cognitive behavioral counseling of unresolved grief through the therapeutic adjunct of...

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COGNITIVE BEHAVIORAL COUNSELING OF UNRESOLVED GRIEF THROUGH THE THERAPEUTIC ADJUNCT OF TAPESTRY-MAKING FRANCES REYNOLDS, PhD* This paper describes counseling work with a client whose presenting problems could be framed as unre- solved grief. An integrative approach was taken to therapy, with cognitive behavioral adjuncts brought into an essentially client-centered perspective when relevant. In collaboration, the client and counselor discovered the therapeutic value of creating an image in tapestry. This experience appeared to help the cli- ent come to terms with past losses. The therapeutic aspects of the creative activity are analyzed from dif- ferent theoretical perspectives. Introduction The client work discussed in this paper is unusual in two respects. Firstly, the client’s grieving process was guided in part by cognitive behavioral principles. Secondly, a creative arts adjunct to verbal counseling was conceptualized within a cognitive behavioral framework. While cognitive and behavioral theories are increasingly used to guide brief forms of psycho- therapy and counseling, there are few published ac- counts of griefwork being informed by these perspec- tives. Cognitive behavioral approaches appear almost entirely missing from the creative therapies literature except in the field of music therapy (Bunt, 1994). The therapeutic use of art is perhaps more com- monly informed by psychodynamic or client-centered principles, and the later discussion will examine as- pects of the therapeutic process from these contrasting perspectives. These insights illustrate the value of an “integrative” approach to therapy. Practitioners whose work is grounded in a specific theoretical perspective may come to accept its sensi- tizing concepts as “given” and taken for granted. Yet all theories are filters for our complex experiences, serving to highlight some aspects for attention, and relegating other aspects to background. Counselors and clients may discover fresh insights from examin- ing their experiences from more than one theoretical viewpoint. The client’s problems were interpreted as unre- solved grief and so some analysis of this problem from a cognitive behavioral perspective is presented. The key objectives of cognitive behavioral counseling are outlined, followed by application of these princi- ples to a creative arts process of tapestry-making. Analyzing Grief Grief is a complex experience, and may be pro- voked by a wide variety of loss and separation expe- riences (Parkes, 1985). Grief reactions commonly in- clude feelings such as sadness, anger and guilt; cognitive problems such as inability to concentrate, obsessive reflections about the lost object and mem- ory losses; behavior disturbances such as social with- drawal, disturbing dreams and crying; and physical sensations such as tightness or emptiness in the stom- ach, shortness of breath and hypersensitivity to envi- ronmental sights and sounds. *Frances Reynolds is Lecturer in Psychology and Rehabilitation Counselling at Brunel University, Osterley Campus, Borough Road, Isleworth, Middlesex TW7 5DU, United Kingdom. The Arts in Psychotherapy, Vol. 26, No. 3, pp. 165–171, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0197-4556/99/$–see front matter PII S0197-4556(98)00062-8 165

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Page 1: Cognitive behavioral counseling of unresolved grief through the therapeutic adjunct of tapestry-making

COGNITIVE BEHAVIORAL COUNSELING OF UNRESOLVED GRIEF

THROUGH THE THERAPEUTIC ADJUNCT OF TAPESTRY-MAKING

FRANCES REYNOLDS, PhD*

This paper describes counseling work with a clientwhose presenting problems could be framed as unre-solved grief. An integrative approach was taken totherapy, with cognitive behavioral adjuncts broughtinto an essentially client-centered perspective whenrelevant. In collaboration, the client and counselordiscovered the therapeutic value of creating an imagein tapestry. This experience appeared to help the cli-ent come to terms with past losses. The therapeuticaspects of the creative activity are analyzed from dif-ferent theoretical perspectives.

Introduction

The client work discussed in this paper is unusualin two respects. Firstly, the client’s grieving processwas guided in part by cognitive behavioral principles.Secondly, a creative arts adjunct to verbal counselingwas conceptualized within a cognitive behavioralframework. While cognitive and behavioral theoriesare increasingly used to guide brief forms of psycho-therapy and counseling, there are few published ac-counts of griefwork being informed by these perspec-tives. Cognitive behavioral approaches appear almostentirely missing from the creative therapies literatureexcept in the field of music therapy (Bunt, 1994).

