TIP 42 Dawn-Elise Snipes PhD, LMHC, CRC, NCC Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
GUIDING PRINCIPLES <ul><li>Employ a Recovery Perspective </li></ul><ul><li>Adopt a Multi-Problem Viewpoint </li></ul><ul><...
Essential Attitudes <ul><li>Desire and willingness to work with people with COD </li></ul><ul><li>Appreciation of the comp...
Assessment Areas <ul><li>Background </li></ul><ul><li>Substance use </li></ul><ul><li>Psychiatric problems </li></ul>Copyr...
Assessment Process <ul><li>Engage the client </li></ul><ul><ul><li>Universal Access/No Wrong Door </li></ul></ul><ul><ul><...
<ul><li>Identify strengths and supports </li></ul><ul><li>Identify problem areas </li></ul><ul><li>Determine stage of chan...
Techniques <ul><li>Stage specific motivational enhancements </li></ul><ul><ul><li>Express empathy </li></ul></ul><ul><ul><...
<ul><li>Use relapse prevention techniques </li></ul><ul><ul><li>Daily inventory </li></ul></ul><ul><ul><li>Recovery group ...
Precontemplation <ul><li>Express concern about the client’s substance use, or the client’s mood </li></ul><ul><li>State no...
Contemplation <ul><li>Elicit positive and negative aspects of substance use or psychological symptoms. </li></ul><ul><li>A...
Preparation <ul><li>Acknowledge the significance of the decision to seek treatment  </li></ul><ul><li>Support self-efficac...
Action <ul><li>Be a source of encouragement and support </li></ul><ul><li>Remember that the client may be in different sta...
Maintenance <ul><li>Anticipate and address difficulties  </li></ul><ul><li>Recognize the client’s struggle with either or ...
Relapse <ul><li>Explore what can be learned from the relapse </li></ul><ul><li>Express concern about the relapse. </li></u...
Special Populations <ul><li>Women </li></ul><ul><li>Homeless </li></ul><ul><li>Criminal Justice </li></ul>Copyright 2008-2...
Women <ul><li>Identify and build on each woman’s strengths. </li></ul><ul><li>Avoid confrontational approaches. </li></ul>...
Pregnancy <ul><li>Careful planning for helping woman address mental health issues during pregnancy and postpartum </li></u...
Homeless <ul><li>Address housing needs. </li></ul><ul><li>Teach clients skills for maintaining housing. </li></ul><ul><li>...
Criminal Justice Offenders <ul><li>Recognize special service needs. </li></ul><ul><li>Give positive reinforcement for smal...
Suicidality <ul><li>Abuse of alcohol and other drugs is a major risk factor in suicide. </li></ul><ul><li>Alcohol abuse is...
What to do <ul><li>Take all suicide threats seriously. </li></ul><ul><li>Assess the client’s risk of suicidality/homicidal...
Personality Disorders <ul><li>Borderline Personality Disorder Characteristics </li></ul><ul><ul><li>pervasive pattern of i...
Antisocial Personality Disorder <ul><li>Essential features of antisocial personality disorder </li></ul><ul><ul><li>a perv...
ASPD cont… <ul><li>What to do: </li></ul><ul><ul><li>Confront dishonest and antisocial behavior </li></ul></ul><ul><ul><li...
Mood Disorders <ul><li>Among women with a substance use disorder, mood disorders may be prevalent. </li></ul><ul><li>Women...
What to do <ul><li>Differentiate among the following:  </li></ul><ul><ul><li>anxiety and mood disorders </li></ul></ul><ul...
Schizophrenia <ul><li>There is no clear pattern of drug choice among clients with schizophrenia. </li></ul><ul><li>What lo...
What to do <ul><li>Obtain a working knowledge of the signs and symptoms of the disorder. </li></ul><ul><li>Work closely wi...
AD/HD <ul><li>AD/HD in 5 to 25 percent of people. </li></ul><ul><li>Approximately 1/3 of adults with AD/HD have histories ...
<ul><li>Clarify for the client repeatedly what elements of a question he or she has responded to and what remains to be ad...
PTSD <ul><li>The rate of PTSD among people with substance use disorders is 12 to 34 percent.  </li></ul><ul><li>For women ...
<ul><li>Proceed slowly </li></ul><ul><li>Develop a plan for increased safety. </li></ul><ul><li>Establish both perceived a...
