by Lawrie A. Ignacio, Psy.D. and Graham Taylor, Psy.D.
Very little has been written about combining individual and couple therapy in clinical practice. Even less common is the practice of combining individual and couple therapy as a co-therapy team. This paper examines the therapeutic merit of combining individual and couple therapy with the same set of patients as a psychodynamically oriented co-therapy team. We have found this practice to manifest significant therapeutic gains within the individual therapy work, as well as within the conjoint couple therapy. We also describe our experience with this novel way of working with patients, including some of its indications and potential contraindications, and describe those we have found to be most suitable for benefitting from our model’s application.
Key words: co-therapy, psychodynamic couples therapy, marital therapy, marriage/couple relationship functioning
Very little has been written about combining individual and couple therapy in clinical practice, likely owing to the prevailing notion that a couple therapist should not also provide individual therapy, and that an individual therapist should not also provide couple therapy, with the same set of patients. Even less common is the practice of combining individual and couple therapy as a co-therapy team, such that each therapist works separately with one member of a couple, while simultaneously providing couple therapy with the same couple as part of a co-therapy team.
This paper examines the therapeutic merit of combining individual and couple therapy with the same set of patients as a psychodynamically oriented co-therapy team. Specifically, it explores our developing experience with the utilization of patients’ relationship episodes, in the form of early memories, in so doing. In our experience, this practice manifests significant therapeutic gains within the individual therapy work conducted separately, as well as within the conjoint couple therapy. Below we describe our experience with this presumably novel way of working with patients, including some of its indications and potential contraindications, and how we identify those we have found to be most suitable for benefitting from our model’s application. We further invite other therapists to compare their experiences with ours, and to expand the literature and enhance clinical practice in working with patients using co-therapy teams.
Shedler’s (2010) article on the efficacy of psychodynamic psychotherapy unequivocally established psychodynamic psychotherapy as empirically effective and efficacious. Reviewing eight meta-analyses of psychodynamic therapy, he challenged the prevailing thinking among some that psychodynamic concepts and treatments lack empirical support and scientific evidence, unlike other approaches to therapy. He found, among other things, not only that effect sizes for psychodynamic therapy are as large as those found by studies of other therapies, but also that patients who undergo psychodynamic therapy realize therapeutic gains that appear to improve over time, even after treatment has ended.
Shedler (2010) outlined seven distinctive principles of psychodynamic technique that are based in long-standing psychoanalytic concepts and methods. All are relevant to, and utilized in, our work with patients. Three of the seven are directly relevant to this paper and our model of utilizing early memories and relationship episodes in working with couples as a co-therapy team.
Case formulation is considered a core clinical skill, as it helps to organize complex and often conflicting information about patients (Eells, 2001). Psychodynamic case formulation, typically referred to as dynamic formulation in the prevailing literature (Barber & Crits-Christoph, 1993), often relies on the use of recurrent relationship themes as its basis, consistent with the psychodynamic principles identified by Shedler and highlighted above. To date, much has been written in the form of books and journal articles about methods of psychoanalytic and psychodynamic case formulation. However, early attempts by researchers to systematically generate dynamic formulations from case material failed to establish strong reliability (Barber & Crits-Christoph, 1993). Primarily in the 1980s and since, more than 15 structured formulation methods have been developed. Luborsky’s CCRT method is reportedly the most researched (Eells, 2001). He and colleague Crits-Christoph were the first to develop a systematic method of organizing relationship narratives, or relationship episodes, told during psychotherapy sessions for use in case formulation (Barber & Crits-Christoph, 1993). Numerous studies have established the CCRT Method’s reliability, validity, and clinical utility (Chance, Bakeman, Kaslow, Farber & Burge-Callaway, 2000; Lubrosky, Popp, Luborsky & Mark, 1994; Okey, McWhirter & Delaney, 2000; Wilczek, Weinryb, Barber, Gustavsson & Asberg, 2000).
Luborsky defines the Core Conflictual Relationship Theme (CCRT) as “the central relationship pattern, script, or schema that each person follows in conducting relationships” (Luborsky & Crits-Christoph, 1998, p. 3). The CCRT describes this central relationship pattern in terms of three elements: wishes, needs, or intentions of the individual; expected or actual responses from others in terms of these wishes, needs, or intentions (abbreviated “RO” for “response of other”); and the individual’s responses to others’ responses, to include emotions, behaviors, and symptoms (abbreviated “RS” for “response of self) (Barber & Crits-Christoph, 1993). The CCRT is derived from analyzing relationship episodes either shared by the patient or enacted within the therapeutic relationship (Luborsky, Popp, Luborsky & Mark, 1994).
