GAS (Goal Attainment Scaling in Rehabilitation), GAS-light, and gaslighting.

rvallee

rvallee

Senior Member (Voting Rights)
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NICE pauses publication of updated ME/CFS guideline hours before publication was due - 17th August 2021

I'm still unsure whether this is a parody, but it appears not. This is the kind of thing that is at stake with the guidelines. As usual, I'm not concerned that anyone is stupid enough to write stuff like that. What's indefensible is that this nonsense is taken seriously. No matter how offensive it gets, they always find ways to be over-the-top offensive, thinking they're very clever.


 
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rvallee said:
I'm still unsure whether this is a parody, but it appears not. This is the kind of thing that is at stake with the guidelines. As usual, I'm not concerned that anyone is stupid enough to write stuff like that. What's indefensible is that this nonsense is taken seriously. No matter how offensive it gets, they always find ways to be over-the-top offensive, thinking they're very clever.


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:emoji_open_mouth::emoji_no_mouth: Stunned

Edited: I had assumed that this was a newly developed thing. It's not it's from 2006 - see further on in thread. In which case it's not particularly remarkable given loads of people had never heard of gaslighting back then.
 
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JemPD said:
:emoji_open_mouth::emoji_no_mouth: Stunned
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I'm not as stunned as I should be.

I'm too busy trying to work out if that's just taking the proverbial issue to how far they can go before someone puts a stop to it

Or

epic lack of self awareness, and awareness of the issues their patients face.

I'm still not convinced some of this behaviour isn't a result of a bet after an evening spent round at the Wessely's blind testing wine.
 
This comes from the document mentioned above

King's College London - GAS - Goal Attainment Scaling in Rehabilitation (kcl.ac.uk)

How is GAS rated?
An important feature of GAS is the ‘a priori ‘ establishment of criteria for a ‘successful’ outcome in that individual, which is agreed with the patient and family before intervention starts so that everyone has a realistic expectation of what is likely to be achieved, and agrees that this would be worth striving for.

How can science be done after that? Does "a priori" "knowledge"have any place within science?
 
chrisb said:
How is GAS rated?
An important feature of GAS is the ‘a priori ‘ establishment of criteria for a ‘successful’ outcome in that individual, which is agreed with the patient and family before intervention starts so that everyone has a realistic expectation of what is likely to be achieved, and agrees that this would be worth striving for.
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That, particularly in the context of a poorly understood condition, is nucking futs. :grumpy:
 
chrisb said:
How is GAS rated?
An important feature of GAS is the ‘a priori ‘ establishment of criteria for a ‘successful’ outcome in that individual, which is agreed with the patient and family before intervention starts so that everyone has a realistic expectation of what is likely to be achieved, and agrees that this would be worth striving for.

How can science be done after that? Does "a priori" "knowledge"have any place within science?
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Think you may be misunderstanding what is being done here @chrisb.

This is a perfectly legitimate and very intelligent approach to genuinely complicated and heterogeneous clinical problems. I published a trial of steroid infusion in lupus using this approach in the 1980s.

The 'a priori' is basically the same as pre-specifying your primary outcome measure - which we all agree is a good idea.

In this case you individualise the outcome criteria for each subject. The main reasons to do this are to make assessment manageable and reduce noise. So, for instance, there are about twenty common pathological problems in lupus, each of which you might want to score. But if you have a patient with kidney involvement and nothing else then scoring them for rash and lung problems and everything else greatly complicates the follow-up assessment needed (including more x-rays) and if at follow up there is a coincidental rash from a drug reaction you would do better not to have had a rash score included - unless you have all sorts of complicated rules for filtering out noise.

For someone with a stroke it makes sense to set up the 'a priori' outcome measures for Mr Smith of ability to form sentences and ability to walk without a frame. For Mrs Jones the a priori measures might be being able to eat unassisted (having a visual lesion that made her unaware of the left side of everything) and go to the loo without incontinence.

That's all. It is the obvious thing to do really. Lynne T-S is very good at that sort of practical thought process. What is so disappointing is that she seems to be blind to the psychology of evidence assessment, attribution of causation and all those things.
 
I'd like to make the following point but this in no way seeks to mitigate:

If you look at the references at the end of the GAS-Light document they are from 2006. References at the end of this KCL page which also includes links to a number of other documents and papers on "GAS - Goal Attainment Scaling in Rehabilitation" are from 2006 to 2010, which suggests that the documents were likely prepared during that period.

As many of you will be aware, the phrase "to gaslight" and the concept of "gaslighting" originates from the title of a 1938 stage play ("Gas Light") and 1940 film.

