Psychoanalysis and Dynamic Therapies
PSYCHOANALYSIS AND DYNAMIC THERAPIES•••
The term psychoanalysis, in its narrow sense refers to a method of psychological therapy originally developed by Sigmund Freud around the turn of the twentieth century and now practiced by analysts trained in the intellectual and clinical tradition that has followed Freud. The earliest psychoanalytic investigations led to revolutionary discoveries about the working of the mind, and therefore the termpsychoanalysis refers also, in a broader sense, to the accumulated body of findings and theories about human mental functioning that have resulted from clinical psychoanalysis, and that are available to guide psychoanalysts in continuing their work.
The issue of the ethical implications of psychoanalysis was not one that greatly preoccupied Freud. He considered ethics to be the reflection of the cultural super-ego at a given moment in history, a "therapeutic attempt" to come to terms with human aggression (1930), and would no doubt have regarded the present concern with bioethics in this light. An examination of its principles and practices may help to show how current ethical reflection is relevant to psychoanalysis.
Clinical psychoanalysis is used as a treatment for a variety of psychological conditions, including both specific symptoms and more general personality problems. The treatment involves individual meetings with an analyst, several times per week, over a period of several years. The patient usually lies on a couch and is instructed to say whatever comes to mind (a technique called free association), including symptoms, life events, memories, fantasies, dreams, physical sensations, and feelings about the analyst. The analyst listens to this material, and eventually interprets it as revealing conflicts between emotional forces ("dynamic" conflicts) of which the patient had previously been unconscious. Feelings about the analyst, called transference feelings, are particularly important for this purpose, since these feelings are unconsciously transferred onto the analyst from significant persons in the patient's past, and can be used to interpret and rework current conflicts derived from these past relationships.
Psychoanalytic theory has been continually revised and expanded since its inception. Its earliest form was codified in Freud's major work, The Interpretation of Dreams (1900). In this volume he presented the topographic theory, which emphasized the division of the mind into conscious and unconscious realms, and explained not only neurotic symptoms but also normal phenomena, such as dreams and slips of the tongue, as the results of unconscious wishes breaking through, in disguised and distorted form, into consciousness. Psychoanalytic techniques, such as free association and the use of the couch, were intended to maximize the possibility of such breakthroughs. In this way, unconscious wishes could be interpreted and made conscious, and the symptoms resulting from those wishes could be relieved.
Dreams, errors, and symptoms remain useful sources of interpretable material for the modern analyst, but topographic theory has been subsumed by later theoretical developments. Freud's 1923 work "The Ego and the Id" presented a structural theory, in which the mind includes three agencies: the id, ego, and superego. Each agency has wishes and directions of its own, and they often come into conflict with each other. Neurotic symptoms, as well as character traits, are interpreted as the results of conflicts among these structures, and the goal of analysis is to strengthen the ego, the structure responsible for resolving conflicts within the mind and negotiating compromises between internal wishes and external reality.
Structural theory forms the core of a theoretical tradition known as "ego psychology," one of the dominant schools of thought in modern psychoanalysis, along with object-relations theory and self psychology. Object-relations theory places greater emphasis on the effects of early relationships, most importantly with the mother. It holds that pathological early relationships are internalized and unconsciously repeated, causing problems in later relationships. Self psychology emphasizes the role of early trauma and parental failure in preventing the establishment of a stable and coherent self. Proponents of these theories hold that they are more serviceable than structural theory for the treatment of seriously disturbed patients, those whose pathological early lives prevented the formation of stable mental structures.
The applicability of clinical psychoanalysis is limited by a number of practical and psychological factors. There are many patients for whom psychoanalytic ideas and insights might be useful, but who cannot be treated with clinical psychoanalysis because they cannot afford the time or money required, because they are interested only in more limited treatment for well-circumscribed problems, or because they do not have the necessary psychological resources, such as curiosity about the mind, access to dreams and fantasies, and an ability to tolerate frustration. The term dynamic therapies refers to a variety of psychotherapeutic techniques that have evolved for use in these situations.
