[Original Voices: Genre]
By Rika Ikuno
Based on the assumption that the phenomenon of music therapy can be conceptualized as unique and expanding “meaningful experiences,” not limited to intervention-effect structure, the multi-layered values of the “meaningful experiences” are investigated.
The narrative story by the therapist, written as a part of the case study, is used as the analysis materials; the “meaningful experiences” by the therapist are categorized into the five value aspects of sharing norms from mainstream culture, development desired, Client’s intrinsic Self, dialogical interrelationship, and co-existing contraposition. Each aspect is interpreted by further classifying into the sub-categories. As the conclusion, I discuss “overview of the interplay of the five value aspects,” “meanings emerged in the mutuality of the field,” and “circular, mutually-influence perspective on therapy” Lastly, perspectives in future formal research are suggested.
Keywords: therapeutic relationship, developmentally delayed, multi-layered meaningful experiences, synchronic space, diachronic story
The purpose of this paper is to explore the multilayered values of “meaningful” experiences perceived by the participants in music therapy sessions, using the example of a 6-year process with a child who has profound developmental delays. The study was motivated by my long-term theme: The phenomenon of music therapy cannot be fully discussed merely from the intervention-effect structure such as “medical treatment,” “education,” or “training” aiming at the clients’ adaptation to the existing society. Instead, there seems to be unique and expanding “meaningful experiences”, which significantly affect the quality of participation by clients as well as therapists. These “meaningful experiences” also have a great impact on the intervention-effect, and it is not my aim to criticize the conventional structure of intervention-effect. Rather, I intend to give a perspective from a different angle.
Such an attitude is particularly important in this evidence-based medicine age when the importance of proving the effect is globally emphasized. Aldridge (2003) states: “The evidence-based medicine needs a counter balance, not against the concept but to counter the idea that such a perspective is the only legitimate perspective to inform practice delivery (p.5).”
The concepts capturing music therapy not limited to “intervention and effect” can be found in several scholarly works. Bruscia (1998) suggests the concept of health as a process, which defines health in three ways. Firstly, health “is holistic, going beyond the body to include mind and spirit,” secondly, “exist along a multidimensional continuum of constant change, ranging from unhealth to health,” and thirdly, “is not something we have, [but] is an active process and our very way of being in that process (p.84, Japanese translation p.90-91.)” Aldridge (2003) points out that “there has been a shift of interest in the concept of disability from an emphasis on biological impairment to the unique experiences of the sufferers (p.7),” and writes “[music therapy] is not an isolated discipline but an agglomeration of concepts taken from a variety of fields,” therefore it involves not only “Western medicine, but also from folk or traditional medicine and modern understandings of psychotherapies and creative arts therapies (p.9). Kenny (1989) sees the therapy process as “two aesthetics of therapist and client merg(ing)” in “an intimate space based on the relationship.” It should be noted that her diagram shows therapist and client as two equal circles merging , instead of showing client at the center with therapist intervening (p.75-82, Japanese translation p.100-106). Stige (2002) suggests a “transactional perspective” with a case example, that development of a child client occurs not only by individual adjustments or environmental adjustments, but by both therapist and child adjusting and changing (p.135-148, Japanese translation p. 183-198). He describes the therapy process as ”learning in relationship,” which he calls “enculturation (p.43, Japanese translation p.75).” From these thoughts, we can imagine gradual shifts in conceptualizing therapy from the ever improving straight line of symptoms and the dualistic structure of intervening therapist and intervened client.
Given these considerations, I became interested in “the meaningful experiences” perceived in the clinical field, since actual sessions proceed and continue by these experiences. In my article, I attempt to explore the meaningful experiences perceived by the therapist in 136 music therapy sessions through a 6-year course of music therapy.
The client in this case is a girl who has profound developmental delays and partial sight due to Down’s syndrome. Her verbal vocabulary was limited to a few words throughout the 6 years, and she did not walk independently until 10 years old even though she had no physical impairment. On the other hand, she showed significantly strong will and receptive/expressive actions in music; and she has spent most of the time at home playing with her electric keyboard and listening to the surrounding music. She enthusiastically participated in the individual music therapy sessions, 40-60 minutes each during the 6–year elementary school period, but she was hesitant to accept the therapist’s direct intervention with the obvious developmental goals.
