Music Therapy Interventions for Deaf Clients with Dual Diagnosis
By Anna Johnson Ward
The current music therapy literature addresses the use of music with the Deaf population, particularly those with cochlear implants. However, few studies or descriptions of music therapy with Deaf individuals who are dually diagnosed with an emotional or behavioral disorder and an intellectual disability have been conducted. Given that music therapy has been found to be an effective intervention for both Deaf individuals and individuals with emotional or behavioral needs, ideas and resources for music therapists working with this population are needed. These case examples provide a description of music therapy for individuals who were dually diagnosed in a residential mental health facility. Music therapy experiences and their effectiveness for Deaf patients with dual diagnoses are presented as well as cultural aspects of music within the Deaf community and their implications for creating music therapy interventions.
Keywords: Deaf, language-dysfluency, vibrotactile feedback, music therapy, mental health, dual diagnosis, intellectual disability
Music Therapy Interventions for Deaf Clients with Dual Diagnosis
Music therapy work with people who are deaf requires a particular approach, and even further modifications and adaptations are necessary when they have other difficulties. The following case examples identify some music therapy methods and techniques that music therapists might introduce to meet some of the diverse needs of individuals who are deaf, and also have emotional or behavioral disorders, and/or intellectual disabilities. The paper will describe the relationships between deafness and music, deafness and mental health, and deafness and intellectual disabilities. Specific music therapy methods such as improvisation, movement to music, and songwriting, will be discussed that may be applicable to meet the complex needs of individuals with dual diagnoses.
Explanation of Terms
The term “Deaf” (with a capitol D) refers to a linguistic-cultural minority of people with a hearing loss (Darrow, 2006a) caused by genetics, illness, or other reasons. Deaf people do not see themselves as disabled, but rather as people with a separate culture with their own language and identity. While many hearing people see deafness as a disability, a condition to be cured, or a condition of powerlessness, most Deaf people see it as a culture and community. Family members and close friends of people with hearing loss can also be members of this minority group. The language used by Deaf individuals in the United States is American Sign Language (ASL). ASL, like other international languages, has its own grammar, vocabulary, and nonverbal cues (Avon, 2006). Deaf culture also involves values, beliefs and behavioral norms that may be different from those in the hearing world (Mindess, 2006). These values, beliefs and behavioral norms, such as the importance of ASL, storytelling, Deaf pride, overcoming stigmas, and equality, unify the Deaf community (Hamill & Stein, 2011). Music is a part of every culture and community in some way, and Deaf culture is no exception. This paper focuses on music therapy work with people who have an additional mental health difficulty or intellectual disability.
For the purpose of this paper, when specifically referring to those who identify with the cultural minority the term Deaf (with a capital D) will be used. In all other cases, the term deaf (with a small D) will be used. Other terms that individuals potentially relate to include: an individual with hearing loss, hard of hearing, or hearing impaired. It is important to determine whether an individual has a preferred term for identification.
The severity of deafness (i.e. mild, moderate, or profound) and the use of devices such as hearing aids or cochlear implants, may affect the level of appreciation and musical responses of individuals who are deaf. Individuals who are deaf may connect to music in different ways than individuals who can hear. Some will appreciate music for its meaning and rhythm, while others might not enjoy music. Sound can play a very distinguished role in the lives of people who are deaf (Avon, 2006). In fact, Avon stated “the very essence of sound is the foundation of the power struggle which exists between the hearing and Deaf cultures” (pp. 189-190). Deaf people experience sound within a musical context, whether it is audible or somatic, in a similar way to their hearing counterparts (Darrow, 1993).
Darrow (2006a) studied how music may be important in working with people who are deaf. She noted, “due to its typical range of frequencies and intensity, music is generally far more accessible than speech to those with a hearing loss” (p. 5). Fulford et al. (2011) interviewed several deaf musicians about their hearing loss, experiences with music, and musical background. They presented strategies that musicians who are deaf use when creating music, such as visual cues and vibrotactile feedback (listening to the music through vibrations in the body). Incorporating a variety of elements with the music can provide a more intense experience for deaf people.
