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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – Wasting Access to Psychological Therapy

by reliance on two screening instruments. Coupled with a failure to conduct an interview that would reliably confirm or reject the impression given by the tests. The effect is that  many are treated needlessly, as most score above the designated cut-offs on the tests [IAPT Manual 2018)]. Further, diagnostic possibilities are constricted by the scope of the 2 instruments, depression (PHQ-9) and generalised anxiety disorder (GAD-7). The message from this Government service is:

 

Usage of the 2 screening tests would not rule out that a person had say an adjustment disorder triggered by job loss, marriage breakdown, serious illness, bereavement or an accident.  But such difficulties are not the domain of the disorders that are the focus of the randomised controlled trials of cbt for depression and the anxiety disorders. Yet such difficulties are the common currency of primary care. Thus the application of the cbt protocols for these disorders to those with these difficulties is not evidence-based and is a waste of resources. It is likely a matter of pathologising normality.

 

One third of those attending NHS Talking therapies have a low intensity intervention alone, i.e they are not treated by a psychological therapist, but by a Psychological Wellbeing Practitioner (PWP) [IAPT Manual (2018)].  But the PWPs do not know the diagnosis of any patient, as they, like all NHS Talking Therapies clinicians are not trained to diagnose. The allegation is that they deliver CBT, but for what?

The evidence-base for low intensity interventions is weak, in that, there is an absence of attention control conditions and independent blind assessment. The evidence that PWPs implement the low intensity interventions from the weak trials is weaker still. There have been no fidelity checks on PWPs ministrations i.e independent assessments of treatment targets and matching treatment strategies. 

Almost half of those entering NHS Talking therapies never progress to treatment defined by the Service as attending 2 or more treatment sessions. This is likely a ‘thanks, but no thanks’ response on behalf of patients. There is a monumental waste of scarce resources. Unsurprisingly I found that only the tip of the iceberg recover.  

The trajectory of patients in NHS Talking Therapies is rather like that of horses entering the Grand National. There were 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions). The much vaunted ‘50% recovery rate’ that this Governmental service boasts about, refers to the significant minority who cross IAPT’s finishing line. Thus even using IAPT’s own yardstick  the true recovery rate is much less than 50%.

With regards to those who cross IAPT’s finishing line, there is no indication that their ‘success’ is lasting. It is not known what proportion of them ever ‘race’ again. 

The NHS Talking Therapies is an exemplar of what happens when there is an unaccountable Service. In which a therapist’s unfettered judgement, on how to treat a patient, is allowed to rule. Opinion-based treatment withers on the vine.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

In NHS Talking Therapies We Doubt

 

This is the take home message of a just published study in the British Journal of Clinical Psychology. Capobianco et al (2023) The authors conclude “Significant questions must remain concerning how effective the treatment element actually is and how much time is needed to realise an adequate dose”. With mean improvements of 2-3 points on the PHQ-9 between 1st and last session and a mean 3 point improvement on the GAD-7 between 1st and last appointment, whether or not treatment was conducted remotely or face-to-face. They further add “however, we are not arguing the treatment was effective and therefore the cause of the changes observed. Such changes could be accounted for by a range/ combination of factors including regression to the mean or spontaneous recovery over time…….. It seems that clinical improvement was slow, and patients do not appear to be receiving the required length of time in order for outcomes to reach the required cut of”.

Their data reflect the failure of NHS Talking Therapies to engage clients thus, “between March 2020 and September 2020, 5515 patients attended at least one session, with 2553 (46%) patients attending at least two treatment sessions.  Similarly pre Covid19, 9199 patients attended at least one session, with 4625 patients (46%) receiving at least two treatment sessions. Participants attended a median of two remote therapy sessions and a median of three in person therapy sessions’. By anybody’s reckoning the median dosage of therapy is sub-therapeutic.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – Doublethink Without Informed Consent

 

In practise clients begin their journey through NHS Talking Therapies at the promptings of the least qualified clinicians, Psychological Wellbeing Practitioners (PWPs). They are not trained therapists. I am not aware of this NHS service formally seeking any informed consent, it is likely unique in this regard. But the public have a right to know what they are letting themselves in for and the effectiveness of the said interventions. If pushed most PWPs would probably reiterate the mantra of its employer that 50% of people recover. But there has been no independent verification of this claim. Rather the best independent evidence suggests that the tip of the iceberg recover. It would not be a sufficient justification for a PWPs action to claim that he/she was only doing/saying what most colleagues are doing. How can there even be an ‘informal’ informed consent if the PWP does not make it clear that they are not a trained therapist, there is an absence of transparency. Further it is doubtful that they have the expertise to advise clients of the sequelae of different pathways.

