The following is the text of Dr Steinman’s presentation at the ISPS (International Society for Psychological and Social Approaches to Psychosis) 15th annual meeting in Boston, MA, USA on October 16, 2016.
I believe that, in the right hands, an Intensive Psychotherapy of psychotic states can lead to healing and, often, a cure of a previously debilitating condition. By cure I mean the cessation of delusions and hallucinations as they are explored psychodynamically, and a gradual titration off of medication, with the cure lasting—even without continuing psychotherapy.
But these are old-line Intensive Psychotherapeutic views, out of synch with the current brain disease model of schizophrenia and the other psychoses. The field of psychiatry views schizophrenics as suffering from a brain disease but my view, over 45 years of out-patient psychiatric practice, is that most psychotic phenomena are comprehensible within the history of the person. Our therapeutic task is to engage our patients in order to try to illuminate their inner preoccupations and engage in a dynamic psychotherapy aimed at healing and a possible CURE of schizophrenia. Of course, biology plays a part in a patient’s disorganization, and some patients would rather take medication than take a serious look at how they became so disturbed, even if the field of psychiatry did offer much in the way of helping an upset person try to understand his or her psychosis—which it usually does not. But to only medicate and work on social skills is a disservice to patients.
What is required in the treatment of severely psychotic patients is to try to help them understand their own metaphor and symbolism contained in delusions and hallucinations; as cognition improves, medication can often be titrated down and frequently stopped. For some severely disturbed psychotic patients, as I have chronicled in Treating the ‘Untreatable’: Healing in the Realms of Madness,(1) and the more academic Self Psychology and Psychosis: the Development of the Self During the Intensive Psychotherapy of Schizophrenia and the other Psychoses(2), there is hope for healing and sometimes CURE via an intensive psychodynamic exploration. TREATING the ‘UNTREATABLE’ presents a dozen schizophrenic patients, successfully treated with an Intensive psychotherapy, along with a rationale and therapeutic principles for such a psychotherapeutic approach with schizophrenics.
With these profoundly distressed, yet creative and fascinating people, I inquire into the nature of severe distortions of reality and how the patient developed hallucinations, delusions and bizarre phenomena of thought and action. Most importantly, we look at the symbolic meaning of such phenomena, as well as the affective state when various psychotic distortions began. I also look to the origin in the patient’s mind of other persona, usually stuck in some early painful and traumatic series of events. As far as I am concerned a psychodynamic psychotherapy, making use of the concepts of unconscious motivation, resistance to change, transference and countertransference phenomena, and the benefit of interpretation of these occurrences is crucial in the psychotherapeutic treatment of schizophrenia and other psychoses.
In addition, just as there is meaning to dreams, there is symbolic meaning to the patient of his or her hallucinations and delusions, as if they are self-told fantasies and fairy tales; it is our job to help the patient understand his or her own metaphor and symbolism that have taken on the concretized form of psychotic delusions and hallucinations. I’m sure this is what we all do, all of us who aspire to a psychodynamic psychotherapy of schizophrenia and other forms of psychosis. I’m sure that we all try to ferret out the origin of all self-states, of disturbing ideas of reference, painful hallucinations, and delusions. Or at least that is what we all should try to do.
All too often, however, I find that disturbed people have been treated with more and more medication, with less and less of an attempt at elucidating how these states began. It’s not that current practitioners of psychiatry have evil intentions in the treatment of psychosis. It’s not that practitioners are unempathetic to the severely disturbed patients they see. It is much more the case that the field of psychiatry for the last 45 years or so has thought that schizophrenia is a brain disease with an organic and biological basis, Hence — the theory goes — those who suffer from schizophrenia need treatment with “antipsychotic” medication. Under the barrage of Big Pharma advertising and the academic psychiatric establishment having bought into the notion that there is nothing psychological in a psychotic person’s delusions or hallucinations, world-wide psychiatry has capitulated to the biologic and genetic origin school of thought of schizophrenia being a brain disease.