Eating Disorders <ul><li>Approximately 15 percent of women and 1 percent of men in inpatient substance abuse treatment cen...
<ul><li>Develop a treatment plan for both the eating and substance use disorder. </li></ul><ul><li>Conduct a behavioral an...
Summary <ul><li>Co-occurring disorders are the rule not the exception </li></ul><ul><li>Mental health issues, especially t...
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Tip42: Assessment and Treatment of Co-Occurring Disorders

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Review best practices for working with persons with addictions and mental health issues. NBCC, NAADAC, CAADAC, and California Board of Behavioral Sciences approved Mental Health continuing education and addictions counselor training series. Narrated versions and CEUs available at http://www.allceus.com

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Tip42: Assessment and Treatment of Co-Occurring Disorders

  1. 1. TIP 42 Dawn-Elise Snipes PhD, LMHC, CRC, NCC Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  2. 2. GUIDING PRINCIPLES <ul><li>Employ a Recovery Perspective </li></ul><ul><li>Adopt a Multi-Problem Viewpoint </li></ul><ul><li>Develop a Phased Approach to Treatment </li></ul><ul><li>Address Specific Real-Life Problems Early in Treatment </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  3. 3. Essential Attitudes <ul><li>Desire and willingness to work with people with COD </li></ul><ul><li>Appreciation of the complexity of COD </li></ul><ul><li>Openness to new information </li></ul><ul><li>Awareness of personal reactions and feelings </li></ul><ul><li>Recognition of one’s own limitations </li></ul><ul><li>Recognition of the value of client input </li></ul><ul><li>Patience, perseverance, and therapeutic optimism </li></ul><ul><li>Ability to employ diverse theories, concepts </li></ul><ul><li>Flexibility of approach </li></ul><ul><li>Cultural competence </li></ul><ul><li>Belief that all individuals are capable of growth </li></ul><ul><li>Recognition of the rights of clients with COD </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  4. 4. Assessment Areas <ul><li>Background </li></ul><ul><li>Substance use </li></ul><ul><li>Psychiatric problems </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  5. 5. Assessment Process <ul><li>Engage the client </li></ul><ul><ul><li>Universal Access/No Wrong Door </li></ul></ul><ul><ul><li>Empathy/Acceptance of Client Choice </li></ul></ul><ul><ul><li>Person-Centered Assessment </li></ul></ul><ul><ul><li>Culture Sensitivity </li></ul></ul><ul><ul><li>Trauma Sensitivity </li></ul></ul><ul><li>Identify other sources of information (collaterals) </li></ul><ul><li>Screen and detect COD </li></ul><ul><li>Determine diagnosis and symptom severity </li></ul><ul><li>Determine Level of Care (LOCUS/ASAM) </li></ul><ul><li>Determine disability and functional impairment </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  6. 6. <ul><li>Identify strengths and supports </li></ul><ul><li>Identify problem areas </li></ul><ul><li>Determine stage of change </li></ul><ul><li>Plan treatment </li></ul><ul><li>Assessment is about getting to know a person with complex and individual needs </li></ul><ul><li>Do not rely on tools alone for a assessment. </li></ul><ul><li>Make every effort to obtain collateral information </li></ul><ul><li>Don’t allow preconceptions about addiction to interfere with learning about what the client really needs </li></ul><ul><li>Know diagnostic criteria </li></ul><ul><li>Don’t assume that there is one correct treatment approach </li></ul><ul><li>E mpathy and hope are the most valuable components </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  7. 7. Techniques <ul><li>Stage specific motivational enhancements </li></ul><ul><ul><li>Express empathy </li></ul></ul><ul><ul><li>Develop discrepancy </li></ul></ul><ul><ul><li>Roll with resistance </li></ul></ul><ul><ul><li>Support self-efficacy </li></ul></ul><ul><li>Use contingency management techniques to target specific behaviors </li></ul><ul><li>Use cognitive-behavioral techniques </li></ul><ul><ul><li>Visual aids </li></ul></ul><ul><ul><li>Role playing/practice </li></ul></ul><ul><ul><li>Outline sessions with specific behavioral objectives </li></ul></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  8. 8. <ul><li>Use relapse prevention techniques </li></ul><ul><ul><li>Daily inventory </li></ul></ul><ul><ul><li>Recovery group participation </li></ul></ul><ul><ul><li>Coping skills training </li></ul></ul><ul><ul><li>Medication adherence </li></ul></ul><ul><li>Skill building to address functional deficits </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  9. 