Would a client who did not make the progress he /she had been led to expect be able to make a claim? Would the family of a client who committed suicide be able to claim that there had been no informed consent garnered at the outset of treatment?

I ran these concerns via a Barrister who opined ‘In principle, however, a person who is given inaccurate or misleading information about the chances of successful treatment, or about the qualifications of a person treating them, may well be found not to have given informed consent’.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

The Gagging of NHS Talking Therapy Clients

In 2021 Drew et al examined audiotapes of Psychological Wellbeing Practitioners (PWPS)  and revealed that clients were not listened to and the PWPs were hellbent on pursuing orders. Despite this no steps were taken to remedy the problem. Next month there is a webinar on how to shut clients up further, euphemistically termed  ‘Managing Time Boundaries……‘ sponsored by the artificial intelligence company Limbic, the major sponsor of  NHS Talking Therapy events. The advertising reads:

‘Managing Time Boundaries in NHS Talking Therapies
Discover how to have assertive conversations with patients to help build helpful time boundaries and reach their recovery.

This free webinar led by Josh Cable-May, CBT Specialist, Limbic has been designed for NHS Talking Therapies professionals working in IAPT across the country to help you build effective time boundaries. In just one hour, learn how you can:
• Manage the ‘run away’ sessions and regain focus to meet therapeutic goals
• Approach and conduct useful conversations with clients about time boundaries
• Map out clear session objectives and pathways with clients to meet recovery targets’

Thank you to our sponsors Limbic’.
 
It appears that artificial intelligence is to be preferred to emotional intelligence.
 

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

‘We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Why Is NHS Talking Therapy The Only Unregulated NHS Service?

With no independent body assessing caring and effectiveness. It has been achieved by IAPT (the former brand name of the service) and BABCP (British Association of of Behavioural and Cognitive Psychotherapies) working under the radar. Their curious tango has prevented the delivery of evidence-based psychological therapy in routine  practice.  They dance for politicians, the Department of Health and Integrated Care Boards (the successors to Clinical Commissioning Groups).

The public face of NHS Talking Therapy and BABCP and their synergy can be seen in an advertised two day BABCP workshop for social anxiety disorder. To be led by Professor David Clark,NHS England’s National Clinical and Informatics Advisor for the Improving Access to Psychological Therapies (IAPT) programme. He and Lord Layard were the prime movers in the development of IAPT.

In advertising the Workshop Professor Clark describes very well an evidence based protocol for treating social anxiety disorder. But there is no evidence any such protocol has has ever been delivered in IAPT. The service has never performed integrity checks for this or any disorder. My own finding Scott (2018) is that only the tip of the iceberg of the Services clients recover in the sense of losing their diagnostic status. NHS Talking Therapies claims to deliver NICE treatment protocols and achieve a 50% recovery rate are self-serving claims, wholly without independent evidence.

The recommended protocol is based on a diagnosis of social anxiety disorder and as the IAPT Manual points out, its clinicians do not make diagnosis and 40% of them are not trained therapists. Both NHS Talking therapy and BABCP have shown no interest in what happens at the coalface, they operate like totalitarian Communist regimes concerned with ideology, operational matters  production quotas, waiting times etc. Like the KGB and Stasi they are superb at working under the radar (see the book Putin’s People) and networking but leaving clients to disappear down a black hole, with almost half of clients not even beginning treatment.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

The Re-Branding of IAPT, ‘Never Mind The Quality Feel The Width’

It is inevitable that when a product fails, it is renamed, so to with The Improving Access to Psychological Therapies (IAPT) service, it is now NHS Talking Therapies, for anxiety and depression.  In 2021 I published a paper ‘Ensuring IAPT Does What It Says On the Tin’ , over the last 2 years it has signally failed to put its’ house in order. On June 28th 2022 the Lets Talk IAPT website identified ‘a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment’. None of these problems have been addressed and so it has been given an air of respectability as NHS Talking Therapies.

The avowed focus is depression and the anxiety disorders, but it has extended its scope to include the psychological  sequelae of long term physical conditions. Given that almost half the adult population have at least one LTC, this offers massive opportunities for expansion. But the evidence on effectiveness with this population is weak to non-existent.  However given that IAPT has usurped the NHS this is likely to matter little.

