Therapist stance

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					Mentalization Based
Treatment

Prof Anthony Bateman
Bergen 2010
Therapist stance
Some consequences for therapy
   Open-minded
      Focus on mental processes
      Therapist mental process accessible to patient
      Beware of stimulating fantasy about therapist
      Perspectives are impressionistic
      Mentalizing crisis plans
   Work within the attachment relationship
      Seek to stimulate mentalizing within emotional states
      Maintain mentalizing within relationship
   Interventions contingent and marked
      Is it you or the patient or both?
      Contrast perspectives
   Beware the still face and low reactivity and over-stimulation of
    attachment
    Therapist Stance

   Not-Knowing
     Neither therapist nor patient experiences interactions other than
      impressionistically
     Identify difference – „I can see how you get to that but when I think
      about it it occurs to me that he may have been pre-occupied with
      something rather than ignoring you‟.
     Acceptance of different perspectives
     Active questioning
     Eschew your need to understand – do not feel under obligation to
      understand the non-understandable.

   Monitor you own mistakes
     Model honesty and courage via acknowledgement of your own mistakes
        o Current
        o Future
     Suggest that mistakes offer opportunities to re-visit to learn more about
      contexts, experiences, and feelings
Therapist Stance

 C – uriosity
 H – ope and optimistic attitude
 A – uthenticity and affect focus
 T - ransference
Essential to the Stance
   Keep it current – what the patient feels right now
   Start by empathising – finding a way of stating
    that you genuinely understand distress
   Explore in the relational realm not just the intra-
    psychic
   Lower arousal by bringing it to the person of the
    therapist
     What have I done?
   Stick to mentalizing aim in somewhat dogged
    manner
   Quickly step back if patient seems to lose control
Contrary Moves
  Patient/Therapist    Therapist/Patient

  Knowing              Unknowing

  Self- reflection     Other reflection

  Emotional distance   Emotional closeness

  Certainty            Doubt
Basic mentalizing
interventions
Interventions: Spectrum
                         Supportive/empathic
 Most involved




                  Clarification, elaboration, challenge
 Least involved




                              affect focus


                     Mentalizing the transference
Interventions:
Supportive & empathic
   Respectful of their narrative and expression
   Positive/hopeful but questioning
   Unknowing stance – you cannot know their position
   Demonstrate a desire to know and to understand
   Constantly check-back your understanding – „as I have
    understood what you have been saying is…
   Spell out emotional impact of narrative based on common
    sense psychology and personal experience
   For the patient but not acting for them – retains patient
    responsibility
Clinical

   Supportive/empathic
    Early in therapy
    Take current mental states
      o „difficult to put feelings into words‟. The MBT
        empathic level relates to her experience of this in
        the context of the therapist
      o Previous therapy. Empathic level is concern about
        engaging in therapy again – „what is it like to come
        and talk about having more therapy given what
        happened before‟.
Interventions:
Basic Mentalizing
   „Stop, Listen, Look’
     During a typical non-mentalizing interaction in a group
        o   stop and investigate
        o   Let the interaction slowly unfold – control it
        o   highlight who feels what
        o   Identify how each aspect is understood from multiple perspectives
        o   Challenge reactive “fillers”
        o   Identify how messages feel and are understood, what reactions occur
     What do you think it feels like for X?
     Can you explain why he did that?
     Can you think of other ways you might be able to help her really
      understand what you feel like?
     How do you explain her distress/overdose
     If someone else was in that position what would you tell them to do
   Recruiting
     Gemma is obviously angry. Can anyone help her with this because I
      wonder if beneath it she is beginning to feel ignored
Intervention:
Clarification & Affect elaboration
   Clarification is the „tidying up‟ of behaviour which
    has resulted from a failure of mentalization
   Establish important „facts‟ from patient
    perspective
   Re-construct the events
   Make behaviour explicit– extensive detail of
    actions
   Avoid mentalizing the behaviours at this point
   Trace action to feeling
   Seek indicators of lack of reading of minds
Affect Focus

