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Cultural considerations require careful assessments on therapists’ part
This column is dedicated to the late Carl C. Bell, MD.
When we work with patients and their families from cultures that are not the culture in which we ourselves were raised, we think more deeply about this balance. In this column, I offer a simple but solid framework for this inquiry.
The first family therapist to crystallize the dialectic between the self and its relationship to others was Murray Bowen, MD. He believed that the differentiation of self from the family was the major task of human development. Dr. Bowen worked in a time when vilification of the “other” was common practice in individual psychotherapies and the goal of individual psychotherapy was the development of a healthy sense of self rather than repairing or developing relationships.
When faced with patients from cultures that are unfamiliar to us, we are less confident about how to assess the balance between self and other. In many cultures, marriages are based on social class and perceived social opportunities and are arranged by the respective families. If you come from a collectivist culture, where the focus is on the belief that the group is more important than the individual, the focus is more on self in relation to a group, belonging to a group, and participating in a group than self-striving. This is most evident in the role of women in many families (as well as in other organizations), in which women shoulder the responsibility for keeping families functional and together.
American culture is focused on serious self-striving. From kindergarten, children are expected to excel and to become the best self that they can be – regardless of the toll this takes on relationships. Self-expression and self-actualization frequently are considered the pinnacle of a life’s achievement. Relationships may take a backseat, often being transitory or utilitarian. This leads to switching relationships, peer groups, and friends – and a strong emphasis on cultivating work relationships.
Exploring Dr. Bowen’s theories
Dr. Bowen posited that the family relational pull affects individual development in a negative way. Despite this, his model is considered one of the most comprehensive explanations for the development of psychological problems from a systemic, relational, and multigenerational perspective.1 He identified the basic self (B-self), which strives for differentiation in contrast to the false/pseudo/relational self (R-self), which strives to meet group or family norms.
Dr. Bowen was the oldest of three and grew up in a small town in Tennessee. His father was the mayor of the town and owned several properties, including the funeral home. Following medical training, Dr. Bowen served during World War II. He accepted a fellowship in surgery at the Mayo Clinic in Rochester, Minn., but his wartime experiences resulted in a change of interest to psychiatry. Dr. Bowen trained at the Menninger Clinic in Topeka, Kan., and in 1954 became the first director of the family division at the National Institute of Mental Health. He and his colleagues studied the families of patients with schizophrenia. They described eight fundamental concepts that supported the important aspects of individual growth. When he moved to Georgetown University in Washington, he developed the Bowen Family Systems Theory.2
Dr. Bowen’s eight concepts
1. Nuclear Family Emotional Process
2. Differentiation of self
3. Triangles
4. Emotional cutoff
5. Family projection process
6. Multigenerational transmission process
7. Sibling position
8. Societal Emotional Process
According to Dr. Bowen, the B-self makes decisions on facts, principles, and intrinsic motivation and decides what they are willing to do/not willing to do based on their own internal ethics. On the other hand, the R-self goes along with everybody else, even when the person internally disagrees. He considered the R-self as wanting acceptance in relationship, possibly changing beliefs to find approval, and striving to be liked. Carmen Knudson-Martin, PhD,3 explored the relationship between the B-self and the R-self and suggested that they exist along two dimensions, both of which are important. My contention is that the R-self is undertheorized and deserves much more exploration.
Developmental psychologists and psychiatrists have focused on understanding the process of psychological maturation of the individual throughout life. However, there is little study of the development of a healthy relationship between self and other. We have, instead, gathered examples and descriptors of the pathological examples of the “other.” We can readily call out enmeshment, the manipulations of the borderline personality disordered, the cold withholding mother – to name the most vilified. What do we know about the healthy R-self?
Measuring the relational self
We have understood the R-self mostly through the study of pathological relationships. For example, pathological parenting has been shown to “result” in individual pathology and as a factor in the development of psychiatric illness. The measurement of the relationship between patient and family member/partner is aimed at elucidating pathology. The supreme example is emotional overinvolvement (EOI).