Professor Clark and Dr Whittington announcing the name change note ‘”Many of those who do find their way to services are looking for help with other difficulties that the services are not set up to treat, such as psychosis or complex emotional needs associated with a diagnosis of “personality disorder”. Clark and Whittington claim ‘You don’t need a “diagnosis” to come for therapy, a skilled practitioner will help work out with you whether and how the service can help’ and add that they offer treatment not only for depression and the anxiety disorders  but also OCD, PTSD, body dysmorphic disorder, health anxiety and mixed anxiety and depression. But given that its practitioners are not trained to diagnose according to the latest IAPT Manual, by what magic do they decide who to treat with what?   No matter, Clark and Whittington proclaim that 50% of treated people recover, this strains credibility.

 

Clark and Whittington state ‘Within NHS Talking Therapies services most of the psychological therapy will be quite practical. It may involve working through self-help materials with guidance from a clinician, possibly via a dedicated online platform (which we call ‘digitally enabled therapies’). It may involve help with problem solving skills or practical exercises to examine and overcome your fears. It may involve facing and working through traumatic memories in a safe way’. Can trauma focussed CBT be really regarded as quite practical, in routine practice most clients find it quite toxic Scott and Stradling (1997).

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

‘Don’t Worry About Exactly What Is Wrong, Just Throw Everything At It’ 

 

This is the rule of thumb operated by Service Providers of psychological therapy. Evidence-based assessment has been thrown out of the window. It is buttressed by a belief that diagnostic labels are particularly inappropriate, nay dangerous.  The results are graphically illustrated by this example:

Recently I encountered a 16 year old who had had variously CBT, Dialectical Behaviour Therapy, EMDR and antidepressants over a 3 year period. He w.as put on this trajectory by a clinician who had the impression  that he had generalised anxiety disorder and made mention of some OCD symptoms. But there was no definitive diagnosis. Part way through this period he began to self-harm. At my assessment, conducted with a standardised diagnostic interview, I found that he was self-harming, had generalised anxiety disorder, social anxiety disorder and panic disorder. I searched in vain in the records for any evidence that there had been fidelity to an evidence based protocol for any of these disorders. The nearest I came was discovering from him that he had been invited to distract himself when he had the urge to self-harm. Fortunately the case has not progressed to suicidal behaviour. But it is perfectly possible to imagine such a person might commit suicide. Suppose then the family decided to sue the Service Providers, how would that work out in Court?

How could the Defendant’s convince a jury that they were not a law unto themselves? The Defendants might rightfully claim that their modus operandi was no different to that of other Service providers. Leaving the jury to muse ‘so they are all crap, then?’.

The Judge is likely to be unimpressed by the Defendant’s Expert Witness claiming that the Service providers approach is evidence-based  when no definitive diagnosis has been made, much less the following of a treatment protocol dictated   by the diagnosis.  The Judge acts a a protector of the jury against ‘junk science’, probably even more  so in the United States legal system. She/he will be at a loss to understand the claims of  the Defendant’s Expert and the Service Providers clinicians that their approach is evidence-based.

The Defendant’s Expert might rail that that vast clinical experience is all that is required for effective treatment. Silenced by the prosecuting barrister’s question ‘did it work in this case?’. Following a deafening silence, the prosecuting barrister asks ‘why was EMDR used to treat him, when there was no evidence that he had PTSD?’. To which the Defendant’s barristers retorts ‘it just might have worked’. Moving on to the self-injury and suicide the treating therapists are asked ‘in training were you taught how to identify the thoughts and behaviours behind injury/suicidal behaviour?’ and ‘were you taught how to modify them?’ . The therapist likely replies ‘no but I went on a workshop for DBT post qualification’.  The prosecuting barrister persists ‘were is the evidence that you tackled the thoughts/behaviours behind self-injurious behaviour?’ 

The Judge may well conclude that the Service Providers have let down this teenager by allowing ‘junk science’ to rule, resulting in his following a horrendous trajectory that was reasonably foreseeable. As such they are legally liable.

On Appeal the Service Providers may protest that diagnosis is overrated. But the Appeal Judge comments that the Improving Access to Psychological Therapies claims NICE compliance and the protocols advocated by the latter are largely diagnosis based.  Further the IAPT’s Manual states that its’ clinicians don’t make diagnosis. The Judge opines that this has the smell of deliberate misrepresentation to secure the Government £2 billion a year funding and that the matter should go to the Crown Prosecution Service that deals with criminal matters.