   Allows move towards
    transference/countertransference
   The dominant affective state shared between
    patient and therapist (not the patients primary
    affect state)
   Identifies and makes explicit the intersubjective
    state
Intervention:
Clarification & Affect elaboration
   Labelling feelings
     During non-mentalizing interaction therapist firmly
      tries to elicit feelings states
     Therapist recognises mixed emotions– probe for
      other feelings than first, particularly if first emotion
      is unlikely to provoke sympathy in others or lead to
      rejection (e.g. frustration, or anger)
     Reflect on what it must be like to feel like that in
      that situation
     Try to learn from individual what would need to
      happen to allow them to feel differently
     How would you need others to think about you, to
      feel differently?
Intervention:
Challenge
   Stop and Stand
     Persist and decline to be deflected from exploration - „Bear with
      me, I think we need to continue trying to understand what is going
      on‟
     Steady resolve - „I can understand that you want me to support
      what you are doing but I don‟t think that would be right because…
     Convert deceit into frank truth - „although you feel he has so much
      that he wouldn‟t miss it, the fact is that having stolen it you are a
      thief‟
     Identify affect attached to action – „I can see that although you
      tried not to „con‟ them, the pleasure and delight of doing it seems
      to have been stronger
     Ensure „here and now‟ aspects are included in the challenge
Interventions:
Basic Mentalizing
   Stop, Re-wind, Explore
     Lets go back and see what happened just then. At first you
      seemed to understand what was going on but then…
     Lets try to trace exactly how that came about
     Hang-on, before we move off lets just re-wind and see if we can
      understand something in all this.
   Labeling with qualification (“I wonder if…” statements)
     Explore manifest feeling but identify consequential experience –
      „Although you are obviously dismissive of them I wonder if that
      leaves you feeling a bit left out?
     „I wonder if there are some resentments that make it hard for you
      to allow yourself to listen to rules. Lets think about why the rules
      are there?
     „I wonder if you are not sure if it‟s OK to show your feelings to
      other people?‟
Components of mentalizing the
transference
   Validation of experience
   Exploration in the current relationship
   Accepting and exploring enactment (therapist
    contribution, therapist‟s own distortions)
   Collaboration in arriving at an understanding
   Present an alternative perspective
   Monitor the patient‟s reaction
   Explore the patient‟s reaction to the new
    understanding
Interventions:
Mentalizing the Transference
   Dangers of using the transference
    Avoid interpreting experience as repetition of
     the past or as a displacement. This simply
     makes the borderline patient feel that
     whatever is happening in therapy is unreal
    Thrown into a pretend mode
    Elaborates a fantasy of understanding with
     therapist
    Little experiential contact with reality
    No generalization
Components of mentalizing the
countertransference
 Monitor states of confusion and puzzlement
 Share the experience of not-knowing
 Eschew therapeutic omnipotence
 Attribute negative feelings to the therapy
  and current situation rather than the patient
  or therapist (initially)
 Aim at achieving an understanding the
  source of negativity or excessive concern
  etc.
Typical Countertransferences
   Pretend mode
     Boredom, temptation to say something trivial
     Sounding like being on autopilot, tempting to go along
     Lack of appropriate affect modulation (feeling flat,
      rigid, no contact,)
   Teleological
     Anxiety
     Wish to DO something (lists, coping strategies)
   Psychic equivalence
     Puzzlement, confused, unclear, excessive nodding
     Not sure what to say, just going
     Anger with the patient
Self-harm and suicidality:
Mentalizing Functional Analysis
   Stop and Rewind to point before mentalizing was lost
   Stop and Explore a point when mentalizing was taking
    place – system restore!
   Micro-slice mental states towards the self destructive
    act
    Continually move around self and other mental states
   Place responsibility for keeping mind on-line back with
    the patient
   Ask patient to identify when she could have possibly
    re-established self-control
Mentalization and
Mentalization based
treatment for antisocial
personality disorder
ASPD characteristics
   Failure to conform to social norms with respect to lawful
    behaviours
   Deceitfulness
   Impulsivity or failure to plan ahead
   Irritability and aggressiveness
   Reckless disregard for safety of self or other
   Consistent irresponsibility
   Lack of remorse

None of these features is endearing to others. The self-
  serving attitude of people with ASPD and unpredictability
  makes people wary of them.
    An evolutionary framework

