PEER REVIEWED

The Finnish open dialogue approach to crisis intervention in : A review

RICHARD LAKEMAN

The open dialogue approach to crisis intervention is an adaptation of the Finnish need-adapted approach to psychosis that stresses flexibility, rapid response to crisis, family-centred therapy meetings, and individual therapy. Open dialogue reflects a way of working with networks by encouraging dialogue between the treatment team, the individual and the wider social network. RICHARD LAKEMAN reviews the outcome studies and descriptive literature published in the English language associated with open dialogue in psychosis and considers the critical ingredients. Findings indicate that in small cohorts of people in Western Lapland the duration of untreated psychosis has been reduced. Most people achieve functional recovery with minimal use of neuroleptic medication, have few residual symptoms and are not in receipt of disability benefits at follow-up. Open dialogue practices have evolved to become part of the integrated service culture. While it is unclear whether the open dialogue components of the service package account for the outcomes achieved, the approach appears well-accepted and has a good philosophical fit with reform agendas to improve service user participation in care. Further large scale trials and naturalistic studies are warranted.

he ‘Finnish open dialogue’ Open dialogue is of particular (Heilbronn, Lloyd, McElwee, Eade, method, sometimes known as interest to Australia which has & Lubman, 2012) and increased T‘Seikkula’s open dialogue approach’ invested heavily in specialist early mortality associated with their use to psychosis (Anderson, 2002) intervention in psychosis teams, the (Weinmann, Read, & Aderhold, encompasses a range of practices and cost effectiveness of which is being 2009). At the same time there is a a philosophy of care that is radically questioned (Raven, 2013). Recent burgeoning interest and optimism different to the way mainstream controlled trials of specialist relapse around the use of in mental health services work with prevention services compared to psychosis (Rosenbaum et al., 2012) people in crisis. Open dialogue has individual and family cognitive and a growing understanding of gained international attention because behavioural therapy have found that how it influences brain functioning it is purported to have reduced the relapse rates are lower at twelve month (Barsaglini et al, 2013). An exploration incidence of people with first episode follow-up for those receiving therapy of the factors in the open dialogue psychosis developing chronic symptoms and that psychosocial functioning programme that might contribute to and associated disability with minimal actually deteriorated in the specialist improved outcomes with minimal use of psychotropic medication. The service which may be an outcome of use of antipsychotic medication could open dialogue approach to psychosis medication adherence (Gleeson et al., usefully inform the development of emphasises a rapid response to crisis 2013). specialist early intervention services with skilled therapy teams meeting In Australia over 90% of people and the improvement of general people in their own homes where diagnosed with a psychotic illness responses to psychiatric crisis. possible, co-ordinating all care until are prescribed medication, and poly- The techniques of open dialogue the crisis is resolved, engaging with the pharmacy is common (Waterreus are derived from and person’s social and support network et al., 2012). Nevertheless, there evolved in the context of service in open dialogue meetings, and the is increasing public disquiet about reform in Western Lapland, a facilitation of intensive individual the impacts of increasing rates small (~70,000 people) culturally therapy. of antipsychotic prescription homogenous community at the edge