There are those who are avowedly anti-diagnosis but this is much less credible when it comes to depression and the anxiety disorders. Albeit, that a more credible case can be made with regards to ADHD, ASD and Psychosis. With regards to depression and the anxiety disorders (the supposed mainstay of IAPT) the levels of inter-rater reliability using standardised diagnostic interviews have been found to range from very good to excellent [ e.g Tolin et al (2018]. This contrasts with reliabilities of no better than chance when the customary open ended interviews alone are used. The burden of proof is on those who oppose diagnosis to demonstrate reliability of assessment and efficacy of outcome. The case above graphically demonstrates the outcome of unbridled clinical judgements. Psychological therapy has to grow up and address the issue of accountability. 

The case presented above is not exceptional, in a sample of Australian psychologists only 11%  of those working with children or adolescents conducted an evidence-based assessment (the comparable figure for those working with adults was 21%) Moses et al (2020).

Dr Mike Scott

 

 

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BABCP Response - NICE Consultation January 2022

The Hijacking of Fatigue by CBT To Foster Expansionism

 

A just published paper by Picariello et al 2023 singles out fatigue across 5  disorders, suggesting that certain cognitions and behaviours  play a pivotal role in the worsening or maintaining  of this symptom. In addition it is suggested that targeting such cognitions and behaviours would   make a clinically significant difference to associated low mood and anxiety. The cognitions and behaviours are enshrined in the authors Cognitive and Behavioural  response to Symptoms Questionnaire  (CBRSQ-SF) short form.  The authors posit that the scale could be a therapeutic aid, indicating treatment targets. Further they suggest  that it may facilitate the development of a low intensity treatment for these conditions.

 

But the data Picariello et al 2023  present is all correlational, it does not establish causation. To establish causation it would be necessary to demonstrate that amongst those who had remitted from the conditions a high score on the CBRQ-SF was predictive of fatigue score, controlling first for the effect of mood. [Dysfuntional attitudes are known to be correlated with mood].  The partial correlation analysis would then need to be repeated with low mood and anxiety as the dependent variables. The danger is that the CBRQ-SF is promoted on the basis of its face validity and used to justify the expansion of psychological therapy into the Long Term Conditions Arena. Given that 43% the  population of England have at least one LTC there is the prospect of rich pickings for service providers, such as the Improving Access to Psychological Therapies Service. One of the authors of the Picariello et al 2023 Trudie Chalder is a regular presenter to IAPT staff on the treatment of LTC’s.

Unfortunately it is unlikely that IAPT and its fellow travellers will take note of the study by Serfaty et al  (2020) on the efficacy of CBT for the treatment of depression in patients with advanced cancer, which used  IAPT therapists and revealed no difference to treatment as usual. Claims for the efficacy of CBT with LTCs rest on studies using self-report measures and without blind assessment. 

Returning to the Picariello et al (2023) study  although 5 populations are considered (chronic fatigue syndrome, multiple sclerosis, hemodialysis, irritable bowel disease and chronic dizziness) the focus was on a particular aspect of these disorders, fatigue. Thus, at best, targeting the dysfunctional attitudes and behaviours enshrined in the instrument would at most have a circumscribed impact on these disorders. With the possible exception of CFS sufferers, it is unlikely that most people with these disorders/difficulties would see fatigue as their primary issue.   It could equally plausibly be suggested that irritability and low mood are accompaniments of these disorders and also of Long Covid. But there is no evidence to suggest that targeting CBRQ-SF items would have a clinically significant impact on this diffuse array of symptoms across a wide range of long term conditions, despite the intimation of Picariello et al 2023.  Arguably the fatigue, low mood, anxiety and irritability are an epiphenomenon of these conditions. The elevation of fatigue to the status of a cardinal symptom of long-term conditions is without  foundation. It is a heuristic designed to short circuit  the assessment of multi-faceted disorders, accuracy is sacrificed for speed.                                  

A pinch of salt is required for the claim of Picariello et al 2023that it is a ‘transdiagnostic measure of cognitive interpretations of symptoms, and related behaviours which are associated with the experience of more severe and disabling symptoms, low mood and anxiety’ and from a treatment perspective ‘the focus and content of therapeutic techniques may vary depending on the coping procedures employed by a client (avoidance/resting versus all-or-nothing behaviour); or developing lower-intensity interventions while retaining key therapeutic techniques in line with stepped-care treatment models’.  

My thanks to Joan Crawford for help with this blog .

Dr Mike Scott 

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BABCP Response - NICE Consultation January 2022

How Can You Know Best Practise When You See It?