Music has the power to go below the surface of typical communication and experience. Abrams (2011) suggested that music is a temporal-aesthetic way of being and that there is a level of music, beyond sound, within all of humanity. This is an important perspective for music therapists to consider when working with deaf people. Music can be the main connection in a client-therapist relationship, crossing bridges that other typical forms of therapy barely touch. Some people, from the Deaf, hard of hearing, and hearing populations, would argue that music is an inappropriate tool when working with deaf people (Darrow, 1993). However, music can be just as meaningful for deaf people as for hearing people due to the internal nature of music. Abrams (2011) proposed that music is internal, within each person, and may resonate in different forms, sometimes aurally. Due to its internal nature, music may be the one resource that can connect us with a client. As therapists, we should be open to the power of music’s internal influence. This is an important concept when considering music therapy with deaf clients. Nevertheless, while it is important for hearing persons to understand that it is possible for individuals who are deaf to enjoy music, it is also important to note that not all people who are deaf are motivated by music.
It is also inappropriate to assume that music will affect all individuals who are deaf in similar ways to hearing individuals. Darrow (2006a) provided a comprehensive review of how individuals within the Deaf community may relate to music. Darrow presented several studies, including questionnaire results, of what deaf individuals understand and enjoy, or dislike, about music, and how this applies to using music therapy techniques with people who are deaf. Her results suggest certain elements of music and “repetition, [the use of] familiar music, and visual cues, being nonjudgmental about the voices…and [noting] how the physical aspects of playing instruments can enhance their experience of music” (p. 9) are important.
In another study, Darrow (2006b) sought to determine whether deaf students (n = 31) would assign the same emotions to music as their hearing peers (n = 31). Results showed significant differences between the deaf students and their hearing peers. The hearing students’ responses more accurately reflected the composers’ intent. Darrow suggested that timbre, texture, and rhythm were the most influential elements in transmitting emotion to persons who are deaf. Darrow suggested songwriting and improvisation might be useful methods for working with individuals who are deaf towards personal expression and the perception of emotion.
Deaf and Mental Health
Vernon and Daigle-King (1999) recognized trends from previous studies (Basilier, 1973; Hansen, 1929; Pollard, 1992; Rainer, Altshuler, & Kallman, 1963) that linked emotional and behavioral disorders to the frustration experienced by a deaf person due to their inability to communicate feelings and problems. Thacker (1994) found that thought disorders influenced sign language production in a similar way that it influenced spoken language production. For example, signing overly fast or too slow compares to changes in prosody of speech in hearing patients with schizophrenia. In addition, some deaf patients may have echopraxic (imitative movements/signs) tendencies, which relates to echolalic patterns exhibited by hearing patients (Trumbetta et al., 2001).
Vernon and Daigle-King (1999) noted that previous studies found paranoid thinking, depression, and schizophrenia to be common illnesses present in the deaf inpatient community, with schizophrenia being slightly more prevalent in patients who are deaf than in the hearing inpatient community (Altshuler & Sarlin, 1962; Remvig 1969). However, there is little to no current literature to support these findings, and diagnostic tools and procedures have been altered and modified since these studies were conducted. Black and Glickman (2006) noted the use of modified versions of the Clinical Evaluation of Risk and Functioning scale (CERF-R), the Allen Cognitive Level scale (ACL), and the Language Rating scale (specifically to assess language disfluency) in the assessment and diagnosis of deaf patients with mental illness. Modifications included an emphasis on communication, specifically including communication specialists (i.e. interpreters) in the diagnostic and assessment process. Mueller (2006, October) reiterated the importance of appropriate communication in conjunction with current, effective diagnostic tools and assessment procedures.
Deaf and Communication Issues
The dual diagnosis of a mental disorder and an intellectual disability is also common within the Deaf community (Vernon & Daigle-King, 1999). This can lead to misdiagnosis, and ultimately result in mistreatment of Deaf patients in psychiatric hospitals. Due to language impairments or lack of interpreters, more non-signing or low-functioning individuals were labeled undiagnosed, or were considered diagnosis-deferred cases, than hearing patients. Consequently, therapists working with these clients may require increased flexibility since the client may display multiple symptoms and needs, and may be more challenging to understand and track progress.
