Vicarious trauma (VT) is a term invented by Irene Lisa McCann and Laurie Anne Pearlman that is used to describe how work with traumatized clients affects trauma therapists.[1] The phenomenon had been known as secondary traumatic stress, a term coined by Charles Figley.[2] In vicarious trauma, the therapist experiences a profound worldview change and is permanently altered by empathetic bonding with a client. This change is thought to have three requirements: empathic engagement and exposure to graphic, traumatizing material; exposure to human cruelty, and the reenactment of trauma in therapy. This can produce changes in a therapist's spirituality, worldview, and self-identity.

Vicarious trauma is a subject of debate by theorists, with some saying that it is based on the concepts of countertransference and compassion fatigue. McCann and Pearlman say that there is probably a relationship to these constructs, but vicarious trauma is distinct. Understanding of the phenomenon is evolving.

Signs and symptoms

Symptoms of vicarious trauma align with those of primary trauma. As professionals attempt to connect with their clients emotionally, the symptoms of vicarious trauma can create emotional disturbances such as sadness, grief, irritability, and mood swings.[3] Signs and symptoms of vicarious trauma parallel those of direct trauma, although they tend to be less intense. Workers with personal-trauma histories may be more vulnerable to VT, although research findings are mixed.[4] Common signs and symptoms include social withdrawal, mood swings, aggression, increased sensitivity to violence, somatic symptoms, sleep difficulties, intrusive imagery, cynicism, sexual difficulties, difficulty managing boundaries with clients, and relationship difficulties which reflect problems with security, trust, esteem, intimacy, and control.[5][6][7][8][9][10][11]

Contributing factors

Vicarious trauma, conceptually based in constructivism,[12][13][14] arises from interaction between individuals and their situations. A helper's personal history (including prior traumatic experiences), coping strategies, support network, and other things interact with his or her situation (including work setting, nature of the work, and clientele served) and may trigger vicarious trauma. Individuals respond and adapt to, and cope with, VT differently. It has been suggested that traumatization occurs when one's view of the world, or a feeling of safety, is shattered by hearing about the experiences of a client. This exposure to trauma can interrupt a clinician's daily functioning, reducing their effectiveness.[15]

Anything that interferes with a helper's ability to fulfill his or her responsibility to assist traumatized clients can contribute to vicarious trauma. Many human-service workers report that administrative and bureaucratic factors that are an impediment to their effectiveness influence work satisfaction.[16] Negative aspects of an organization such as reorganization, downsizing in the name of change management, and a lack of resources in the name of lean management contribute to burned-out workers.[17][18][19]

Vicarious trauma has also been attributed to the stigmatization of mental-health care by service providers. Stigma leads to an inability to engage in self-care; the service provider may reach burnout and become more likely to experience VT.[20] Research has begun to indicate that vicarious trauma is more prominent in those with a prior history of trauma and adversity.[20] A mental-health provider's defense style might pose a risk factor for vicarious traumatization; mental-health providers with self-sacrificing defense styles have been found to experience increased vicarious traumatization.[21] Among EMS personnel, previous-veteran status increased the likelihood of experiencing vicarious trauma. [22]

Although the term "vicarious trauma" has been used interchangeably with "compassion fatigue", "secondary traumatic stress disorder," "burnout," "countertransference" and "work-related stress," differences exist:

  • Unlike compassion fatigue, VT is a theory-based construct. Observable symptoms can begin the process of discovering contributing factors and related signs, symptoms, and adaptations. VT specifies psychological domains that can be affected, rather than specific symptoms. This may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices).
  • Countertransference is a psychotherapist's response to a particular client. VT refers to responses across clients and time.
  • Unlike burnout, countertransference and work-related stress, VT is specific to trauma workers; a helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference.[13] Burnout and vicarious traumatization overlap regarding emotional exhaustion.[23] A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other.[13]
  • Unlike vicarious trauma, countertransference can provide psychotherapists with important information about their clients.
  • Work-related stress is a generic term without a theoretical basis, specific signs and symptoms, contributing factors, or remedies. Burnout and vicarious trauma can co-exist. Countertransference responses may increase vicarious trauma.[13]
  • Vicarious post-traumatic growth is not a theory-based construct, but is based on self-reported signs.[24]
  • Body-centred countertransference