9. Precontemplation <ul><li>Express concern about the client’s substance use, or the client’s mood </li></ul><ul><li>State nonjudgmentally that substance use (or mood, anxiety, self-destructiveness) is a problem. </li></ul><ul><li>Agree to disagree about the severity of the issues </li></ul><ul><li>Consider a trial of abstinence to clarify the issue </li></ul><ul><li>Suggest bringing a family member to an appointment. </li></ul><ul><li>Explore the client’s perception of the problems. </li></ul><ul><li>Emphasize the importance of seeing the client again and that you will try to help. </li></ul><ul><li>For involuntary clients, develop mutually acceptable goals </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  10. 10. Contemplation <ul><li>Elicit positive and negative aspects of substance use or psychological symptoms. </li></ul><ul><li>Ask about positive and negative aspects of past periods of abstinence and remission </li></ul><ul><li>Summarize the client’s comments </li></ul><ul><li>Make explicit discrepancies between values and actions. </li></ul><ul><li>Consider a trial of abstinence and/or psychological evaluation. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  11. 11. Preparation <ul><li>Acknowledge the significance of the decision to seek treatment </li></ul><ul><li>Support self-efficacy </li></ul><ul><li>Help the client decide on appropriate, achievable action for each issue </li></ul><ul><li>Caution that the road ahead is tough </li></ul><ul><li>Explain that relapse should not disrupt the client–clinician relationship. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  12. 12. Action <ul><li>Be a source of encouragement and support </li></ul><ul><li>Remember that the client may be in different stages of readiness for change for different issues </li></ul><ul><li>Acknowledge the uncomfortable aspects of withdrawal and/or psychological symptoms. </li></ul><ul><li>Reinforce the importance of remaining in recovery from both problems. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  13. 13. Maintenance <ul><li>Anticipate and address difficulties </li></ul><ul><li>Recognize the client’s struggle with either or both problems </li></ul><ul><li>Support the client’s resolve. </li></ul><ul><li>Reiterate that relapse or psychological symptoms should not disrupt the counseling relationship. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  14. 14. Relapse <ul><li>Explore what can be learned from the relapse </li></ul><ul><li>Express concern about the relapse. </li></ul><ul><li>Emphasize the positive aspect of the effort to seek care. </li></ul><ul><li>Support the client’s self-efficacy </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  15. 15. Special Populations <ul><li>Women </li></ul><ul><li>Homeless </li></ul><ul><li>Criminal Justice </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  16. 16. Women <ul><li>Identify and build on each woman’s strengths. </li></ul><ul><li>Avoid confrontational approaches. </li></ul><ul><li>Arrange for daily needs such as childcare and transportation. </li></ul><ul><li>Have a strong female presence on staff. </li></ul><ul><li>Promote bonding among women in the program. </li></ul><ul><li>Help women reduce the stress associated with parenting </li></ul><ul><li>Develop programs for both women and children. </li></ul><ul><li>Provide interventions that focus on trauma and abuse. </li></ul><ul><li>Foster family reintegration and family building </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  17. 17. Pregnancy <ul><li>Careful planning for helping woman address mental health issues during pregnancy and postpartum </li></ul><ul><li>Parenting often retriggers childhood traumas. </li></ul><ul><li>Focus on the woman’s interest in and desire to be a good mother. </li></ul><ul><li>Screen for dependence on substances that can produce a life-threatening withdrawal for the mother: alcohol, benzodiazepines, and barbiturates. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  18. 18. Homeless <ul><li>Address housing needs. </li></ul><ul><li>Teach clients skills for maintaining housing. </li></ul><ul><li>Work closely with shelter workers and other providers for the homeless. </li></ul><ul><li>Address real-life issues </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  19. 19. Criminal Justice Offenders <ul><li>Recognize special service needs. </li></ul><ul><li>Give positive reinforcement for small successes and progress. </li></ul><ul><li>Clarify expectations regarding supervision. </li></ul><ul><li>Use flexible responses to infractions. </li></ul><ul><li>Give concrete directions. </li></ul><ul><li>Design highly structured activities. </li></ul><ul><li>Provide ongoing monitoring of symptoms. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  20. 