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The Assessment of
Mentalization
Patrick Luyten, PhD
University of Leuven, Belgium
University College London, UK
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Pretend
Mode
Psychic
Equivalence
Teleological
Mode
Temporary Failure of Mentalisation
Unstable Interpersonal Relationships
Affective Dysregulation
Impulsive Acts of Violence, Suicide, Self-Harm
Psychotic Symptoms
Figure 2.x Understanding BPD in terms of the suppression of mentalization
Pseudo
Mentalisation
Concrete
Understanding
Misuse of
Mentalisation
Why important?
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Overview
Theoretical considerations
Clinical assessment of mentalizing:
the mentalizing profile
Structured assessment of mentalizing
Therapeutic implications
Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment
of mentalization. In A. Bateman & P. Fonagy (Eds.), Handbook of
mentalizing in mental health practice (pp. 43-65). Washington, DC:
American Psychiatric Association.
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The formula to understand women
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Team Psychoanalysis Unit London (UK): Peter
Fonagy, Anthony Bateman, Mary Target
UPC Kortenberg (België): Rudi Vermote, Benedicte Lowyck, Yannic Verhaest, Bart Vandeneede
Yale University (USA): Sidney J. Blatt, Linda Mayes, Helena Rutherford, Michael Crowley
Psychoanalysis Unit Leuven: Nicole Vliegen, Liesbet Nijssens, Naouma Siouta, Tamara Ruijten
University of Durham (UK): Elizabeth Meins
Viersprong & MBT consortium The Netherlands
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Some Theory…
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What is mentalizing?
Mentalizing is a form of imaginative
mental activity about others or oneself,
namely, perceiving and interpreting
human behaviour in terms of
intentional mental states (e.g. needs,
desires, feelings, beliefs, goals,
purposes, and reasons).
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What is mentalization? It is a capacity we use all the time
It is what we need:
To collaborate
To compete
To teach
To learn
To know who we are
To understand each other and ourselves
Is fundamental in our ability to navigate the
social world
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Mentalizing is multi-dimensional:
Four polarities
Automatic – controlled
Internal – external
Self – other
Cognitive - affective
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based
approach to the understanding and treatment of borderline personality disorder.
Development and Psychopathology, 21(4), 1355-1381.
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Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychological understanding drops and is
rapidly replaced by confusion about mental
states under high arousal
That handkerchief which I so loved and gave thee
Thou gavest to Cassio.
By heaven, I saw my handkerchief in's hand.
Controlled Automatic
Arousal
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Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Arousal
Psychotherapist’s demand to explore issues
that trigger intense emotional reactions
involving conscious reflection and explicit
mentalization are inconsistent with the
patient’s ability to perform these tasks when
arousal is high
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That handkerchief which I so loved and gave thee
Thou gavest to Cassio.
By heaven, I saw my handkerchief in's hand.
Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Controlled Automatic
Lateral PFC Medial PFC
Lateral
temporal
cortex
Amygdala Ventromedial PFC
Arousal
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Dimensions of mentalization: internally vs externally
focused (mental interiors vs visible clues)
Internal External
I wonder if he feels
his mother loved
him?
He looks tired;
perhaps he slept
badly
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With selective loss of sense of mental interiors, external features
are given inappropriate weight and misinterpreted as indicating
dispositional states
You’re covering your eyes; you can hardly bear to look at me
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Dimensions of mentalization: Cognitive vs
affective mentalization
Agent attitude
propositions
“I thought that Rutten would
succeed in forming a
proper government”
Associated with several
areas of prefrontal cortex
Cognition Emotion
Self affect state
propositions
“I feel sad about it too”
Associated with inferior
prefrontal gyrus
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Mentalize This! Ik denk niet dat het makkelijk
zal worden, maar we komen er
wel!
Maar ja,
zonder
mij zal
het toch
niet
lukken
Ik zal alles
doen om dit
te laten
slagen
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With diminution of cognitive mentalization the logic of
emotional mentalization (self-affect state proposition)
comes to be inappropriately extended to cognitions.
“I feel sad, you must have hurt me”
Dimensions of mentalization: Cognitive vs
affective mentalization
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Mentalize This! Oh nee, wat
zal mijn
moeder nu
zeggen Mijn vader
heeft altijd
gezegd dat ik
niets kon
Ik voel me zo
rot
Wij voelen
ons allemaal
rot
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Implicit-
Automatic
Explicit-
Controlled
Mental
interior
focused
Mental
exterior
focused
Cognitive
agent:attitude
propositions
Affective
self:affect state
propositions
Imitative
frontoparietal
mirror neurone
system
Belief-desire
MPFC/ACC
inhibitory
system
BPD
BPD
BPD
BPD
Mentalizing Profile of Prototypical BPD patient
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Assessment of
Mentalization
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Pretend
Mode
Psychic
Equivalence
Teleological
Mode
Temporary Failure of Mentalisation
Unstable Interpersonal Relationships
Affective Dysregulation
Impulsive Acts of Violence, Suicide, Self-Harm
Psychotic Symptoms
Figure 2.x Understanding BPD in terms of the suppression of mentalization
Pseudo
Mentalisation
Concrete
Understanding
Misuse of
Mentalisation
Why important?
