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The community-reinforcement approach

Reinforcement Approach William R. Miller, Ph.D., and Robert J. Meyers, M.S., with Susanne Hiller-Sturmhöfel, Ph.D.
The community-reinforcement approach (CRA) is an alcoholism treatment approach that
aims to achieve abstinence by eliminating positive reinforcement for drinking and enhancing
positive reinforcement for sobriety. CRA integrates several treatment components, including
building the client's motivation to quit drinking, helping the client initiate sobriety, analyzing
the client's drinking pattern, increasing positive reinforcement, learning new coping
behaviors, and involving significant others in the recovery process. These components can be
adjusted to the individual client's needs to achieve optimal treatment outcome. In addition,
treatment outcome can be influenced by factors such as therapist style and initial treatment
intensity. Several studies have provided evidence for CRA's effectiveness in achieving
abstinence. Furthermore, CRA has been successfully integrated with a variety of other
treatment approaches, such as family therapy and motivational interviewing, and has been
tested in the treatment of other drug abuse.
KEY WORDS: AODU (alcohol and other drug use)
treatment method; reinforcement; AOD (alcohol and other drug) abstinence; motivation; AOD
use pattern; AODD (alcohol and other drug dependence) recovery; treatment outcome;
cessation of AODU; professional client relations; family therapy; motivational interviewing;
spouse or significant other; literature review

In nearly every review of alcohol The user experiences effects that moti- treatment outcome research, the vate him or her to continue drinking, WILLIAM R. MILLER, PH.D., is director which can lead to alcohol dependence.
of research and ROBERT J. MEYERS, M.S., (CRA) is listed among approaches with What then would make a dependent is a senior research scientist at the Center the strongest scientific evidence of efficacy.
drinker want to give up drinking? One on Alcoholism, Substance Abuse, and Yet many clinicians who treat alcohol common approach is to "turn up the Addiction, University of New Mexico, problems have never heard of it, despite pain"—that is, to confront the person Albuquerque, New Mexico. the fact that the first clinical trial of with unpleasant and costly consequences CRA was published over a quarter of a of drinking. This approach attempts to SUSANNE HILLER-STURMHÖFEL, PH.D., century ago—an example of the contin- render drinking less attractive, and can is a science editor of Alcohol Research uing gap between research and practice.
include aversion therapies, pharma- The underlying philosophy of CRA cotherapy with the medication disulfi- is disarmingly simple: In order to over- ram, confrontational counseling, and The authors gratefully acknowledge the come alcohol problems, it is important infliction of negative consequences (i.e., support of the National Institute on to rearrange the person's life so that punishment). Such negative approaches, Alcohol Abuse and Alcoholism and the abstinence is more rewarding than however, frequently have been found to National Institute on Drug Abuse for drinking. The use of alcohol as well as be ineffective in decreasing drinking and several of the clinical studies summarized other drugs can be highly reinforcing: alcohol problems (Miller et al. 1998).
in this report. Alcohol Research & Health
Even seasoned clinicians are often amazed Analyzing Drinking Patterns
at how much adversity an alcoholic will The initial step in CRA generally is an CRA involves a thorough functional endure in order to continue drinking.
exploration of the client's motivations analysis of the client's drinking patterns.
In fact, it has been said that if punishmentworked, there would be no alcoholics.
for change. Particularly in early versions This analysis helps identify situations CRA takes a different approach to of CRA, this process involved the iden- in which drinking is most likely to overcoming alcohol problems, one that tification of positive reinforcers (e.g., occur (i.e., high-risk situations) as well is based on providing incentives to stop praise and shared pleasant events) that as positive consequences of alcohol drinking rather than punishment for could serve as effective incentives for consumption that may have reinforced continued drinking. To that end, client, the client to change his or her behavior.
drinking in the past. This step, which therapist, and significant others work The CRA therapist also reviews with is often underemphasized in cognitive- together to change the drinker's lifestyle the client the current and future nega- behavioral therapy, is useful in individ- (e.g., his or her social support system tive consequences of the client's drink- ualizing treatment and in determining and activities) so that abstinence becomes ing patterns. For example, the therapist specific treatment components, or more rewarding than drinking. Since may offer an "inconvenience review modules, that are most likely to be suc- its introduction by Hunt and Azrin in checklist"—a list of frequent negative cessful for a particular client.