Borrowing from Schafer (1983), Luborsky describes a relationship episode as a discrete part of a therapy session that includes explicit narration about one’s relationships with others or with the self (Luborsky & Crits-Christoph, 1998). Capturing relationship episodes is essentially a matter of listening for narrative stories told by the patient that tends to have a beginning, a middle, and an end. Relationship episodes may cover any span of time, and a sample of at least 10 of them is sufficient to generate a CCRT (Luborsky & Crits-Cristoph, 1998). Luborsky devised a Relationship Anecdotes Paradigms (RAP) interview that can be used to elicit narratives from those in psychotherapy, while Luborsky and Crits-Christoph (1998) devised a three-step process for scoring each relationship episode and integrating them into an overall dynamic formulation, or CCRT, for an individual. Empirical and theoretical research studies have confirmed the CCRT’s relevance and applicability to both case formulation and clinical work, and its clinical utility has also been widely demonstrated (Barber, Luborsky, Crits-Christoph, & Diguer, 1995; Hackett, Porter, & Taylor, 2013; Jarry, 2010; Waldinger, Seidman, Gerber, Liem, Allen, & Hauser, 2003; Wilczek, Weinryb, Barber, Gustavsson, & Asberg, 2004). Consistent with this research, the collection of relationship episodes to yield an overall dynamic formulation for an individual, as well as for purposes of guiding treatment and clinical intervention, have proven to be particularly beneficial in our work.
Collecting relationship episodes narrated during psychotherapy appears to be the most common method of rendering a dynamic formulation and developing a clinical focus about a patient based on these episodes. Luborsky’s RAP Interview can be used to elicit narratives from which to generate a CCRT for an individual. Interestingly, Popp, Luborsky, and Crits-Christoph (1990) suggest that the CCRT may also reliably be extracted from dream narratives shared in therapy, Luborsky (Luborsky & Crits-Christoph, 1998), however, cautions against including dreams and fantasies in the final formulation of a CCRT. Book (1998) developed a method for collecting and utilizing the CCRT Method within a brief, psychodynamically oriented psychotherapy, based on relationship episodes reported by patients from their everyday encounters with others. As for utilizing narratives generated from the Thematic Apperception Test (TAT) for CCRT formulation, Luborsky (Luborsky & Crits-Christoph, 1998) recommends against it, given that TAT narratives are not intended to be about real events.
We utilize early memories (EMs) for collecting relationship episodes in our work with couples. Psychoanalytic interest in EMs can be traced back to a paper written by Freud in 1899 on screen memory, defined as an early memory used as a screen for a later event (Reichbart, 2008). Subsequently, in 1914, he wrote that “Not only some but all of what is essential in childhood has been retained on these [screen] memories. It is simply a question of knowing how to extract it out of them by analysis. They represent the forgotten years of childhood as adequately as the manifest content of a dream represents the dream-thoughts” (LaFarge, 2015, pp. 37–38). The utilization of EMs as a projective technique also has a long history (Last, 1997). The work of Mayman and Faris (1960) on the collection of early memories as relationship paradigms that reveal the personality of the informant may be credited for a renewed interest in EMs as valuable for clinical work. As Mayman and Faris (1960) conclude, the use of EMs rest on the hypothesis that asking a person for recollections of early events sets off a process of selecting and sifting through memories, then working them over. The use of an early memories inventory allows an individual to select and edit early memories unconsciously, according to his or her personal dynamics. They then “can be used as a source of inferences regarding tacit, ingrained preconceptions of self and others; one’s incorporated repertoire of transference paradigms; and some of the determinants which may have led to the development of these character patterns” (Mayman & Faris, 1960, pp. 508–509). Indeed, the value of EMs in psychotherapy is well documented (Acklin, Sauer, Alexander, & Dugoni, (1989); Androutsopoulou, 2013; Bruhn, 1981; Demuth & Bruhn, 1997; Fowler, Hilsenroth & Handler, 2000; Kahana, Weiland, Snyder & Rosenbaum, 1953; Wild, Hackman & Clark, 2008). An important empirical investigation by Acklin, Bibb, Boyer, and Jain (1991) demonstrated that relationship episodes may be reliably coded using EMs.