This is a simplistic view. A closer look at the origins of psychotic thinking in people who end up being diagnosed schizophrenic, or psychotic in some other fashion, is that these people are very upset. With anxiety, with intense terror, with withdrawal from the world, comes a cascade of thoughts and swirling neurochemicals that worsen the situation. Of course “antipsychotic” medication can be helpful to quell intense anxiety, but finding out the origin of disturbed beliefs is an all-important task of practitioners with an analytic or psychodynamic bent. Sometimes medication is helpful for that. But generally not as a lifetime treatment. All too often medication, which might help someone calm so that they can look at psychodynamic issues that have played a major part in the development of psychosis, becomes a treatment for life. Of course I use neuroleptic medication if necessary, but generally for a short period of time and at low doses. This use can be during a period of crisis, of intense anxiety or psychotic decompensation into delusional beliefs, alter personalities, hallucinations and bizarre thoughts and feelings. There are many cases that exemplify the type of work that I do; suffice it to say that a large percentage of my psychotic patients respond to psychodynamic exploration, often titrating down and stopping medication.
Let us keep in mind Bockoven and Solomon’s(4) AJP paper from the 1970’s that compared patient groups before the use of “antipsychotics” with those who took them. Those who took them had less initiative and motivation and a poorer prognosis. Nor should we forget Loren Mosher’s 20-year follow-up on patients who didn’t take “antipsychotic” medication; depending on the criteria used, 60-85% showed a good social recovery without drugs.(5) Harrow and Jobe,(6) in a 2007 article, found that a high percentage of patients who refused or stopped the drugs had a higher global level of functioning than those who took them.
If “antipsychotics” work — without causing metabolic syndrome, extreme weight gain, altered glucose and lipid metabolism, and other serious side effects — there may be no problem with their extended use. All too often, though, side-effects occur and patients either suffer them chronically or go off medications, never having learned to recognize and deal with their own inner demons, since understanding of the content and the origin of psychosis is rarely a part of psychiatric treatment.
In 2006, we held an ISPS meeting, Trauma and Psychosis(7), on the traumatic origin of psychosis in Santa Monica. Now, not every case of psychosis appears to have this kind of intense traumatic origin, but quite a number of them do. Certainly, over 45 years of practice I have had many patients who easily fit into that way of looking at psychosis.
Here is a case example of a CURE effected by the use of Intensive psychodynamic psychotherapy in a person repeatedly hospitalized and overly medicated by other psychiatrists for more than seven years. The illustration is similar to many others I have treated successfully and demonstrates how Intensive psychotherapy can heal and sometimes CURE schizophrenic patients. The vignette shows how painful external (and hence internal) events led to dissociation or withdrawal into a world of psychotic thought. Even though this patient had been heavily medicated, and in and out of psychiatric hospital settings repeatedly for more than seven years, psychotic thinking and symptoms ceased only when the origin of psychosis had been understood by the patient and myself, and worked through in the usual psychodynamic psychotherapeutic fashion.
Three Rats and the Extraterrestrial
Lois was a depressed, withdrawn woman in her mid-thirties when she consulted with me. She had a previous diagnosis of chronic paranoid schizophrenia, had been hospitalized several times, and had been treated for the previous seven years with high doses of “antipsychotic” medication. She had lived in a halfway house for the better part of a year, had had extensive daytime hospitalization and other supportive ancillary therapies and now lived alone in a rooming house. She was unkempt, disheveled, clearly preoccupied and hallucinating.
She had been married, but was now divorced. She had given up custody of her children, and had had a persistent delusion for years that three rats were gnawing away at her. She had little contact with anyone except for an old friend of hers who sent her to me. By everyone’s account — previous friends, family, psychiatrists and ancillary staff — she was a burnt-out case.
The diagnosis of chronic paranoid schizophrenia had been made during one of her first hospitalizations, when she told a psychiatrist about the three rats gnawing at her. In failing to help her try to fathom the meaning of three rats gnawing at her, he missed the opportunity to open a pathway to an understanding of Lois’ projected imagination.
People with delusions are beset by images and a concatenation of feelings that it is impossible for them to bear — at least to bear in their current vulnerable state. Hence the delusion; the projection outside of themselves of issues they can’t handle. Like Freud’s notion of the return of the repressed, having to do with issues one has put out of consciousness coming back to bedevil one, these people—perhaps due to a greater imaginative quality, perhaps a poorer synthetic ability, perhaps more pain and trauma in life—project issues outside of themselves.