Mechanism

The posited mechanism for vicarious traumatization is empathy.[13][25][26] Different forms of empathy may have different effects on helpers. Batson and his colleagues have conducted research that might aid trauma helpers in managing empathic connection constructively.[27][28]

Measurement

VT has been measured in a variety of ways. Vicarious trauma is a multifaceted construct, requiring a multifaceted assessment. Aspects of VT that would need to be measured for a full assessment include self-capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms.[12][29][14] They include:

  • Psychological needs, using the Trauma and Attachment Belief Scale[10]
  • Self-capacities, using the Inner Experience Questionnaire[13] or the Inventory of Altered Self-Capacities[30]
  • Trauma symptoms, using the PTSD Checklist,[31] Impact of Events Scale,[32] Impact of Events Scale-Revised,[33] children's revised Impact of Events Scale (Arabic Version),[34] Trauma Symptom Inventory,[35] Detailed Assessment of Posttraumatic Stress,[36] or the World Assumptions Scale[37]
  • Secondary Traumatic Stress Scale is a 17-item, five-point Likert scale that distinguishes between PTSD measures by framing the questions as stressors from exposure to clients.[38]
  • The Professional Quality of Life (ProQol) version five, with 30 questions on a five-point Likert scale, measures compassion fatigue and secondary trauma.[39]

Vicarious traumatizationmay be addressed with awareness, balance, and connection.[40] One set of approaches is coping strategies, which include self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies, which aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one's personal[14][40] and professional lives.[41] Organizations that provide trauma services can also play a role in mitigating vicarious trauma.[42][43]

Many simple things increase happiness, which lessens the impact of vicarious traumatization. People who are more socially connected tend to be happier.[44] People who consciously practice gratitude are also shown happier.[45] Creative endeavors that are detached from work also increase happiness.[46] Self-care practices such as yoga, qigong, and sitting meditation have been found helpful.[47][48][49] Harvard Business Review, in a case study of traumatization, noted the importance of an organizational culture which values social workers and counselors.[50] Research indicates that clinicians exposed to vicarious trauma need targeted interventions such as respite, increasing self-efficacy, and appropriate professional support increase their resilience and act as a buffer against vicarious trauma.[51]

Prognosis

Children have been found to experience vicarious trauma from trauma experienced by their caregivers and peers. Girls experience VT more than boys, and socioeconomic status and race have been found to predict vicarious trauma symptoms.

Counselors and other mental-health professionals have been found to experience vicarious trauma when working with veterans and others who have experienced trauma. Factors that predict vicarious-trauma severity include professional trauma, level of peer supervision, population served by the clinician,[52] defense mechanisms of the therapist,[53] emotional coping strategies, and social-support availability. Foster parents have also been found to experience vicarious trauma related to the trauma of their children. Several studies have found that foster parents experience vicarious trauma, burnout and compassion fatigue, and report emotional disengagement (a common symptom of VT) as a coping strategy.[54][55]