We specifically utilize Bruhn’s Early Memories Procedure (EMP) (Bruhn, 1992) to collect relationship narratives from our patients and utilize his strategy for organizing and interpreting the data yielded from the process. Bruhn defines the EMP as a self-administered, pencil-and-paper projective test of autobiographical memory. Early Memories (EMs) written about and organized by the EMP are understood by Bruhn as fantasies about the past that spotlight present concerns. However, unlike the TAT, early spontaneous memories (e.g., first early memory), as well as directed memories (e.g., happiest memory) reported on the EMP are those understood by the individual to be based in perceived real events. According to Bruhn, in some cases, EMs accurately depict historical events (Bruhn, 1992).
While our approach to utilizing the collected EMs is consistent with the cognitive-perceptual model Bruhn utilizes to ground the EMP and its interpretation, we also appreciate its implicit dynamic relevance to uncovering core conflictual relationship themes, or what Bruhn (1992) calls “unfinished business” represented by the “core of the memory” (p. 4), that mark early relationship patterns with primary attachment figures, which subsequently become activated in contemporary relationships with intimates. We have found the utilization of the EMP in our shared work to be particularly effective in helping couples discover these patterns and utilize them in the interest of change. Consistent with Bruhn’s interpretative strategy, we analyze each of our respective patient’s EMs in terms of his or her Perception of Self, Perception of Others, and Major Unresolved Issue (or unfinished business) within each EM. We then identify recurrent relationship themes across the patient’s EMs in terms of those that remain unfinished, unresolved, and/or conflicted (typically represented in negative-affect memories), as well as those that illustrate resolution of interpersonal conflict (those represented in positive-affect memories). We then synthesize these relationship themes into a succinct, integrative narrative that identifies the major unresolved relational issue(s) for the individual. These narratives are then incorporated into our conjoint work with couples as a co-therapy team.
While there is ample literature on the effectiveness of co-therapy in group work (Caligor, Fieldsteel, & Brok, 1984; Porter, 1980; Schermer, 2009), there is scant research on the merits of combining individual and couple therapy as a co-therapy team, likely due to prevailing notion that the ideal model for working with couples is therapy provided by one therapist. Counselman (2006) proposes a combined individual and couple therapy model in which she challenges what she refers to as the accepted principle of psychodynamic couple therapy that a couple therapist should not also provide individual therapy for either member of the couple. She proposes that under certain circumstances, combining individual and couple therapy by the same therapist can be therapeutic. However, she considers only the addition of individual therapy to an existing couple therapy, and not the converse, arguing that the former is far less complicated than adding couple therapy to an existing individual therapy. For a solo therapist, Counselman contends, the added partner may not feel equal in the earlier established therapy relationship, and the therapist may encounter challenges in doing so.
Roller and Nelson’s (1991) book, The Art of Co-Therapy: How Therapists Work Together, exquisitely captures the process and art of co-therapy practice. In it, the authors define co-therapy as “a special practice of psychotherapy in which two therapists treat a patient or patients in any mode of treatment at the same time and in the same place. Furthermore, co-therapy is a special practice of psychotherapy in which the relationship between the therapists is fundamental to the treatment process” (p. 2). As a special practice (as opposed to a technique, or a series of techniques), the authors assume that the therapists’ relationship with each other and their patients are the primary sources of healing, and that the transactions within the therapy context become critical to the change process.
We have found that many of the benefits of combining couple and individual work by the same co-therapist team include those associated with providing couple therapy to couples as a co-therapy team. Bellville, Raths, and Bellville (1968) present some of these advantages while discussing the merits of conjoint marriage therapy with a husband-and-wife therapist team. Two therapists, they suggest, have a greater chance of observing things that a single therapist might miss, so that a more complete therapy can prevail over a shorter period of time. Two therapists working together also allows for less collaborative time outside of sessions. It also reduces the problem often faced by the individual therapist in becoming a referee in working with couples. Co-therapists, they further suggest, are in a unique position of monitoring each other as to content and method in working with couples. Finally, and maybe most importantly, co-therapy teaming up models dyad healthy egalitarianism and shared power for members of the couple. In our conjoint work with couples, we have experienced each of these benefits. We would add that working as a co-therapist team also models for couples mutual intersubjectivity, or an interest in, attunement to, and responsiveness to the inner experience of the other person (Jordan, 1986), as well as healthy differentiation, or the process by which individuals in relationship effectively navigate independence and interdependence (Schnarch & Regas, 2012).