   Interpersonal aggression is an important
    evolutionary adaptation.
    In certain human environments it is likely to
     contribute materially to the survival of the
     individual's genes.
    In other contexts it is seriously maladaptive
       o it undermines the possibility of safe collaboration
       o the optimization of human capacities for meaning
         generation, communication and creativity.
What differentiates persistent
violent trajectory?
   Across a number of studies
    socio demographic risk (e.g., poverty, low
     maternal education, single parenting)
    less sensitive and involved parenting during
     the course of childhood
    have mothers with low levels of education.
    have mothers who started childbearing early
    have mothers who are depressed
    Boys more fearless
    Experienced maternal rejection
    The mechanism for the development of
    violence: A failure of inhibition
   Family processes conceptualized as
    promoting aggression may interfere with the
    socialization of aggression
    low income, low maternal education reflects
     family environments in which children cannot
     learn to inhibit physical aggression, as well as
     difficulty learning alternative strategies to solve
     problems
    Characterised by disrespect for the child
       o Parenting qualities of disrespect for child
       o Similar qualities in the broader social environment
    The Role of Attachment
   The developmental trajectory is established early on
     The choice has to be made because there is an
      evolutionary cost to following the physical aggression
      trajectory.
   Evolution uses the early attachment relationship as
    a signaling system to the newborn as to the kind of
    environment he/she might expect.
     An environment where caregivers do not have the time or
      resources to devote attention to the infant is far more
      likely to necessitate the later use of violence in order to
      ensure the survival of the individual in subsequent
      struggles for limited resources.
     Disorganised attachment and
     externalising behaviour
   Fear of an abusive or ill parent activates their
    need for proximity-seeking, which, in turn,
    increases their fear
    results in a collapse of the infant‟s behavioral and
     attentional strategies
   van IJzendoorn, Schuengel, and Bakermans-
    Kranenberg (1999) reviewed twelve studies on
    734 children and demonstrated a clear
    association between disorganization and
    externalizing problems (r = .29, p<.00001).
Inhibition of social understanding associated with
maltreatment can lead to exposure to further abuse

                       DISTRESS/FEAR




Exposure to maltreatment                   Intensification of attachment




                    Inhibition of mentalisation

                  Inaccurate judgements of facial affects,
                   Delayed theory-of-mind understanding
      Failure to understand the situational determinants of emotions
    Attachment as a Signal of Environmental
    Stress
   Where caregivers do not have the time or resources
    to devote attention to the infant physical aggression
    is more likely to be needed to ensure survival
   This is the mechanism for the transgenerational
    transmission of violent interpersonal strategies.
   The child‟s mind and body needs to be prepared for
    violent competition for resources
     Alternative but incompatible strategies for ways of relating
      to others (intra-species collaboration) are sacrificed.
   What is sacrificed?
     Namely, the uniquely human capacity to envision mental
      states in our fellow humans in order to understand their
      actions.
Greater activation of amygdala and other temporal
and prefrontal regions of CD youths compared to
controls viewing others in pain (Decety et al
2009)
                               Amygdala responses in
                               CD youths correlated
                               with parents‟ ratings of
                               daring behaviour and
                               sadism

                               Increased amygdala
                               response may indicate
                               excitement or
                               enjoyment of others‟
                               pain
Summary of findings: Amygdala
   Dysfunction in limbic structures (amygdala)
    Hyperresponsiveness of amygdala in relation
     to observing pain in others  excitement
     about the brutality of a situation as opposed to
     emotion recognition in others or threat
    AND/OR
    Differentially involved in aggressive behaviour
     resulting from anxiety vs. aggression due to
     emotional callousness
Mentalizing:
A new word for an ancient concept

Implicitly and explicitly interpreting
 the actions of oneself and other as
 meaningful on the basis of
 intentional mental states
   (e.g., desires, needs, feelings,
           beliefs, & reasons)
    Mentalization and Human Aggression
 Mentalizing someone makes it hard to hurt
  them because we feel them from the inside.
 Aggressive acts are only possible if
  mentalization is temporarily inhibited or
  decoupled
 Mentalisation has the potential to advance
  culture and inhibit violence but is, at least
  partially, maladaptive in the context of life-
  and-death struggle.
    Multiple dimensions of mentalizing
    in psychodynamic psychotherapy
   Moving from implicit - automatic mentalization to
    explicit – controlled mentalization
      Challenging automatic assumptions
   Elaborating internal representations of mental states
    of self and others - external and internal mentalizing
      Challenging superficial judgements based on
       „appearances‟
   Connect feelings with thoughts (affect and cognition)
      Overcoming splitting of affect and cognition (the feeling of
       feelings)
   Differentiating self and other in psychotherapy
      Adopting the perspective of the other to the self
      Reducing the impact of the other on the self
      Reading the Mind in the Eyes