The therapeutic use of art is perhaps more com-monly informed by psychodynamic or client-centeredprinciples, and the later discussion will examine as-pects of the therapeutic process from these contrasting

perspectives. These insights illustrate the value of an“integrative” approach to therapy.

Practitioners whose work is grounded in a specifictheoretical perspective may come to accept its sensi-tizing concepts as “given” and taken for granted. Yetall theories are filters for our complex experiences,serving to highlight some aspects for attention, andrelegating other aspects to background. Counselorsand clients may discover fresh insights from examin-ing their experiences from more than one theoreticalviewpoint.

The client’s problems were interpreted as unre-solved grief and so some analysis of this problemfrom a cognitive behavioral perspective is presented.The key objectives of cognitive behavioral counselingare outlined, followed by application of these princi-ples to a creative arts process of tapestry-making.

Analyzing Grief

Grief is a complex experience, and may be pro-voked by a wide variety of loss and separation expe-riences (Parkes, 1985). Grief reactions commonly in-clude feelings such as sadness, anger and guilt;cognitive problems such as inability to concentrate,obsessive reflections about the lost object and mem-ory losses; behavior disturbances such as social with-drawal, disturbing dreams and crying; and physicalsensations such as tightness or emptiness in the stom-ach, shortness of breath and hypersensitivity to envi-ronmental sights and sounds.

*Frances Reynolds is Lecturer in Psychology and Rehabilitation Counselling at Brunel University, Osterley Campus, Borough Road,Isleworth, Middlesex TW7 5DU, United Kingdom.

The Arts in Psychotherapy, Vol. 26, No. 3, pp. 165–171, 1999Copyright © 1999 Elsevier Science LtdPrinted in the USA. All rights reserved

0197-4556/99/$–see front matter

PII S0197-4556(98)00062-8

165

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There are a variety of theoretical perspectives toguide counselors or therapists in working with griev-ing clients, and an integrated approach may be bene-ficial (Barbato & Irwin, 1992). Different interventionsmay be helpful according to the client’s position inthe grieving process. Initially, the task of the coun-selor is to listen to the client’s story and accept thepainful feelings which arise (Staudacher, 1987; Wor-den, 1982).

While nonjudgemental listening is important tohelp the client disclose painful experiences, it may notprovide sufficient conditions for the resolution ofgrief, particularly for clients who experience chronicor masked grief (Worden, 1982). In chronic grief, theresponse to loss is prolonged and perhaps marked bylimited emotions (such as intense sadness or anger).In masked grief, the person may not attribute ongoingpsychological difficulties to the grief process, andmay indeed avoid all references to or reminders of theloss. They may have been supported in this avoidanceby the family, leading to the “cognitive incubation” ofgrief (Eysenck, 1968; Gauthier & Marshall, 1977).The therapist may need to discover ways of helpingthe client to recontact the range of emotions experi-enced by the loss so that these can be worked throughand some greater resolution achieved.

Grief from a Cognitive Behavioral Perspective

There are relatively few accounts of therapistsworking with grief from a cognitive behavioral per-spective (Gauthier & Marshall, 1977; Kavanagh,1990; Mawson, Marks, Ramm, & Stern, 1981; Ram-sey, 1979). How may the cognitive behavioral per-spective be relevant to griefwork? The cognitive per-spective (Beck, 1976; Stern & Drummond, 1991)emphasizes the role of ongoing, unwarranted negativethoughts and assumptions in perpetuating problemssuch as depression. For those who are grieving a loss(be it of a person, possession or valued aspect of theself), the event itself may be very real and not open toreinterpretation. However, the person’s responses tothat loss, including thoughts of regret, self-blame andso on, may work against resolving grief.

At a cognitive level, there are similar targetswhether working with grief or depression more gen-erally. Beck (1976) noted how depressed clientstended to hold negative cognitions about the self (asdeficient, blameworthy, and so on), the world (aslacking essentials or as invalidating valued assump-tions), and the future (as promising nothing but fur-

ther strife, guilt, helplessness, and other unpleasantexperiences). The therapist is likely to assist the clientin identifying and challenging this so-called “negativecognitive triad.”