The dynamic therapies, which are now considered the treatment of choice in some situations, are similar to psychoanalysis in that they involve regular meetings between patient and therapist in which talking is the primary therapeutic activity, an effort is made to understand the unconscious origins of the patient's problems, the patient's relationship to the therapist is used as an important source of information and a vehicle for change, and the practitioner is guided by psychoanalytic ideas about the working of the mind, including the idea that psychological problems are caused by "dynamic" conflict between unconscious forces. The dynamic therapies differ from psychoanalysis in that they are usually less intensive and involve less frequent meetings, the patient usually sits in a chair facing the therapist, the overall duration of the treatment may be shorter, the treatment may be focused on more specific goals, and the therapist is more likely to use techniques that offer emotional support to the patient as well as exploration of the unconscious. To the extent that the dynamic therapies are derivatives of psychoanalysis, similar considerations of ethics and values apply to both. This article will focus on ethical and value-related issues in psychoanalysis, with the understanding that similar considerations apply to the other dynamic therapies.
Training and Practice
Freud was trained as a neurologist, but most medical psychoanalysts have been psychiatrists. Freud believed that a medical background was not necessary for analysts (1926), and in Europe it has been common for nonphysicians to become analysts. In the United States analysis was for many years seen primarily as a subspecialty of psychiatry, but recently some nonphysicians have been admitted to analytic training.
Training in psychoanalysis begins after the completion of professional school and specialty training, and includes classroom education, a personal analysis of the trainee, and the treatment of several analytic cases under the supervision of senior analysts. Becoming a psychoanalyst involves not only mastering theory and technique but also becoming a member of a nonmedical profession, and accepting that profession's ethical judgments. The psychoanalytic profession's formal organization, the International Psychoanalytical Association, and its component associations, articulate and enforce ethical standards for the profession, as well as standards for training and procedures for certifying the skills of psychoanalysts. However, these bodies have no legal authority and cannot prevent nonmembers from calling themselves psychoanalysts.
The field of psychotherapy is much less organized and regulated. Individuals from many different professional backgrounds are free to call themselves therapists. Those individuals may be answerable to the standards of their own professions, but there is no overarching set of standards for training or ethical practice in psychotherapy.
Clinical Theory Versus Theory of the Mind
Over the decades, psychoanalysis has evolved two related but quite different bodies of theory. The first, "clinical theory," is a set of ideas about how the process of psychoanalysis works and a set of principles about how the analyst should behave. The second, comprising ideas about the working of the human mind that have resulted from psychoanalytic investigations in the past, might be broadly termed a psychoanalytic "theory of the mind"; this body of theory includes ideas about normal development, about the nature and origins of psychopathology, and about the structure and functioning of the mind (a branch of theory termed meta-psychology). For the purpose of ethical analysis, these two bodies of theory present quite different challenges. Psychoanalytic clinical theory strives to remain value-neutral, while the psychoanalytic theory of the mind embodies a host of value-laden assumptions about normality and deviance, health and sickness, and the relationship of the individual to society, many of which have been challenged by critics of psychoanalysis.
Freud argued that psychoanalysis was a scientific method of investigation, and therefore neutral with respect to values (1927). The assertion that clinical analysis is value-neutral is related to the tenet in clinical theory that the analyst is guided by the principles of abstinence (Freud, 1915a) and neutrality (Freud, 1919; LaPlanche and Pontalis). The principle of abstinence enjoins the analyst from indulging in any kind of gratification (for patient or analyst) other than the satisfactions of analysis itself; sexual contact between analyst and patient, extra-analytic friendship, and nonanalytic emotional support are all proscribed.
The principle of neutrality dictates, in terms of structural theory, that the analyst should occupy a position equidistant from the competing forces in the mind (Freud, 1946), analyzing the conflict between them but not trying to influence the outcome of that conflict. In lay terms, the principle of neutrality means that the analyst should not try to influence the patient to adopt any particular set of values, or to conduct his or her life in any particular way; the analyst's job is only to analyze conflicts and remove inhibitions. Neurotic inhibitions limit the patient's freedom, and their successful removal liberates the patient to live however he or she chooses.
The Limits of Neutrality
The attitude of neutrality is not easy to adopt or to maintain. It requires that the analyst first become aware of his or her own values and preferences, unconscious as well as conscious, and then exert a constant and vigilant self-discipline, in order not to let these personal values influence the conduct of analysis. Much of the analyst's lengthy training, especially the personal analysis that he or she must undergo, is directed toward this end. However, it can be argued that absolute neutrality is not possible, even with a thorough personal analysis and a consistent adherence to the principle. The process of psychoanalysis necessarily embodies certain values, both in its selection of patients and in the ideals that inhere in the process itself.