 

Best practise networking is in vogue. It is a central plank in the Improving Access to Psychological Therapies (IAPT) Service  professional development programme. But who decides what should be marketed as best practice? Is it the powerholders within the Service in conjunction with those who are happy to eloquently re-iterate the party line? What assurance can there be that it is not a matter of the blind leading the blind? The dissemination of ‘best practice’ in psychological therapy rests primarily on a consensus. In Britain, the self-proclaimed lead organisation for cognitive behaviour therapy (CBT), the British Association of Behavioural and Cognitive Psychotherapy (BABCP) sees itself as the custodian of ‘best practice’ and has bestowed an imprimatur on IAPT.

But the British Medical Journal has a very different notion of what constitutes ‘best practice’. For each of the common mental disorders, it identifies screening psychometric tests complemented by standardised diagnostic interviews to identify the particular disorder. Then a treatment algorithm for each disorder. However IAPT clinicians are not trained to make diagnoses so that their ‘best practise’ must diverge from the BMJ’s. Who is right and on what basis?

The gulf between evidence-based practise and IAPT’s ministrations is shown in sharp relief if we focus on the latter’s low intensity guided self-help (LIGSH). I could find no study of LIGSH in which there was a blind assessor of the treatment and comparison with an active placebo. Thus any effects of LIGSH could be attributed to simply attention. By contrast over half (58.7%) of randomised controlled trials of CBT have employed blind assessors.  

The behaviour of IAPT clinicians is highly prescribed. In a study of LIGSH transcripts of tape recordings of client’s first contacts with the Service analysed by Drew et al (2021) there is a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

‘We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’.

But not only does the IAPT Service refuse to listen to its clients, it refuses to listen to outside criticism. There has been no change in its’ modus operandi in over a decade as it pursues expansionism.  But it is an expansionism to areas were there has been no demonstrated efficacy and evidence is at best circumstantial. Operating on the dubious premis that ‘it just might be the answer to the world’s problems’. 

The networking of IAPT clinicians, whose operation is validated by BABCP, is an ‘In Group’ that talks amongst themselves, reinforcing their world view and refuses to engage in effortful processing of external criticism.

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

The Juries “Give Us a Break” Response to IAPT Claims

The afternoon session begins with my cross examination by the Defence barrister, ‘isn’t it the case that those who wrote the IAPT Manual and proclaim a 50% recovery rate are emminent in their field?’. I reply in the affirmative. The Defence barrister continues ‘Have IAPT’s findings been publicly questioned  by bodies such as NHS England? To which I replied ‘no’. He continues ‘so you set yourself up against the acknowledged Experts? My response is ‘I am not setting myself up against anyone, this is not a gladiatorial combat. I am simply insisting that the psychological therapy provided by IAPT should be evidence-based and not eminence-based. The credibility of any service is called into question when it does not rely on the data of an independent assessment. The Expert’s you cite, authors of the Manual, NHS England all have a vested interest in proclaiming the merits of the IAPT Service’. The Defence barrister retorts ‘NHS England is responsible for the health of the nation, are you seriously suggesting that there has been a derogation of duty? I respond ‘yes, for over a decade it has unquestionably accepted IAPT’s claims, with staff holding posts in both Organisations. Recently at the behest of the Department of Health I asked NHS England seven questions with regards to IAPT, they simply told me to go and ask the questions of the Department of Health’. 

I continued ‘With  breathtaking skill, IAPT engages in eminence-based medicine, vehemence-based medicine and eloquence-based medicine. It also engages in ‘it won’t hurt to try’, for example running groups for those traumatised despite a paucity of evidence as too efficacy and under waiting list pressures assigning a clear PTSD case to a trainee’. My own findings of 90 litigants  who went through IAPT whether or not before or after personal injury was that only the tip of the iceberg recover’. The defence barrister continues ‘this is using your own idiosyncratic view of recovery not that used by IAPT, is that not the case?. My response was ‘No, I was using the criteria that is used in Court in personal injury litigation, is the person still suffering from the disorder acquired as a result of the personal injury, it is very straightforward’. The defence barrister continues ‘IAPT uses a drop in score on a psychometric test as evidence of recovery, is this not more reliable?’ My response is if it were, such a metric would be in routine use in Personal Injury litigation, it has had no such status over my 30 years of medico-legal work. The danger of a psychometric test administered at the end of a treatment session is that the recipient of the services does not wish to appear ungrateful and makes an exaggeratedly positive response’.  

Jury members are most likely to use a credible metric in determining whether a Service has failed to deliver and whether or not it has made exaggerated claims for its’ own ends.  Expert Witnesses may protest their independence, but the possibility of bias cannot be excluded as they appear either for the Defence or Prosecution. Additionally they may have an academic bias, re-iterating current mainstream opinions, with scant regard for alternative views.

Dr Mike Scott

 

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