1973, CRA treatment has evolved con- consequences of drinking, such as med- siderably, and the clientele has expanded ical problems, marital problems, or dif- to include spouses of alcoholics and ficulties at work. The client then checks users of drugs other than alcohol. This all those negative consequences that Once the analysis of the client's drink- article summarizes the components of apply to his or her current situation or ing patterns is completed, both the CRA as well as factors influencing its are likely to occur in the future. This client and therapist select appropriate effectiveness. In addition, the article assessment can be conducted in an modules from a menu of treatment briefly reviews clinical studies demon- empathic motivational interviewing procedures to address the client's indi- strating CRA's efficacy in treating clients style rather than a confrontational style vidual needs. Many of these treatment with alcohol and other drug (AOD) (Miller and Rollnick 1991), thereby modules focus on increasing the client's encouraging the client, rather than the sources of positive reinforcement that therapist, to voice the advantages of are unrelated to drinking. For example, change and the disadvantages of his or as people become increasingly depen- What Is CRA?
her current drinking.
dent on alcohol, their range of non-drinking activities (e.g., hobbies, sports, To provide an alcoholic with the incen- and social involvement) narrows substan- tive to quit drinking, CRA has the fol- tially, resulting in increasing isolation.
lowing two major goals: Once the client has identified factors Consequently, an important component that provide the motivation to change of recovery for the drinker is to reverse • Elimination of positive reinforce- his or her drinking behavior, the thera- this isolation process by becoming ment for drinking pist moves on to setting goals for involved with other nondrinking people achieving abstinence. Because many and by increasing the range of enjoyable • Enhancement of positive reinforce- clients are reluctant to commit them- activities that do not involve drinking.
ment for sobriety.
selves to immediate total and perma- Several treatment modules can help nent abstinence, a procedure called in this process. For example, social and To achieve those goals, CRA thera- sobriety sampling can be helpful. This recreational counseling is used to help pists combine a variety of treatment procedure uses various counseling the client choose positive activities to strategies, such as increasing the client's strategies to negotiate intermediate fill time that was previously consumed motivation to stop drinking, initiating goals, such as a trial period of sobriety by drinking and recuperating from its a trial period of sobriety, performing a (see Miller and Page 1991). For exam- effects. If the client cannot easily decide functional analysis of the client's drink- ple, the therapist may encourage the on such activities, an approach called ing behavior, increasing positive rein- client to try not drinking for 1 month, activity sampling can encourage him forcement through various measures, to see how it feels and to learn more or her to try out or renew various activ- rehearsing new coping behaviors, and about the ways in which he or she has ities that might be, or once were, fun involving the client's significant others.
been depending on alcohol. Sanchez- and rewarding. For this strategy, the Other factors, such as therapist style Craig and colleagues (1984) found therapist and client schedule activities and initial treatment intensity, also may that clients who explicitly were given that the client will try between counseling influence the client's outcome. These a choice about a trial period of absti- sessions and plan where, when, how, treatment components and treatment- nence were more likely to abstain than and with whom the client will participate related factors are described in the fol- were clients who were given a firm pre- in those activities. Those plans empha- lowing sections.
scription for abstinence.
size activities that bring the client into Vol. 23, No. 2, 1999
contact with other people in nondrinking encourages, whenever possible, the forward to coming back for future ses- contexts. Such activities might include cooperation of other people who are sions and leave those sessions feeling involvement in a church, attendance of close and significant to the drinker.
hopeful and good about themselves. 12-step meetings or classes, participation Significant others, particularly those Although many therapists can deliver in common-interest clubs (e.g., sports who live with a drinker, can be helpful CRA, some clinicians might find this clubs), visits to alcohol-free establish- in identifying the social context of the approach easier to adopt than will ments, or participation in volunteer client's drinking behavior and in sup- other clinicians. For example, therapists programs. The choice of programs is porting change in that behavior.
with generally optimistic or enthusias- tailored to the client's personal interests Consequently, even early versions of tic personalities might be best suited to ensure that the client experiences the CRA included brief relationship coun- for CRA. In contrast, therapists who activities as positive reinforcers.
seling (Hunt and Azrin 1973). Rather have been trained to use a relatively Other components of CRA are than providing protracted marital ther- confrontational approach in order to designed to help clients organize not apy, this counseling offers practical break down denial may find the CRA only their leisure activities but also, if skills training to improve positive com- approach more difficult to practice.
necessary, their regular daily lives. For munication and reinforcement between example, a component called access the client and his or her significant Initial Treatment Intensity. Another
counseling addresses practical barriers, other, reduce aversive communication characteristic of CRA that may con- such as the lack of information sources (e.g., arguments), and facilitate the tribute to the success of this approach is and means of communication, that stand negotiation of specific changes in the its "jump-start" quality. Ideally, a client between the client and those activities drinker's behavior (Meyers and Smith who is ready for change can schedule an that provide positive reinforcement.