Language issues are also a challenge for therapists working with deaf patients with mental health needs. Glickman (2010) discussed his experiences over 17 years as a director of a specialty psychiatric inpatient unit for deaf patients. The author suggested working with clients who were fluent in ASL, as well as clients with severe language disfluency, can be challenging. A deaf client with language disfluency may hesitate while signing. Additionally, others may misunderstand what the client is signing, and therefore misunderstand their feelings, wants, and needs. Glickman reported that more than half of the clients were language-disffluent, and estimated over half had experienced some form of abuse during their lifetime. Glickman noted that many people who are deaf experience mental health disorders associated with language deprivation and occasionally with neurological (deafness related) problems. Glickman suggested that language rehabilitation and the promotion of independence is important to include in psychosocial rehabilitation.
Deafness and Music Therapy Interventions
Creating music therapy experiences for clients who are deaf and have an intellectual disability may be challenging. Limited information and resources for working with this population increases the challenge. Keats (1995) worked with Doug, a 40-year-old deaf male with autism (no intellectual disability). Improvised music with strong rhythmic elements formed the foundation of the sessions. Keats stressed that musical interaction and communication meant that few words were necessary. The music provided an expressive outlet for Doug, and met both interpersonal and intramusical goals as well. The structure and flexibility of the improvisation with a rhythmic foundation was success- and client-oriented.
Improvisation can be adapted and modified in any situation to create a success-oriented environment. Darrow (2006b) proposed adaptive strategies, which included providing tactile and visual elements (picture symbols, scarves, balloons, etc.) to supplement the music. She also suggested a songwriting intervention, in which the client could write original stories and choose accompanying music. In another publication (Darrow, 2006a) she also touched on aspects of signing songs in ASL, with an emphasis on the importance of choosing songs with meaningful lyrics. This concept compliments Rolvsjord’s (2005) ideas of using songwriting interventions with clients with mental health needs. Songwriting allows clients to communicate personal feelings and experiences, as well as cultural experiences and identity. This is important because in psychiatric inpatient patients who are deaf these aspects are often neglected or lost. Rolvsjord listed several strategies for creating lyrics, including co-creation (selecting ideas from a list of words, client generated words, and using client poetry).
Individuals with dual diagnoses of deafness and mental health disorders, or deafness and intellectual disabilities all have special needs. Diagnoses and particular needs should be considered when developing and adapting music therapy interventions. The following case studies propose a variety of therapeutic interventions, suggestions for modifications, and the particular goals they address for the identified population.
The following case examples outline music therapy sessions with deaf adults dually diagnosed with a mental health disorder and an intellectual disability. The studies predominately examine the feasibility of music therapy and some potential interventions. A discussion of the overall process follows each case description. The clients provided informed consent for their stories to be included. Their names and locations have been changed to protect their confidentiality.
I, the author, was the practicing music therapist. The music therapy took place when I was a Masters Equivalency student in my final semester of my music therapy training program. I received indirect supervision during this research. I am bilingual, fluent in both English and ASL. Raised in the Deaf community, I am familiar with various aspects of Deaf culture. My fluency in ASL played an important role in my interactions and relationships with the deaf clients with whom I worked.
Deafness-Related Assessment Information
Important assessment information includes, but is not limited to, length of time the client has been deaf (hearing loss pre- or post-lingually), his or her primary mode of communication (ASL, gestures, lip-reading, etc.), and level of education. This information is not always available, but can be valuable during assessment and treatment planning.
Case Example 1
Carly was a 38-year old woman with schizoaffective disorder, bipolar type, and mild intellectual disability. It was unclear how long Carly had been deaf. However, she was fluent in ASL. According to Carly’s medical charts, she had some high school education, and since turning 18 years old had been in and out of the state hospital and group homes between 15 and 20 times. Throughout Carly’s music therapy sessions, we communicated in ASL. She was very open about events in her life, both past and present and she enjoyed music, especially gospel music.
Carly attended eight 30-minute music therapy sessions, held in the music therapy room of the psychiatric facility. Data collection included SOAP notes and narrative style notes after each session. During assessment, Carly’s affect was flat, and she repeatedly stated that she felt “fine.” She explored all the instruments presented to her, and was eager to participate in music therapy. When asked what she felt while playing the drums, she responded, “I felt the vibrations inside.” When prompted to improvise with me, Carly attempted to follow the beat and general style of my music. She alternated playing and feeling the drum as I continued to play. Carly’s goals were to increase coping skills and emotional expression through verbal (spoken or ASL) self-expression. I implemented interventions that emphasized exploration of emotions and identifying coping mechanisms through improvisation, song discussions, and songwriting. See Table 1 for more information.