The analyst can adopt the attitude of neutrality only if certain preconditions are met in the patient. Patient and analyst must have a common view of reality, at least in a broad way, for the analyst will probably find it impossible to remain neutral with respect to frankly psychotic ideas. Similarly, if the patient's illness is of the type that produces serious danger to the patient or others, the analyst may be unable to remain neutral with respect to that danger, and may instead intervene to protect the values of life and health, concluding that these medical and therapeutic values take precedence over analytic goals in this situation. In order to adopt an attitude of neutrality, the analyst must also believe that the patient possesses an adequately sound moral character; if the analyst believes the patient to be an evil person, neutrality will be impossible. It is part of the individual analyst's clinical and ethical responsibility to become aware of the kinds of patients with whom he or she has particular difficulty. Thus, some of the preconditions in the selection of patients for analysis embody value-laden assumptions that limit the scope of the principle of neutrality.
Moreover, the process of analysis itself can be seen to embody certain values that are not universally held and deviate from absolute neutrality (Michels and Oldham). Psychoanalysis assumes that insight is a goal worth pursuing; that it is always better to know things, especially about oneself, than not to know them; and that greater knowledge will ultimately lead to decreased suffering. This is a common belief, but by no means an unquestionable one; indeed, the Greek drama on which Freud based much of his theory of the mind, Sophocles's Oedipus Rex, primarily concerns the question whether knowledge or insight is an unmitigated good.
Clinical analysis also embodies the value of individuality; it is a process in which an individual patient spends a great deal of time, energy, and money exploring his or her individual mind and personal history in order, ultimately, to achieve greater individual happiness. This is not to say that relationships with others are neglected, or that the individual is encouraged to promote his or her welfare at the expense of others. However, to members of other cultures, especially non-Western ones, the idea of devoting so much attention to the individual alone, rather than as a member of the group, would seem strange and inappropriate. Thus the principle of neutrality, while central in clinical theory, is limited in its scope; the process requires that patient and analyst share certain value-laden assumptions about the perception of reality, about morally acceptable behavior, and about the importance of individuality and insight.
Limitations on the Analyst's Role
The principles of abstinence and neutrality dictate that the analyst may not assume other roles in the patient's life. As noted above, nonprofessional contacts, such as sexual, social, or business relationships, or exchanging gifts with patients, are inconsistent with analytic abstinence. Certain other professional functions, which might well be beneficial, are still proscribed because they are inconsistent with neutrality, and therefore are not analytic. For example, advising the patient on life decisions or on how to manage relationships with important others, as one might do in a supportive psychotherapy, would constitute a deviation from analytic neutrality. Similarly, certain assessment or advocacy functions, such as testifying on a patient's behalf in a legal proceeding, would violate the analytic role. In certain circumstances, such violations are inescapable or necessary; if an analytic patient becomes suicidally depressed, the analyst may have to intervene in a nonabstinent and nonneutral fashion. However, such a situation is best understood not as an exception to the principles of analysis but as a point at which other values, such as preserving life, override the importance of analysis, and the analyst chooses temporarily to suspend analysis in order to serve other goals.
The Analyst's Obligations
In the broadest sense, the analyst's primary obligation is to give good treatment. In practice, this means ensuring that he or she is well-trained; that his or her skills remain current and consistent with professional standards, by keeping up with the analytic literature and being involved with professional associations; selecting patients for analysis carefully, to be sure that they have the psychological resources necessary for analysis, and that there is no more appropriate treatment for each patient's condition; and conducting the analysis under the guidance of the principles of neutrality and abstinence. By adhering to these guidelines, the analyst will fulfill most of his or her ethical obligations. However, certain obligations deserve particular notice.
COUNTERTRANSFERENCE. Just as the patient in a successful analysis predictably develops intense transference feelings about the analyst, the analyst predictably develops intense feelings about the patient, which are called countertransference. These feelings may be positive or negative, and their specific content will be determined both by the nature of the patient's transference and by the analyst's own history and unconscious dynamics. In any case, countertransference feelings, especially unconscious ones, constitute the most serious challenge to analytic neutrality. The ability to recognize and manage countertransference feelings is both an essential goal of analytic training and supervision, and an ongoing ethical obligation for the practicing analyst.