The behavioral perspective emphasizes how be-havioral patterns and habits come to be maintained inthe long-term by subtle rewards, including attentionfrom others, and relief from anxiety. In the context ofgrief, avoiding reminders of the loss and inhibitingexpression of feelings, may reduce the burden of sad-ness in the short-term. However, in time, the personmay become “entrapped” by their avoidance behav-ior. The fears of examining their loss experience in-tensify and their grief reactions may become moreprolonged. The foundations of exposure therapy andsystematic desensitization rest on the premise thatconfronting anxiety-provoking situations is a potentway of reducing their threat value (Marks, 1987). Incases of grief, it has been noted that individuals withcomplicated and prolonged responses to loss fre-quently avoid reminders of the lost person or situa-tion. Some counseling interventions (such as invitingthe client to bring mementoes, photographs and other“linking objects” to the session) aim to revive mem-ories of the loss and associated emotions (Volkan,1972). Such techniques can be viewed from a cogni-tive behavioral perspective as helping to challengeavoidance (and the long-standing “cognitive incuba-tion” of anxiety).

There is a common misinterpretation that cognitivebehavioral therapy is only concerned with intellectualresponses to situations and is highly directive. Thevaried interventions can be highly eliciting of strongemotional expression, and the therapist needs to beable to “hold” these emotions within a strong em-pathic alliance (Newell & Dryden, 1991).

Working with Grief Through Experiential Processes

Cognitive behavioral forms of therapy frequentlyinclude behavioral “projects” as homework. The cli-ent may most readily challenge long-standing cogni-tive assumptions about the self and the responses ofothers by trying out new behaviors. Experiential cre-ative processes may help the client to access buriedfeelings and test their cognitive “landscape” of as-sumptions and expectations. However, the therapeuticuse of art is rarely included within cognitive behav-ioral therapy.

From a cognitive behavioral perspective, creativeactivity may facilitate clients in gaining awareness of

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tacit negative assumptions. The visibility and perma-nence of the art product may help to challenge beliefsabout low self-worth. Creative activity is by defini-tion novel and so may to provide the client with newbehavioral coping strategies, as well as evidence thatchange is indeed possible.

Those working with art more often ground thework in a psychodynamic perspective. There is anacceptance of the power of the unconscious and artactivities are regarded as having the potential (withina safe therapuetic relationship) of releasing painful,repressed material. The frame in art therapy has beenlikened to a container for the feelings therein (Scha-verien, 1989). The art object can act as a bridge be-tween the unconscious and the conscious (Case &Dalley, 1992). As the client may not be fully aware ofthe deeper nonverbal meanings held within the art-work, anxiety about engaging in the therapy may bealleviated (Dekker, 1996). Art may have particularvalue in griefwork, readily providing the client with ameans of structuring chaotic feelings, as well as con-structing a symbolically satisfying closure. Creativeactivity also permits the client self expression and theopportunity to experience a more potent self, lesstainted by feelings of guilt or rejection.

The counseling work described below reveals howthe healing properties of creative work can be under-stood within a cognitive behavioral framework. Inlater discussion, further reflections on aspects of theprocess that are better understood by alternative the-oretical perspectives will be offered.

The Client

Anne (name changed) was 45 years old when shecame for counseling. She was married, with two chil-dren, aged 14 and 10 years. Employed full-time as ateacher, she described herself as over-immersed inwork and excessively conscientious.

Presenting Problems

She described her initial reasons for coming tocounseling as longstanding depression and maritaldiscord. She dated the onset of her difficulties asoccurring about 5 years previously, when the familymoved from their first home to a larger house. Thechildren had been born during the 9 years (1980–1989) spent at the first house. She described her hus-band as blaming her for abandoning the home inwhich he had felt safe and contented. Even 5 years

later, minor everyday disputes would tend to be esca-lated by the husband into accusations of blame for thismove and the ensuing change in their lives. The clientbelieved that he had never recovered warm feelingstowards her. Anne described a pervasive sense ofhelplessness, knowing that events could not be re-versed and yet feeling great regret and apparentshame for the ongoing difficulties in the relationship.