1995). In addition, CRA therapists appointment for the same or following Thus, access counseling assists the client may coach significant others on how day, rather than being placed on a wait- in obtaining everyday necessities, such to avoid inadvertent reinforcement of ing list for 1 or more months. In addi- as a telephone, a newspaper, a place to drinking (sometimes called "enabling") tion, during the initial treatment phase, live, or a job. Another approach to help- and increase positive reinforcement for counseling sessions may be scheduled ing clients find rewarding work involves sobriety—for example, by spending more frequently than once per week.
job club procedures (e.g., interview skills time with the drinker when he or she is The intervals between sessions can then training and résumé development), which sober and withdrawing attention when be extended as the client's abstinence have been shown to be successful even he or she is drinking.
becomes more stable.
for difficult-to-employ people (Azrin Finally, CRA can involve procedures and Besalel 1980). The common goal Factors Influencing CRA
to initiate abstinence immediately. For of all these CRA treatment modules is example, in some cases the client can to make the client's alcohol-free life more be evaluated right away as to whether rewarding and affirming and to re-engage In addition to the treatment compo- he or she is a candidate for taking disul- the client in his or her community.
nents previously described, several fac- firam, an agent that induces unpleasant tors related to treatment delivery may effects (e.g., nausea and vomiting) after influence treatment effectiveness and, alcohol consumption and is used to consequently, the patient's outcome.
discourage drinking. In those cases, a CRA therapists do not just talk about Two of those factors are therapist style medical staff member of the treatment new behavior; instead, they have clients and initial treatment intensity.
facility can promptly issue and fill a actually practice new coping skills, par- disulfiram prescription, and the client ticularly those involving interpersonal Therapist Style. An important aspect of
can take the first dose in the therapist's communication, during the counseling CRA that is sometimes underempha- presence. If a concerned significant sessions. For example, a therapist may sized is the therapeutic style with which other is willing to help the client, he or first demonstrate the new behavior this treatment approach is delivered.
she can be trained along with the client (e.g., drink refusal or assertive commu- An optimal CRA therapist is consis- in procedures to ensure that the client nication), then reverse roles and guide tently positive, energetic, optimistic, takes the medication regularly. This the client in practicing the new skill.
supportive, and enthusiastic. Any and process also can be used to promote Again, the therapist gives praise for any all signs of progress, no matter how patient compliance with other medica- and all steps in the right direction.
small—even the client just showing up tion regimens.
for a counseling session—are recog- Involving Significant Others
nized and praised. CRA counseling isprovided in a personal, engaging style, Evidence for CRA's
Because CRA emphasizes change not not in the form of a businesslike nego- only in the client's behavior but also in tiation or impersonal education. With his or her social environment, this a therapist who successfully executes During the past 25 years, numerous treatment approach emphasizes and this counseling approach, clients look studies have demonstrated the efficacy Alcohol Research & Health
of CRA in the treatment of alcoholism.
Other evaluations of CRA's effec- the drinker may respond favorably to In the first evaluation, Hunt and Azrin tiveness have been conducted at the an offer of help and support and may (1973) compared CRA with traditional University of New Mexico's Center on be willing to enter treatment. disease-model treatment1 for alcohol- Alcoholism, Substance Abuse, and A recently completed clinical trial dependent people receiving inpatient Addictions (CASAA). In one outpatient funded by the National Institute on treatment. In that study, the patients treatment study (Meyers and Miller in Alcohol Abuse and Alcoholism evalu- who received CRA fared much better press), CRA was found to be more suc- ated the efficacy of CRAFT (Miller et than did the patients who received tra- cessful in suppressing drinking than al. in press). In that study, 64 percent ditional treatment—in fact, almost no was a traditional disease-model coun- of the clients who received CRAFT overlap existed in the distribution of seling treatment approach.
counseling succeeded in recruiting their the two groups on several outcome After Meyers and Smith (1995) loved one into treatment following an measures at followup. The CRA clients published the first manual delineating average of four to five counseling sessions.
drank substantially less and less often, the components of CRA for therapists In contrast, two traditional methods had fewer institutionalized days and treating patients with alcohol problems, for engaging unmotivated problem more days of employment, and exhib- CASAA researchers conducted a study drinkers into treatment—the Johnson ited greater social stability compared on CRA's efficacy among homeless Institute intervention2 and counseling with patients who were treated with alcohol-dependent men and women at to engage in Al-Anon—resulted in sig- the traditional approach.
a large day shelter. The study found nificantly lower proportions of signifi- Additional improvements to CRA, that compared with the standard 12- cant others (30 percent and 13 percent, such as monitored disulfiram adminis- step-oriented group therapy provided respectively) motivating their loved tration, mood monitoring, and spousal at the shelter, CRA, when implemented ones to enter treatment. In a parallel involvement, further increased the differ- as described in the manual, resulted in study sponsored by the National Institute ence in outcome between patients who significantly improved outcomes dur- on Drug Abuse that focused on abusers received CRA and those who received ing the 1-year followup period (Smith of other drugs, family members receiving traditional treatment (Azrin 1976). For et al. 1998). As in previous studies, CRAFT successfully engaged 74 per- example, with these improvements, alcohol consumption in the CRA group cent of initially unmotivated drug users drinking days in the CRA group dropped was almost completely suppressed during in treatment (Meyers et al. 1999).
to 2 percent of all days during a 6-month 1 year of followup. In contrast, patients followup period compared with 55 in the standard care group reported CRA in the Treatment of Other
percent of all days in the standard treat- drinking on about 40 percent of the days as well as high levels of intoxication.