28 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 of the Arctic Circle. It has come to (Lakeman et al., 2012; Sutela, 2012; psychosis in Finland. The need- international attention largely through Thomas, 2011; Trimble, 2002) but has adapted model of care is a broader advocacy and promotion by critical had little exposure in English language integrative treatment approach that psychiatry networks, and service user psychiatric journals, although the latest has become more widely implemented movements. Whitaker (2010), in the Cochrane review on early intervention as part of the deinstitutionalisation epilogue to his best-selling book on in psychosis cautiously endorses ‘family and mental health reform process in the iatrogenic harm associated with an overzealous emphasis on medication in responding to mental distress in Open dialogue has gained international North America, offers ‘open dialogue’ as an example of a treatment system attention because it is purported to have that has transformed the outcomes of those who present with psychosis. It reduced the incidence of people with first has, he argued, improved outcomes to the point where at the end of two episode psychosis developing chronic years, 84 percent of people with first episode psychosis had returned to work symptoms and associated disability with or school and only 20 percent were taking anti-psychotic medications. minimal use of psychotropic medication. Contentiously, Whitaker also argues that schizophrenia (i.e., symptoms interventions’ as one of the few specific Finland (Alanen, 2011; Alanen et al, of psychosis lasting longer than six intervention forms that currently might 1991; Lehtinen, 1994). It emphasises months) is disappearing from the be considered helpful. No studies on adapting a therapeutic approach region. open dialogue met their criteria for to changing individual and family In one of his more moderate reviews inclusion (Marshall & Rathbone, 2011). needs rather than a diagnosis driven of Whitaker’s book Torrey (2011) Whilst ‘open-dialogue’ does not approach to problem identification objects and rhetorically asks why there appear to have been evaluated or and treatment, integrating family are ‘… almost no publications describing included as part of a wider systematic and individual therapy into treatment its results and nobody in Finland or review of interventions in psychosis, and responding with crisis-orientated elsewhere has tried to replicate it?’ Open Gromer (2012) undertook a review family interventions delivered dialogue has nevertheless taken hold of studies relating to need-adapted by responsive mobile teams of of the collective imagination and a and open-dialogue approaches to professionals. Google search limited to the exact phrase ‘Finnish Open Dialogue’ reveals more than 32,000 results (as at 30 April 2014), with a documentary film released in 2011 (Mackler, 2011) and widely promoted on the internet (over 25,000 views of the Youtube trailer1). Whilst, the academic interest in open dialogue appears modest and largely confined to family therapy literature there have been increases in citations of the primary sources for open dialogue since 2011. For example, according to Scopus there were a mere 15 citations for the main outcome study on open dialogue approach (Seikkula et al., 2006) from 2006 to 2011, but a further twenty citations in the two years following the release of Whitaker’s book. Open dialogue has attracted editorial commentary in mental health related journals 1 Dr Fuller Torrey may well be correct regarding the lack of academic interest in open dialogue as a treatment approach but the broader public interest is considerable. Dr Torrey’s most watched Youtube clip had 3000 views as at the 30th April 2014. Illustration: © IStock, 2014.

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 29 What probably distinguishes to 48 papers including editorials, or principles. As an ‘entire network- need-adapted treatment from other commentary and theoretical papers. centred treatment’ (Seikkula, 2011, integrative treatment approaches and The abstracts of these papers were read p.184) open dialogue shares much the now well-established need to and the full text obtained for most. in common with Needs Adapted engage with families, reduce expressed Whilst many did not deal specifically Treatment. Seikkula et al. (2003) emotion (really ‘hostile intrusiveness’), with open dialogue they did deal with describes the main features of open provide psycho-education, and help salient theoretical and background dialogue as: • the provision of immediate help with an initial network meeting …open dialogue proceeds without any