Carly’s treatment sessions began with a receptive music experience of drawing to music (see Table 1). Her drawings were a literal presentation of her experience (the therapist playing the piano “loud”). I had positioned the piano in such a way that Carly could hear it and feel the vibrations. Carly also played the piano, improvising in an atonal style. She began vocalizing, smiling throughout. These experiences led to a discussion of Carly’s coping skills. Throughout the sessions, Carly identified six coping skills for when she becomes mad, as well as potential leisure activities in which to participate. She accompanied herself on the piano while vocally singing her lyrics as the therapist sang in ASL.
Carly also benefitted from improvisation on preferred instruments such as the drum set, gathering drums and djembes, electric guitar, piano, xylophone, and a microphone with amplifier. Carly often sang into the microphone as I accompanied on the piano. I gave her a balloon to hold as she sang in order to help her become more aware of and present in the improvisation, and to feel the vibrations of her voice externally. I noticed that she began to express a wider range of emotions, a contrast from the flat affect she demonstrated during the assessment sessions.
Carly participated in a lyric analysis and fill-in-the-blank songwriting experience about friendship. Below is Carly’s version of “You Raise Me Up” (original music and lyrics by Rolf Løvland and Brendan Graham of Secret Garden). Carly contributed to the songwriting by signing new lyrics in ASL, with prompting, as I wrote them down on paper. The re-written lyrics (italicized) resulted in the following:
I am sad, when I am at Petrie hospital
Problems come, with people in the Cardhart group home.
Then I wait while I improve at Petrie hospital,
And I hope to go to the Herrington group home.
My friend helps me,
So I can improve my health.
My friend supports me,
So I can move to the group home.
I am happy when my friend is here.
My friend helps me, so I can think positively and go to church.
Due to the visual nature of ASL, we translated original lyrics and Carly’s new lyrics in a conceptual manner, rather than in a literal English translation, and during our discussions, I provided a clear, meaning-based and concept-focused ASL interpretation of the pre-composed lyrics. For example, rather than singing/signing “when I am down,” the lyric was translated “I am sad when…”
One of the final interventions I used with Carly was a “scribble art” experience (see Table 1). This experience incorporated receptive music listening as one person scribbled and the other followed. When asked what she noticed in the scribbles, Carly immediately found a frown. Carly was able to discuss feelings and emotions based on this experience and follow up with an improvisation on the gathering drum.
Carly made improvements in emotional expression, consistently expressing an average of at least two emotions per session (either musically or verbally). Though she was able to identify multiple coping skills during two of the sessions, she did meet the goal to do this consistently (once per session).
Case Example 2
Shane was a 59-year-old male with intermittent explosive disorder, mood disorder (not otherwise specified), and mild to moderate intellectual disability. His chart indicated that his original assessment suggested he had an IQ of 47-67. A revised assessment suggested his IQ was 78. He had been deaf since birth, and had 3 years of secondary school, in addition to vocational training at the age of 18. The amount of time Shane had been in treatment was unclear, and according to his records, his behavioral difficulties started at age 20. It seems he had spent much of his life in an institution. Though Shane’s main form of communication was ASL, his language was echopraxic in nature; i.e. he would sign back what people said to him. Shane’s affect was low, but when asked if he enjoyed music he became excited.
Shane attended five 30-minute music therapy sessions. Following each, I generated formal SOAP notes, informal journal entries, and narrative notes. Shane’s goals were to increase his attention span and cognition. Objectives included focusing on a task and following a two-step direction at least once per session. I implemented interventions that emphasized turn-taking, the exploration of emotions, and movement. The turn-taking objective allowed Shane to explore instruments and activities while also working on delaying gratification and developing impulse control. The needs associated with Shane’s mood disorder would be addressed as he took the opportunity to express his emotions.
Since Shane responded well to improvisation, we used the method throughout most sessions (see Table 1). During the assessment sessions, Shane had the task to identify an emotion (given two options) and to improvise in response to the emotion card. When Shane improvised, he played for about 30 seconds, and would then very adamantly end the improvisation with two accented beats. He also played the piano in a call-and-response type pattern with me. With modeling, Shane began to spontaneously sign “your turn/my turn” during improvisations. Though Shane’s language was limited, I was able to establish a relationship with him through the music, as evidenced by turn-taking improvisations, his increased awareness of me, his increased eye contact, and his tendency to end the music in sync with me.