Projected issues, however, are just that. Like a tethered rubber ball on a paddle, they keep coming back to where they began. The fearful, isolated, lonely paranoid gets the interest and involvement he or she craves, but to a much more heightened and intense extent than anyone could ever desire. In the delusion or hallucination, though, may lie a key to the code of the person’s thinking. Sometimes, it may take years to decipher the meaning of delusions; here it was much simpler and moved very quickly.
Lois presented herself as withdrawn, apathetic and quite noncommunicative. Luckily, her friend had brought in her hospital records. As I tried to get her to talk, I thumbed through the beginning of her copious chart and came across the chief complaint of her first hospitalization: three rats gnawing at her heart. This was the opening I needed, so I asked Lois: “Do three rats gnawing at you mean anything to you?” Needless to say, she hadn’t been asked that question by previous psychiatrists or even thought very much about the meaning of such a powerful image. As usual, since this was early in my years of treating people, I was dumbfounded that she hadn’t been asked about the meaning of her image; unfortunately, though, I was beginning to expect such a reply. What this said about our profession and the way most of us treat schizophrenics and delusional people, I was only beginning to suspect.
I always find it strange that a person can be totally immersed in a terrifying or otherwise very upsetting series of thoughts, or a delusion, and not think much about why they’re having such thoughts or be asked by their psychiatrist what the meaning to them is of such thoughts. How can one gain control over psychotic material if one can’t step back and understand it? How can patient or psychiatrist make sense of bizarre delusions if they never discuss their content and possible meaning?
If you ask the lay person what a psychologically-minded therapist does, he’ll say something like: “help people make sense of their dreams and life and fantasies; maybe, he’ll help the person make sense of the symbols of his creations.” But not so with psychosis. Here we are led to believe that brain disease trumps all and that it is impossible to ferret out the meaning of psychotic phenomena, helping a patient to calm and heal as internal material is understood. So, seven and a half years later, Lois was where she was when she first was hospitalized, in large part because her psychiatrists and other treaters had not engaged her and asked the questions that might have released her from her delusional bondage.
What did the three rats mean? She didn’t know. I had some sense immediately, for she had three children. When did the image begin? It was prior to the long (six month) hospitalization, after the birth of her youngest child, when she couldn’t bear to see her children, felt terribly guilty about being away from them, yet was unable to handle any interaction with them. Frustrated with the lack of any previous psychological treatment for Lois—and being a very young clinician—I quickly asked: “Could the number three relate to your three children, burrowing into you as your own feelings of loss and guilt about not being involved with your three children burrow into you?” She hadn’t thought about such a possibility.
This not having thought about it is a major part of the difficulty in a delusional person. If they did think about it, the meaning would most likely become clear, as did the meaning of the three rats. But the issues involved are, for whatever idiosyncratic reasons, too much. Such a person needs help to understand the meaning of his or her productions, the psychological mechanisms involved and, most of all, to deal with the underlying feelings that led to the formation of delusions. This is why it is essential that the treating psychiatrist or therapist attempt to help clarify the ramifications of illusions and delusions and hallucinations. To not do so, to diagnose and medicate alone, often leaves a patient without a channel to understanding him or herself.
She agreed that the rats might represent her three children gnawing at her feelings. She seemed comforted by this possibility, and much more willing to bring up historical and, — gradually, over a period of several months of twice a week psychotherapy — intra-psychic and emotional material that had persisted for many years. She was an only child of a critical and negative mother and a loving, indulgent father. Her father loved her unconditionally and served as a buffer against the constant jibes and denigrating comments of her mother. Her mother excoriated her; her father extolled her.
When she was seven, she and her father were told by her intimidating, extremely impressive old Russian ballet teacher that she “dances like she comes from another planet.” This served as the seed of a strong fantasy that she came from outer space. If she did come from outer space, this might account for her mother’s criticism and caustic comments. She was sheltered in her father’s love, because he too must come from outer space; her mother must be an earthling, jealous of her extraterrestrial origin. Such a belief comforted her, seeming innocuous enough, but laden with unforeseen difficulty.
When she was thirteen, her father died unexpectedly. She was grief-stricken and had to be hospitalized for a number of months. During those months she did the expected for someone who has broken the bounds of reality. She created not a fantasy, but a delusion, of her father always with her. She had never talked of this to anyone before, neither when hospitalized in her early teens nor during later hospitalizations and other periods of psychotherapy. She felt safe enough to tell me this, perhaps because she had been so frightened of the three rats which we had deciphered, perhaps because she felt we both could speak the same language — the language of understanding the meaning of her delusional imagery.