20. Suicidality <ul><li>Abuse of alcohol and other drugs is a major risk factor in suicide. </li></ul><ul><li>Alcohol abuse is associated with 25 to 50 percent of suicides. </li></ul><ul><li>Comorbidity of alcoholism and depression increases suicide risk. </li></ul><ul><li>Substance intoxication is associated with increased violence toward others and self. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  21. 21. What to do <ul><li>Take all suicide threats seriously. </li></ul><ul><li>Assess the client’s risk of suicidality/homicidality </li></ul><ul><li>Develop a safety and risk management plan </li></ul><ul><li>Provide availability of contact 24 hours a day </li></ul><ul><li>Refer high-risk clients for psychiatric intervention. </li></ul><ul><li>Monitor and develop strategies to ensure medication adherence. </li></ul><ul><li>Develop long-term recovery plans </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  22. 22. Personality Disorders <ul><li>Borderline Personality Disorder Characteristics </li></ul><ul><ul><li>pervasive pattern of instability of </li></ul></ul><ul><ul><ul><li>interpersonal relationships </li></ul></ul></ul><ul><ul><ul><li>self-image </li></ul></ul></ul><ul><ul><ul><li>emotions, </li></ul></ul></ul><ul><ul><li>along with marked impulsivity </li></ul></ul><ul><li>Anticipate that client progress will be slow and uneven. </li></ul><ul><li>Assess the risk of self-harm </li></ul><ul><li>Set clear boundaries and expectations regarding roles and behavior </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  23. 23. Antisocial Personality Disorder <ul><li>Essential features of antisocial personality disorder </li></ul><ul><ul><li>a pervasive disregard for and violation of the rights of others </li></ul></ul><ul><ul><li>an inability to form meaningful interpersonal relationships </li></ul></ul><ul><li>The prevalence of co-occurring antisocial personality disorder and substance abuse is high </li></ul><ul><li>Most people diagnosed as having antisocial personality disorder are not true psychopaths </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  24. 24. ASPD cont… <ul><li>What to do: </li></ul><ul><ul><li>Confront dishonest and antisocial behavior </li></ul></ul><ul><ul><li>Stress immediate learning experiences that teach corrective responses. </li></ul></ul><ul><ul><li>Hold clients responsible for their behavior and </li></ul></ul><ul><ul><li>Use peer communities to confront behavior and foster change. </li></ul></ul><ul><ul><li>Assess and correct antisocial and criminal thinking. </li></ul></ul><ul><ul><li>Foster longer-term individual value change and the establishment of new peer reference groups </li></ul></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  25. 25. Mood Disorders <ul><li>Among women with a substance use disorder, mood disorders may be prevalent. </li></ul><ul><li>Women are more likely than men to experience clinical depression or anxiety </li></ul><ul><li>Certain populations are at higher risk such as clients with HIV, clients maintained on methadone, and older adults. </li></ul><ul><li>Older adults are at highest risk for combined mood disorder and substance problems. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  26. 26. What to do <ul><li>Differentiate among the following: </li></ul><ul><ul><li>anxiety and mood disorders </li></ul></ul><ul><ul><li>commonplace expressions of anxiety and depression </li></ul></ul><ul><ul><li>anxiety and depression associated with more serious mental illness </li></ul></ul><ul><ul><li>medical conditions and medication side effects </li></ul></ul><ul><ul><li>substance-induced changes. </li></ul></ul><ul><li>Start low, go slow </li></ul><ul><li>Combine addiction counseling with medication and mental health treatment </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  27. 27. Schizophrenia <ul><li>There is no clear pattern of drug choice among clients with schizophrenia. </li></ul><ul><li>What looks like resistance or denial may in reality be negative symptoms of schizophrenia. </li></ul><ul><li>An accurate understanding of the role of substance use disorders in the client’s illness requires a multiple-contact, longitudinal assessment. </li></ul><ul><li>Clients with COD involving psychosis have a higher risk for self-destructive and violent behaviors, homelessness, victimization, poor nutrition, and poverty </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  28. 