I would like to start by describing the reasons why I chose this case as study material. First, let us turn our eyes to a general situation when we meet those who are atypical in their nature. Having close contact with those who are atypical often teaches us the essentials of what it means to be a human being more deeply and clearly than with those who are typical. Likewise we sometimes see through the essentials of music therapy better in the clients who have difficulties in their progress, are stuck in recursive problems, or even decrease their surface health, than those who do well in their instant effects.
This particular case is characterized by 1) extremely limited verbal communication ability, 2) strong and active enthusiasm for music, 3) hesitancy to accept many of the interventions planned by the therapist, which resulted in the co-initiated process between therapist and client. In other words, the clinical process of this case was so complicated that it could not be fully grasped just through the “immediate effects of the therapeutic intervention,” while the existence of music was fundamental and all the participants including the client herself were strongly motivated to continue the music therapy sessions for her wellness. So I regard this case to be appropriate for exploring “the unique and expanding meanings” of the music therapy phenomenon, as described above.
I define ”Wellness” in this therapy as follows: “The client’s sense of well-being at the realistic level” which includes physical, cognitive, emotional and social aspects as well as relationship with the environment. It does not aim at the instant achievement of developmental tasks or the decrease of atypical behaviors, isolated from her whole being.
Music therapy clinicians often talk about “the meaningful moments” on a daily basis with expressions like “I was strongly impressed,” “We were mutually awakened,” “I felt something meaningful that cannot be put in words,” and so on, some of which directly relate to the clinical effects, some do not. However, they are regarded as something we cannot logically rely upon or convince others regarding the veracity of these claims. Consequently, there are not enough academic discussions about this kind of experience. So we tend to focus only on the obvious developmental effects.
Another difficult side of “meaningful” is that it reflects slightly different aspects according to individual, cultural, and historical contexts. I would like to position the ”meaningful” in this study, quoting the concepts of Amir and Stige as the bases of discussion.
Amir (1992) attempts an analysis of “meaningful moments” in music therapy sessions based on interviews with music therapists and clients. The present article shares the common concepts with Amir’s in the following points: it is the standing out events, both inter- and intra-personal between the therapist and the client; it has a great influence on the process of therapy; it is something “felt” by them but not to be measured or stipulated.
On the other hand, they are different in some ways. In Amir’s study (1992), the meaningful moments are regarded as the therapeutic goals or the direct trigger for them. A “meaningful moment” seems to be a special “moment” in a different dimension brought by the therapist’s professional abilities or something beyond. Also her notion of meaningful moments seems to largely reflect the value system of humanistic psychology such as “ joy,” “beauty,” “transformation,” “true self,” “spiritual”, “freedom,” and so on (p. 56-59).
Although this article does not necessarily oppose Amir’s position, the “meaningful experiences” that it focuses upon are more from daily and ordinary perspectives. They are a series of small awarenesses constantly occurring in the sessions, which are the daily food to determine the therapy direction and to keep it going. The therapist would rather lower the “treatment” bindings which predetermine the way human beings should be and the client to be led, and would create the direction by finding the “meanings” born between the particular therapist and the client, trying to experience them deeply. In other words, “meaningful” here is not something given or something for which the therapist strives, but something born in the mutual and realistic relationship.
In the interview about “meaning in music therapy” conducted with Amir by Stige (2001), he poses the question, “who is the privileged reader of meaning, is it the therapist or is it the client?” He also puts a question based on his two concepts of meaning, “which is given, and you have to kind of search for it,” or “that everything has the potentiality for us to be used and created meaning out of it (p.216). “ Here he seems to be questioning the conventional therapy forms that are often one-sided relationships premised on the universal goals selected by the therapists, suggesting that Amir’s concept might be on similar track in a different manifestation.
As mentioned earlier, Stige (2002) attempts to define therapy as “learning in relationship, that is, as enculturation and accumulation of cultural knowledge about oneself and the world 〔mutually by the client and people around including therapist〕.” This perspective is closer to my study in than Amir’s study in terms of co-structured meanings. However, this article does not focus on the conflict among the multi-dimensional meanings that belong to each participant. Rather, its focus is on the meanings experienced by the therapist, as a symbol of collective consensus spontaneously formed in the field. I will discuss this point again at the end of article.