pre- convened within 24 hours of first contact at which the person with planned themes or forms to enable clients to psychosis participates; • a social network perspective — key construct a new language through which they members of the person’s social network such as family, friends, can express the difficulties in their lives. neighbours, employers or helping agencies are invited to the first people solve problems (Falloon et issues that assist in understanding the meetings; al., 1982), is the highly structured open dialogue process. For example a • flexibility and mobility — the initial family therapy informed crisis body of theory and research addresses therapeutic response is adapted to network meeting that occurs as soon how self-dialogue may be disrupted the specific and changing needs as practicable after the person engages in psychosis (Holma & Aaltonen, of the case. No firm treatment with the service (Räkköläinen et al, 1998; Larner, 2011; Lysaker et al., plans are made whilst the person 1991). Open dialogue represents a 2012; Lysaker & Lysaker, 2001, 2010, is experiencing crisis. Network particular adaptation of how these 2011). The evaluation and adaptation meetings are typically convened in treatment meetings take place with of the need-adapted approach was also the person’s home and during the an emphasis on generating dialogue useful background to understanding crisis period may occur every day; within the treatment system and how open dialogue evolved as it did • responsibility — the staff families rather than attempting to (Alanen, 1990; Lehtinen, 1993, 1994; member who is first contacted change the family system (Seikkula et Räkköläinen et al., 1991). is responsible for organising the al., 2006). Gromer (2012) concluded A total of twenty-five papers first meeting and the team is that both forms of intervention addressed open dialogue directly then responsible for the entire appeared safe and conferred substantial (excluding editorials). Four papers treatment process including in- benefits over previous models of care. (Aaltonen et al., 2011; Seikkula et al., hospital treatment if needed; Methodology 2006; Seikkula et al., 2003; Seikkula • psychological continuity — the team et al, 2011) examined the outcomes is responsible for treatment for This review aimed to identify and associated with the open dialogue as long as it takes and wherever describe the evidence base for open approach. Several additional papers it occurs. Different therapeutic dialogue in psychosis, and second, to have described open dialogue with approaches are combined as identify the critical ingredients of the detailed case examples in particular required (e.g., individual therapy approach so that it might be adopted with illustrations of how the quality or rehabilitation) to provide and trialled in different service settings of the dialogue generated in network integrated treatment. All decisions and health systems. meetings differed between good and about treatment are made with Electronic searches were carried out poor outcome cases (Seikkula, Alakare, a family in the family meetings. to identify resources on open dialogue & Aaltonen, 2001a, 2001b; Seikkula, Members of the person’s social and psychosis. The searches included 2002b; Seikkula, 2005). A further network continue to meet in the following databases: CinAHL ten were theoretical and descriptive. network meetings; with full text, PsychInfo, Medline Several books address open dialogue • tolerance of uncertainty — this is with full text and PsycArticles. Search and summarise the research to date described as an active attitude terms used were: ‘open dialogue’ or and outline the principles and process on the part of therapists to avoid ‘dialogical’ or ‘need adapted’ AND (Haarakangas et al., 2007; Seikkula premature conclusions or decisions psychosis OR schiz* OR psychotic & Alakare, 2012; Seikkula & Arnkil, about treatment. The advisability OR Crisis, limited to the English 2006). of neuroleptic medication is language and peer reviewed journals. The critical ingredients discussed at least several meetings Reference lists of those papers which of open dialogue before implementation; directly addressed open dialogue were • dialogism — the primary focus examined and relevant papers obtained. The open dialogue approach is of the network meetings are to The initial yield was 100 papers. A amply described in the literature with promote dialogue and to build first review of the titles and abstracts most research papers providing an a new understanding between for relevancy reduced the yield elaborate description of the process participants in the language of the family.