The eye region can signal specific social information, such as guilt, fear or
flirtatiousness
Aggressive individuals are either very poor at reading these signals but
some are exceptionally good..
Mentalizing and ASPD
   Unable to develop any real understanding of their own inner
    world (Self)
   Experts at reading the inner states of others (Other)
      misuse this capacity to coerce or manipulate them
   Lack abilities to read accurately certain emotions, an externally
    based component of mentalizing
   Cannot generate how they would feel in the others situation
   Fail to recognise fearful emotions from facial expressions. This
    implicates dysfunction in neural structures such as the
    amygdala that subserve fearful expression processing.
   Marsh and Blair (2008) in a meta-analysis of 20 studies
    showed a robust link between antisocial behaviour and specific
    deficits in recognizing fearful expressions. This impairment was
    not attributed solely to task difficulty.
Mentalizing and psychopathy:
Compart-mentalization
   Psychopathy entails elements of intact
    mentalizing

   Partial mindblindness:

     Failure of imaginative empathy
     Failure to identify with victim‟s distress
     Mind uninfluenced and unchanged easily – control and
      protection of self from shame/humiliation paramount
     Distorted mentalizing – paranoid demonizing e.g.
      interpreting frustrating behaviour as intended to
      torment
Mentalization based
treatment for antisocial
personality disorder
Why develop MBT for ASPD?
   Theoretical and clinical
      Mentalizing problems in ASPD
      Common problem and receive poor mental health care
      25% of all violent incidents committed by people with
       ASPD
      Increasing referrals from probation and courts
      Needs of patients different from other personality
       disorders
      Dangers of „overseeing‟ exploitation of others when
       treated with patients with BPD
      Treatment recommendations uncertain (NICE)
Demographics
Variable             N=16

Mean age             31.3   SD7.6

Male gender           16    100.0%

Married               1     6.25%

Living alone          15    87.5%

Children              12     75%

Tertiary education    1     6.25%

Current employment    0      0%

State benefit         16    100%
Demographics
Number                                N=16

White British/European                   12   75%

Black African/ Afro-Caribbean            4    25%

Sexual abuse                             4    25%

Physical abuse                           16   100%

Assaultative behaviour                   16   100%

Trouble with law arrests (lifetime)      16   100%

Prison sentences > 1year                 16   100%
Clinical Characteristics
Number                                      N=16

Suicide attempt past 6 months                  2    12.5%

Serious self-harm episodes past 6 months       5    31.25%

Psychiatric hospitalization past 6 months      2    12.5%

Depressive disorder at presentation            9    56.25%

Posttraumatic stress disorder                  3    18.75%

Number of Axis 1 diagnoses                    2.8   SD 1.3

Number of Axis 2 diagnosis (PPD and NPD)      2.4   SD 1.0
Measures
 Diagnostic measures SCID and PCL-R
 Symptom measures
 Locus of Control Questionnaire,
 Distress Tolerance Scale
 DAST (Drug Abuse Screening Test)
 AUDIT (Alcohol Use Disorders
  Identification Test)
 HCR-20
Treatment Format

 Treatment   for 1 year
 Group therapy 1x per week for 75
  minutes with initial introductory group
 Individual therapy with group therapist
  1x per month
 Integrated psychiatric care
 Crisis planning
 Code of Conduct
Group features
 Slow open group
 Avoid
    Time out contracts
    Discharge due to failure to meet attendance
     contract
    Exhortation based on the effect on others of an
     individual‟s absence
    Challenging a hierarchical relationship early in
     therapy
    Some features of a successfully
    mentalizing group
   Is relaxed and flexible, not “stuck” in one point of view
   Can be playful, with humour that engages rather than
    hurting or distancing
   Can solve problems by give-and-take between own and
    others‟ perspectives
   Advocates describing ones own experience, rather than
    defining other people‟s experience or intentions
   Conveys individual “ownership” of behaviour rather than a
    sense that it “happens” to them
   Is curious about other people‟s perspectives, and expect to
    have their own views extended by others‟
   Collaboration with others requires prioritizing their
    subjective states, thus placing limits upon the urge to
    physically control the behaviour of less powerful members
    of the group
  Vicious Cycles of Non- Mentalizing Within a
  Dysfunctional Social System