EOI is an integral part of the construct called expressed emotion and is often measured using the Camberwell Family Interview.4 High EOI has been identified routinely as predictive of worsening of psychiatric illness.5 However, exceptions are found (when you look for them)! In African American families, for example, high EOI is predictive of better outcomes in patients with schizophrenia.6 Jill M. Hooley, DPhil, also has identified that patients with borderline personality disorders do better in families with high EOI.7
A shorter equivalent research tool is the 5-minute speech sample (FMSS). The FMSS analyses 5 minutes of the speech of a parent/family member who is asked to describe the identified patient. EOI is identified by expressions of excessive worry or concern, self-sacrifice, or exaggerated praise. In a study of 223 child-mother dyads, 56.5% of which were Hispanic, use of the FMSS found high EOI predicted externalizing behaviors.8
More recently, psychiatry has sought to identify and measure positive factors, such as family warmth. In Puerto Rican children, high parental warmth was found to be protective against psychiatric disorders.9 In a study of Burmese migrant families from 20 communities in Thailand (513 caregivers and 479 patients with schizophrenia, aged 7-15 years), families were randomized to a waitlist or a 12-week family intervention that promoted warmth.10 The family intervention resulted in increased parental warmth and affection and increased family well-being.
Applying the theories to practice
An adolescent, Jan, does not speak when her mother is in the room. Jan has a small B-self, and her mother has a large B-self. Not only does Jan have to develop a strong B, but she also has to change how she is in relation – she has to change her R-self. For Jan, individual therapy supports the development of a stronger B-self. Working with the patient and her mother, the balance between both B-selves and the joined R-self can be reworked. In essence, the therapist encourages Jan to speak and helps the mother keep her own counsel. This is a situation in which the individual and family intervention are best implemented by the same therapist.
Systemic family therapy, a specific type of family intervention, focuses on how all the R-selves in a family work together as a unit called the family, or F-self. The F-self also has its own family history, as relationship patterns are transmitted and played out through families and play out through subsequent generations. A new type of family therapy called family constellation therapy (FCT) focuses on the F-self as a collection of ancestral selves. This resonates strongly with families who have experienced significant trauma, such as war and Holocaust survivors. FCT is popular in collectivist cultures, where there is a strong belief in the power and influence of ancestors and where the self is understood as an “assemblage of ancestral relationships that often creates problems in the present day.”11 Dr. Bowen recognized this multigenerational pattern as one of his eight fundamental principles.
The patients whom we see often have failing or fractured relationships. They might be stuck in dysfunctional transactional patterns with intimate partners, or they might fail to find a suitable intimate partner. We recognize relational dysfunction such as “codependency,” “symbiosis,” and “enmeshment.” We recognize too much distance, identifying family cutoffs. We still have a long way to go before clinical practice incorporates the importance of assessment and development of healthy relationships in a deep way. A typical question heard across all clinics: Is your partner/family supportive? Not much else is asked in regard to relationships, unless the answer is no. We have yet to develop a good set of inquiring questions that focus on the assessment of healthy relationships.
What can the therapist do to help the patient manage this continual dialectic? The therapist can ask the questions: How important is your B-self versus your R-self? What is the balance between your B-self and your R-self? What do you know about your family or F-self? Is your F-self important to you?
References
1. Nichols MP and Davis S. Family Therapy: Concepts & Methods, 8th ed. (Boston: Allyn & Bacon, 2008).
2. The Bowen Center for the Study of the Family.
3. Knudson-Martin C. Fam J. 1996 Jul 1. doi: 1066480796043002.
4. Leff J and Vaughn C. Expressed Emotion in Families. (New York: The Guilford Press, 1985).
5. Breitborde NJK et al. J Nerv Ment Dis. 2013 Oct;201(10):833-40.
6. Gurak K and de Mamani AW. Fam Process. 2017;56(2):476-86.
7. Hooley JM et al. J Clin Psychiatry. 2010 Aug;71(8):1017-24.
8. Khafi TY et al. J Fam Psychol. 2015 Aug;29(4):585-94.
9. Santesteban-Echarr et al. J Psychiatr Res. 2017 Apr;87:30-6.
10. Puffer ES et al. PLoS One. 2017 Mar 28;12(3):e0172611.
11. Pritzker SE and WL Duncan. Cult Med Psychiatry. 2019 Sep;43(3):468-95.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of Working With Families in Family Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest.