To summarize, “the meaningful” experiences in this study are the interpretation of the events remembered with deep impressions by the therapist working in the setting toward the client’s “wellness”. However in this regard, they do not merely belong to the therapist as an individual person, but reflect the collective meaning as it emerges in the field. Here, so-called developmental progress and therapeutic effects naturally have a great impact, but are not limited to them. In addition, they include not only what gives the “positive” impressions, but also disappointments, unexpected impressions, conflicts and so on.
The purpose of this study is to shed light on the “meaningful” experiences in a long-term music therapy practice with a child with profound developmental delays.
I use data from a narrative story written by the therapist as a part of the case study “Ongaku o Mini Matotta Kodomo ［a child who puts music on her］ (Ikuno, in press)”. The overview of the procedure of assembling the narrative story is as follows:
In this narrative material, the events I capture as “meaningful experiences” are categorized under similar features as “value aspects.” Next, the subcategories of the value aspects are formed, and interpret the quality of the experiences.
I have been given the parent permission to keep the written and visual records of the clinical practices with this child, to study them and to publicize the studies under the privacy protection. They have also approved the content of this study.
~Meaning of being able to/ not being able to understand the client through the premises of abled society, or revising the understanding structure~
Reviewing the 6-year narrative story from the perspective of “meaningful” experiences, what emerges as the most superficial part is the value aspect based on the premises of a non-disabled society. This value aspect is classified as follows.
The value aspect of sharing norms from the mainstream culture is born from the assumption of positioning the disabled child at the edge of non-disabled society. The representative of the non-disabled society is the therapist herself, and she consciously/unconsciously tries to include the client in the non-disabled society represented by the therapist. It might sound like an overly unprofessional discussion regarding the therapist, but nobody can completely remove her own value system, worldview, and the comprehending frame, even in the therapy setting. As a result, understandable actions of the client are naturally experienced as meaningful by the therapist; but there is always a risk that the negative form of countertransference arises unexpectedly as her inner needs are reflected.
On the other hand, there is a long period of time throughout the course of the sessions with this profoundly disabled client that the therapist cannot comprehend even with her professional knowledge. These experiences give the therapist discomfort and an isolated feeling even in the therapy environment. However, whether to leave this experience outside of the “meaning” or to contain it inside must be the critical point for therapy. The latter attitude requires the therapist to gaze, allow, and hold the discomfort as a base for the new “meaning.”
In this case, both simple joys and disappointments experienced by the therapist keep her stepping into the client’s world, and modifying her concept of the client and of therapy in general.
~Meaning regarding the client’s development~
Facilitating developmental growth is a primary goal when working in music therapy with disabled children. However, since the process of this particular case has not followed the typical notion of developmental music therapy, the diverse kinds of “meaning” are experienced around this theme of growth. They are classified as follows.
The position of “development” as the highest priority in music therapy for people with disabilities brings the driving impetus and the joy of accomplishment to the session process in this case, as well as strong conflict. However these conflictual experiences have become an opportunity for the therapy to evolve uniquely.
By constantly reflecting on these diverse “meaningful” experiences, the therapist is led into a role of establishing hypothetical views on the developmental world of this client, supporting her to live in that world, and continuously modifying the therapist’s view when necessary. Although probably not limited to this client, the development of one person is an extremely comprehensive and different process for each individual, and it is sometimes difficult to capture this development by observing just one part for a short period of time. With this client who has profound developmental delays and high musical perception, the developmental process involves organic intertwining under the surface. For the therapist, the unique relationship between the value aspect of desired development and of client’s intrinsic self is particularly meaningful.
~Meaning of the client’s intrinsic musical desires and satisfactions~
Other constant meaningful moments noted by the therapist in the session are when the client exhibits her unique personality and strong will; in other words, her own personhood shines through her disabilities. Her intrinsic desires about music were distinctly strong. When she felt a strong influence from the music, she changed her actions, such as “gazes at the space,” “ecstatic facial expressions,” “the whole body engaged in performing,” or “approaching the exit of the room and coming back (which can be interpreted in various ways)”, all of which suggest that her inner world is being deeply shaken. The value aspect of the client’s intrinsic self is classified as follows:
The power of the value aspect of the client’s intrinsic self is experienced as significantly meaningful to the therapist. When this power is experienced strongly, the therapist’s objectifying attitude toward the client diminishes. She might yield the session initiatives to the client or release her own emotions. Then the basic standpoint as a therapist starts to be shaken. The events happening in the client are experienced as that of a whole human being including the therapist herself. This experience might even be described with an expression such as “celebration.” From this point on, the meaning in the sessions gradually break through the boundaries of the client/therapist structure. Value aspects of the client’s intrinsic self in this case is highly transactional.