Since his death more than twenty years previously, her father had been by her side all her waking life. When she passed someone a cup of coffee, she passed him one too. When she went bicycling, he went along on his own bike. Whatever she did, she was accompanied by her much-loved father. He was kept healthy and whole in her delusional reality; as far as Lois was concerned, her father remained vibrant and alive, not mouldering and decaying in the ground.
Long days and nights, when she was apparently alone, were spent immersed in conversation and delight with her lost and protective father. She kept her delusion secret, probably because some part of her knew her father was dead and she didn’t want to disrupt her internal world with the harsh reality that included her continuously sniping and now depressed mother, and the fact that her father had died. She appeared to the world to be recovered from the serious decompensation that had led to her adolescent hospitalization, but internally she maintained a rich and vivid delusional life and constant activities with her father. Externally, Lois appeared to keep it together, enough so that she married in her late teens. In her early twenties, she went further into her comforting delusions of her father when her first husband hanged himself, for no apparent reason other than that he was having a “bad trip” on the psychedelic drugs he was taking at the time. Another sudden and unexpected death reinforced her retreat into delusional reality. Several years later she married a very understanding, solid man who looked after her until she decompensated in the postpartum period following the birth of their third child.
A delusional reality is both fragile and rigid. Patients cling to delusions tenaciously and, once having created delusions, have a propensity to become delusional in every which way. Lois had two very important losses which she attempted to deal with by creating the delusional reality of her comforting father. Now, with her breakdown in her thirties, she developed paranoid delusions that terrified her, in addition to the delusion of the rats gnawing away at her heart. What harm is there in the protective delusion of the father to help an adolescent cope with his death? The harm lies in the increasing propensity to develop all types of delusions, running the gamut from protective and playful to destructive and terrorizing. In the process one’s actual self gets buried under a layer of self-obfuscating phenomena contained within the delusion.
In the telling of her delusions and history, with a little prodding from me about how difficult it was to accept her father’s death, her mother’s neglect and abusiveness, and the other pains of life, she gave up her delusions in the following fashion. She recognized that the belief that she was an extraterrestrial was a way of seeming important and special, as she had seemed special to her ballet teacher, and definitely was special to her father. It was a way to protect her from her mother, and give importance to her existence. The delusion of her father being constantly with her evaporated over a period of about three months, aided by several few day hospitalizations to keep her from harming herself. This was a dangerous time for her, so I kept a very close watch over her, seeing her more frequently for a few weeks, trying to be alert to any potential suicidality; hence the short hospitalizations during this critical time.
To give up this delusion was risky. Not only was it comforting, but she had never mourned her father’s death twenty years earlier. In addition, the fused, psychotic delusional intensity meant that her father meant, if anything, more to her as a delusional figure than as a real and loving person. My experience with delusional people is that they are very creative. Consequently, I wasn’t surprised when Lois found the means to give up the long-held delusion of her father. This was accomplished by the development of a transitional, short term delusion of her three children constantly by her side. In short, she substituted her children for her father in delusion land. (Once open to delusion formation, there is no end to them until one becomes aware of what one is doing.
Rather than being an impediment, though, this new delusion was a flash of inspiration and a therapeutic aid. We were able to talk about her yearning for those she loved, whether father or estranged children. She used delusions as a way of believing she was in contact with loved ones, all the while feeling powerless to actually be in contact with loved ones. Delusions were seen as yearning for those she loved. I suggested that she try to make contact with her ex-husband and become a part of her children’s lives. With this change of focus toward the world, and an emphasis on the means of reconciling with her children—a definite possibility, as opposed to being in touch with her long dead father—the patient gave up all delusions and focused her considerable energy on her children. Without internal delusions taking up her loving vital energy, she was able to relate to her former husband and reestablish a very good and continuing relationship with her children. In addition, she became quite successful at two different careers, neither of which was ballet.