30 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 The open dialogue meeting draws The person experiencing psychosis meetings (to enable one person to on some techniques used in systemic has not found a way to be in dialogue always be listening). The health family therapy such as the use of a with the self or others so the professionals in the network meeting reflective team (pausing to share their monologue that is ‘psychotic speech’ may engage in a reflective conversation thoughts and observations — Seikkula, becomes the only way of describing amongst team members whereby they 2003), but philosophically it is more the experience (Anderson, 2002) or as may share their thoughts about what akin to which holds Seikkula (2002) suggests in psychotic others have said. that reality is socially constructed speech people talk about things ‘…that The procedures for network through discourse or dialogue (Angus do not yet have any other words than those meetings and examples of meetings & McLeod, 2004). Unlike narrative of hallucinations and delusions’ (p. 265). associated with good outcomes have therapy in which there is often an Each person is considered to have their been described in detail (see: Seikkula intent to ‘re-author’ the person’s story own voice in constructing problems & Arnkil, 2006; Seikkula et al., 2001a, or create a preferred or more positive and Seikkula et al. (2006) suggest that 2001b). It appears that open dialogue narrative, open dialogue proceeds it is important to accept the psychotic is the preferred way of engaging with without any pre-planned themes or hallucinations or delusions of the networks and this form of engagement forms to enable clients to construct a patient as one voice among others. is considered therapeutic in its own new language through which they can In open dialogue listening and right. In keeping with needs adapted express the difficulties in their lives responsively responding to what protocols, the crisis meetings also serve (Seikkula, 2003). different members of the network say the pragmatic purposes of gathering An emphasis on dialogism and is more important than intervening or information about the problem, tolerance of uncertainty distinguishes interpreting speech (Seikkula, 2011). planning treatment on the basis of open dialogue from other programmes Seikkula (2002a) suggests that relating the diagnosis, making decisions about and needs adapted treatment (Seikkula to each other in a series of monologues what is needed and facilitating concrete et al., 2003). It is worth elaborating constitutes the crisis experience and cooperation between relevant parties on the concept of dialogism as used people are often seeking the certainty involved with the patient’s life and as a treatment principle in open of a monological answer to their future (Seikkula et al., 2006). dialogue and, in particular, how suffering, advice on what to do or Open dialogue and outcomes dialogue relates to psychosis. Dialogue an assurance about what is wrong. is a communicative process through Prematurely offering monological Outcome data was collected for a which reality is socially constructed responses may encourage dependence small cohort of patients who received and problems are seen as reformulated on the system, impede the emergence an early incarnation of open dialogue in every conversation (Seikkula, of a shared understanding of the in 1992 and 1993 as part of a Finnish 2002). Dialogism was coined by the meaning of the problem, and reduce national multicentre study called the philosopher Mikhail Bakhtin. Being the capacity of the network to draw on Acute Psychosis Integrated Treatment in dialogue involves responding their shared resources to resolve the project (API) which sought to evaluate to what has been said before or in problem. the Need-Adapted approach and to anticipation of what will be said in response. In contrast to a monologue, dialogue is relational, dynamic and Dialogue is a communicative process produces new descriptions of the world and is considered a process that through which reality is socially enables meaning to be generated. As Holma and Aaltonen (1998) note: ‘Any constructed and problems are seen as action, speech, or other action, is always is search of a narrative interpretation. reformulated in every conversation. This narrative interpretation has to be constructed socially and maintained in How to listen and how to respond explore the use of neuroleptics in dialogue in relationships with others’ to or answer each utterance of the the context of providing intensive (p. 262). They argue that if we attempt client is the treating team’s challenge psychosocial support in first episode to understand experience through and indeed the goal of therapy is the psychosis (Lehtinen et al., 2000). stories in which the meanings of facilitation of open dialogue through Three sites that were deemed to experiences are already determined responding to each utterance with a have considerable experience in the (monologues) then real dialogical view to building up new understanding provision of psychosocial treatment conversation will not be created and between the different participants. (including Western Lapland) used the real needs of the patient and Seikkula (2002) suggests that it is a minimal neuroleptic regime for family will not be discovered and will pivotal that those nearest to the patient all people who were consecutively remain unsatisfied. Dialogue, therefore (their social network) are included admitted to hospital with first episode is the primary means by which an in this process and that three is the of psychosis (the experimental group). individual’s needs might be revealed to optimal number of professional team This involved deferring neuroleptic others. members who participate in network prescription where possible for three

PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 31 weeks (using benzodiazepines to reduce Both received fewer neuroleptics, had group recovered more slowly. However, anxiety if needed) and if improvement more family meetings and had fewer there were no differences at five years was noted in that time a neuroleptic days in hospital. The ODAP group had at which point 82% of the ODAP was not prescribed. The control group significantly fewer hospital days than group and 76% of the API group had also received a form of need-adapted the API group. However, Seikkula no residual psychotic symptoms. At treatment including family therapy et al. (2003) notes that the API least one relapse occurred in 29% of but without a protocol relating to group had higher symptom severity the ODAP group and 39% of the API minimal neuroleptic use. A total of as measured on the Brief Psychiatric group over the five years with most 106 patients were enrolled across six Symptom Rating Scale (BPRS) and occurring within the first two years. sites and it was found that 42.9% of two individuals had particularly The majority of people had returned the experimental group did not receive high scores. The small sample sizes to work or study at five years (76% of any neuroleptics during the two year (reflective of the small number of new the ODAP patients and 70% of the follow-up (compared to 5.9% of the psychosis cases in a small town) mean API group). Most differences between control group). The outcomes of the that results could be skewed relatively the groups were in favour of the more experimental group were as good or easily by one or two individuals. The mature open dialogue approach but better than the control group at two ratings too, as Seikkula et al. (2003) failed to reach statistical significance. years. They were more likely to have no psychotic symptoms during the last year and over 50% had spent less than two weeks in hospital over the … there has been a sustained cultural shift past two years (compared to 25% of towards a more responsive, psychotherapeutically the control group). The good overall prognosis and outcomes associated orientated and community engaged service, and a with minimal neuroleptic use in itself challenges contemporary wisdom and way of working with people in crisis that is largely provides empirical support for intensive psychosocial interventions in psychosis accepted by the community and seems to work. (Lehtinen et al., 2000). Seikkula et al. (2003) explained that open dialogue at the time of the notes, were undertaken by the authors Seikkula, Alakare, & Aaltonen API project was in its infancy but the who were not blind to treatment (2011) examined a second cohort of 18 results were so impressive relative to allocation and had developed the OD people (ODAP2) with non-affective the local historical outcomes for people approach thus introducing potential first episode psychosis who were with psychosis that they chose to bias. Thus the positive findings in consecutively admitted to the local continue the project in an attempt to favour of open dialogue ought to be service and received open dialogue sustain the positive results. Outcomes treated cautiously. between 2003 and 2005. This cohort for the API cohort with a diagnosis Seikkula et al. (2006) examined data at two years was compared to the of schizophrenia, schizophreniform for the API (n=33) and ODAP (n=42) previous groups and were found to or schizoaffective psychosis (n=22) groups after five years. In this instance be younger, single, and more likely was compared to a cohort of people all people who were treated for first to be studying rather than being in consecutively admitted to the service episode psychosis, could be reached at employment on first presentation. The with the same diagnosis between 1994 follow-up, and who provided consent DUP had declined to half a month and 1997. This group received a more were included in the analysis and thus in the ODAP2 group. There was no developed ‘Open Dialogue Approach the groups were larger. The duration difference between the two cohorts in Acute Psychosis’ in which the of untreated psychosis (DUP) was 3.3 of ODAP on the number of hospital principles of tolerance of uncertainty months in the ODAP group compared days experienced by users although and dialogism had been established as to 4.2 months for the API. The ODAP 50% of the ODAP2 group had taken working guidelines (ODAP) (n=23). group had fewer hospital days during neuroleptics and 28% were continuing Both groups were compared to a the first two years but there was no to take medication (an increase relative control group of consecutively admitted difference at the five year follow-up to previous groups). The ODAP2 group patients from a similar municipality period. There were no significant had fewer residual psychotic symptoms who received a more conventional differences between groups on the use than other groups but had higher approach of need adapted treatment of neuroleptics at five year follow up overall BPRS scores. In the ODAP2 (n=14). (17% of the ODAP group and 24% of group 72% had returned to work or Compared to the comparison group, the API group) or use of neuroleptics study at two years. Seikkula, Alakare, the ODAP group had fewer residual over the entire five year period (29% & Aaltonen (2011) included those symptoms, better employment status of ODAP and 39% of API). The API who were unemployed and not on a and fewer relapses than the comparison group had significantly higher BPRS disability allowance in the two ODAP group. There were few differences scores at two years which Seikkula et groups (13% and 12% respectively) to between the API and ODAP group. al. (2006) suggested indicated that the conclude that in the last two periods