On the other hand, although it is not possible for the therapist to see a whole picture of the client’s intrinsic world, this world is experienced as a self-sufficient, or almost closed structure to enter as an outsider. The therapist also finds meaning from the fact that this inner world seems to be continuously growing/flourishing along with the client’s biological/cognitive development.
In the early stages, the value aspects of the client’s intrinsic self emerge only as fragments, but from the fourth year, the client sometimes reaches out to the external world with her intrinsic self in a cohesive way. For example in the eighty-fourth session, the client was aware of her intrinsic musical goal to beat the base sound of Chopin’s “Raindrops Prelude,” and started integrating the multi-dimensional resources, described as follows:
The therapist experiences this process as significantly meaningful, which her intuition perceives/senses in the relationship between the value aspect of developmentally desired and of the client’s intrinsic self. Namely, the closed/ self-sufficient world of this client has its own coherence, and this realization can assuredly provide developmental growth in the client -- “opening to the inner/outer resources.” The nature of music here is experienced as something different from the fragmented uses of it, for example, as a "motivational tool" or a "positive reinforcement" in developmental music therapy in general. Along with this experience, knowing the client’s inner world more deeply has become a meaningful approach for the therapist.
Meaning of verbal/nonverbal dialogues in the mutual field
Among the four participants who had been meeting in a small, intimate therapy room regularly for 6 years, diverse forms of dialogue had been exchanged, sensing each other’s physical/psychological attributes. It builds a mutual field. The Value aspect of dialogical interrelationship in this mutual field is classified as follows.
Communication from the client
Communication from the therapist
Interaction between the therapist and the client
Mutuality of the field
In the early stages, meaningful experiences are mainly found in the communication from each side as well as the establishment of the interaction between the two. The client sends strong messages in music in spite of the extreme immaturity in her general communication abilities. To the therapist, every form of her actions around music (sound, voice, approaching and treating ways of the sound making materials, line of the sight, facial expression, body posture, action, and so on) is perceived as meaningful communication. Although the client rarely reacts to the verbal communication, she responds explicitly to music. So the therapist forms alternative dialogues by sending music to her, observing how it is received, and adjusting it. By accumulating these experiences, a primitive form of musical interaction gradually grows. These interactions were limited to the musical ones, which slowly transformed into the personal, and to empathic interaction. The therapist finds strong meanings in these processes.
However this development of interaction slows down in the fourth year, when her autistic tendency intensifies. Then, a new form of dialogue emerges based on the “mutuality of the field,” which is proposed from the client’s side.
This “mutuality of the field” is something constantly cultivated from the very beginning of the therapy process, in parallel to the specific communications and interactions mentioned above. Since the value aspect of sharing norms from the mainstream and of the desired development had not evolved in a simple manner in this case, while the Value aspect of intrinsic self had been standing out, the therapist, assistant, and mother have been required to constantly question, “To which direction and through which path is this child growing? What kind of approaches can support her?” Although the inner world of the client cannot be expressed verbally, it is obvious that she herself is also desperately seeking a direction for growth, clinging onto the music. In other words, there have been intense and ongoing commitments to the common question at the center of the four people, “to where, and how?” This commitment-equilibrium has formulated the mutuality of a dialogical field, -- a community where each person’s thoughts, emotions, words (including pre-linguistic communications), music, and motions are encountered.
Return to the subject of the new stage, from the fifth year when the client’s intensified autistic feature has been sustained for approximately one year, the therapist starts to experience the increase in the client’s interdependent presence. In other words, when they have gotten stuck in direct interactions, the client starts to use this “mutuality of the field,” as if she spontaneously picked an alternative. She grasps the characteristics and the role of the people and the objects in the field, positions and moves them depending on the directions she has to take. These actions naturally include the autistic and manipulating features; but they also accompany “temperature” of interpersonal affective expressions such as shyness and joy. This suggests that “the mutuality of the field” has become an important communication media for the participants. And when the therapist is aware of the meaning of her actions, accepts and participates in them, the mutuality of the field warms up and grows further.