Her twenty-year-long delusional orientation dissolved over a six- to eight-month period. We had talked her language in such a way that her psychic energy could travel outward toward life, instead of incessantly cycling inwardly toward delusion, blockage and death. She finished therapy, over the next two years — off all “antipsychotic” medication — having more than achieved gains she had never dared to hope for. Over some years, she kept in touch by mail, apparently having maintained the gains of an exploratory psychotherapy of delusions, without resort to dramatic and delusional representations of feeling states.
More than thirty years after last hearing from Lois, I was on an NPR radio talk show, discussing “Treating the ‘Untreatable’.” The staff gave me an email from a former patient, saying that our work had saved her life. It was Lois, reaching out after all these years. We talked. She had done very well in life, had re-established contact with her children and had become a hands-on grandmother. She had remarried and had a full life with her third husband of more than twenty years and had survived his death with no retreat to psychosis. She had had a very successful career in her chosen field. Most importantly, there had been no further hallucinations or delusions and no more “antipsychotic” medication. She had learned well that understanding her internal phenomena and fantasies could take the place of a delusional psychotic reality. Her life was returned to her via an intensive psychodynamic psychotherapy.
From my perspective, having been free of delusions and hallucinations and off antipsychotic medication for more than thirty years, she is a prime illustration of Intensive Psychotherapy having CURED schizophrenia. So what have we learned here? We can see how a dynamic psychotherapy of psychosis has yielded not just understanding, but healing — giving up, long-lasting belief systems — and Cure of previously intractable psychotic appearing phenomena. We have seen that an inquiring exploration of the meaning to the patient of his or her hallucinations, delusions and strange thoughts leads to an understanding of the origin of these psychotic distortions of reality. With such an approach, Lois and many others have returned to a life of relationships and function.
How was such a treatment done? It was done via the usual empathic psychodynamic exploration of past events, of transference and countertransference phenomena and of affective states that occurred around the time of the development of symptoms. It is the usual psychodynamic psychotherapy, with the understanding that terrible, traumatic events may indeed have happened, and that intense phenomena may occur during psychotherapy.
Five things are most important.
First is the understanding that there is psychological meaning to the patient of his or her delusions or hallucinations; we have but to explore them in a fashion that allows the patient to integrate the information and to develop an observing self.
Second, and equally important, is the necessity for arriving at what Harry Guntrip called “the lost heart of the self.”(8) Sitting there with a person in this vulnerable state allows inchoate feelings to rise to the surface. Trust gradually develops, and soon the underpinnings of a delusional, hallucinatory, or other psychotic orientation become clear.
Third, it is crucial that the therapist understand that it is possible to peel the onion and get to the origin of the most bizarre and extreme psychotic phenomena. It certainly helps if one has had the experience of previously helping patients heal from schizophrenic and paranoid delusions, via the use of a psychodynamic psychotherapy.
Fourth, we as therapists of patients suffering from psychotic states must take a thorough history of both the patient and his or her psychotic productions. In the exploration, in the taking of a psychological history of how these strange occurrences started, we begin to establish a beachhead from which the patient can begin to observe and understand his or her own distortions and bizarre preoccupations.
Lastly, we must not shy away from those most disturbed and offer little but medication, halfway houses, partial care and daytime activities. We must engage the patient where their attention lies, in the world of psychotic thought. Most importantly, we must learn to speak schizophrenese; to understand and work with the patient’s own metaphor and symbolism, wherever it takes us. Not only does understanding develop, but isolation and alienation succumb to our therapeutic efforts to reach the person using his own language and meaning. Instead of being an isolated hallucinating terrified schizophrenic, he or she feels understood and cared for, no longer alone. As we engage psychotherapeutically and move toward the core of the person and the isolated, withdrawn self, defensive schizophrenic barriers melt and a person emerges. A person emerges quite capable of tremendous insight and change.
Often, clinicians attempt to treat patients such as Lois with the long-term use of “antipsychotic” medication, thereby blunting affect and never allowing the patient to fully explore the emotional and psychological underpinnings of psychotic distortions. The field of psychiatry has turned toward viewing psychotic patients as suffering from brain disease, hence prescribes medication in a far too facile and cookbook fashion. All too often. it is possible to use medications sparingly, often stopping them as the gains of an intensive psychodynamic psychotherapy lead to the exploration and understanding of previously bizarre seeming phenomena. For Lois, a psychodynamic understanding led to healing and the resolution of the previously debilitating delusional state. I would go so far as to say that for Lois, an Intensive dynamic psychotherapy has led to a lasting CURE, without continued medication and treatment after the previous seven years of heavily medicated treatment of schizophrenia left her in a seemingly ‘untreatable’ psychotic condition.