In the third session, a more specific difficulty wasdisclosed, the client expressing shame at the apparent“irrationality” of the problem. She described how shecould not bear to look at family photographs from theperiod spent at the first home. She did not even feelcomfortable looking inside the cupboard where thephotographs were kept. She disclosed with consider-able sadness that even thinking about the children’searly years brought such feelings of regret that shefeared being overwhelmed. The client noted that thisavoidance of photographs and memories was increas-ing, rather than abating with time. The past wastainted with such recrimination and regret that shevery rarely engaged in any reminiscence of that timewith her husband. She saw the past as split off, anddisowned as a dark secret. Such disowning appearedto render the present rootless and meaningless as well.She feared that the children also sensed the disquiet,worrying that they too would not be able to “own”their pasts with confidence or pride.

Interpretation

The client was evidently entangled in a complexweb of difficulties. However, in essence, she could beunderstood as locked into unresolved grief for thelosses (of home, and beliefs about her husband andmarriage relationship), which occurred 5 years previ-ously. The husband also seemed to be locked intounresolved grief. The past had become idealized, un-examined and associated with painful feelings of re-gret and shame. Such feelings had remained potentrather than discharged, through avoidance of discus-sion and photographs of the past. The grief could beunderstood as masked, as the client did not con-sciously attribute her difficulties to the losses experi-enced.

Integrative Approach to Counseling

An initial contract was established for 10 sessions,subject to later review. It has been argued (Lamb,1988) that delayed mourning may be more effectively

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accomplished if a limited time period for counselingis established that both encourages urgency, but alsorespects the client’s need for boundaries around thepain of grief.

Sessions 1 and 2

The initial exploration was essentially client-cen-tered, allowing the client to locate and describe herfeelings and beliefs about her self-worth, blame forevents and helplessness in the face of marital diffi-culties. The counselor worked towards establishing arelationship of trust.

Session 3

When the strong avoidance of early family photo-graphs was revealed, the behavioral technique ofgraded exposure seemed likely to be helpful. It hasbeen noted by Marks (1987) that exposure to theanxiety-provoking stimulus is the most effective strat-egy for overcoming long-standing phobias and com-pulsions. Avoidance temporarily relieves anxiety, re-inforcing subsequent avoidance actions, but leavingthe sufferer with chronic fears. However, exposure, ifit lasts for long enough (30 minutes to 2 hours), usu-ally results in the abating of fears/anxieties. The fearsneed not be of physical objects or situations. In thetreatment of chronic nightmares, deliberate self-expo-sure to the imagery has been shown to be helpful.Behaviorists argue that exposure allows the person tohabituate to the anxiety. On the other hand, the tech-nique may be effective because of the emotional andcognitive work that goes on during the anxious timewhen the person is confronting the feared stimulus.Cognitive-symbolic work on the part of the client isillustrated later in this paper.

The theory of graded exposure was explained tothe client and she drew up a hierarchy of threateningphotographs –from most to least threatening to herwell-being were photographs of:

1. Her children in the former home or garden2. Inside the former home3. Garden of the former home4. Holidays during 1980–1985 period (away from

home).

She was intrigued by the theory and evidence aboutthis approach to threat and anxiety and agreed to askher children to sort out relevant photographs from thelowest level in the hierarchy. As homework, she

would look at these photographs for extended periods,with her children as supportive company. It can beargued that encouraging this active involvement ofthe client to tackle personal difficulties following abehavioral strategy need not be incompatible withhumanistic values, and it did not diminish the thera-peutic alliance or facilitative climate of the counsel-ing. The client expressed relief that “at last somethingmight happen.” Therapeutic movement was much de-sired by her.