See also

References

  1. ↑ McCann, Irene Lisa; Pearlman, Laurie Anne (1990). "Vicarious traumatization: A framework for understanding the psychological effects of working with victims". Journal of Traumatic Stress. 3: 131–149. doi:10.1007/BF00975140. Retrieved 1 January 2024.
  2. ↑ Russo, Chuck; Aukhojee, Prashant; McQuerrey Tuttle, Brooke; Johnson, Olivia; Davies, Mark; A. Chopko, Brian; Papazoglou, Konstantinos (2020). "7". POWER: Police Officer Wellness, Ethics, and Resilience. Academic Press. pp. 97–115. doi:10.1016/B978-0-12-817872-0.00007-0. ISBN 978-0-12-817872-0.
  3. ↑ Catanese, Shiloh A. (September 2010). "Traumatized by association: The risk of working sex crimes". Federal Probation. 74 (2). ISSN 1555-0303.
  4. ↑ For a review of this literature, see Bride, Brian E. (1 January 2004). "The Impact of Providing Psychosocial Services to Traumatized Populations". Stress, Trauma, and Crisis. 7 (1): 29–46. doi:10.1080/15434610490281101. ISSN 1543-4613. S2CID 71313058.
  5. ↑ Arvay, M.; Uhlemann, M.R. (1996). "Counsellor stress in the field of trauma: A preliminary study". Canadian Journal of Counselling. 30 (3): 193–210.
  6. ↑ Bober, Ted; Regehr, Cheryl; Zhou, Yanqiu Rachel (January 2006). "Development of the Coping Strategies Inventory for Trauma Counselors". Journal of Loss and Trauma. 11 (1): 71–83. doi:10.1080/15325020500358225. ISSN 1532-5024. S2CID 144405929.
  7. ↑ Brady, Joan Laidig; Guy, James D.; Poelstra, Paul L.; Brokaw, Beth Fletcher (1999). "Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors: A national survey of women psychotherapists". Professional Psychology: Research and Practice. 30 (4): 386–393. doi:10.1037/0735-7028.30.4.386. ISSN 1939-1323.
  8. ↑ Cunningham, Maddy (1 August 1999). "The Impact of Sexual Abuse Treatment on the Social Work Clinician". Child and Adolescent Social Work Journal. 16 (4): 277–290. doi:10.1023/A:1022334911833. ISSN 0738-0151. S2CID 140975279.
  9. ↑ Ghahramanlou, M.; Brodbeck, C. (2000). "Predictors of secondary trauma in sexual assault trauma counselors". International Journal of Emergency Mental Health. 2 (4): 229–240. ISSN 1522-4821. PMID 11217154.
  10. 1 2 Pearlman, Laurie A (2003). Trauma and Attachment Belief Scale Manual. Los Angeles: Western Psychological Services. OCLC 828744792.
  11. ↑ Schauben, Laura J.; Frazier, Patricia A. (1995). "Vicarious Trauma: The Effects on Female Counselors of Working with Sexual Violence Survivors". Psychology of Women Quarterly. 19 (1): 49–64. doi:10.1111/j.1471-6402.1995.tb00278.x. ISSN 0361-6843. S2CID 145635689.
  12. 1 2 McCann, I. Lisa (1990). Psychological trauma and the adult survivor: theory, therapy, and transformation. New York: Brunner/Mazel. ISBN 978-0-87630-594-2.
  13. 1 2 3 4 5 6 Pearlman, Laurie A.; Saakvitne, Karen W. (1995). Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors. Norton. ISBN 978-0-393-70183-8.
  14. 1 2 3 Saakvitne, Karen W. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Sidran Press. ISBN 978-1-886968-08-0.
  15. ↑ Foreman, Tamarine (2018-04-01). "Wellness, Exposure to Trauma, and Vicarious Traumatization: A Pilot Study". Journal of Mental Health Counseling. 40 (2): 142–155. doi:10.17744/mehc.40.2.04. ISSN 1040-2861.
  16. ↑ Pryce, Josephine G; Shackelford, Kimberly K.; Pryce, David H. (2007). Secondary Traumatic Stress and the Child Welfare Professional. Chicago: Lyceum Books, Inc. ISBN 978-0-19-061591-8.
  17. ↑ Maslach, Christina; Schaufeli, Wilmar B.; Leiter, Michael P. (February 2001). "Job Burnout". Annual Review of Psychology. 52 (1): 397–422. doi:10.1146/annurev.psych.52.1.397. ISSN 0066-4308. PMID 11148311. S2CID 42874270.
  18. ↑ Maslach, Christina (1 October 2003). "Job Burnout: New Directions in Research and Intervention". Current Directions in Psychological Science. 12 (5): 189–192. doi:10.1111/1467-8721.01258. ISSN 0963-7214. S2CID 145581839.
  19. ↑ Rupert, Patricia; Morgan, David (1 October 2005). "Work Setting and Burnout Among Professional Psychologists". Professional Psychology: Research and Practice. 36 (5): 544–550. doi:10.1037/0735-7028.36.5.544.