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Clinical Strategy to Assess Mz
2-3 clinical interviews
Essential components:
Demand questions explicitly probing for
mentalization
Exploring mentalizing in specific
relationships and high arousal contexts
Exploring mentalization with regard to
symptoms and complaints
Attention to interpersonal process: self-
correcting tendency of Mz and ability to allow
the clinician to correct mentalizing lapses
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General Strategy
Assess general mentalizing abilities
Assess specific mentalizing abilities:
Mentalizing profile based on polarities
Non-mentalizing modes
Individual differences in attachment
Allows to predict what is likely to happen in
treatment
Tailoring of interventions
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Demand questions that can reveal
quality of mentalisation
why did your parents behave as they did during your childhood?
do you think your childhood experiences have an influence on who you are today?
did you ever feel rejected as a child?
in relation to losses, abuse or other trauma, how did you feel at the time and how have your feelings changed over time?
have there been changes in your relationship with your parents since childhood?
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Elaboration of interpersonal event
Thoughts and feelings in relation to the event
Ideas about the other person’s mental state at turning points in narrative
Elaborate on actual experience
Reflecting on reconstructed past
Understanding own actions (actual past and reflection on past)
Counter-factual follow-up questions
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Interpersonal interaction
Last night Rachel and I had an argument
about whether I was doing enough around
the house. She thought I didn’t do as much
as her and I should do more. I said I did as
much as my work obligations allow. Rachel
got angry and we stopped talking to each
other. In the end I agreed to do the
shopping from now on. But I ended up
feeling furious with her
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What does non-mentalizing look
like?
Excessive detail to the exclusion of
motivations, feelings or thoughts
Focus on external social factors, such as
the school, the council, the neighbours
Focus on physical or structural labels
(tired, lazy, clever, self-destructive,
depressed, short-fused)
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What does non-mentalizing look
like?
Preoccupation with rules, responsibilities,
‘shoulds’ and ‘should nots’
Denial of involvement in problem
Blaming or fault-finding
Expressions of complete certainty about
thoughts or feelings of others (“I just know”)
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What does good mentalizing look
like?
In relation to other people’s thoughts and feelings
Acknowledgement of opaqueness
Contemplation and reflection
Perspective taking
Genuine interest
Openness to discovery
Forgiveness
Predictability
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What does good mentalizing look
like? Perception of own mental functioning
Appreciation of changeability
Developmental perspective
Realistic scepticism
Acknowledgement of pre-conscious function
Awareness of impact of affect
Self-presentation (e.g. autobiographical continuity vs. identity diffusion)
General values and attitudes (e.g. tentativeness and moderation)
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What does extremely poor mentalizing
look like? Anti-reflective
hostility
active evasion
non-verbal reactions
Failure of adequate elaboration
Complete lack of integration
Complete lack of explanation
Inappropriate
Complete non-sequiturs
Gross assumptions about the interviewer
Literal meaning of words
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Assessment of mentalization
Distinguish four main types of problems - not
mutually exclusive; more than one may apply to
the same person
Concrete understanding
o Generalised lack of mentalising
Context-specific non-mentalising
o Non-mentalising is variable and occurs in particular contexts
Pseudo-mentalising
o Looks like mentalising but missing essential features
Misuse of mentalising
o Others’ minds understood and thought about, but used to hurt,
manipulate, control or undermine
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Concrete understanding
General failure to appreciate feelings of self or others as well as the relationships between thoughts, feelings and actions
General lack of attention to the thoughts, feelings and wishes of others and an interpretation of behaviour (own or others) in terms of the influence of situational or physical constraints rather than feelings and thoughts
May vary markedly in degree
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Context Specific - Relational
Dramatic temporary failures of
mentalisation
“You’re trying to drive me crazy”
“You hate me”
‘I can’t think once she starts on me’
Particular problem in family/group therapy!