After several sessions, Shane requested certain experiences and instruments (i.e. improvisation on the electric guitar), identifying his wants and demonstrating his sense of control through the music. Receptive music experiences were also effective for Shane. When given the option to draw to music, Shane lost interest, but when given a balloon to hold while listening to music, I noticed an obvious shift in his facial affect (from blank to a softened, content affect). The balloon helped Shane connect with the vibrations more than listening alone. I had given Shane the opportunity to experience an emotion in a new way.
Shane also progressed in following two-step directions. One experience that was particularly effective involved the use of visual stimulation within an improvisation. I set up the music therapy space with a xylophone and drum on either side of him and me. An hourglass was set on a piano bench slightly in front of Shane, close enough for him to reach it. The hourglass provided visual stimulation, as well as a specific amount of time for focus of attention. I gave Shane directions in ASL first to turn over the hourglass, and second to play one instrument. When the hourglass ran out of sand, I prompted him to turn it over once more, and play the other instrument. After several rounds of this two-step task, Shane began to perform the task without any prompts. The repetition of the task, with the visual stimulation, and instrumental motivation, allowed Shane to be successful.
One other intervention that incorporated visual stimulation was also successful for Shane. I chose finger lights (see Table 1) because they were visual, appropriate for his hearing loss, and would maintain his attention and increase his participation and connection to the music. This movement to music experience provided opportunities for Shane to increase gross and fine motor movements, follow multi-step directions, and show independence.
Shane made strides toward both his goals and objectives. By the end of treatment, he was focusing in each session on multiple tasks for up to 5 minutes, with little to no prompting. He also followed two-step directions an average of two times per session.
Findings From The Case Studies
These two case examples illustrate the use of multi-modal music experiences, songwriting, and improvisation and how they may be adapted to meet the specific needs of these deaf clients with dual diagnoses. The use of other modalities, in addition to music, was valuable for Carly’s treatment progress. Carly was able to express herself in a non-traditional way, which led to a deeper verbal discussion regarding the situation. The adaptation of songwriting was also powerful for Carly (who exhibited higher cognitive functioning). Music therapy gave Carly the power to make a pre-recorded song more personal, and to identify her strengths and support systems. For Shane, a deaf client with more prominent intellectual disability, the use of visuals and repetition created a space for success-oriented experience. Visual stimulation, repetition, and motivating stimuli were all beneficial in Shane’s progress in music therapy.
|Interventions||Carly||Shane||Additional Comments||Goals Addressed|
|Receptive Music Therapy||
|Movement to Music||
|Drawing to Music||
|Scribble Art (Tague, 2012)||
Deaf people generally might experience a slightly greater prevalence of mental health disorders than those in the hearing community (Vernon & Daigle-King, 1999). Music, due to its range of frequencies and intensity (Darrow, 2006a), may be a more effective form of therapy than traditional therapies (i.e. psychotherapy) for deaf patients. However, dual diagnosis of mental health disorder and intellectual disability for deaf individuals creates more challenges, in implementing effective interventions, for music therapists. It is important for clinicians to recognize these challenges, and be willing to adapt and modify interventions to meet the needs of these clients.
The use of visual stimulation and vibrotactile feedback (with balloons), suggested by Fulford et al. (2011), was very effective in the cases described above. Also, Darrow’s (2006b) proposed adaptive songwriting method provided clients with an outlet for emotional expression and the identification of coping skills. Improvisation gave them control over their environment, i.e. the instruments allowed for emotional expression and led to increased ability to sustain attention. This experience was similar to Keats’ (1995) portrayal of communication within the improvisational music with his client, Doug. Lyric analysis of songs translated into ASL (Darrow 2006a; Quam, 2012) proved to be motivating for discussing personal issues and identifying coping skills.
At the same time, lyric analysis and songwriting may not be effective for all clients, depending on their intellectual abilities, capacity for abstract thought, and culture. The concept of providing structure as proposed by Keats (1995) may also be appropriate. Drawing, or the use of other modalities, may not always be motivating depending on the client’s attention span, needs, and interests.