                          Powerful emotion                                                       Powerful emotion




Frightening, undermining,                     Poor mentalising         Frightening, undermining,                     Poor mentalising
 frustrating, distressing or                                            frustrating, distressing or
    coercive interactions                                                  coercive interactions

                               Person 1      Inability to understand                                  Person 2      Inability to understand
                                             or even pay attention                                                  or even pay attention
                                              to feelings of others                                                  to feelings of others

      Try to control or                                                      Try to control or
      change others or                                                       change others or
      oneself                                                                oneself
                                       Others seem                                                            Others seem
                                     incomprehensible                                                       incomprehensible
Non-Mentalizing Disorganized Groups:
Teleological Systems
   Expectations concerning the agency of the other
    are present but these are formulated uniquely in
    terms restricted to the physical world
     Only what is material can be meaningful
   Attitudes to ideas and feelings
     A focus on understanding actions in terms of their
      physical as opposed to mental outcomes
     Only a modification in the realm of the physical is
      regarded as a true index of the intentions of the other.
     Only action that has physical impact is felt as potentially
      capable of altering mental state in both self and other
       o Physical acts of harm  aggression is seen as legitimate
       o Demand for physical acts of demonstration of intent by others
          payment, acts of subservience, retributive justice
 Group process
   Agree code of conduct between all patients
    Money
    Meeting outside
 Emphasise a focus on self
 Develop an awareness of internal states
 Consider „others‟ subjective experience
 Build up a capacity of what someone else
  feels
 Identify hierarchical aspects of relationship
So how to create a mentalizing group?
 Activate attachment by creating an attitude of
  caring and compassion
 Enhance the curiosity which members of the
  group have about each others‟ thoughts and
  feelings
 Be careful to identify when mentalization has
  turned into pseudomentalization (pretending to
  know)
 Focuses on misunderstanding (mentalization
  is the understanding of misunderstanding)
 Curiosity coupled with respectful not knowing
Moderators of
outcome
New RCT: Outpatient Treatment
                                  168 patients screened for eligibility



                                                              34 patients excluded:

Consort Diagram – IOP Study:                                    10 did not attend interview
                                                                12 declined participation
                                                                  5 did not meet inclusion criteria
Patient Recruitment Flow-Chart                                    4 met exclusion criteria
                                                                  3 were uncontactable




                                           134 randomized




            71 patients allocated to MBT-OP                 63 patients allocated to SCM-OP



                6 attended < 6 months                            10 attended < 6 months
               13 attended 6-12 months                           6 attended 6-12 months




                52 completed treatment                           47 completed treatment




                71 included in analyses                          63 included in analyses
Impact of demography on specific
relative benefit from MBT
                        0.8

                        0.6

                        0.4
 Change in Overall ES




                        0.2

                          0
                               Tertiary Education   Employment   OnBenefits
                        -0.2

                        -0.4

                        -0.6

                        -0.8

                         -1
Impact of Axis I diagnosis on
specific relative benefit from MBT
                       1.6

                       1.4

                       1.2
Change in Overall ES




                         1

                       0.8

                       0.6

                       0.4

                       0.2

                         0
                              Dysthymia   Major Depression   Anxiety
                       -0.2
                     Impact of substance use on overall
                     outcome of treatment (change in ES)
                                                                      Severe Alchohol   Severe Substance
                                 Regular Drug Use   Severe Drug Use         Use               Use
                            0



                          -0.5
Reduction in Overall ES




                           -1



                          -1.5



                           -2



                          -2.5
Impact of substance use on specific
relative benefit from MBT
                           1.5



                             1
 Reduction in Overall ES




                           0.5



                             0
                                  Regular Drug Use   Severe Drug Use   Severe Alchohol   Severe Substance
                                                                             Use               Use
                           -0.5



                            -1



                           -1.5
Impact of Axis II diagnosis on
specific relative benefit from MBT
                       1.2