32 PSYCHOTHERAPY IN AUSTRALIA • VOL 20 NO 3 • MAY 2014 84% were studying, employed, or Discussion trend towards diminishing incidence actively seeking employment at two The service response in Western over time. Suvisaari et al. (1999) has years follow-up. Lapland appears to have greatly noted a dramatic decline in the age- In relation to Whitaker’s reduced the duration of untreated specific incidence of schizophrenia in (2010) claim that the incidence of psychosis (DUP) in the region. Finnish Cohorts born from 1954 to schizophrenia is reducing in Western Engagement with the service system 1965, however these were still many Lapland Aaltonen et al. (2011) might broadly be considered ‘treatment’ times higher than the non-age specific examined in detail the case notes of all as often this does not include incidence reported by Aaltonen, first episode case of psychosis before pharmacotherapy. The relationship Seikkula and Lehtinen (2011). the introduction of OD in the years of DUP to prognosis is unclear and There is little question that mental 1985–1989 and after the introduction some have argued that a long DUP health services in Western Lapland of OD from 1990–1994. A rich and may be a proxy for a more severe appear to have achieved admirable detailed description of each case was clinical phenotype (Penttilä et al., outcomes for people presenting with written up by one of the authors who 2013). To date it is not clear whether a psychosis in that small community and had not worked previously within the longer duration of untreated psychosis what they have done and how ought district and a consensus diagnosis was causes poorer outcomes (Marshall to be scrutinised carefully. It appears reached between the two principle et al., 2005). An examination of the that there has been a sustained cultural researchers (sometimes after re-reading relationship between duration of shift towards a more responsive, the full record). To prevent bias an untreated psychosis and outcome 12 psychotherapeutically orientated and expert independent psychiatrist who years after a first episode of psychosis community engaged service and a way was blind to the consensus diagnosis in Ireland suggested that longer of working with people in crisis that read a randomised sample of complete duration of untreated psychosis was is largely accepted by the community records (with dates removed) from highly predictive of more severe and seems to work. The way of working both periods and made a diagnosis. symptoms, poorer remission status, has evolved over several decades The kappa coefficient as a measure of poor functioning and quality of and as Seikkula et al. (2003) notes diagnostic reliability was 0.6 (p<.001) life in Ireland. It was not, however, the majority of staff working within and the consistency of diagnosis was associated with gainful employment the service (from all disciplines) are the same across time periods but with or independent living, which the qualified psychotherapists with a the researchers more likely to diagnose authors suggest might be more minimum of three years postgraduate schizophrenia in the second period. It related to socio-cultural factors and study in family therapy and/or open is unclear whether the authors adjusted individual opportunity (Hill et al., dialogue processes. Few services in their diagnoses where there were points 2012). Open dialogue as practiced in the world would have available such a of difference with the independent Western Lapland does appear to have concentration of psychotherapeutically diagnostician. demonstrated that it is possible to informed staff across the service Aaltonen et al. (2011) state that successfully engage with the person’s system. This has inevitably contributed the incidence of all schizophrenic social network to maximise the to their success. disorders (i.e., schizophrenia and opportunities that exist. To what extent The small numbers of patients schizophreniform psychoses) fell this can be replicated in other more involved in the naturalistic cohort significantly (from 73 to 41 patients) heterogeneous cultures and different studies point to good outcomes but or a mean annual incidence of 33.3 service systems remains to be seen. do not provide compelling evidence between 1985–1989 to 17.1 per On the face of it the changing about which elements of this integrated hundred thousand between 1990–1994. incidence in new cases diagnosed service system are pivotal. The The reduction in schizophrenia was with schizophrenia and the reduction differences in outcomes between the offset in part by a small but significant in residual psychotic symptoms in early cohort of patients who experience increase in brief psychotic reactions those that are diagnosed is impressive. enhanced needs adapted treatment (from 3 to 16 patients). Other non- The incidence of schizophrenia (API), and subsequent patients affective psychosis and the incidence (new cases per year) has been found who received a more developed and of prodromal psychosis essentially to vary considerably across studies. proceduralised open dialogue approach remained the same and overall the McGrath et al. (2008) examined three are not so convincingly great that one number of all first admission patients systematic reviews on the incidence, might assume that the open dialogue for any diagnosis increased from 173 to prevalence, and mortality associated element is the critical ingredient that 216. Aaltonen et al. (2011) suggest this with schizophrenia in other countries has made the difference. is evidence that the apparent decline in and found a median incidence of So few are the numbers of people the number of psychotic patients was 15.2/100,000 persons. The distribution likely to present with first episode not due to an overall decline in the use of incidence was right skewed with psychosis in a small centre such as of psychiatric services. They also note many more estimates in the upper western Lapland that any number of that no new long stay patients (those tail, studies based on higher latitudes confounding factors might impinge in hospital for longer than a year) had having a higher median estimate, males on outcomes. It would appear that this been admitted since 1992. having a slightly higher incidence, is a well-established and articulated migrants having a higher rate and a system of care that needs to be scaled

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AUTHOR NOTES

RICHARD LAKEMAN, DNSci, MMH(Psychotherapy), BA(Hons), BN, is a Senior Lecturer, Southern Cross University and a Clinical Nurse Consultant, Acute Care Team, Emergency Department, Cairns Base Hospital. Richard has juggled various roles as a nurse, researcher, psychotherapist and educator over 20 years in the mental health field. He has published over 50 peer reviewed articles, numerous book chapters, and presented at many conferences around the world on mental health recovery, working with people with complex psychosocial problems, and research on an eclectic range of topics. He is a member of the International Society for Psychological and Social Approaches to Psychosis. Comments: [email protected]

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