Cultural considerations require careful assessments on therapists’ part
Cultural considerations require careful assessments on therapists’ part
This column is dedicated to the late Carl C. Bell, MD.
When we work with patients and their families from cultures that are not the culture in which we ourselves were raised, we think more deeply about this balance. In this column, I offer a simple but solid framework for this inquiry.
The first family therapist to crystallize the dialectic between the self and its relationship to others was Murray Bowen, MD. He believed that the differentiation of self from the family was the major task of human development. Dr. Bowen worked in a time when vilification of the “other” was common practice in individual psychotherapies and the goal of individual psychotherapy was the development of a healthy sense of self rather than repairing or developing relationships.
When faced with patients from cultures that are unfamiliar to us, we are less confident about how to assess the balance between self and other. In many cultures, marriages are based on social class and perceived social opportunities and are arranged by the respective families. If you come from a collectivist culture, where the focus is on the belief that the group is more important than the individual, the focus is more on self in relation to a group, belonging to a group, and participating in a group than self-striving. This is most evident in the role of women in many families (as well as in other organizations), in which women shoulder the responsibility for keeping families functional and together.
American culture is focused on serious self-striving. From kindergarten, children are expected to excel and to become the best self that they can be – regardless of the toll this takes on relationships. Self-expression and self-actualization frequently are considered the pinnacle of a life’s achievement. Relationships may take a backseat, often being transitory or utilitarian. This leads to switching relationships, peer groups, and friends – and a strong emphasis on cultivating work relationships.
Exploring Dr. Bowen’s theories
Dr. Bowen posited that the family relational pull affects individual development in a negative way. Despite this, his model is considered one of the most comprehensive explanations for the development of psychological problems from a systemic, relational, and multigenerational perspective.1 He identified the basic self (B-self), which strives for differentiation in contrast to the false/pseudo/relational self (R-self), which strives to meet group or family norms.
Dr. Bowen was the oldest of three and grew up in a small town in Tennessee. His father was the mayor of the town and owned several properties, including the funeral home. Following medical training, Dr. Bowen served during World War II. He accepted a fellowship in surgery at the Mayo Clinic in Rochester, Minn., but his wartime experiences resulted in a change of interest to psychiatry. Dr. Bowen trained at the Menninger Clinic in Topeka, Kan., and in 1954 became the first director of the family division at the National Institute of Mental Health. He and his colleagues studied the families of patients with schizophrenia. They described eight fundamental concepts that supported the important aspects of individual growth. When he moved to Georgetown University in Washington, he developed the Bowen Family Systems Theory.2
Dr. Bowen’s eight concepts
1. Nuclear Family Emotional Process
2. Differentiation of self
3. Triangles
4. Emotional cutoff
5. Family projection process
6. Multigenerational transmission process
7. Sibling position
8. Societal Emotional Process
According to Dr. Bowen, the B-self makes decisions on facts, principles, and intrinsic motivation and decides what they are willing to do/not willing to do based on their own internal ethics. On the other hand, the R-self goes along with everybody else, even when the person internally disagrees. He considered the R-self as wanting acceptance in relationship, possibly changing beliefs to find approval, and striving to be liked. Carmen Knudson-Martin, PhD,3 explored the relationship between the B-self and the R-self and suggested that they exist along two dimensions, both of which are important. My contention is that the R-self is undertheorized and deserves much more exploration.
Developmental psychologists and psychiatrists have focused on understanding the process of psychological maturation of the individual throughout life. However, there is little study of the development of a healthy relationship between self and other. We have, instead, gathered examples and descriptors of the pathological examples of the “other.” We can readily call out enmeshment, the manipulations of the borderline personality disordered, the cold withholding mother – to name the most vilified. What do we know about the healthy R-self?
Measuring the relational self
We have understood the R-self mostly through the study of pathological relationships. For example, pathological parenting has been shown to “result” in individual pathology and as a factor in the development of psychiatric illness. The measurement of the relationship between patient and family member/partner is aimed at elucidating pathology. The supreme example is emotional overinvolvement (EOI).