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Pseudo-mentalising subtypes
Intrusive mentalising Opaqueness of mental states not respected
Thoughts and feelings talked about, may be relatively plausible and roughly accurate, but assumed without qualification
Overactive-inaccurate mentalising Lots of effort made, preoccupation with mental states
Off-the-mark and un-inquisitive
Destructively inaccurate Denial of objective reality, highly psychologically
implausible mental states inferred
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Misuse of Mentalizing (1)
Understanding of the mental state of the
individual is not directly impaired yet the way
in which it is used is detrimental
May be unconscious but is assumed to be
motivated
Self-serving distortion of the other’s feelings
Self-serving empathic understanding
A person’s feelings are exaggerated or distorted
in the service of someone else’s agenda
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Misuse of Mentalizing(2)
Coercion against or induction of the thoughts
of others
Deliberate undermining of a person’s capacity
to think by humiliation
Extreme form is sadistic or psychopathic use of
knowledge of other’s feelings or wishes
Milder form is manipulation for personal gain
o inducing guilt
o engendering unwarranted loyalty
o power games
o Understanding used as ammunition in a battle
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Non-mentalizing modes
Teleological mode
Psychic equivalence mode
Extreme pretend mode
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Teleological mode Behavior and thought/intentions are
equated
Primacy of the physical/observable
“I only believe you when I see it”
Extra sessions
Need for physical contact
Yawning means you are bored of me
Going on holiday means you want to get rid of
me
Only what you see is real
Doubts about honesty/hypocrisy
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Gergely, G., & Csibra, G. (2003). Teleological reasoning in infancy: The
naive theory of rational action. Trends in Cognitive Sciences, 7, 287-292.
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Psychic equivalence
What is thought is real
Everything becomes too real (e.g.,
thoughts, feelings, lying on the couch)
Decoupling of Mz or de-symbolization
(concreteness of thought): Rejection
literally hurts (Eisenberger et al., 2003)
Very painful feelings of shame, sadness,
emptiness, badness, which threaten to
disintegrate the self -> evacuation by
means of projection, dissociation, self-harm
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Extreme pretend mode Hypermentalization
Mentalization severed from reality (“the
educated neurotic”, “canned language”)
Elaborate, often highly cognitive, or
affective overwhelming, confusing
narratives (e.g., on TAT, Rorschach)
Dissociation/”driving oneself crazy”
May lead to wrong impression of
therapeutic work and progress/indication
for insight-oriented treatment
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Creating a Coherent Self-representation by Controlling
and Manipulation – Hyper-activation of Attachment
Attachment
figure
Self experienced
as incoherent
Alien part of self Self representation
Self experienced
as incoherent
Externalization
Through coercive, controlling behavior the individual with
disorganized attachment history achieves a measure of
coherence within the self representation
Attachment
figure
Self experienced
as coherent
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Individual Differences
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A biobehavioral switch model of the relationship
between stress and controlled versus automatic
mentalization
Attachment - Arousal/Stress
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Attachment history determines
Setting of switch
o when controlled Mz switches to automatic Mz
Steepness or slope of change
o how extensive the switch is
Time to recovery from switch
=> Determines affect/stress regulation
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Adult Attachment Interview coding system (Main & Goldwyn, 1994)
• Autonomous [secure]
▫ coherent: undefended access to consistent memories and judgments
▫ believable
▫ value attachment and acknowledge impact
• Dismissing [avoidant]
▫ can’t remember / idealise / devalue
• Preoccupied [resistant]
▫ entangled in angry / passive / fearful associations
• Unresolved with respect to trauma [disorganised]
▫ slips, contradictions, gaps, reliving of trauma
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Attachment security
High threshold for switching under stress
Fast recovery
Ability for simultaneous activation of ATT
system and Mz system
Associated with effective affect/stress regulation
Leads to so-called “broaden and build” cycles
associated with attachment security
(Frederickson, 2001)
o Security of internal mental exploration, even under
stress
o Ability to ask others for help = relationship-recruiting
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Attachment hyperactivation
Lowered threshold for attachment activation
and thus switch
Longer time to recovery
May explain typical pattern of
o Fast attachment to others
o But to unreliable others because of deactivation of
controlled mentalization
o Hypervigilance to emotional states in others
o Hypo-hypermentalization cycles (overly trusting-
overly distrusting)
o Through negative feedback: increasing
hyperactivation of the ATT system and lowered
threshold for decoupling of Mz
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Hyperactivation and Maltreatment
DISTRESS/FEAR
Exposure to maltreatment
Proximity seeking
Activation of attachment
The ‘hyperactivation’ of the attachment system
Adverse Emotional Experience
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Trauma and Mentalizing
Frightening/frightened states of mind of
caregivers
Lead to defensive inhibition of mentalizing
about caregivers’ mental states
Leads paradoxically to
hypervigilance/hypersensitivity to mental
states in others
But dominated by non-reflective
assumptions about the mind of others
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Attachment deactivating strategies
Resembles secure attachment on first
impression
High mentalizing, even under stress
but often hypermentalization =
mentalization “on the loose”
The “educated neurotic” that uses “canned
language”
Collapses under increasing stress
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Failure of defense mechanisms
under increasing cognitive load
*Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the
psychodynamic approach to personality. Journal of Research in Personality, 39, 22-45.