SEXUAL MISCONDUCT. A very common variety of transference and countertransference involves erotic attraction between patient and analyst. The analyst is under a strict ethical obligation to strive to recognize the transferential origin of this attraction and, in any event, to refrain from acting on it (Freud, 1915a). Sexual contact between doctor and patient is prohibited in general medicine, as stated in the Hippocratic Oath, and in psychiatry, but there are additional reasons for this rule in psychoanalysis. In general medicine and psychiatry, the patient is in a dependent position, and the chance that the patient's needs could be exploited for the doctor's sexual satisfaction is so great that the American Medical Association (AMA) has seen fit to ban sex between physicians and their current patients (Council on Ethical and Judicial Affairs). In 1993 the American Psychiatric Association (APA) went further and stated in their Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry that "Sexual activity with a current or former patient is unethical" (p. 4).
In psychoanalysis, the same argument about dependency and exploitation applies, but another and more encompassing argument exists as well. The conduct of psychoanalysis rests on the proposition that the treatment is conducted in words only, not in action; the patient is free to say or imagine anything, because no action will ensue. If this principle is violated and the patient and analyst act on their erotic attraction to each other, either during or long after the analysis, the credibility of the treatment itself is seriously damaged, and the interests of those who might benefit from analysis in the future are thus harmed. Accordingly, the American Psychoanalytic Association, recognizing that the unconscious is timeless (Freud, 1915b), absolutely prohibits sexual contact between analyst and patient, with no special exemption for a postanalytic relationship (1983).
CONFIDENTIALITY. The analyst's obligation to respect the patient's confidentiality derives not specifically from the principles of clinical psychoanalysis but from the general principle of confidentiality recognized in both physician–patient and therapist–client relationships. However, the principle assumes special importance in psychoanalysis, since the analyst specifically instructs the patient to hold no information back, and thereby acquires the obligation to treat the patient's communications with full respect for privacy.
Psychoanalysis and Social Values: Common Criticisms
CRITICISMS OF THE THEORY OF THE MIND. Many of the value-laden assumptions embodied in the psychoanalytic theory of the mind have been attacked as promoting negative stereotypes and producing destructive social consequences. For example, feminist critics have argued that the psychoanalytic theory of female development and psychology offers a negative view of women as psychologically inferior to men. The argument is based on Freud's early position that women do not experience castration anxiety in the same way men do, and are therefore less likely to develop a rigorous superego. This criticism is generally accurate with respect to Freud's original theory, which was very much a product of the culture in which he lived and his personal predilections. However, psychoanalytic ideas about female psychology and social roles have been extensively revised since that time, with the result that current psychoanalytic theorizing on the subject offers a much fuller, more positive, and more nuanced view of both male and female development and psychology.
Similarly, spokespersons for the gay community have argued that psychoanalysis treats gays unfairly and advances a biased view that homosexuality is invariably a pathological outcome of disturbed development. This criticism could only be directed at organized psychoanalysis after Freud, since Freud himself argued strongly that homosexuality need not be considered a form of pathology (1905). Debate on the subject has been intense over the last decades, involving such questions as whether homosexuality has significant concurrence with certain forms of psychopathology, especially narcissistic disorders; whether the psycho-pathology seen in homosexuals can be understood as a result of familial and social condemnation of biologically determined orientation; whether heterosexuality can or should be a goal of analytic treatment; and whether homosexuals are acceptable candidates for training as analysts. As far as the American Psychoanalytic Association is involved, the issue has been formally settled by a position statement affirming that "same-gender sexual orientation cannot be assumed to represent a deficit in personality development or the expression of psychopathology," and disavowing "efforts to 'convert' or 'repair' an individual's sexual orientation" (American Psychoanalytic Association, 2000; for the history of this debate, see also Bayer).
Another important criticism of psychoanalysis, deriving largely from the circumstances of Freud's personality and culture, is that it is hostile to religion. Freud himself made clear his belief that religion was nothing more than a cultural neurosis (1927). For many years, psychoanalysis and religion saw each other as enemies, but in recent decades this situation has changed. Analysts have come to recognize religion as an important domain of human mental activity, not to be lightly dismissed, and theologians have become increasingly interested in the use of psychoanalytic insights in their thinking and pastoral practice.