EOI is an integral part of the construct called expressed emotion and is often measured using the Camberwell Family Interview.4 High EOI has been identified routinely as predictive of worsening of psychiatric illness.5 However, exceptions are found (when you look for them)! In African American families, for example, high EOI is predictive of better outcomes in patients with schizophrenia.6 Jill M. Hooley, DPhil, also has identified that patients with borderline personality disorders do better in families with high EOI.7
A shorter equivalent research tool is the 5-minute speech sample (FMSS). The FMSS analyses 5 minutes of the speech of a parent/family member who is asked to describe the identified patient. EOI is identified by expressions of excessive worry or concern, self-sacrifice, or exaggerated praise. In a study of 223 child-mother dyads, 56.5% of which were Hispanic, use of the FMSS found high EOI predicted externalizing behaviors.8
More recently, psychiatry has sought to identify and measure positive factors, such as family warmth. In Puerto Rican children, high parental warmth was found to be protective against psychiatric disorders.9 In a study of Burmese migrant families from 20 communities in Thailand (513 caregivers and 479 patients with schizophrenia, aged 7-15 years), families were randomized to a waitlist or a 12-week family intervention that promoted warmth.10 The family intervention resulted in increased parental warmth and affection and increased family well-being.
Applying the theories to practice
An adolescent, Jan, does not speak when her mother is in the room. Jan has a small B-self, and her mother has a large B-self. Not only does Jan have to develop a strong B, but she also has to change how she is in relation – she has to change her R-self. For Jan, individual therapy supports the development of a stronger B-self. Working with the patient and her mother, the balance between both B-selves and the joined R-self can be reworked. In essence, the therapist encourages Jan to speak and helps the mother keep her own counsel. This is a situation in which the individual and family intervention are best implemented by the same therapist.
Systemic family therapy, a specific type of family intervention, focuses on how all the R-selves in a family work together as a unit called the family, or F-self. The F-self also has its own family history, as relationship patterns are transmitted and played out through families and play out through subsequent generations. A new type of family therapy called family constellation therapy (FCT) focuses on the F-self as a collection of ancestral selves. This resonates strongly with families who have experienced significant trauma, such as war and Holocaust survivors. FCT is popular in collectivist cultures, where there is a strong belief in the power and influence of ancestors and where the self is understood as an “assemblage of ancestral relationships that often creates problems in the present day.”11 Dr. Bowen recognized this multigenerational pattern as one of his eight fundamental principles.
The patients whom we see often have failing or fractured relationships. They might be stuck in dysfunctional transactional patterns with intimate partners, or they might fail to find a suitable intimate partner. We recognize relational dysfunction such as “codependency,” “symbiosis,” and “enmeshment.” We recognize too much distance, identifying family cutoffs. We still have a long way to go before clinical practice incorporates the importance of assessment and development of healthy relationships in a deep way. A typical question heard across all clinics: Is your partner/family supportive? Not much else is asked in regard to relationships, unless the answer is no. We have yet to develop a good set of inquiring questions that focus on the assessment of healthy relationships.
What can the therapist do to help the patient manage this continual dialectic? The therapist can ask the questions: How important is your B-self versus your R-self? What is the balance between your B-self and your R-self? What do you know about your family or F-self? Is your F-self important to you?
References
1. Nichols MP and Davis S. Family Therapy: Concepts & Methods, 8th ed. (Boston: Allyn & Bacon, 2008).
2. The Bowen Center for the Study of the Family.
3. Knudson-Martin C. Fam J. 1996 Jul 1. doi: 1066480796043002.
4. Leff J and Vaughn C. Expressed Emotion in Families. (New York: The Guilford Press, 1985).
5. Breitborde NJK et al. J Nerv Ment Dis. 2013 Oct;201(10):833-40.
6. Gurak K and de Mamani AW. Fam Process. 2017;56(2):476-86.
7. Hooley JM et al. J Clin Psychiatry. 2010 Aug;71(8):1017-24.
8. Khafi TY et al. J Fam Psychol. 2015 Aug;29(4):585-94.
9. Santesteban-Echarr et al. J Psychiatr Res. 2017 Apr;87:30-6.
10. Puffer ES et al. PLoS One. 2017 Mar 28;12(3):e0172611.
11. Pritzker SE and WL Duncan. Cult Med Psychiatry. 2019 Sep;43(3):468-95.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of Working With Families in Family Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest.