We now see this term splashed all over social media, where it is often applied incorrectly. I would estimate it's been perhaps four to five years since this term exploded into popular use; I certainly don't recall it being used as early as 2006-2010. I now see the term "gaslighting" applied to any form of interaction between individuals that feels inappropriate to one of the parties. Once a term catches on there is a tendency to feel that it's always been around.

My point is this: when the phrase "The GAS-Light model" was first used in these rehab related documents and papers the term would not have had the resonance it now has for people familiar with the use of "gaslight" in social media.

However, now that the word and concept of "gaslighting" is in common use, Turner-Stokes would do well to reconsider the use of this term.

So I've deleted my previous post.


Edited to add: I have a very old Monotype type specimen book which includes ornamental borders for use in advertisements etc featuring swastikas.
 
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Dx Revision Watch said:
My point is this: when the phrase "The GAS-Light model" was first used in these rehab related documents and papers the term would not have had the resonance it now has for people familiar with the use of "gaslight" in social media.
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I'd love to believe that to be true, but, two of the references on the Wikipedia page about gaslighting are these:

  1. Gass PhD, Gertrude Zemon; Nichols EdD, William C. (18 March 1988). "Gaslighting: A marital syndrome". Contemp Family Therapy. 8: 3-16. doi:10.1007/BF00922429.
  2. ^ Jump up to:a b c Dorpat, Theodore L. (1996). Gaslighting, the Double Whammy, Interrogation, and Other Methods of Covert Control in Psychotherapy and Psychoanalysis. Northvale, NJ: Jason Aronson. ISBN 978-1-56821-828-1. OCLC 34548677. Retrieved 24 April 2021.
  3. ^ Lund, C.A.; Gardiner, A.Q. (1977). "The Gaslight Phenomenon: An Institutional Variant". British Journal of Psychiatry. 131 (5): 533–34. doi:10.1192/bjp.131.5.533. PMID 588872.
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It may not have been in widespread use on social media, but I certainly remember the term being used between 2006 and 2010 by several of my acquaintances, and I don't think they were particular outliers. It was definitely being used on some forums, but I don't think social media was as prevalent then.

Edited to add: the numbering is incorrect, the references are actually numbered 9 to 11 on the Wikipedia page, but the number didn't copy over, and I can't change them. Apologies.
 
Jonathan Edwards said:
That's all. It is the obvious thing to do really. Lynne T-S is very good at that sort of practical thought process. What is so disappointing is that she seems to be blind to the psychology of evidence assessment, attribution of causation and all those things.
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Sure, the idea of GAS is ok - define what you are trying to achieve beforehand, and the measure of success. So, the expected outcome is that Mr Smith can work without a frame from his bedroom to his bathroom. A +2 result might be that he's back playing tennis, and a -2 result might be that he can't walk at all without a frame.

The GAS-light document said:
GAS provides a flexible and responsive method of evaluating outcomes in complex interventions, but clinicians have reported a number of problems that have limit its uptake as an outcome measure for routine clinical practice:

  1. According to the original GAS method, descriptions of achievement should be pre-defined for each of the five outcome score levels (-2, -1, 0, +1 and +2) using a ‘follow-up guide. This is very time-consuming, when ultimately only one level will be used.
  2. Clinicians are confused by the various different numerical scoring methods reported in the literature.
  3. They generally dislike applying negative scores which may be discouraging to patients, and are put off by the complex formula.
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But the GAS-light model is different, apparently because clinicians got confused by complex formulas, and because they didn't want negative scores.

the GAS-light document said:
This ‘GAS-light’ model has been devised to help clinicians to build GAS into their clinical thinking so that GAS is not a separate outcome measurement exercise but an integral part of the decision-making and review process. Key differences between the GAS-Light and the original method are:
  1. The only predefined scoring level is that for the zero score (ie a clear description of the intended level of achievement) SMARTly set and fully documented - all other levels are rated retrospectively
  2. The patient and treating team are both involved in both goal setting and evaluation
  3. Goal rating is done using a 6-point verbal score in the clinic setting (which is later translated into numerical scores to derive the T-score)
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You can see there that apparently the clinicians found defining 5 different 'levels' for an outcome too troublesome. So, with GAS-light, only one 'level' is defined i.e. Mr Smith walking without a frame from his bedroom to his bathroom. As the document says 'all other levels are rated retrospectively'. Which perhaps is realistic in a clinical situation, but it also means that, if you set the zero option low enough, you can make sure neither the patient nor the clinician fails, and that expectations are modified over time in accordance with actual outcomes. When you come to assess the success of the rehabilitation and Mr Smith is not only walking to the bathroom but also all the way to the kitchen without a frame, you can decide that's a great success and mark it down as a +2. Nevermind that he wanted to play tennis at the outset.