The concept of "psychic reality" is both a central tenet of psychoanalytic theory and a source of some important criticisms of that theory. The concept appeared when Freud revised his theory about the role of childhood seduction in causing neurosis; at first, he believed his patients' frequent stories of being sexually abused as children were historically accurate, but later he came to appreciate the psychological importance of fantasies and wishes as capable of producing neurosis even in the absence of actual seduction. Critics have argued that psychoanalytic theory went too far in this direction, presenting a view in which all memories of childhood sexual abuse were dismissed as fantasies, and that this development was responsible for long-standing and widespread denial, until recently, of the extent of actual sexual abuse of children.
Finally, psychoanalysis has been criticized by the antipsychiatry movement as a form of mind control. Spokespeople for this movement are opposed to all psychiatric practice as a tool of social control that imposes on patients a view of reality acceptable to the politically powerful. As a particularly influential form of psychiatric treatment, these critics argue, psychoanalysis is very effective in imposing the analyst's view of reality on the unsuspecting patient. Whether this general criticism is valid or not, the behavior it describes is clearly inconsistent with analytic neutrality and good analytic practice.
CRITICISMS OF CLINICAL THEORY AND PRACTICE. Various ethical objections have been raised against clinical psychoanalysis, concerning both its status as a form of treatment and the effects it has on individuals and on society.
Critics have argued that it is impossible for a patient to give informed consent to analysis, since the patient cannot possibly appreciate beforehand what an exploration of the unconscious will involve. This situation is analogous to other investigative procedures in medicine, in which neither patient nor doctor can know beforehand what will be found, and the patient can be informed only as to the risks and potential benefits of the procedure itself, with the understanding that the findings cannot be predicted. In clinical analysis, the patient's act of giving consent is ongoing throughout the treatment. Opponents of psychoanalysis, including many prominent psychiatrists, have argued extensively that it is unethical to offer a treatment, like psychoanalytic therapy, the value of which has not been demonstrated in controlled statistical studies, when other treatments are available that have been shown by such studies to be effective (Klerman). However, the vast majority of treatments and practices in clinical medicine have not yet been proven effective in this rigorous fashion. The fact that psychoanalysis still awaits such proof requires only that the prospective patient be informed of what is known about the treatment's effectiveness, and of other treatments that might be available.
A related issue arises from a concerted attack on psychoanalysis as science (see, for example, the work of Adolf Grunbaum) that has worked against the support of psychoanalytic treatment in a climate of managed care and health maintenance organizations (HMOs) (Gunderson and Gabbard). One aspect of this problem is the difficulty of research for the purpose of empirical validation in a situation that "allows the presence of no third person" (Freud, 1926). Indeed, some early studies may have crossed the line later to be laid down by committees on experimentation with human subjects (Wallerstein). But the negative effects of outside observers on therapy may have been overestimated (Busch et al.), and comparative studies of dynamic and other therapies for specific disorders seem to promise new support for their effectiveness (Barber and Crits-Christoph).
With respect to the effects of analysis, critics have argued that it discourages spontaneity, encourages dependence and self-centeredness, excuses evil or criminal behavior, and medicalizes human relationships. For the most part, these criticisms describe expectable complications and distortions of the analytic process, or inappropriate applications of analytic principles outside of analytic treatment, rather than the process of analysis as it should be conducted.
The idea that analysis discourages spontaneity by requiring that the patient substitute thought for action presents a common and analyzable distortion of the process. While it is true that analysis requires substituting thought for action during the analytic hour, it does not follow that the patient is expected to behave this way outside the hour. In fact, an inhibition of spontaneity outside of analysis would usually be seen as a manifestation of obsessional pathology, in which thought is substituted for action, or as an enactment of the transference, and in any case as an indication for further analytic work. Similarly, the idea that the focus on oneself required in the analytic hour should extend to the rest of life is a miscarriage of analysis, requiring interpretation and correction.
The argument that analysis encourages dependency results from the fact that a dependent transference toward the analyst commonly develops, since the patient's relationship to important others in the past will often have been a dependent one, or that the experience of a dependent time of life is remembered when regression occurs in the analysis. However, analysis itself neither encourages nor discourages dependency; it encourages only the emergence and resolution of the transference, whatever its content may be. If the patient is reluctant to relinquish this dependent posture, that development is an interpretable distortion. Some varieties of dynamic therapy, in contrast, may encourage dependency as the cost of attaining important therapeutic goals.