My lack of experience working with people who have multiple diagnoses is a study limitation. Several sessions involved “trial and error” type experiences. Lyric analysis and songwriting were not always effective. Sometimes I began a lyric analysis or songwriting experience, only to find that the client was not ready to participate. I also tried an intervention using emotion pictures with Shane in which I would “act out” the emotion, and give him an opportunity to choose the correct one (given two options). This intervention did not seem helpful, possibly due to his limited cognitive functioning, my unclear directions, or because my interpretation of the emotion did not match his experience or understanding of the emotion. Another limitation was the lack of technology. For example, my clients needed higher quality speakers for listening to music as I interpreted the words into ASL. Further, the use of an iPad would have provided more visual stimulation and motivation for Shane.
More research will be necessary, to determine best practice for deaf individuals with a dual diagnosis (mental illness and intellectual disability). It would be interesting for example to consider whether there are particular ways to structure improvisation experiences for people with higher cognitive functioning. It may be important to expand the repertoire of interventions that are successful for clients with lower cognitive functioning. In addition, we need more information on appropriate interventions and techniques for conducting group music therapy sessions with deaf clients. Finally, we need to explore various theoretical models to determine which music therapy approach might be most beneficial in this context.
Music therapists need to be prepared to work with deaf clients with multiple diagnoses. Preparation for therapy sessions must focus on several aspects: how the patient relates to music, the needs of the individual, and how one can adapt and modify typical music therapy interventions to fit the needs of the client. Modifications and adaptations may include the use of additional non-musical items (balloons, finger lights, visuals, etc.) to enhance the music therapy experiences. Also, adapting lyric analysis (by interpreting songs in ASL with little to no metaphoric interpretation), and songwriting experiences (singing in ASL with very little musical accompaniment) is important to consider (Humphrey, Alcorn, & Humphrey, 2007).
It is imperative for the music therapist working with Deaf clients who identify with the Deaf culture and utilize ASL as their first language, to be fluent, or at least be knowledgeable enough to have a conversation, in ASL. For music therapists who are not fluent in ASL, using an ASL interpreter is possible, though this may affect the client-therapist relationship and therapeutic process. Hamerdinger and Karlin (2003) stated that it is essential that interpreters be trained to work in a clinical setting, and possess a basic understanding of the therapeutic process, in order to provide effective interpreting services for the client in the mental health setting. Regardless of training, several potential effects of this arrangement may still occur. The client may potentially know the interpreter (due to the small nature of the Deaf community), creating an awkward tension during the session. Conversely, the client and interpreter may be friends, resulting in the therapist being “left out.” It is possible the client may be embarrassed to create music in the presence of another hearing individual or may have reservations and lack a willingness to be open and vulnerable within the client-therapist relationship since a third party is present. Additional transference and countertransference may be present that otherwise would not exist in a purely dyadic client-therapist relationship.
On the other hand, an ASL interpreter may build a cultural bridge between the client and therapist, allowing for increased vulnerability and presence in the therapeutic process. The interpreter may unintentionally help the client feel empowered and accepted (Hamerdinger & Karlin, 2003). Hamerdinger and Karlin suggested it is likely language and communication issues will become diminished.
I would recommend that the music therapist have a basic sign language repertoire in order to communicate with deaf clients. Resources for attaining this repertoire range from using the internet to learn specific signs, to taking a local ASL class. PECS (Picture Exchange Communication System) (“What is PECS?,” n.d.), and other AAC (Augmentative and Alternative Communication) devices (“Augmentative and Alternative Communication (AAC),” n.d., para. 1) may also be used to communicate with deaf clients. It is important to collaborate with the client and other health care professionals to discover the most beneficial form of communication for the client. Co-treatment with other professionals may also be a beneficial option. It is also important to understand, as much as possible, the individual’s cultural and linguistic preferences. However, as these case studies demonstrate, determining the best way to interact with people who have multiple difficulties can be difficult. Nevertheless, as Miller (2012) suggested, a counselor “must also have an ‘other-awareness’ of how the client’s multicultural traits can influence the client’s openness to the use of different internal and external resources” (p. 192). Deaf people make up a unique culture; therefore they are no exception to this idea. Involvement in music therapy can be a challenging and rewarding experience for people of all ages and abilities, and with some adaptations, it can be an appropriate form of therapy for deaf clients with dual diagnoses as well.
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