This column is dedicated to the late Carl C. Bell, MD.
When we work with patients and their families from cultures that are not the culture in which we ourselves were raised, we think more deeply about this balance. In this column, I offer a simple but solid framework for this inquiry.
The first family therapist to crystallize the dialectic between the self and its relationship to others was Murray Bowen, MD. He believed that the differentiation of self from the family was the major task of human development. Dr. Bowen worked in a time when vilification of the “other” was common practice in individual psychotherapies and the goal of individual psychotherapy was the development of a healthy sense of self rather than repairing or developing relationships.
When faced with patients from cultures that are unfamiliar to us, we are less confident about how to assess the balance between self and other. In many cultures, marriages are based on social class and perceived social opportunities and are arranged by the respective families. If you come from a collectivist culture, where the focus is on the belief that the group is more important than the individual, the focus is more on self in relation to a group, belonging to a group, and participating in a group than self-striving. This is most evident in the role of women in many families (as well as in other organizations), in which women shoulder the responsibility for keeping families functional and together.
American culture is focused on serious self-striving. From kindergarten, children are expected to excel and to become the best self that they can be – regardless of the toll this takes on relationships. Self-expression and self-actualization frequently are considered the pinnacle of a life’s achievement. Relationships may take a backseat, often being transitory or utilitarian. This leads to switching relationships, peer groups, and friends – and a strong emphasis on cultivating work relationships.
Exploring Dr. Bowen’s theories
Dr. Bowen posited that the family relational pull affects individual development in a negative way. Despite this, his model is considered one of the most comprehensive explanations for the development of psychological problems from a systemic, relational, and multigenerational perspective.1 He identified the basic self (B-self), which strives for differentiation in contrast to the false/pseudo/relational self (R-self), which strives to meet group or family norms.
Dr. Bowen was the oldest of three and grew up in a small town in Tennessee. His father was the mayor of the town and owned several properties, including the funeral home. Following medical training, Dr. Bowen served during World War II. He accepted a fellowship in surgery at the Mayo Clinic in Rochester, Minn., but his wartime experiences resulted in a change of interest to psychiatry. Dr. Bowen trained at the Menninger Clinic in Topeka, Kan., and in 1954 became the first director of the family division at the National Institute of Mental Health. He and his colleagues studied the families of patients with schizophrenia. They described eight fundamental concepts that supported the important aspects of individual growth. When he moved to Georgetown University in Washington, he developed the Bowen Family Systems Theory.2
Dr. Bowen’s eight concepts
1. Nuclear Family Emotional Process
2. Differentiation of self
3. Triangles
4. Emotional cutoff
5. Family projection process
6. Multigenerational transmission process
7. Sibling position
8. Societal Emotional Process
According to Dr. Bowen, the B-self makes decisions on facts, principles, and intrinsic motivation and decides what they are willing to do/not willing to do based on their own internal ethics. On the other hand, the R-self goes along with everybody else, even when the person internally disagrees. He considered the R-self as wanting acceptance in relationship, possibly changing beliefs to find approval, and striving to be liked. Carmen Knudson-Martin, PhD,3 explored the relationship between the B-self and the R-self and suggested that they exist along two dimensions, both of which are important. My contention is that the R-self is undertheorized and deserves much more exploration.
Developmental psychologists and psychiatrists have focused on understanding the process of psychological maturation of the individual throughout life. However, there is little study of the development of a healthy relationship between self and other. We have, instead, gathered examples and descriptors of the pathological examples of the “other.” We can readily call out enmeshment, the manipulations of the borderline personality disordered, the cold withholding mother – to name the most vilified. What do we know about the healthy R-self?
Measuring the relational self
We have understood the R-self mostly through the study of pathological relationships. For example, pathological parenting has been shown to “result” in individual pathology and as a factor in the development of psychiatric illness. The measurement of the relationship between patient and family member/partner is aimed at elucidating pathology. The supreme example is emotional overinvolvement (EOI).