This course of development suggests that the phenomenon of therapy can also be an “interdependent“ process between therapist and client.
~Meaning of transformation in the contraposition between client and therapist~
The “interdependent” relationship cannot be explained from the conventional distance and roles of the disabled versus the helper, but it needs a new contraposition. This does not mean that therapist and client lay aside or disengage their conventional roles. Rather, it means that the conventional role-relationship is reformulated so that they re-encounter each other through a fundamental respect and questioning of the human-presence. Of course all music therapists practice their clinical sessions based on a respect and questioning to the clients, but when it is put in the “co-existing contraposition,” the therapist sees the client more as a human-fellow, travelling together in the same journey with different equipment. The value aspect of co-existing contraposition in this case is classified as follows:
The Value aspect of co-existing contraposition is something usually positioned outside of the discussion on music therapy as a health service, or even avoided as a taboo, since it could be considered as deviant from the professional stance. The academic/professional discussions on “changes that occur in therapy” converge into those of the clients since the primary goal of therapy is improvement in their health. The statements about the changes naturally occur from the therapist’s perspective and are sometimes regarded as the symbol of a lack of assurance or even amateurism. This tendency might be rooted in the culture of the Western medicinal science. However, in the process of this case, the influence from this value aspect on the therapist and the therapy is enormous. So it should not be excluded as a meaningful experience.
For example, watching the client struggle in music and accomplish (or not be able to accomplish) something brings a sense of awe to the therapist, since for this client, music is not just leisure but serious affairs of life. The therapist gets insight, “regardless of the developmental disability or not, a child or an adult, each person walks her own path holding her own great universe.” On the contrary, discrepancies and disappointments continue to be experienced. However, while the discrepancies are received as a discomfort that has to be resolved in the value of sharing norms from the mainstream culture, they are experienced here as a meaning of “seeing her off to her own way”.
And whether it is awe or discrepancy, the therapist uses her imagination vicariously to experience what the client might be feeling instead of understanding the content of it.
Another substantially meaningful experience is that she starts to see the client’s disability as one component to build her complete world, instead of something added or reduced from the normal status of wellness. For example, her autistic withdrawing is recaptured as a procedure she needs to conduct in order to live her world and upon which she will formulate her own growth.
It is also meaningful that music can become the vehicle for this delicate and constantly changing inner world of the client as a symbolic medium.
These changes in the therapist’s eyes naturally bring diverse qualities into the contraposition. For example, there are descriptions of meaningful roles and experiences such as “music co-creators,” “the rivals in the musical game,” “the therapist singing from inside of the client’s body.” Above all, the most significantly meaningful experience is that the therapist recognizes and sympathizes with the client’s suffering as a “human-being,” not as a “disabled person.” This awareness evokes the sense of “co-existing as a human-fellow,” more than any other experience. This awareness is described in the therapist’s narrative story:
“Suffering of living” here does not mean something she carries due to her disability, but it is a struggle all human beings universally carry to live. Therefore, the therapist is not in a position to take over or decrease it, but to encounter her client as an equal human being across this “suffering.” In this process of therapy, “suffering” is not a seed of the disease to be removed, but it can be the seed that eventually grows into full bloom. The therapist’s presence participates in the blossoming by “being there with full attention,” and helping to “create beauty out of it.” (Ikuno, in press)
These experiences of co-existing are made possible by liberating the therapist and the client from limited and conventional positioning. However, such a transformation also provides new inspiration for the therapist’s role with the client as well as a new intuition toward therapy in general.
Pavlicevic (1997, Japanese translation 2002) suggests that therapeutic relationships, due to the psychological needs of both therapist and client, tend to shape the therapist into a so-called healer whose role is healthy and powerful and the so-called patient who passively relies on the healer/therapist; and she suggests a different way for healers to accompany patients (Japanese translation p.266-268). In this particular case, the mutuality of the field nurtured by the value aspect of dialogical interrelationship has become the foundation for the value aspect of co-existing contraposition.
The multi-layered value aspects that construct the “meaning” of the clinical process act in a relational and complex manner, repeating like the themes of polyphony. The clinical sessions are alive and keep going, because of these experiences of “meaning.” The overview can be represented as Figure 1.