                         1

                       0.8

                       0.6
Change in Overall ES




                       0.4

                       0.2

                         0
                              Cluster A   Cluster B   Cluster C   Paranoid PD   Antisocial PD
                       -0.2

                       -0.4

                       -0.6

                       -0.8
The Cassel Step-down Treatment
Study (Chiesa & Fonagy, in prep)
   297 patients in personality disorder services
      (112 complete data, 31 males 81 females, 40% with some tertiary education)
   Recruited through
      Cassel Residential inpatient programme (n=120)
      Cassel Community stepdown/outpatient programme (n=113)
      MAU: Devon Personality Disorder services (n=64)
   Gender: % female                               Employment: % unemployed
      Residential: 77%                               Residential: 85%
      Community: 78%                                 Community: 88%
      Mau: 65%                                       Mau: 85%
   Trauma: % at least one                         Major depression:
      Residential: 84%                               Residential: 60%
      Community: 75%                                 Community: 77%
      Mau: 87%                                       Mau: 67%
   Cluster B PD:                                  Alcohol:
      Residential: 80%                               Residential: 35%
      Community: 76%                                 Community: 37%
      Mau: 70%                                       Mau: 38%
   Cluster A PD:                                  Suicidal:
      Residential: 61%                               Residential: 45%
      Community: 51%                                 Community: 55%
      Mau: 50%                                       Mau: 40%
 The Cassel Step down Treatment Study: Reflective Function
 Gain (Chiesa & Fonagy, in prep)
                        Residential   Community   Management as usual

                 5



                4.5



                 4
       AAI_RF




                3.5



                 3



                2.5
                        Baseline                        Follow-up

Mixed effects model: β(Residential)=.25, z= 2.28, p<0.02, 95%CI: .035, .467
Mixed effects model: β(Community)=.50, z= 4.19, p<0.000, 95%CI: .264, .728
                    Thank you for
                    mentalizing!

For further information
anthony@mullins.plus.com
http://www.ucl.ac.uk/psychoanalysis/unit-staff/staff.htm
Impact of clinical history on overall
outcome of treatment (change in ES)
                        0.4

                        0.2

                          0
                               Early loss   Sexual Abuse   Physical Abuse   Antisocial
                        -0.2                                                Behavior
 Change in Overall ES




                        -0.4

                        -0.6

                        -0.8

                         -1

                        -1.2

                        -1.4

                        -1.6

                        -1.8
Impact of clinical history on specific
relative benefit from MBT
                        0.8


                        0.6


                        0.4
 Change in Overall ES




                        0.2


                          0
                               Early loss   Sexual Abuse   Physical Abuse   Antisocial
                        -0.2                                                Behavior


                        -0.4


                        -0.6


                        -0.8
Impact of Axis II diagnosis on overall
outcome of treatment (change in ES)
                                 Cluster A   Cluster B   Cluster C   Paranoid PD   Antisocial PD
                            0



                          -0.5
Reduction in Overall ES




                           -1



                          -1.5



                           -2



                          -2.5



                           -3
Impact of demography on overall
outcome of treatment (change in ES)
                         1



                       0.8
Change in Overall ES




                       0.6



                       0.4



                       0.2



                         0
                              Tertiary Education   Employment   OnBenefits

                       -0.2
Impact of Axis I diagnosis on overall
outcome of treatment (change in ES)
                       0.8


                       0.7


                       0.6
Change in Overall ES




                       0.5


                       0.4

                       0.3


                       0.2


                       0.1


                        0
                             Dysthymia   Major Depression   Anxiety
Theory: Self-destructiveness and
                Externalisation Following Trauma
          Torturing alien self     Self representation




    Perceived                    Unbearably painful
    other                        emotional states:
                                 Self experienced
                                   as shameful
                 Self-harm state
    Attack from within is turned against body and/or mind.
        Theory: Destructiveness and
                 Externalisation Following Trauma
Torturing alien self   Self representation                         Torturing alien self
                                                          Externalization




Perceived         Unbearably painful
other             emotional states:          Container          Coercive state
                  Self experienced
                   as evil/hateful            Addictive bond

Tortured state                          Torturing/Hierarchical state
  Externalisation becomes a matter of self-survival and addictive bonds may
                                  develop

				
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posted:12/3/2011
language:English
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