Session 4

The client described her experiences of studyingthe selected photographs. As the holiday photographshad produced (contrary to her expectations) relativelylittle anxiety or regret, she had decided to go furtherwith the exposure experience than planned and hadspent time studying photographs of the 1980–1985garden. She described feelings of overwhelming grieffor specifics such as cherished plants, the view whichshe had much admired and for the work she hadaccomplished in the garden. She also experiencedsharp sadness about the deeper losses, for example, ofher beliefs in the strength of her marriage and her ownself-worth. She reported gaining some understandingof the losses that preoccupied her husband. She keptfaith with the premises of exposure therapy and per-sisted in “staying with” the photographs and pain,which was surfacing. She then described a suddenintuition—that she could create a tapestry version ofthe photograph. Although she was not experienced inneedlework, she had completed two pictures from kits(with the picture already designed), and felt confidentthat she could work from a photograph. The authorsensed the therapeutic value of constructing a picture,which could then be “owned” physically and psycho-logically. Tapestry-making is a slow process andwould hence require very lengthy exposure to theanxiety-provoking material. The client, therefore,found her intuition validated within the collaborativecounseling relationship.

Over the next 6 weeks, the client proceeded todraw up the design from the photograph and sew thetapestry. This project became the main “homework”of the counseling sessions, with the cognitive andemotional work stimulated by the sewing reviewed ineach session (together with other issues). With morethan 4 hours spent each week on the stitching, in thesight of the initially anxiety-provoking photograph,this seemed to be an effective vehicle of exposure

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therapy, with all the cognitive and emotional processwhich it entails.

Session 5

The client described the drawing of the design andfirst stitching as slow and emotionally painful.

I can hardly bear to look at the photo ormaterial. I decided just to do the rose border thisweek as the design works around the roses. Ifelt such sharp pain and longing to be backthere, when everything seemed so safe and spe-cial.

She spent 3 to 4 hours on this part of the picture andat the end of this time reported that the pain hadbecome less intense. She began to experience curios-ity about whether she could indeed finish the wholepicture.

Session 6

I’ve done so much thinking this week. I’mfinding that memories are returning when I’mstitching that haven’t surfaced for years. Likethe tree—we rigged up a rope swing for thechildren. I felt happy and sad remembering that.I like to see the solid tree emerging from thestitching. It feels good to touch and see it grow-ing as I stitch. Like it’s my tree again.

Not only were painful feelings being experienced in-stead of avoided, but the first signs appeared that thepast was becoming integrated with the present(through recovery of forgotten memories and a senseof re-ownership). There was evident mourning forspecific losses, and the counseling session provided asafe space in which to explore and acknowledgethese.

Session 7

The client seemed to be experiencing less helpless-ness and a greater sense of control over feelings andevents. Symbolically, this was manifested in her de-cision to “axe the shed” from the garden tapestry (“italways did look a bit of an eyesore”) and to add someflowers on the lilac tree. There were further clues toher greater sense of freedom. “In the picture, I’mlooking at the garden from the back door. This week

I feel like I can move around in the picture a bitmore—I’m not so pinned back against the door that Ican’t breathe.” The very physical signs of anxiety(“pinned back so I can’t breathe”) were subsiding.Such changes were also apparent in the larger issuesdiscussed in the counseling sessions (the experienceof moving on and being less preoccupied with thepast) and in the appearance of some humor about pastevents.

Session 8

I feel I’ve worn out all the regret by pouringit into the stitching. It really has almost gone.And I’m beginning to see that our time therewasn’t totally glorious and peaceful. Therewere good bits and bad bits. I was particularlystruck by that when I was stitching the grass(which seemed to go on forever). I suddenlyremembered the bother we had clearing cats’mess off the grass before letting the children outto play. Our next door neighbours had about 7cats so the flower beds couldn’t cope and theywould come into our garden and mess on thelawn. I decided not to put any in the picture butI know it’s there!

The client in her humor revealed that the past hadbecome more differentiated. She was no longer think-ing in black and white terms (a feature of depressionas noted by Beck) but could accept the mixture ofgood and bad. The mourned past was no longer ide-alized. The availability of more realistic memoriesfurther explored in the session, perhaps helped todissipate the regret.

Session 9

When I started the picture I felt sure that Iwouldn’t be able to hang it up. I had thought ofburying it in a sort of funeral ritual which wouldmark that episode of our lives. But I think I willhang it up as a monument to my recovery.

The client appeared to recall the garden more objec-tively, as something lovely and loved, but throughfewer layers of distorting emotions. The work hadalso helped the client develop a more satisfactoryself-image. She discussed how the experience hadtouched more creative facets of her self.