The advantages of working as a co-therapy team with individuals and couples further include the following: widened transference possibilities for patients and more targets for patients to project onto (Roller & Nelson, 1991); the provision of a “symbolic” representation of a working couple or family unit for patients (Gullerud & Harlan, 1962); opportunities for effective modeling by co-therapists of healthy interactive styles and patterns for couples (Epstein, Jayne-Lazarus, & DeGiovanni, 1979); greater opportunities for co-therapists to check and balance their countertransference reactions in the course of therapy (Mintz, 1965); and the opportunity for patients to identify with either or both therapists, thereby enhancing their ability to explore and reveal more psychological parts of themselves, since they are presented two mirrors of themselves in the form of co-therapists (Roller & Nelson, 1992).
Advantages of combining couple and individual work by the same therapist team further include those outlined by Counselman (2006) who argues, among other things, that this integration avoids the problem of the individual or couple therapist having to collaborate with different therapists working with the same individuals. We find that this advantage is retained for combining couple and individual work by a co-therapist team. As much as we know each other, have similar theoretical orientations (we are both psychodynamically oriented), respect each other, and make time for case discussions, our collaboration works well and potential challenges associated with working with different therapists are avoided. Presumably, if the members of a co-therapist team do not know each other very well, have different theoretical orientations, or do not make time for case discussions, challenges that a solo therapist might encounter in working with different therapists in treating patients in common would likely prevail.
Our model of combining individual and couple therapy as a co-therapy team typically emerges in this way: A couple comes in to see either one of us for couple therapy. Within no more than two sessions, it is determined that the couple either requires, or would benefit from, the addition of individual therapy for each member of the dyad. The couple is then invited to consider working within our integrated individual and couple therapy model. The potential gains and limits of this integration are discussed with the couple, and upon agreement by each member of the couple dyad to utilize our model, a referral for individual therapy is made for one of the members of the dyad to begin work with the other therapist. Each of us then works with a member of the dyad on an individual basis. The couples work ensues concurrent with, or after sufficient individual work is undergone with each member of the dyad, relative to the unique needs of the couple.
In addition to the benefits and merits of co-therapy outlined above, we have found that there are unique advantages to combining individual and couple work as a co-therapist team. A primary one is best described as a kind of synergy that is created from this combination. We have found that the therapeutic work conducted by each of us in individual therapy with each member of the couple dyad almost immediately becomes relevant to the couple therapy. The reverse is also true. The insights and successful working through gained in one context naturally inform, infuses, and advance the work in the other. Moreover, insights garnered within each respective context become additive and cumulative, creating a potent, synergistic, and immediate way of working within each therapeutic context that is quite different compared with individual or couple work conducted independently.
The following serves as an example. As mentioned earlier, we are both psychodynamically oriented psychotherapists. We also both utilize the identification of central relationship patterns within the context of our dynamic work with patients as a means by which to discover their core needs and relationship themes (Luborsky & Crits-Christoph, 1998; Wilczek, Weinryb, Barber, Gustavsson & Asberg, 2004). We utilize the EMP to collect and elucidate these themes, and use Bruhn’s (1992) method of integrating them into an overarching synthesis that describes each person’s core relationship themes and unmet core wishes. The main portion of the EMP work is conducted during individual sessions with each member of the couple, a process that ultimately allows each partner to develop meaningful and informed self-awareness, and each of us, as therapists, the opportunity to understand our respective individual patient in complex and nuanced ways. We have found that when we integrate individual and couple therapy with the same couple, the EMP work that originated in our individual therapy with each member of the dyad powerfully catalyzes the couple therapy. There are at least three ways we have found that this can happen. First, the EMP work conducted within our individual therapy sessions becomes the primary data from which to conceptualize the case outside of sessions, and formulate ways of working as a co-therapy team in our ongoing work with our shared couple. It also becomes the vehicle by which to inform each other, and subsequently understand, how to become corrective objects for each other's individual patients during the couple work.
Second, the EMP work conducted within our individual therapy sessions actively allows each therapist to partner with our respective individual patient within the couple therapy in a way that enhances communication between them. Such partnering often takes the form of assisting our respective individual patients to elucidate and communicate his or her current relationship core needs for the other. With our help in further contextualizing these needs in terms of early unmet ones, we find that accurate attunement and mutual empathy are enhanced between the couple, and they become more amenable to changing hurtful and potentially damaging relationship patterns that mark the relationship. We also find that, because each member of the couple comes to view conflicts between them more broadly and in context, personalization, blaming, and shutting down are minimized. The couple comes to appreciate that their current relationship patterns are part of a larger narrative rooted in first-family relationships that are reenacted between them as a means of fulfilling early unmet core needs, or “unfinished business” from the past (Bruhn, 1992).
The following is an example of what partnering with our respective individual patient during couple therapy sessions might sound like:
John (husband): It's the same thing over and over, Susan, and I'm tired of it. Your social life seems more important to you than spending time with me. I'm beginning to think spending time with your friends is your way of avoiding me. It's been going on for years.
Susan (wife): Time with my friends is not more important than you, John. And it's not a competition. It just feels like you need me too much and I can't breathe in this relationship. What's been going on for years is that I’m suffocating. It feels like I'm your sole source of support and entertainment. It's a lot of responsibility.
Dr. Taylor (to John): John, would you be willing to share with Susan what we talked about during our recent individual time together—how in your first family it was very difficult for you to feel important and special?
John: Sure. Susan, you know that my sister became bedridden after she fell from a tree when she was five years old and suffered a severe head injury, right?
John: Even though I was just three when it happened, as you can imagine my sister got most of my parents' attention. She was in and out of hospitals continually, and required round-the-clock care. Both of my parents worked full time, and the rest of the time was spent mostly with her. I knew my parents loved me, but I didn't get much time with either one of them for most of my childhood.
Dr. Taylor: John would help take care of his sister a lot, too, as time went on, even though he was younger than her. He understands now, looking back, how hard his parents had it taking care of his sister. But growing up, he never felt special to them, and he can't remember any times when he was put first by them. So, a core need for John is to feel worthy, chosen, important. And sometimes, he wants to feel second-to-none by you, Susan.
Dr. Ignacio (to Susan): Susan, this might be a good time to help John understand why, at times, his want for more time with you can feel suffocating.
Susan: You mean explain to him what it was like taking care of my brothers after my mother died?
Dr. Ignacio: Yes.
Susan: John, you know my mom died when I was five, so my two brothers and I were raised by my dad. He did a great job, but like your parents, had to work a lot, in our case, to make ends meet. Being the oldest, I was relied on a lot to help take care of my brothers. When I was young, it might have been just making sure that they didn't put anything dangerous in their mouths. Over time, I was relied on to do more things, like bathe them and feed them.
Dr. Ignacio: Susan became, over time, like a second mother to her brothers. Her sick grandfather—her dad's dad—also moved into her family home when Susan was nine, and she was expected to help care for him as well. This lasted at least another six or seven years, right, Susan?
Susan: Yes, that's right. So, growing up, I didn't have much time to myself, to do things I wanted to do. I was busy with schoolwork mostly, and taking care of my brothers and grandfather. I need time to myself—time to connect with myself that is separate from someone else’s needs.
Dr. Ignacio: This is why Susan can sometimes feel overwhelmed if it starts to feel as though she becomes the only source of support and connection in her important relationships. She's currently working on finding a healthier balance between togetherness and separateness, so she can enjoy both in her relationship with you, John.
Third, the results of our individual and collective EMP work with our couple allows us to actively intervene at the intersection of each partner's attempts to manifest unmet core relationship needs. Continuing with John and Susan, the session might proceed as follows:
Dr. Taylor: Susan, I noticed that as John explained why he never felt very seen as a young boy, you began tearing up. What were you feeling and thinking?
Susan: I just pictured him as a sad and lonely kid when he was at home. That must have been really hard on him.
Dr. Ignacio: John, what's coming up for you right now?
John: I'm actually feeling angry. How could your dad do that to you? Give you so much responsibility as a kid? Also makes me sad to think you always had to put your needs aside.
Dr. Taylor: Understanding the conflicts in our intimate relationship often takes on new meaning when viewed in terms of our early unmet needs.
Dr. Ignacio: It also helps us experience the other more empathically, as each of you are feeling for each other right now.
Dr. Taylor: So where might we go from here? When John feels a need for special closeness with Susan, she can sometimes find herself feeling overwhelmed and burdened. When Susan feels a need to pursue interests separate from John, he can sometimes find himself feeling avoided and unimportant to Susan.
Dr. Ignacio: What might another way through this look like, do we suppose? How might each give to the other in a way that allows a core need to be met, while not undermining one's own, and doesn't leave room for resentment?
We have found that working at the intersection this way typically manifests beneficial therapeutic movement and gains. Often, the couple becomes more generously amenable to crafting progressive, creative, and alternative ways of relating to each other based on the actualization of their own, and their partner’s, core unmet relationship needs.
Working as a co-therapist team with couples in the way described is not without its challenges. Two potential difficulties are discussed here. First, the work is inherently complicated by the complex transference and countertransference reactions that emerge between therapists and patients. In terms of transference, not only are there transference dynamics that mark, and are activated between, each member of the couple dyad; there are also individual transferences each member of the couple makes to each therapist, as well individual and collective transferences made to us collectively. On the latter point, Belleville, Raths, and Belville (1969) put it succinctly that, "Couples view us in two ways—as parents and as a successful marital pair" (p. 478). Complex reactions to our patients in the form of countertransference reactions also inevitably become a part of our work with couples. Finally, transference and countertransference dynamics between us as colleagues and co-therapists also enrich the complexity of working with couples as a co-therapist team.
We subscribe to Scharff and Scharff's (1994) notion that transference is not limited to the therapeutic relationship but exists in all relationships. As psychodynamic psychotherapists, we also appreciate and value complexity. We contend that working with couples as a co-therapist team dedicated to navigating the complexities of multiple, simultaneous transference–countertransference reactions, provides our patients with a realistically valuable experience of having to negotiate complex transferences always found in intimate relationships outside of therapy. Consistent with the psychodynamic orientation, we also take the view that transference and countertransference reactions provide rich data from which to guide our work with patients. We work hard to identify, understand, and monitor transference reactions to us individually and collectively within each therapy context and across them. We expect that our patients will inevitably and unconsciously project feelings, needs, and wishes onto us as their therapists, and welcome them. Paying close attention to transference–countertransference dynamics allows us to, among other things, mindfully provide corrective emotional experiences for our patients.
Another potential challenge in combining individual and couple therapy as a co-therapist team comes with the occasional patient's request that the therapist working with him or her individually keep a secret from his or partner that would otherwise affect the relationship if disclosed. The solo couple therapist who spends one or several sessions with each member of the dyad separately, and is asked by one of the partners to hold an issue in confidence from his or her partner, is not immune from the same scenario. We have found that maintaining a working agreement with our couples on this issue at the start of therapy helps. Specifically, we forge an agreement with our couple that during individual therapy sessions, each therapist may hold something in confidence for a discretionary time (barring legal exceptions), but only with the agreement that the non-disclosing patient will work to understand the reason for the need to keep information from his or her partner, and subsequently work to share the information with his or her partner as soon as feasible.
Integrating individual and couple therapy consistent with our model presumably works best with those who can be described as emotionally healthy or situated at the neurotic end of the neurotic–borderline–psychotic spectrum of personality (McWilliams, 2011). Such individuals can maintain adequate reality testing even under significant stress; are identity-integrated; have a well-developed observing ego (Hughes, Wells, & Chance, 1996); can establish, and maintain a trusting therapeutic alliance; and can tolerate the complexities associated with working individually, as well as simultaneously, as part of a four-way couple therapy. We are aware that not all individuals may have the capacity to tolerate shifts in the therapeutic frame from having one therapist's full attention to sharing it. It is important to assess each individual patient’s capacity to tolerate complex transferential reactions as a prerequisite to utilizing the integrated couple therapy model we describe here. It may be contraindicated for some individuals. The individuals we have worked with using our model are emotionally healthy in the ways just described. It would be worth exploring if, or to what extent, our model may have to be modified for individuals who experience significant difficulties with relational intimacy as a function of underdeveloped ego-strength.
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