  20. 1 2 Newcomb, Michelle; Burton, Judith; Edwards, Niki (2017-08-18). "Service user or service provider? How social work and human services students integrate dual identities". Social Work Education. 36 (6): 678–689. doi:10.1080/02615479.2017.1327574. ISSN 0261-5479. S2CID 149202002.
  21. ↑ Adams, Shelah A.; Riggs, Shelley A. (2008). "An exploratory study of vicarious trauma among therapist trainees". Training and Education in Professional Psychology. 2 (1): 26–34. doi:10.1037/1931-3918.2.1.26. ISSN 1931-3926.
  22. ↑ Renkiewicz, Ginny K.; Hubble, Michael W. (2021-06-15). "Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying and Predicting Compassion Fatigue in Emergency Medical Services Personnel". Prehospital Emergency Care. 26 (5): 652–663. doi:10.1080/10903127.2021.1943578. ISSN 1090-3127. PMID 34128453. S2CID 235439364.
  23. ↑ Gamble, SJ; Pearlman, LA; Lucca, AM; Allen, GJ (1994). Vicarious traumatization and burnout among Connecticut psychologists: Empirical findings. Annual meeting of the Connecticut Psychological Association. Waterbury, CT.
  24. ↑ Arnold, Debora; Calhoun, Lawrence G.; Tedeschi, Richard; Cann, Arnie (1 April 2005). "Vicarious Posttraumatic Growth in Psychotherapy". Journal of Humanistic Psychology. 45 (2): 239–263. doi:10.1177/0022167805274729. ISSN 0022-1678. S2CID 145618063.
  25. ↑ Rothschild, Babette; Rand, Marjorie L. (2006). Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. Norton. ISBN 978-0-393-70422-8.
  26. ↑ Wilson, John P.; Thomas, Rhiannon Brywnn (23 November 2004). Empathy in the Treatment of Trauma and PTSD. Routledge. ISBN 978-1-135-93746-1.
  27. ↑ Batson, C. Daniel; Fultz, Jim; Schoenrade, Patricia A. (1 March 1987). "Distress and Empathy: Two Qualitatively Distinct Vicarious Emotions with Different Motivational Consequences". Journal of Personality. 55 (1): 19–39. doi:10.1111/j.1467-6494.1987.tb00426.x. ISSN 1467-6494. PMID 3572705.
  28. ↑ Lamm, Claus; Batson, C. Daniel; Decety, Jean (1 January 2007). "The Neural Substrate of Human Empathy: Effects of Perspective-taking and Cognitive Appraisal" (PDF). Journal of Cognitive Neuroscience. 19 (1): 42–58. CiteSeerX 10.1.1.511.3950. doi:10.1162/jocn.2007.19.1.42. ISSN 0898-929X. PMID 17214562. S2CID 2828843.
  29. ↑ Pearlman, Laurie Anne (2001). "The treatment of persons with complex PTSD and other trauma-related disruptions of the self". In Wilson, J.P.; Friedman; Lindy (eds.). Treating psychological trauma & PTSD. New York: Guilford Press. pp. 205–236.
  30. ↑ Briere, John; Runtz, Marsha (1 September 2002). "The Inventory of Altered Self-Capacities (IASC): A Standardized Measure of Identity, Affect Regulation, and Relationship Disturbance" (PDF). Assessment. 9 (3): 230–239. doi:10.1177/1073191102009003002. ISSN 1073-1911. PMID 12216780. S2CID 14719358.
  31. ↑ Weathers, Frank W; Litz, Brett T; Herman, Debra S; Huska, Jennifer A; Keane, Terence M (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Annual convention of the International Society for Traumatic Stress Studies. Vol. 462. San Antonio, Texas.
  32. ↑ Horowitz, M.; Wilner, N.; Alvarez, W. (May 1979). "Impact of Event Scale: a measure of subjective stress" (PDF). Psychosomatic Medicine. 41 (3): 209–218. doi:10.1097/00006842-197905000-00004. ISSN 0033-3174. PMID 472086. S2CID 4506565.
  33. ↑ "Impact of Event Scale – Revised (IES-R)". PTSD: National Center for PTSD. US Department of Veterans' Affairs.
  34. ↑ Veronese, Guido; Pepe, Alessandro (1 November 2013). "Psychometric Properties of IES-R, Short Arabic Version in Contexts of Military Violence". Research on Social Work Practice. 23 (6): 710–718. CiteSeerX 10.1.1.951.5841. doi:10.1177/1049731513486360. ISSN 1049-7315. S2CID 144835107.
  35. ↑ Briere 1996.
  36. ↑ Briere, John (2001). Detailed Assessment of Posttraumatic Stress: DAPS: Professional Manual. Psychological Assessment Resources Lutz, FL.
  37. ↑ Janoff-Bulman, Ronnie (1 June 1989). "Assumptive Worlds and the Stress of Traumatic Events: Applications of the Schema Construct". Social Cognition. 7 (2): 113–136. doi:10.1521/soco.1989.7.2.113. ISSN 0278-016X.
  38. ↑ Bride, Brian E.; Robinson, Margaret M.; Yegidis, Bonnie; Figley, Charles R. (2012-06-11). "Secondary Traumatic Stress Scale". doi:10.1037/t06768-000.