Debates about the insanity defense in criminal proceedings have often involved a misapplication of the psychoanalytic principle of neutrality. Critics argue that by trying to make all behavior understandable in terms of the interplay of unconscious forces, psychoanalysis has removed the sense of personal responsibility for behavior. However, as described above, the principle of neutrality is employed only in a very specific setting, the psychoanalytic hour, and only with a well-selected population and for a specific limited purpose. Analysts do not encourage the adoption of an attitude of neutrality outside of clinical psychoanalysis (Gaylin).
The argument that psychoanalysis tends inappropriately to medicalize problems in human life and relationships is based partly on a peculiar historical association between analysis and medicine. Freud was a physician, as were his earliest disciples, but the psychoanalytic movement in Europe rapidly expanded to include nonmedical practitioners. In the United States, analysis has been dominated by the medical profession, though the 1991 decision of the American Psychoanalytic Association to approve full training for nonmedical candidates presages a significant increase in the proportion and influence of nonmedical analysts in the United States. The distinction between prescribing analysis and conducting analysis may be useful in elucidating the proper relationship between medicine and analysis. The act of prescribing psychoanalysis as the treatment of choice for a particular patient is a medical act, since it requires diagnosing the patient's problem and knowing the possible alternative treatments; but the act of conducting the analysis, while it requires good clinical judgment, does not require medical knowledge or training.
Finally, psychotherapeutic practices have come under scrutiny because of a widespread feeling that medicine in general and psychiatry in particular have paid insufficient attention to the real needs and sensitivities of patients as individual human beings. This feeling has been articulated in part by advocacy groups like the National Alliance for the Mentally Ill (NAMI), but has also been evidenced in independent critiques of the profession by writers who have claimed that it is out of its depth and "omits the moral dimension of living" (Lomas) or that it is in disorder and desperately needs a "culture of responsibility" (Luhrmann). Such manifestations of the moral and social preoccupations of the current cultural epoch can only be welcomed; they represent challenges that it is in everyone's interest to meet openly and honestly.
PUBLIC-HEALTH ISSUES. Some criticisms of psychoanalysis contend that it is a luxury for the rich, is suitable only for a tiny minority of the most prosperous and least disturbed members of society, and consumes a vast amount of medical resources that could be put to better use meeting the needs of the poor and the seriously mentally ill. Psychoanalysts offer several rebuttals. First, it is not true that the problems of psychoanalytic patients are trivial; while analysis does require certain particular psychological strengths, patients in analysis can be seriously impaired and genuinely suffering in many ways, and analysis can provide significant relief to them. Second, the benefits of psychoanalysis extend well beyond the patients who are treated with full analysis. Many other forms of treatment, including the dynamic therapies and even pharmacotherapy and general medical treatment, can be rendered more effective if the practitioner understands and makes use of psychoanalytic insights about human motivation. Finally, analysts recognize that few individuals can afford to pay a standard psychiatric fee several times per week over many years, and many analysts are willing to reduce their fees to enable a wider range of people to benefit from psychoanalytic treatment. These financial problems could be mitigated if systems of reimbursement paid fairly for cognitive and interpersonal services in comparison with surgical and invasive procedures. But such decisions are usually governed by political and economic concerns rather than by ethical imperatives.
Until the 1960s, psychoanalysis was the dominant theory and psychoanalytically derived therapies were the most common treatment in the mental health professions. Since then the dominance has waned, partly as a result of economic forces leading to the development of briefer treatments, and partly as the result of the rise of biological psychiatry and the development of effective pharmacologic treatments. In recent decades only a small fraction of psychiatrists have chosen to become psychoanalysts, and only a small fraction of patients are treated with full psychoanalysis. However, the influence of analytic theories and findings continues to be felt throughout the fields of psychiatry, psychotherapy, and medicine. It is likely that there will remain a population of patients who have problems of sufficient breadth and depth, and who can support its financial costs, who will choose psychoanalysis and its related therapies as their treatments of choice.
kevin v. kelly (1995)
revised by peter caws
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