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Disorganized attachment
Particularly maladaptive mix of
hyperactivating and deactivating strategies
Leading to hypermentalization-
hypomentalization cycles
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Relationship-specific nature of
mentalizing!
Mentalizing is interpersonal: can patients
allow co-regulation of mentalizing and affect?
Different profiles/switch points in different
relationships
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Immediate therapeutic
implications
Finding optimal balance between ATT
activation and Mz
Tailoring interventions to patients
In hyperactivating patients, failure of Mz
easily ensues: emphasis on insight or deep
interpretations, especially in early phases,
probably counterproductive
In deactivating patients: risk of
pseudomentalization
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Threshold for switch Strength of automatic response
Recovery of controlled mentalization
Secure High Moderate Fast
Hyperactivating Low: Hyperresponsivity Strong Slow
Deactivating Relatively high: Hyporesponsive, but
failure under increasing stress
Weak, but moderate to strong under increasing
stress
Relatively fast
Disorganized Incoherent: hyperresponsive, but
often frantic attempts to downregulate
Strong Slow
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Implicit-
Automatic
Explicit-
Controlled
Mental
interior
focused
Mental
exterior
focused
Cognitive
agent:attitude
propositions
Affective
self:affect state
propositions
Imitative
frontoparietal
mirror neurone
system
Belief-desire
MPFC/ACC
inhibitory
system
BPD
BPD
BPD
BPD
Mentalizing Profile of Prototypical BPD patient
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Ordinary/Average
Low
High
Very Low
Very High
Internal External
Self Other
Cognitive Affective
●
●
●
●
●
● ●
●
●
●
●
●
Legend:
= Typical mentalizing profile for Borderline Personality Disorder
= Typical mentalizing profile for Narcissistic Personality Disorder
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Implicit-
Automatic
Explicit-
Controlled
Mental
interior
focused
Mental
exterior
focused
Cognitive
agent:attitude
propositions
Affective
self:affect state
propositions
Imitative
frontoparietal
mirror neurone
system
Belief-desire
MPFC/ACC
inhibitory
system
Impression driven
Appearance
Certainty of emotion
Treatment vectors in re-establishing mentalizing
Controlled
Inference
Doubt of cognition
Emotional contagion Autonomy
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Structured assessment
of mentalization
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Selective Trust!
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Approaches to measure Mz
(Parental) Reflective Functioning is typically
measured based on interviews
Adult Attachment Interview (AAI)
Child Attachment Interview (CAI)
Parent Development Interview (PDI)
Pregnancy Interview (PI)
Working Model of the Child Interview (WMCI)
Limitations:
Time and cost-intensive
Mostly uni-dimensional
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Score
on RF
Scale
Description
Moderate to high RF
9
Full or Exceptional
Interviewee’s answers show exceptional
sophistication, are surprising, quite
complex or elaborate and consistently
manifest reasoning in a causal way using
mental states
7
Marked
Numerous statements indicating full RF,
which show awareness of the nature of
mental states, and explicit attempts at
teasing out mental states underlying
behaviour
5
Definite or Ordinary
Interviewee shows a number of instances of
reflective functioning even if prompted by
the interviewer rather than emerging
spontaneously from the interviewee
Negative to limited RF
3
Questionable or Low
Some evidence of consideration of mental
states throughout the interview, albeit at a
fairly rudimentary level
1
Absent but not Repudiated
Reflective functioning is totally or almost
totally absent
-1
Negative
Interviewee systematically resists taking a
reflective stance throughout the interview
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Multi-dimensional assessment with RF-
scale is possible:
Specific issues (eg trauma and loss) on the
AAI (Berthelot, Ensink et al., 2012)
Symptoms (e.g. Rudden et al. 2009)
Specific attachment figures (e.g. Diamond et
al. 2003)
Yet:
remains time/cost-intensive
Remains “off-line” measure <---> “on-line”
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Assessment of mentalization polarities
Various proxies of mentalizing exist
Different “off-line” and “on-line”
measures can be used an adapted
Multi-dimensional appraoch provides a
guide to measurement selection and
development
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Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment of mentalization. In A. Bateman & P. Fonagy
(Eds.), Handbook of mentalizing in mental health practice (pp. 43-65). Washington, DC: American Psychiatric
Association.
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