  39. ↑ Stamm, B.H. (2010). "Professional Quality of Life Scale 5". The National Child Traumatic Stress Network.
  40. 1 2 Saakvitne, Karen W.; Pearlman, Laurie A. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. W.W. Norton. ISBN 978-0-393-70233-0.
  41. ↑ Pearlman, Laurie A.; Caringi, J. (2009). "Living and working self-reflectively to address vicarious trauma". In Courtois, Christine; Ford (eds.). Treating complex traumatic stress disorders: an evidence-based guide. New York: Guilford Press. pp. 202–224. ISBN 978-1-60623-039-8.
  42. ↑ Rosenbloom, D.J.; Pratt, A.C.; Pearlman, Laurie A. (1995). "Helpers' responses to trauma work: Understanding and intervening in an organization". In Stamm, B. (ed.). Secondary traumatic stress: self-care issues for clinicians, researchers, and educators. Sidran Press. pp. 66–79. ISBN 978-0-9629164-9-6.
  43. ↑ Stamm, B., ed. (1999). Secondary Traumatic Stress: Self-care Issues for Clinicians, Researchers, and Educators. Sidran Press. ISBN 978-1-886968-07-3.
  44. ↑ Kawachi, Ichiro; Berkman, Lisa F. (1 September 2001). "Social ties and mental health". Journal of Urban Health. 78 (3): 458–467. doi:10.1093/jurban/78.3.458. ISSN 1099-3460. PMC 3455910. PMID 11564849.
  45. ↑ Seligman, Martin E. P.; Steen, Tracy A.; Park, Nansook; Peterson, Christopher (2005). "Positive Psychology Progress: Empirical Validation of Interventions" (PDF). American Psychologist. 60 (5): 410–421. CiteSeerX 10.1.1.465.7003. doi:10.1037/0003-066X.60.5.410. ISSN 1935-990X. PMID 16045394. S2CID 6262678.
  46. ↑ Csikszentmihalyi, Mihaly (1999). "If we are so rich, why aren't we happy?". American Psychologist. 54 (10): 821–827. doi:10.1037/0003-066X.54.10.821. ISSN 1935-990X.
  47. ↑ Christopher, John Chambers; Chrisman, Jennifer A.; Trotter-Mathison, Michelle J.; Schure, Marc B.; Dahlen, Penny; Christopher, Suzanne B. (1 July 2011). "Perceptions of the Long-Term Influence of Mindfulness Training on Counselors and Psychotherapists: A Qualitative Inquiry". Journal of Humanistic Psychology. 51 (3): 318–349. doi:10.1177/0022167810381471. ISSN 0022-1678. S2CID 145411787.
  48. ↑ Christopher, John Chambers; Christopher, Suzanne E.; Dunnagan, Tim; Schure, Marc (1 October 2006). "Teaching Self-Care Through Mindfulness Practices: The Application of Yoga, Meditation, and Qigong to Counselor Training". Journal of Humanistic Psychology. 46 (4): 494–509. doi:10.1177/0022167806290215. ISSN 0022-1678. S2CID 143592253.
  49. ↑ Newsome, Sandy; Christopher, John; Dahlen, Penny; Christopher, Suzanne (1 September 2006). "Teaching Counselors Self-Care Through Mindfulness Practices". Teachers College Record. 108 (9): 1881–1900. doi:10.1111/j.1467-9620.2006.00766.x.
  50. ↑ Quelch, John A.; Knoop, Carin-Isabel (6 November 2014). "Mental Health and the American Workplace".
  51. ↑ Finklestein, M.; Stein, E.; Greene, T.; Bronstein, I.; Solomon, Z. (2015-05-01). "Posttraumatic Stress Disorder and Vicarious Trauma in Mental Health Professionals". Health & Social Work. 40 (2): e25–e31. doi:10.1093/hsw/hlv026. ISSN 0360-7283.
  52. ↑ Helpingstine, Claire; Kenny, Maureen C.; Malik, Fayeza (2021-06-17). "Vicarious Traumatization and Burnout among Service Providers for Victims of Commercial Sexual Exploitation". Journal of Child Sexual Abuse. 30 (6): 722–745. doi:10.1080/10538712.2021.1938771. ISSN 1053-8712. PMID 34137346. S2CID 235460538.
  53. ↑ Aafjes-Van Doorn, Katie; Békés, Vera; Luo, Xiaochen; Prout, Tracy A.; Hoffman, Leon (2021-07-30). "What Do Therapist Defense Mechanisms Have to Do With Their Experience of Professional Self-Doubt and Vicarious Trauma During the COVID-19 Pandemic?". Frontiers in Psychology. 12: 647503. doi:10.3389/fpsyg.2021.647503. ISSN 1664-1078. PMC 8363079. PMID 34393887.
  54. ↑ K. B. McLain. The impact of burnout, compassion fatigue, and compassion satisfaction on foster parenting. Unpublished PhD dissertation. State University of New York (2008)
  55. ↑ Blanchette, J. A. (2011). Compassion Fatigue, Forgiveness, and Empathy in Foster Parents (Order No. 3442295). Available from ProQuest 851709362