It was interesting that the tapestry in its completion

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would provide a concrete ending to the emotionalprocess which accompanied the stitching. The pictureacted as physical evidence of cognitive and emotionalhealing and preparedness to move on.

Session 10

The finished tapestry was brought to the last ses-sion. The client described how she could now see theanger which had infused the first efforts

The roses were all over the place. Thestitches were really uneven and some were re-versed in direction. I wasn’t aware of that at allat the time. It seems symbolic that I started withangry red and finished with brilliant yellowthread. The tall straight stems of the roses werelast to be put in place. Nothing could knockthem down. That made me feel that there wassomething deep down, organising the making ofthe picture, making the most of the experience.

Anne agreed that 10 sessions had been sufficient timefor her to achieve changes in her feelings and self-image. Although problems with the marriage had byno means been fully resolved, the client had begun toview her husband’s anger as less personally directedand more an expression of his own unresolved grief.Through this, she felt somewhat less vulnerable to hisattacks and more prepared to help him talk throughhis feelings. She also found that her husband wasrelating to her more warmly, and attributed this to hermore responsive, less depressed state.

Reflections—Drawing on Diverse TheoreticalPerspectives

Recreating a grief-provoking photograph throughneedlework had considerable therapeutic value. Itstimulated not only a lengthy behavioral and cogni-tive exposure to a threatening reminder of the past(likely to result in reduced anxiety), but it could alsobe understood as the vehicle for considerable emo-tional and symbolic griefwork.

The first task of griefwork is to experience the painof grief (Worden, 1982). Lengthy exposure to photo-graphs (or other mementoes of loss) may trigger pain-ful feelings that can then be confronted rather thanavoided. During the lengthy periods of stitching, theclient noticed recollections of forgotten memories,though often painful, helped to challenge idealistic

thinking, and led to more ownership of the past—withless splitting and a greater integration with thepresent. These experiences seemed to help the re-integration that is the ultimate goal of griefwork.

The cognitive behavioral perspective provided auseful rationale for the hierarchical approach to deal-ing with anxiety-provoking material and explainedthe value of “staying with” anxiety for substantialperiods. Nevertheless, some of the material elicited bythe project appeared to reflect unconscious processesand these aspects may be better explained by psy-chodynamic concepts. For example, the initial focuson particular aspects of the scene (foreground roses)and colour (red), together with the rather “untamed”approach to stitching, resulted in a vibrant, rathermessy product at first. It was only once some of therepressed feelings had been discharged that the clientcould reflect on the several hidden meanings of theseinitial choices. Later work moved towards increasinglevels of self-awareness and reflection, including de-cisions to alter the scene. Such choices could be in-terpreted as metaphorical attempts to control and per-haps distance the self from the grip of the originalexperience.

At a deeper level, the finished picture also pro-vided a physical closure of the episode, with a sym-bolic function much like a headstone to a loved one.The physical frame held much more than stitches. Thestitching process permitted disengagement fromyearning and regret while creating a physical markerof the past.

Feelings of fragile identity often accompany loss.In the present case, these were magnified through thelong-standing conflict and other-blaming which wasoccurring in the marriage. The completed projecthelped to disconfirm the client’s feelings of helpless-ness and poor self-worth at home. The creative skillsdeveloped through the project could be understood ashelping the client to integrate previously unacknowl-edged or forgotten facets of the self, a therapeuticgoal emphasized by Jung (see Tuby, 1996).

Lastly, the counseling process seems to illustrateclearly the “collaborative” approach advocated bycognitive behavioral therapists (Newell & Dryden,1991), as well as by client-centered therapists (Silver-stone, 1997). The therapeutic relationship containedthe necessary elements of empathy, genuineness andunconditional respect (an experience in particularlyshort supply in the client’s life). A high level of mu-tual regard enabled the counselor to appreciate theclient’s own intuitions about her needs and insight

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regarding a personally relevant approach to exposuretherapy. The client benefitted in turn from the coun-selor’s developing insights into the role of a creativeactivity as a vehicle for cognitive behavioral therapy.This joint enterprise led to a therapeutic strategy ofgreat value.

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