not substantially change. Nine items were excluded as they did not meet these criteria, showing a narrow range of responses or a low reproducibility over a short period of time in a comparable situation (same patient-physician dyad, same setting, similar psychopathological state; n = 60). Although these items had been conceived to describe important features of the clinician’s interpersonal feelings, their ability to be really informative about certain experiences, or to reliably represent specific aspects of the interaction rather than accidental observations was not satisfactory. It was the case, for example, of sexual attraction, which is undoubtedly a feeling that can arise in the clinician when she sees a patient, but that was almost never endorsed by our sample of psychiatrists. Clearly, it should be bear in mind that it is the item – and not the experience – that is removed.
The study of the factor structure is a customary step in the validation of an assessment instrument, and it was of special significance for our questionnaire. In fact, in investigating the clinician’s subjective reaction during the encounter with the patient, we not only pursued the epistemological objective of applying an objective method to the exploration of a specific subjective field, but we also aimed to develop a sort of in vivo map of the experiential dimensions underlying that field. It would have been possible to postulate a priori the plausible domains of the clinician’s feelings, based on our experience or on accredited clinical descriptions, and indeed we did make some hypotheses during the construction phase. However, we preferred to follow an exploratory approach and let factor analysis identify the dimensions underlying the clinician’s subjective experience. In our validation study, factor analysis yielded a coherent five-factor structure and led to the exclusion of further 10 items that showed ambiguous loadings or poor communality values. The remaining 46 items were well defined by the factor solution, which accounted for 57,4% of the total variance. Based on item composition, the factors were interpreted as Tension, Difficulty in Attunement, Engagement, Disconfirmation, and Impotence. Subsequent analyses provided evidence of internal consistency, temporal stability, and convergent validity for the five factorially derived scales.
Our findings suggest that the clinician’s subjective experience during the interaction with a new patient can be reliably represented by a quantitative profile consisting of five well-defined dimensions. Interestingly, with the exception of the Engagement scale that consists of items describing pleasant experiences (e.g., “I experienced a feeling of tenderness towards the patient”, “I felt emotionally close to the patient”), the ACSE dimensions illustrate different ways in which the clinical interaction can be subjectively perceived by clinician as a challenging and demanding task. Our findings are consistent with and corroborate a number of theoretical formulations, as the nuances of this difficulty mirror the experiences delineated in some famous psychopathological and phenomenological descriptions, such as the empathic failure, the relational ruptures, the spectre of aggression, or the feeling of frozen potentialities (Rümke 1941; Kernberg 1975; Fuchs and Pallagrosi 2018). This is particularly intriguing, since our study was carried out on a heterogeneous group of psychiatrists who were mostly unfamiliar with the phenomenological or the psychodynamic literature. This suggests that some fundamental intersubjective experiences are naturally perceived by clinicians without the need of specific training. Rather, the ACSE questionnaire may provide a means by which the attention of the clinician can be readily drawn to her own spontaneous relational experience.
Conclusions and perspectives
Since the introduction of the first rating scale in the 1950s, scientific research in clinical psychiatry has mainly been based on the use of psychometric instruments. Such instruments represent the ultimate expression of the third-person approach to psychiatric assessment, as they all share the implicit assumption that the reality of mental disorders can be observed and described by an external point of view,
In recent years, however, new psychometric instruments were developed to merge first-person qualitative descriptions with quantifiable outputs suitable for empirical research. This ushered in a new line of psychopathological reflection, with particular emphasis on the investigations into the first-person experience of psychiatric patients. The integration of these new instruments with the traditional psychiatric assessment tools has been indicated as a worthwhile avenue for future research.
The ACSE grows within this framework and contributes to it in two ways. First, it explores an empirically neglected dimension of the psychiatric encounter, namely the clinician’s side of the intersubjective experience. The ACSE is rooted, in fact, in a second-person perspective on the psychiatric assessment, according to which the nature of the intersubjective experience could provide original elements about the patient’s inner condition, to be integrated with both the patient’s subjective narrative and the objective clinical description. Second, the ACSE is a relatively simple assessment instrument that is brief, easy to score, and does not require detailed instructions for administering an interview and coding the responses. It can be used in any clinical setting, by all clinicians, with every patient, which implies that the clinician’s subjective experience can be reliably measured also when the patient is not able to put into words her experience (due to psychopathological, pharmacological or linguistic problems) or when she intentionally or unwittingly conceals some information. This versatility can be particularly important for studies on patients who are in the early stages of psychiatric disorders, since in such cases the subtle alteration of being-with-others may be the only psychopathological detectable sign.
These considerations are supported by the results of the first applications of the ACSE in clinical research and practice. After the validation process, we have used the ACSE to measure the subjective experience of more than 50 psychiatrists and psychiatry residents during the assessment of over 1000 new patients. The studies focused on the relationship between the subjective experience of the clinicians and the psychopathological characteristics of the patients (Pallagrosi et al. 2016; Picardi et al. 2017; Pallagrosi et al. 2018). A number of significant associations were found between the ACSE dimensions and psychiatric diagnosis considered from both a categorical and a dimensional perspective. These findings suggest that a typical profile of subjective experience can be expected when a clinician sees a certain type of patient. The association between ACSE dimensions and diagnosis was particularly strong for schizophrenia and cluster B personality disorders, which are two conditions in which a severe and typical impairment of the intersubjective experience has been traditionally posited.
Possibly, the most interesting finding in the context of the present discussion is that in our studies the association between the clinician’s subjective experience and both categorical and dimensional diagnosis was independent of the number of years of clinical experience. This finding is intriguing, since it suggests that expert psychiatrists and young residents reacted in an analogous way to similar patients, as if the quality of the experience during interaction were not substantially affected by the expertise gained over the years. It may be hypothesized that the clinician’s experience is more related to a basic human sensitivity to the encounter with the other, which is an ability common to all psychiatrists and is independent of reflective thinking. This interpretation is corroborated by the finding that a theoretically coherent factor structure for ACSE items was identified in a group of clinicians who were mostly not well acquainted with phenomenology, nor specifically trained in the analysis of their feelings. Further studies are needed to test this hypothesis.
In conclusion, the research work carried out with the ACSE further encourages the collaboration between phenomenology and psychiatry, which may be enriched by the introduction of additional elements in the reflection about the knowing and diagnosing processes. Indeed, these empirical studies and their future developments are relevant not only for their clinical and training implications, but also as part of a broader exploration of the intersubjective aspects inherent to the human encounter.
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Fonzi, L., Pallagrosi, J., Picardi, A. et al. Exploring how the psychiatrist experiences the patient during the diagnostic evaluation: the Assessment of Clinician’s Subjective Experience (ACSE). Phenom Cogn Sci (2021). https://doi.org/10.1007/s11097-021-09729-y