In each session, the three value aspects of sharing norms from the mainstream, desired development, and of the client’s intrinsic self function as “clamps” or “railroad ties” to build an activated synchronic space. They also continuously work out the very next moment of the session. The exploration around these three value aspects having been accumulated, the value aspect of dialogical interrelationship is nurtured among the participants. The fruit of the value aspect of dialogical interrelationship is reflected in the session procedure, while weaving a diachronic clinical story. Participating in this story weaving, the inner worlds of the participants are influenced by the value aspect of co-existing contraposition as if “blurred color stains” begin to mark on their beings. This will influence not only clinical engagements, but also their personal world-views, which could ultimately affect the value aspects of sharing norms from the mainstream culture in an indirect way.
All through this study, “meaning experienced by the therapist” is used as the source materials, but I do not intend to suggest that this meaning belongs exclusively to the therapist as an individual. “Meaning” experienced by the therapist within the interplay with the client belongs to the relationship between the two, which is captured through the therapist’s vision as an instrument of the process. It is not a means to prove the objective exactness, but a means to recognize one coherent truth as interpreted through the therapist, who participates in the process.
In this regard, the process also includes the views of the mother and the assistant, since the meaning experienced by the four people around the sessions is strongly influenced by each other in verbal and nonverbal ways. They have shared the same field of assumed meaningful existence.
Especially in the “mutuality in the field” in the value aspect of dialogical relationship, and of co-existing contraposition, the meaning in the sessions gradually breaks through the boundaries of the client/therapist structure into a collective notion. This phase has a slightly different quality from the earlier quoted Stige’s （2002） concept “learning in relationship” and “enculturation,” in terms of their individually oriented interrelationship.
This collectivity might be related to the characteristics of this client who has difficulties in her verbal self-expressions, as well as the Japanese cultural context. Japanese people are deeply rooted in the unique community culture of “collective beyond individual identity” and “nonverbal sharing of meaning (Ikuno, 2005)” and apply it in many different life situations including the domain of physical and mental health. However, a discussion of this cultural norm is beyond the scope of this article at the present time.
Evidence-based medicine that has been strongly influencing the music therapy field as well as welfare and education over the last few decades in particular, requires clarification of the intervention and the effect. This view can be boiled down until reduced by the procedure where the therapist stands on the fixed point, decides the goals, and makes changes only on the clients. Modern music therapy originated in the West seems to be broadly based on the interventionist premise of “If one makes ‘x’ intervention, then ‘y’ result will occur.” more or less, from the medical to the behaviorist or even to the humanistic approach. To me, Amir and Stige are not totally exceptions in this discourse.
However this case analysis suggests that the nature of therapy is “the transformation of both client and therapist and both are spontaneously led into the growing mutuality a of field.” It is a perspective of circular, or mutually influenced processes, different from that of linier, or intervention-effect process which is symbolized by the basic structure of “one individual helping the other.”
Again, I am not denying the intervention-effect therapy process, but suggesting a counterbalance view from a different angle. Also I do not mean to imply or affirm merely a recreational event or a coincidental/experimental art session without a therapeutic direction as therapy. Therapy has to be constructed aiming at clients’ wellness as the first priority. However, this study suggests that as long as two or more people meet in the shared field, mutuality absolutely arises, even if it is an intentionally constructed field with therapeutic aims in the consciousness of the therapist. It also suggests thar when the participants interrelate with each other through music, it is almost impossible that one person stands on the fixed point and manipulates all the process, even if she is a therapist.
On the contrary, I presume a different way of positioning the therapist NOT to stand on the fixed point, for example, by throwing herself into the mutual influences, as one of basic character of the music therapy experience. This characterization seems to be introduced by some music therapists, sometimes boldly and sometimes hesitantly into their daily practices. In order to characterize the therapy experience not as a fall into merely a habitual usage, in my study, I explored one way of understanding the experience through classification and interpretation of the meaningful experiences by the participants.
In order for us to have a broad vision of the multi-layered structure of clinical “meaning” and to understand this meaning carefully and theoretically, we might need diverse research methods from the diverse angles for a single case. For example, hermeneutic phenomenological studies with/without verbal interviewing, an innovative form of musical analysis, ethnographic study, narrative study, might be effective.
My formal research will focus on the relationship in the mutuality of the field, bringing these methodologies into my view.
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