EOI is an integral part of the construct called expressed emotion and is often measured using the Camberwell Family Interview.4 High EOI has been identified routinely as predictive of worsening of psychiatric illness.5 However, exceptions are found (when you look for them)! In African American families, for example, high EOI is predictive of better outcomes in patients with schizophrenia.6 Jill M. Hooley, DPhil, also has identified that patients with borderline personality disorders do better in families with high EOI.7
A shorter equivalent research tool is the 5-minute speech sample (FMSS). The FMSS analyses 5 minutes of the speech of a parent/family member who is asked to describe the identified patient. EOI is identified by expressions of excessive worry or concern, self-sacrifice, or exaggerated praise. In a study of 223 child-mother dyads, 56.5% of which were Hispanic, use of the FMSS found high EOI predicted externalizing behaviors.8
More recently, psychiatry has sought to identify and measure positive factors, such as family warmth. In Puerto Rican children, high parental warmth was found to be protective against psychiatric disorders.9 In a study of Burmese migrant families from 20 communities in Thailand (513 caregivers and 479 patients with schizophrenia, aged 7-15 years), families were randomized to a waitlist or a 12-week family intervention that promoted warmth.10 The family intervention resulted in increased parental warmth and affection and increased family well-being.
Applying the theories to practice
An adolescent, Jan, does not speak when her mother is in the room. Jan has a small B-self, and her mother has a large B-self. Not only does Jan have to develop a strong B, but she also has to change how she is in relation – she has to change her R-self. For Jan, individual therapy supports the development of a stronger B-self. Working with the patient and her mother, the balance between both B-selves and the joined R-self can be reworked. In essence, the therapist encourages Jan to speak and helps the mother keep her own counsel. This is a situation in which the individual and family intervention are best implemented by the same therapist.
Systemic family therapy, a specific type of family intervention, focuses on how all the R-selves in a family work together as a unit called the family, or F-self. The F-self also has its own family history, as relationship patterns are transmitted and played out through families and play out through subsequent generations. A new type of family therapy called family constellation therapy (FCT) focuses on the F-self as a collection of ancestral selves. This resonates strongly with families who have experienced significant trauma, such as war and Holocaust survivors. FCT is popular in collectivist cultures, where there is a strong belief in the power and influence of ancestors and where the self is understood as an “assemblage of ancestral relationships that often creates problems in the present day.”11 Dr. Bowen recognized this multigenerational pattern as one of his eight fundamental principles.
The patients whom we see often have failing or fractured relationships. They might be stuck in dysfunctional transactional patterns with intimate partners, or they might fail to find a suitable intimate partner. We recognize relational dysfunction such as “codependency,” “symbiosis,” and “enmeshment.” We recognize too much distance, identifying family cutoffs. We still have a long way to go before clinical practice incorporates the importance of assessment and development of healthy relationships in a deep way. A typical question heard across all clinics: Is your partner/family supportive? Not much else is asked in regard to relationships, unless the answer is no. We have yet to develop a good set of inquiring questions that focus on the assessment of healthy relationships.
What can the therapist do to help the patient manage this continual dialectic? The therapist can ask the questions: How important is your B-self versus your R-self? What is the balance between your B-self and your R-self? What do you know about your family or F-self? Is your F-self important to you?
References
1. Nichols MP and Davis S. Family Therapy: Concepts & Methods, 8th ed. (Boston: Allyn & Bacon, 2008).
2. The Bowen Center for the Study of the Family.
3. Knudson-Martin C. Fam J. 1996 Jul 1. doi: 1066480796043002.
4. Leff J and Vaughn C. Expressed Emotion in Families. (New York: The Guilford Press, 1985).
5. Breitborde NJK et al. J Nerv Ment Dis. 2013 Oct;201(10):833-40.
6. Gurak K and de Mamani AW. Fam Process. 2017;56(2):476-86.
7. Hooley JM et al. J Clin Psychiatry. 2010 Aug;71(8):1017-24.
8. Khafi TY et al. J Fam Psychol. 2015 Aug;29(4):585-94.
9. Santesteban-Echarr et al. J Psychiatr Res. 2017 Apr;87:30-6.
10. Puffer ES et al. PLoS One. 2017 Mar 28;12(3):e0172611.
11. Pritzker SE and WL Duncan. Cult Med Psychiatry. 2019 Sep;43(3):468-95.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of Working With Families in Family Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest.