Topic 2: Development, Structure, & Implementation of (CBT) Groups {by 9/17}

There are four readings due this week – Bieling et al. Chapter 5 & and Yalom Chapters 8-10.  Address the following two discussion points: (1) Beiling et al. discuss some of the more basic (but important) structural elements of implementing a CBT group. What stuck out to you as some of the more important elements to assure a good start to a CBT group? (2) For Yalom, simply share your thoughts on his view on criteria for inclusion/exclusion of group members and overall composition of group. Your original post should be posted by the beginning of class 9/17.  Have your two replies no later than 9/19.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

26 Comments (+add yours?)

  1. Gil
    Sep 14, 2014 @ 09:45:38

    The check-in and agenda seem to provide a helpful balance to the group session. The agenda provides direction and allows the therapist to use his or her knowledge and techniques to guide the group on a specified path. The check-in gives participants a voice and allows them to add their own feelings and feel more control. However, if done correctly, the agenda also allows for collaboration and joint control. The agenda gives transparency and allows participants to feel more comfortable about the schedule for that day. Group members can agree on additional agenda items to make sure their needs are being met. Finally, the agenda helps organize the information being learned. The information and techniques fall under a specific topic on the agenda and allow for individuals to understand how information is connected under the topic. Sequential check-ins might take too much time away from the group. One suggestion is to ask if anyone needs time to address their feelings. The thought may have been weighing on the mind of the individual, so this allows an opportunity for catharsis and reframing, most likely allowing greater focus on the next steps for group. If the subject brought up during check-ins is serious or affects others, the subject can be added to the agenda to address as an item for the day.

    Yalom places considerable importance on the formation of the group and using the best inclusion/exclusion criteria. This falls in line with his view that the other group members are the primary change mechanism for group therapy. The main conflict seem to be the heterogeneity vs. homogeneity of the group and identifying the criteria that best predicts suitability for a group. A membership terminated too early can have harmful effects on individuals, making selection even more important. The overall theme seems to be that there is more research about factors that may jeopardize an individual’s group prognosis than factors that predict beneficial group prognosis. A group that is too homogeneous might not reflect a real-world situation, yet the safety and comfort it provides, gives clients a chance to explore and evaluate parts of themselves that they would have previously defended or been unaware. Similarity breeds comfort and comfort breeds exploration and openness. Homogeneity can never be ensured; there are too many variables. After finding similarity on certain aspects and gaining skill and insight, this can be generalized to a heterogeneous, real world situation. Focusing on interpersonal style, readiness of change, and diagnosis appear to be valid starting points to match.

    Reply

    • Richard Hisman
      Sep 17, 2014 @ 07:18:13

      It’s interesting that Yalom’s exclusion criteria is really clear, until you get to his inclusion criteria. He tends to muddy the water by appearing to contradict himself. In the end he offers that even though a candidate may not look good for a group overall. That the individual might be the most in need of the group. There by one should not dismiss the possibility of inclusion of that individual. Where as Bieling is much clearer in his description on selection for inclusion. It is more important to match clients afflictions for cohesion.

      Reply

    • Michelle
      Sep 17, 2014 @ 16:10:06

      Gil, I agree that interpersonal style is an important factor. Yalom had talked in his writing about group deviants, not in that the individuals were each different from one another in personal styles such as appearance or past behaviors, but that these deviants had a differnt interpersonal style from the other members of the group. Group mebers even tend to show increased satisfaction if they feel they are a valuable part of the group; for them to be valued, their relational style is responded to by other members of the group. It’s that interpersonal ability to relate to eachother that seems so much a part of what makes group therapy what it is.

      Reply

    • Sarah Gagne
      Sep 19, 2014 @ 20:37:23

      I do think a check-in is an important tool to allow clients to feel they have a voice immediately as group begins. Consider a quiet, introverted client. If not for a check-in, the individual may never speak up and may not get the full benefit of the group. This type of interaction, even if a bit structured, may be a social goal in itself for a group member.
      The interactions within the check-in may bring up issues that have progressed throughout the week that may be added to the agenda if deemed appropriate, another way of giving group members and a sense of shared control with the group facilitator.

      Reply

  2. Richard Hisman
    Sep 15, 2014 @ 12:46:09

    Bieling speaks at length about using a suitability interview to aid in selecting the appropriate members for a group. Utilizing similar primary diagnoses and likewise similar comorbidities to assure some homogeneity in group members. But that through interview processes individual needs are not to be overlooked to ensure the group progresses as one. The establishment of what stance the therapists are to take as to the direction is vital. This eliminates any possible dissention and eliminates possible confusion for the group.
    Establishing each therapist’s duties during after and before meetings can aid in a smooth transition throughout the therapy process. Establishing the criteria to be covered, overall goal of the group and what homework is to be done is another example of how therapists working together will improve the therapy experience. Structure of the group needs to include a clarification phase each meeting where unresolved issues can be identified and discussed. An individual self-report can be completed while the therapists examine the completed homework. After reviewing the self-report and homework answers, unresolved questions can be clarified before discussing the day’s new agenda. Once the desired work for the day has been completed, summaries should be presented for all key points as an assurance that these points are understood. Followed by assignment of the next homework to be completed.
    Yalom’s position on inclusion interestingly enough centered more on how to exclude clients. He suggest that is much clearer to decide who should not be in a group rather than who should be. He warns that by over selecting the criteria for selection, that one could easily exclude a client who most needs to be in the group. Curiously he highlights the need for the therapist to evaluate the like or dislike of potential member. That suitability interviews are important to determine whether individuals will be able to work with others or participate in the overall group activities.

    Reply

    • Angela Vizzo
      Sep 16, 2014 @ 22:04:02

      Richard, I liked your discussion on Yalom’s ideas on inclusion and exclusion. As you mentioned, an interview can be a great tool to determine a member’s eligibility for the group. As was also mentioned in the reading, trying to make that interview as similar to how the group will actually function is important too in order to allow the potential member to show how they would interact in the group circumstances.

      Reply

    • Robert
      Sep 17, 2014 @ 22:12:28

      I agree with you, Rick, on the importance of establishing each therapist’s duties before the group meeting begins. I meet with my co-therapist at least 15 minutes before our group therapy session starts so that we’re on the same page with the day’s agenda and what our roles will be. It may seem obvious, but it greatly helps in keeping a good pace on the session and staying on target.

      Reply

  3. Sarah-Eve
    Sep 15, 2014 @ 15:54:35

    CBT involves much consideration in the planning and organizing of group sessions to achieve utmost efficiency. Of the four elements (patient selection, therapist factors, between-session structure, and within-session structure) that Beiling et al. describes, I find group structure to be quite important. Especially true in CBT, each group session follows a rational and comprehensive sequence in a way that is predictable to the group members and the therapist(s). Cognitive behavioral therapy’s effectiveness is based on the extent to which clients effectively learn and implement the tools presented in therapy, structure (at least in the beginning) aids in guiding clients through these stages. Planning between-session structure, such as homework, is another major part of the CBT framework. Having an organized way of assigning and reviewing homework can help motivate clients to learn and implement the tools and skills presented in group therapy. Practicing these skills in real life is much more effective than simply being taught them.
    Yalom indicates that it is far easier to specify exclusion characteristics of group members rather than inclusion criteria. A single trait may exclude an individual, while a complex profile is required in order to justify that this individual should be included in the group. Specific features that exclude individuals from one type of group may make them an ideal candidate for another group (e.g., a psychopathic individual might not fit in to a heterogeneous long-term group, but may fit in well in a homogeneous group of other individuals who have the same psychopathic traits). Yalom does not specify too many traits in which make an individual not suitable for group therapy, but it is best to infer the likelihood of some factors that might be deleterious to the group (e.g., dropout, defiance, fear of emotional contagion, etc.) Traits that make an individual suitable for group therapy should also be inferred, such as motivation and potential relationships with other group members. Overall, Yalom states that the typical, though not ideal, method of selecting group members is through deselection: excluding certain clients from consideration and accepting all the others.

    Reply

    • Gil
      Sep 17, 2014 @ 21:56:13

      Good point about applying the skills learned in therapy through the homework. Even in the structured setting, there are elements of flexibility to address participants’ desires. Giving a few choices in possible homework assignments or having participants give input can go a long way in enhancing motivation and aiding self-efficacy and generalization. Generalization is the ultimate key of therapy. Making strides in group means little if the skills can’t be applied in real-world situations. An hour or two of group therapy a week is just a drop in the bucket. Having participants complete homework helps therapy spill over into everyday life.

      Reply

  4. Sarah Gagne
    Sep 15, 2014 @ 21:57:43

    The structure of group provides a somewhat predictable environment so that both group facilitators and members are more able to prepare for group and follow along as group progresses. Bieling et. al suggest most effective CBT groups combine a structured approach with leeway for group members to present real life examples and problems. This allows for group members to learn a set of skills and share how these skills do or do not work when practiced. Both assigning and reviewing homework is important within this structure. Time spent on clarification is effective not only for solidifying skills for those who are able to follow along, but also accommodates individuals with cognitive deficits that may struggle with independent homework assignments. The group structure should promote collaboration between facilitators and members. While the group may follow a preset order of topics, discussing an agenda for each group allows for members to identify areas of specific importance within these topics.
    Yalom places a heavier focus on criteria of exclusion rather than inclusion, asserting that it is easier to determine a single exclusion factor rather than identifying several common factors of inclusion. It is important to consider how the individual will affect other group members rather than the potential benefit of the individual. Yalom provides examples of a depressed suicidal patient, a compulsive talker, or any individual in acute distress, all of which may be better served in individual sessions before group is appropriate.

    Reply

    • Angela Vizzo
      Sep 16, 2014 @ 21:55:56

      Sarah, I agree with your comments about how a CBT group should be structured yet still allowing the opportunity for the group members to interject their own opinions and/or issues. If a group is too structured and regimented it becomes more like class than therapy and does not allow for any emotional relase, which I believe is key during the therapeutic process. However, on the other hand the group cannot be too relaxed either as certain goals need to be established and met in order for members to gain from the group therapy as well. Finding that balance between the two extremes, as you mentioned, seems to be important when running groups.

      Reply

  5. Paige Hartmann
    Sep 16, 2014 @ 09:24:26

    Bieling et al. focuses on four basic structural elements that are necessary when implementing a CBT group, including patient selection, therapist factors, between-session structure, and within-session structure. I found the element of overall group structure to be important in providing CBT effectiveness. CBT groups are generally closed groups that have group sessions that run from 90 minutes to 2 hours in length. The overall structure of the group, including the sequence of material covered, provides some predictability to both the group members and the therapist. In order for a CBT group to be effective, the group members need to learn the skills and tools presented within the group sessions. In addition to practicing these skills within session, homework is another essential feature. Assigning homework to the group members allows them an additional opportunity to practice the new skills learned within the session in their daily lives.

    Yalom focuses more on criteria for exclusion of group members rather than on inclusion criteria, which is referred to as deselection. Yalom explains that it is easier to specify exclusion criteria than inclusion criteria. An individual can be excluded from the group based on a single characteristic, while a complex profile is necessary to justify an individual’s inclusion. Yalom also explains that most clients will fit into some group, since a factor that excludes the individual from one group may secure them into a different group.

    Reply

    • Sarah-Eve
      Sep 17, 2014 @ 09:14:11

      Practice helps to enforce the things that you learn. Just as in math class, you have take-home exercises, it is only fair that the CBT skills learned in group be practiced outside of that type of setting. This not only reinforces the behaviors, but allows for the CBT process to proceed at a quicker pace. These groups tend to be more time limited than process groups due to this type of structure.

      Reply

    • Michelle
      Sep 17, 2014 @ 16:03:18

      Paige, yes, it seems to me as well that especially in consideration of a CBT focus, development of a group structure would be important. Although this seems almost obvious, I wonder how many group leaders really do so. I also wonder what kind of level of flexbibility there should be along the way. For instance, if group members seem to need help in an area not addressed in the structured program, I wonder if under this theory, or even in our own views, it would be okay to deviate, then later returning to the original lesson plan. Planning is important, but I’m wondering how others would feel about incorporation of flexibility, too.

      Reply

      • Jessica
        Sep 17, 2014 @ 18:26:44

        I see that in many cases, flexibility is needed. At the group homes I work at I’ve seen individual problems brought up in group often addressed by agreeing to meet the therapist about it after group so it doesn’t take up group time. If it is something that the whole group needs to work on, whether it be a process issue or a skill, deviating from the topic/agenda to address this may be beneficial in the long run, Having a problem looming in the background (such as sub-grouping, chronic departure from group “rules” like talking over others, or general failure to understand a concept) would negatively impact future learning in group and may make the group less beneficial or even detrimental.
        I wonder if having a highly structured group with homework assignments makes group seem too much like a class to some clients, many of whom may have a negative attitude towards school. Particularly among a group that may have less than favorable school experiences (take adolescent drop outs, for example), how do you retain them in a CBT group AND enforce doing the homework? Any ideas?

        Reply

  6. Angela Vizzo
    Sep 16, 2014 @ 21:48:44

    Beiling et al. describe four factors that are important to consider with CBT group development; they are patient selection, therapist factors, between-session structure and within session structure. In particular, I think patient selection is important to ensure a good start to the group. While in practice patient selection cannot always be as picky as described in the text, but some criteria for selection is important. Stage of change should be considered as all patients in a CBT group should be ready to change in order to ensure motivation to learn and participate in the techniques being taught. Selection of demographics is also important to allow for enough, but not too much diversity. Having enough diversity allows group members to learn from others’ experiences; however, that diversity cannot be so extreme that members cannot relate to one another. Selection also becomes important based on the issue that is being treated as certain groups need less diversity in order to allow members to be comfortable enough that the treatment can be effective. For example, a group focused on eating disorders would be best to be same gender.

    Yalom believes that it is easier to define criteria for exclusion from group than criteria for inclusion. This makes sense as many factors must be described and met for inclusion rather than only one that can be enough for exclusion. Yalom discussed reasons for drop-out that could be avoided through better selection and exclusion. In particular, he mentions logistical/external factors, problems of intimacy, and group deviancy. Of the three, group deviancy seems like it would be the easiest to control for during group selection as the therapist would be able to determine that one member differs from all other members in a particular way. Once that is recognized, this individual could be chosen by the therapist to be excluded prior to the beginning of group in order to better the individual as well as the group as a whole. By excluding that member, the individual does not feel uncomfortable or discouraged and the group is allowed to become more cohesive, more quickly. Yalom also identifies motivation and interpersonal skills as important inclusion criteria.

    Reply

    • Sarah-Eve
      Sep 17, 2014 @ 08:59:53

      It’s great that you identified that patient selection is sometimes extremely limited. It is not a fool proof way of obtaining a successful group of individuals. Though categories for inclusion tend to be wider than categories for exclusion, it is important to identify specific characteristics of the participants in order to have a more homogeneous group. Having a group with too many exclusion characteristics puts the leader at a disadvantage when there are not enough people to make up a successful group. Casting the net too wide, on the otherhand, may result in poor group cohesion when individuals do not feel that they have enough in common with each other.

      Reply

    • Paige Hartmann
      Sep 18, 2014 @ 11:57:18

      As we have discussed in class, you mentioned the importance of considering an individual’s current stage of change during the patient selection process. Evaluating the current stage of change for a potential group member is essential in determining their degree of readiness and motivation to participate in group therapy. Some clients may require more individual therapy to ensure they have the skills necessary to effectively participate in group therapy.

      Reply

    • Sarah Gagne
      Sep 19, 2014 @ 20:27:38

      Angela,
      I liked that you mentioned diversity in group selection. It would be optimal to have the group diversity as true to life as it would be if they were out in the community, if possible. This would make for a more accurate representation of the social experience and facilitate social learning. Having too much diversity within group may be a struggle in a city or town that is more homogenous, and vice versa.

      Reply

  7. Robert
    Sep 17, 2014 @ 11:27:36

    The bridge and agenda are elements that help to facilitate a coherent and consistent learning environment to assist in the group process. The bridge gives a narrative of the therapy, otherwise sessions can seem disjointed and lacking an overall theme or sense of progression. It connects the lessons of previous sessions to the present session and this connection is enhanced by including examples from group members and homework. The agenda forms a key element of the session by helping to address what areas group members would like to cover and the therapist’s protocol is introduced. Appropriately balancing process issues and the protocol is a challenging aspect for a CBT group therapist to consider in starting and maintaining the group in a positive direction.

    For Yalom, it is easier to select group members based on criteria for exclusion from the group rather than on inclusion criteria. It is easier for the therapist to exclude a possible group member based on one factor that could conflict with a group’s cohesiveness as opposed to trying to estimate a member’s goodness of fit into a group based on several inclusionary factors. Yalom clearly supports a cohesiveness theory to group composition with its underlying homogeneous approach over the dissonance model’s heterogeneous approach. The more group members have a sense of similarity to each other, the more likely that they will attend group, express and tolerate hostility, and are more sensitive to influencing and being influenced by each other. This common ground allows for dissonance to develop within the group in a therapeutic way whereas more a heterogeneous group carries a greater risk of such dissonance creating negative effects such as having members feeling isolated and dropping out of the group.

    Reply

  8. Michelle
    Sep 17, 2014 @ 15:59:40

    Beiling proposes four main factors that therapists should consider when forming and beginning a group; these include patient factors and variables, therapist factors, homework and between-session considerations, and session structure. Of course, the mundane details such as session length, location, and time of session are important considerations. A room too large may seem cold, whereas a room too small may impede group member’s personal space and not be a great fit. The factor that receives the most attention is that of member selection. Beiling referred to a suitability interview that assesses potential members on ten domains. A few examples are the ability to address automatic thoughts, the willingness to reflect on one’s own behavior, and the level of hope that change can take place. Other considerations address relational issues. For instance, should a potential member be so aggressive that he or she can simply not refrain from being a distraction, they may not only be unable to reap the benefits of the group, but may also impede on others’ as well. Should the person be unable to relate or communicate, this may also become problematic in the group setting; considering the client’s ability to collaborate is an important consideration. Beiling suggests that a suitability interview be conducted to address the above-listed concerns, as well as to educate the client about CBT, and to give them a better understanding about what to expect from the group experience.
    Counselors should be prepared and trained in group therapy and CBT before they should attempt to run a group. This can be done through formal training, after which the therapist works as an assistant leader in a group. Because this is a CBT model, the therapist’s strategies should align with this therapeutic intervention. Before group gets under way, the therapist should have a plan that follows the CBT model by incorporating lesson plans, activities, and homework that move progressively toward goals, flowing from week’s plans to the next.
    Overall, the main factors that seemed to especially ring true in my mind are those of client selection, and therapist preparation of materials. Other factors are important considerations as well, and may help provide the most advantage for group members if addressed well.
    Yalom asserts that clients will be unable to be successful in therapy if they are unable to attend to the therapeutic interventions. This aligns well with CBT, and is hard to argue against. If a client, for instance, is to work through cognitions, they must be able to do so. Yalom focuses on exclusion rather through inclusion, as there are simply too many details and factors for inclusion to be a reasonable focus. In many ways, Yalom’s exclusion criteria is in accord with Beiling’s. Yalom’s inclusion criteria of motivation relates to Beiling’s assertion that clients should be hopeful that therapy can help. Yalom’s description of group deviants looks very much like Beiling’s relational issues. Overall, my thoughts are that these two approaches share many commonalities, many of which highlight the importance of creating a group that is comprised of members who are similar enough, while also being different enough, as well.

    Reply

    • Robert
      Sep 17, 2014 @ 18:31:25

      Michelle, I can relate to some of the themes you mentioned in your discussion. At my internship, the room we use for my group therapy sessions with children aged 11-15 that is too big for a group of only four children and two interns. While there is more than enough space to do activities, the extra space can be more of a distraction to the children and hinders in fostering more emotional connection with fellow group members if they were physically closer together. I had one client over the summer who showed little improvement being in the group after several months and he often hindered the activities and processes in group, frustrating the other members. He had difficulty picking up on the social cues and dynamics of the group, showed marked anxiety in a group setting versus one-on-one and engaged in negative attention-seeking behavior. My supervisor and I referred him to individual therapy as he was not ready for group therapy yet, but unfortunately that was not realized until halfway through the group theory program. It would have been much easier for the group if he was screened out before so screening is very important to foster a therapeutic environment.

      Reply

    • Gil
      Sep 17, 2014 @ 22:05:52

      The pragmatics of a group seem unimportant and might be overlooked, but I think you’re right to say that they can be important. It seems like when everything is going right those issues will be unnoticed, but when they go wrong, it can be a hindrance to effective group therapy. Effective therapy requires attention and mindfulness.

      Reply

      • Richard Hisman
        Sep 19, 2014 @ 09:24:28

        While I agree with what is said here, I believe that it does not usually happen. If we are trained and licensed, why is it that organizations do not see these issues at inception? Is it because the organizational leadership is too diverse, trained too long ago, or ambivalent to the needs of groups? How organizations are comprised is an interest of mine. The VA at inception was comprised mainly of LWCSs and had a very heavy social psychology slant to it for many decades. With the decree by Obama in 2008 to dramatically increase the number of LMHCs by 12,000 (which has not happened), the integration of theories is point of interest. Something simple as LWCSs are responsible for hiring LMHCs at many facilities. Does it work?
        Coming back to the needs of CBT groups, do those in charge realize what is necessary to enable a group to succeed? Bieling establishes what would be the optimum conditions and composition for a group setting. Can we hope to come close to that?

        Reply

  9. Jessica
    Sep 17, 2014 @ 17:38:03

    Several things struck me from the Bieling et al. chapter, that are also discussed in the the Yalom chapters. First, a I had not heard of a suitability interview before, but it appears beneficial to screen clients for readiness to possible CBT therapy in either individual or group formats. It seems more difficult to assess a client’s “fit” for group therapy because only so much interpersonal interaction can be displayed in this interview, so it may be ideal to conduct both a suitability interview and to observe clients in waiting list groups to see their interpersonal styles, as Yalom suggests. However that would probably require more time and money than most agencies would allow to formulate groups, and some groups may overlook selection processes simply to accept new members if membership is low. In reality, being able to select which clients would make a good group seems like a bit of luxury that most therapists don’t have, at least with groups just starting out or that occur in a fixed place like a hospital or group home.
    Another interesting point I haven’t thought much about before was heterogeneity vs. homogeneity of the group. I initially thought “the more similar you can get a group to be the better because they can relate more to each other and get along better.” But that defeats one of the main benefits of group: to get different perspectives, interact with different personalities, and learn social skills and about their own interaction styles that may not come to light in a highly homogeneous group. For example, men who fear intimacy would likely not benefit from a group filled with all men who fear intimacy; the group may take on competitive atmosphere that never touches up the “here and now” relationships among members and vulnerabilities of the individuals. Having other clients who are willing to model vulnerability and be the “social risk takers” to bring discussion to a more therapeutic level would be ideal (maybe be incorporating a model group participant from a similar previous group or a peer group leader). However, I am not sure what Yalom means by looking for homogeneity in “ego strength”, a term I do not understand used in any context except in a Freudian sense. He seemed to describe this as “homogeneity with regard to intelligence, capacity to tolerate anxiety, and ability to give and receive feedback and to engage in the therapeutic process” (p. 273), and I agree that these are factors are better controlled for a homogeneous group.
    I liked the structure of group that Bieling et al. outlined and got very little sense of structure from Yalom process oriented groups, for which matters of group composition may be more salient. I was slightly surprised and liked the fact that Bieling et al. ask the group members what their goals are for the session. I’m wondering what kinds of goals these would be, because the group would likely know the therapist has a topic for that day and material to be covered, and how these group goals get integrated into the agenda. I was also wondering how Bieling et al.do a “status check” at the beginning of each session and keep the client’s sharing brief and on topic. With a focused group, like CBT, I imagine that most clients quickly pick up on that it would be inappropriate to launch into a long winded tirade about politics or anything else at this point (or at any point during group). Even in Yalom’s group, I imagine that people may discuss what they are passionate about but when it starts to bore others, they let that person know the discussion needs to move on. However not every client picks up on these social cues and it may be good for them to be in group so that they can learn these social cues, but at what point does that impede the other’s therapy? This group member may become “deviant” and may be harmed by the group therapy experience if he/she experiences the group as growing more indifferent and not accepting towards him/her, without much awareness of how his/her behavior is contributing to that. Ideally this is figured out in the selection process, if there is one.

    Reply

    • Paige Hartmann
      Sep 18, 2014 @ 12:15:17

      Jessica,

      I also wondered what goals that the group members would develop for sessions despite knowing the therapist already has a planned agenda. I think that it is important to assess these goals that the group members establish within each session. Although the therapist already has a plan for each session, the therapist can be mindful of these established goals.

      Reply

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Adam M. Volungis, PhD, LMHC

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