28. What to do <ul><li>Obtain a working knowledge of the signs and symptoms of the disorder. </li></ul><ul><li>Work closely with a psychiatrist or mental health professional. </li></ul><ul><li>Expect crises associated with the mental disorder </li></ul><ul><li>Assist the client to obtain social services, housing, vocational services. </li></ul><ul><li>Monitor medication and promote medication adherence. </li></ul><ul><li>Provide frequent breaks and shorter sessions or meetings. </li></ul><ul><li>Employ structure and support. </li></ul><ul><li>Present material in simple, concrete terms with examples and use multimedia methods. </li></ul><ul><li>Encourage participation in social clubs </li></ul><ul><li>Teach the client skills for detecting early signs of relapse for both mental illness and addiction </li></ul><ul><li>Involve family in psychoeducational groups </li></ul><ul><li>Monitor clients for signs of relapse and a return of psychotic symptoms </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  29. 29. AD/HD <ul><li>AD/HD in 5 to 25 percent of people. </li></ul><ul><li>Approximately 1/3 of adults with AD/HD have histories of alcohol abuse or dependence </li></ul><ul><li>Adults with AD/HD have been found primarily to use alcohol or marijuana </li></ul><ul><li>The client may use self-medication for AD/HD as an excuse </li></ul><ul><li>The presence of AD/HD complicates the treatment </li></ul><ul><li>of substance abuse, since these clients may have more difficulty engaging in treatment and learning abstinence skills, </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  30. 30. <ul><li>Clarify for the client repeatedly what elements of a question he or she has responded to and what remains to be addressed. </li></ul><ul><li>Eliminate distracting stimuli (e.g., noise, desktop items) from the environment. </li></ul><ul><li>Use visual aids </li></ul><ul><li>Reduce the length of meetings </li></ul><ul><li>Encourage the client to use organization tools </li></ul><ul><li>Refer the client for evaluation for medication. </li></ul><ul><li>Enhance the client’s knowledge about AD/HD and substance abuse. </li></ul><ul><li>Examine with the client any false beliefs about the history of both AD/HD and substance abuse difficulties. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  31. 31. PTSD <ul><li>The rate of PTSD among people with substance use disorders is 12 to 34 percent. </li></ul><ul><li>For women with substance use disorders, it is 30 to 59 percent </li></ul><ul><li>55 to 99 percent of women with addictions report a lifetime history of physical and/or sexual abuse </li></ul><ul><li>Repeated trauma is common in domestic violence, child abuse, and some substance-using lifestyles </li></ul><ul><li>People with PTSD tend to abuse the most serious substances (cocaine and opioids); however, abuse of prescription medications, marijuana, and alcohol are also common. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  32. 32. <ul><li>Proceed slowly </li></ul><ul><li>Develop a plan for increased safety. </li></ul><ul><li>Establish both perceived and real trust. </li></ul><ul><li>Attend to behavior even more than words. </li></ul><ul><li>Limit questioning about details of trauma. </li></ul><ul><li>Recognize that trauma injures an individual’s capacity for attachment </li></ul><ul><li>Recognize the importance of one’s own trauma history and countertransference </li></ul><ul><li>Help the client learn to de-escalate intense emotions. </li></ul><ul><li>Help the client to link PTSD and substance abuse. </li></ul><ul><li>Provide psychoeducation about PTSD and substance abuse. </li></ul><ul><li>Teach coping skills to control PTSD symptoms. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  33. 33. Eating Disorders <ul><li>Approximately 15 percent of women and 1 percent of men in inpatient substance abuse treatment centers have had an eating disorder </li></ul><ul><li>Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids </li></ul><ul><li>Many individuals alternate between substance abuse and eating disorders. </li></ul><ul><li>Nicotine and caffeine must also be considered when assessing substance abuse in people with eating disorders. </li></ul><ul><li>Individuals with eating disorders experience urges (or cravings) for binge-foods similar to urges for drugs. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  34. 34. <ul><li>Develop a treatment plan for both the eating and substance use disorder. </li></ul><ul><li>Conduct a behavioral analysis of the foods and substances of choice; high-risk times and situations for engaging in disordered eating and substance abuse behaviors </li></ul><ul><li>Employ psychoeducation and cognitive–behavioral techniques for bulimia nervosa. </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC
  35. 35. Summary <ul><li>Co-occurring disorders are the rule not the exception </li></ul><ul><li>Mental health issues, especially trauma and eating disorders may not be revealed during the initial assessment </li></ul><ul><li>Be alert for “substitute” addictions </li></ul><ul><li>Adequate treatment must address the person as a whole </li></ul>Copyright 2008-2012 AllCEUs.com a subsidiary of CDS Ventures, LLC

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