Further reading

  • Hernández, Pilar; Gangsei, David; Engstrom, David (1 June 2007). "Vicarious Resilience: A New Concept in Work With Those Who Survive Trauma". Family Process. 46 (2): 229–241. doi:10.1111/j.1545-5300.2007.00206.x. ISSN 1545-5300. PMID 17593887. S2CID 8874592.
  • Kearney, Michael K.; Weininger, Radhule B.; Vachon, Mary L. S.; Harrison, Richard L.; Mount, Balfour M. (18 March 2009). "Self-care of Physicians Caring for Patients at the End of Life: "Being Connected . . . A Key to My Survival"" (PDF). JAMA. 301 (11): 1155–64, E1. doi:10.1001/jama.2009.352. ISSN 0098-7484. PMID 19293416.
  • Meadors, Patrick; Lamson, Angela (1 January 2008). "Compassion Fatigue and Secondary Traumatization: Provider Self Care on Intensive Care Units for Children". Journal of Pediatric Health Care. 22 (1): 24–34. doi:10.1016/j.pedhc.2007.01.006. ISSN 0891-5245. PMID 18174086.
  • Norcross, John C.; Guy, James D. (25 June 2007). Leaving It at the Office: A Guide to Psychotherapist Self-Care. Guilford Press. ISBN 978-1-59385-576-5.
  • Shah, Siddharth Ashvin (15 October 2009). "'To do no harm,' Spiritual Care and Ethnomedical Competence: Four cases of Psychosocial Trauma Recovery for the 2004 Tsunami and 2005 Earthquake in South Asia.". In Brenner, Grant; Bush; Moses (eds.). Creating Spiritual and Psychological Resilience: Integrating Care in Disaster Relief Work. Taylor & Francis. pp. 157–178. ISBN 978-0-203-86953-6.
  • Wicks, Robert J. (13 September 2007). The Resilient Clinician. Oxford University Press. ISBN 978-0-19-972449-9.
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