As you say Jonathan, it may be all very practical, but it is a bit rubbish in terms of evidence assessment. The woolliness means that the clinician has a lot of leeway to count successes. That might sometimes be ok, but it does indeed have potential to gaslight the patients, making them accept a low level of function as 'recovery'. It could be used in ME/CFS, changing a patient's original definition of recovery from 'going back to work' to 'pottering in the garden'.

The mindset of a clinician used to redefining success in terms of what is actually achieved might be a bit of a problem in a clinical trial.
 
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Tao Fogger said:
I'd love to believe that to be true, but, two of the references on the Wikipedia page about gaslighting are these:



It may not have been in widespread use on social media, but I certainly remember the term being used between 2006 and 2010 by several of my acquaintances, and I don't think they were particular outliers. It was definitely being used on some forums, but I don't think social media was as prevalent then.

Edited to add: the numbering is incorrect, the references are actually numbered 9 to 11 on the Wikipedia page, but the number didn't copy over, and I can't change them. Apologies.
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Thank you for providing evidence that the term "gaslighting" as a concept was being used in academic papers as early as 1977.

In 2006, Turner-Stokes may or may not have been familiar with the concept and from where the term originated. In 2006, the term, "The GAS-Light model" was applied to a modified form of the original "GAS model".

What I am seeing on Twitter, is folk jumping up and down who appear not to have considered the date when the "The GAS-Light model" adaptation was developed and writing comments like:

"It’s inconceivable that psychiatrists don’t know the meanings and associations of these words so they either did it on purpose or don’t care."

I agree that the phrase "The GAS-Light model" needs reviewing - but one cannot assume that Turner-Stokes had "gaslighting" in mind when she referred to the "Light" GAS model, as "The GAS-Light model".

[Edited for clarity]
 
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Jonathan Edwards said:
Think you may be misunderstanding what is being done here @chrisb.

This is a perfectly legitimate and very intelligent approach to genuinely complicated and heterogeneous clinical problems. I published a trial of steroid infusion in lupus using this approach in the 1980s.
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I bet you never thought of the name GAS-light.

I think I see what is being done and that my objection is to the use of the term "a priori" in this context. It appears to be merely grandiloquent and either otiose or not normal usage. "A priori" to what? These expectations appear to be based on inductive reasoning from the evidence of other cases. As such it is " a posteriori" to those cases, but could hardly be anything but " a priori" to the individual case in question.

I realise that this has now taken this valuable thread well, or badly, off topic.
 
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Hutan said:
When you come to assess the success of the rehabilitation and Mr Smith is not only walking to the bathroom but also all the way to the kitchen without a frame, you can decide that's a great success and mark it down as a +2. Nevermind that he wanted to play tennis at the outset.

As you say Jonathan, it may be all very practical, but it is a bit rubbish in terms of evidence assessment. The woolliness means that the clinician has a lot of leeway to count successes.
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Yes, and the bolded words are the devil in the detail. All that can be assessed in an uncontrolled case observation is improvement - or the success of the patient. The whole piece is written with the assumption that all improvement is due to the rehabilitation.

I wonder what this GAS-light system was designed for - maybe audit? I cannot see what use it is to the individual patient. It is presumably intended as ammunition for asking for more resources through audit. Audit was always a bad idea. It really means 'research done badly' in medicine.
 
Dx Revision Watch said:
Thank you for providing evidence that the term "gaslighting" as a concept was being used in academic papers as early as 1977.

In 2006, Turner-Stokes may or may not have been familiar with the concept and from where the term originated. In 2006, she had used the term, "The GAS-Light model" (presumably to distinguish from the original "GAS model").

What I am seeing on Twitter, is folk jumping up and down who appear not to have considered the date when this document was prepared and writing comments like: "It’s inconceivable that psychiatrists don’t know the meanings and associations of these words so they either did it on purpose or don’t care."

I agree that the phrase "The GAS-Light model" needs reviewing - but one cannot assume that Turner-Stokes had "gaslighting" in mind when she referred to the "Light" GAS model, as "The GAS-Light model".
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Dx Revision Watch said:
"Gaslighting" is the new "cupcake".
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I first heard of the gaslighting term in the mid - late noughties, but it was then very 'localised' to fields of domestic abuse etc, and was only ever used to mean what it was originally coined for - what the husband did to the wife in the movie - ie an abuser trying to convince the victim that they are going insane/losing their grip on reality, for the benefit of the abuser - usually to gain power/control.
Now i often hear it being used if someone simply disagrees or has a different take on 'reality'/how things are.

Your post was first time i heard of the cupcake term, i had to look it up.

I completely agree that we cant know what Turner Stokes intended when she used the term/model back in 2006, but i also agree that it needs reviewing.
 
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