How have things changed in my practice with psychotic patients over the last 45 years? Not very much. If anything, I’m even more convinced of the benefits of psychodynamic exploration in the treatment of psychotic patients. Even back in the early 70s. I found myself looking at various regressive self states and inquiring into how they developed. From a similar four+ decades-long practice perspective, I question people’s delusional beliefs over time and tell them that I understand that they believe these things, but that to me it makes more sense to try to ferret out how such notions began.
As practitioners, we have the option of treating very disturbed psychotic patients with the usual amalgam of supportive psychotherapy and ancillary services, such as day care and repeated hospitalization, coupled with the excessive use of medication. Such an approach often leaves patients in the throes of the psychotic distortions with which they came in, continuing to fear their hallucinations and delusions and continuing to fear those out there who appear to orchestrate giant conspiracies against them. Such an approach often leaves patients consigned to excessive medication, with their lipid and glucose side effects, for life.
I prefer the option of a psychodynamic psychotherapy, with the judicious use of medication, in an attempt to help patients understand the origin of their psychotic symptoms and the meaning to them of their hallucinations and delusions. Such an approach often leads to the cessation of “antipsychotic” medication, healing and CURE of previously unfathomable psychotic dilemmae. Such was the case with Lois.
To my mind, the proper approach to a psychotic patient is to attempt to understand the meaning to him or her of psychotic phenomena. This can be coupled with either a short course of medication or the titration downward of medication, as the patient gains control of previously frightening and poorly understood psychological processes. What was once seen as coming from the outside, as something in the form of voices or delusions, as something over which one had no control, becomes fathomable and understandable, during the course of a psychodynamic psychotherapy of psychosis. When successful, such an Intensive psychotherapeutic approach leads to increasing acceptance and integration of oneself and one’s delusions and hallucinations. Most importantly, psychotic occurrences come under one’s own mastery as one realizes that hallucinations and delusions emanate from previously unconscious material within the self.
Such a psychodynamic approach runs counter to the general run-of-the-mill excessive prescription of medications, but gives the patient a chance to make sense of his psychosis and achieve lasting healing and sometimes CURE. Such was the fortunate outcome with Lois. And such is the possible outcome of an Intensive Psychotherapy of schizophrenia with many other patients.
Which would we as therapists prefer? A heavily medicated, debilitated patient, subject to delusions and hallucinations, overwhelmed by inner demons? Or a patient like Lois, who was that way when she came in, where we speak her language of symbols and metaphor, gradually leading to a CURE off all “antipsychotic” medication? The first leads to stasis, hopelessness and deterioration. An Intensive Psychotherapy may lead, as it did for Lois and many others, to a creative solution and toward a productive life of work and relationships, without debilitating hallucinations and delusions. Using Lois as a teaching example, we can see how an Intensive Psychotherapy of Schizophrenia may lead to a lasting CURE.
* * * * *
I want to thank Karnac Books for allowing the reproduction of material contained in “Treating the ‘Untreatable’: Healing in the Realms of Madness.”
Steinman, I, Treating the ‘Untreatable’: Healing in the Realms of Madness, Karnac Books, London, 2009
Garfield, D., Steinman, I., Self Psychology and Psychosis: The Development of the Self during Intensive Psychotherapy of Schizophrenia and the other Psychoses, Karnac Books, London, 2015
Kohut, H., How Does Analysis Cure?, University of Chicago Press, Chicago, 1984
Bockoven,J., Solomon, L ,(1975) Comparison of two five year follow up studies, American Journal Psychiatry, 132: 796-801
Mosher, L. (1987) Review of Recovery from Schizophrenia: Psychiatry and Political Economy by Richard Warner. Am. J. Psychiatry, 144: 956-957
Harrow, M., Jobe, T. (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. Journal of Nervous and Mental Disease, 195: 406-414
Trauma and Psychosis, International Society for the Psychotherapy of Schizophrenia. US National Meeting, Santa Monica, 2006
Guntrip, H, Schizoid Phenomena, Object-relations and the Self, International Universities press, New York, 1969
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