Whereas those initial studies were CRA also has been used in the treatment conducted in an inpatient setting, CRA CRA as Family Therapy
of other drug abuse and dependence.
subsequently was shortened and adapted For example, researchers at CASAA for use in outpatient settings (e.g., by In recent years, CRA also has been conducted a trial in which heroin addicts instituting immediate disulfiram integrated into a unilateral family therapy receiving methadone maintenance administration). The modified CRA (FT) approach in which the person therapy were randomly assigned to approach also was considerably more seeking help is not the drinker (who CRA or standard treatment approaches.
effective than traditional outpatient refuses to get treatment) but a concerned Although both CRA and the traditional treatment mirroring the Minnesota spouse or other family member— approaches resulted in good treatment model (Azrin et al. 1982). As in previous resulting in the community reinforce- outcomes in this study, CRA was asso- studies, CRA clients showed substan- ment and family training (CRAFT) ciated with a modest but statistically tially increased rates of abstinence and approach (Meyers and Smith 1997). The significant advantage over the standard employment and less institutionalization CRAFT treatment approach is based care approaches (Abbott et al. 1998).
and incarceration.
on studies demonstrating that the involve- Furthermore, researchers studying the In another study, researchers assessed ment of family members can help initiate treatment of cocaine addicts found the effectiveness of a social intervention and promote the treatment of people substantially better outcomes for clients consistent with CRA. They provided with alcohol problems (Sisson and who received CRA combined with pos- an alcohol-free club where clients could socialize and have fun without drinking.
Without the drinker present, the Clients given access to this club evidenced CRAFT therapist works with the family 1Traditional disease-model treatment is similar to better outcomes than did clients with- member to change the drinker's social the Minnesota model, which posits that alcoholismis a disease characterized by loss of control over out such access (Mallams et al. 1982).
environment in a way that removes drinking and which emphasizes a 12-step approach Because these studies employed scien- inadvertent reinforcement for drinking to recovery.
tifically sound methodology, they and instead reinforces abstinence. The 2The Johnson Institute intervention entails five ther- provided strong evidence for the effec- therapist also helps the family member apy sessions that prepare the client and his or her tiveness of CRA.
prepare for the next opportunity when family members for a family confrontation meeting.
Vol. 23, No. 2, 1999
itive reinforcement in the form of A behavioral approach to achieving initial cocaine monetary vouchers issued when the abstinence. American Journal of Psychiatry 148:1218– clients tested drug free compared with CRA is a comprehensive, individualized clients who participated in an outpa- treatment approach designed to initiate HUNT, G.M., AND AZRIN, N.H. A community- tient 12-step counseling program changes in both lifestyle and social reinforcement approach to alcoholism. Behavior (Higgins et al. 1991).
environment that will support a client's Research and Therapy 11:91–104, 1973.
long-term sobriety. CRA focuses on MALLAMS, J.H.; GODLEY, M.D.; HALL, G.M.; AND finding and using the client's own intrin- MEYERS, R.A. A social-systems approach to resocial- Can CRA Be Used in
sic reinforcers in the community and is izing alcoholics in the community. Journal of Studies based on a flexible treatment approach on Alcohol 43:1115–1123, 1982.
with an underlying philosophy of posi- MEYERS, R.J., AND MILLER, W.R., EDS. A Community tive reinforcement. Those characteristics Reinforcement Approach to Addiction Treatment. CRA has sometimes been delivered in make CRA (with certain modifications) Cambridge, UK: Cambridge University Press, in press.
relatively expensive ways (e.g., in inpa- applicable to a wide range of client MEYERS, R.J., AND SMITH, J.E. Clinical Guide to tient programs, through home visits, Alcohol Treatment: The Community Reinforcement Numerous clinical trials have found and in combination with vouchers).
Approach. New York: Guilford Press, 1995.
CRA to be effective in treating AOD However, CRA is also amenable to and abuse and dependence and in helping MEYERS, R.J., AND SMITH, J.E. Getting off the fence: effective in the typical outpatient treat- relatives recruit their loved ones into Procedures to engage treatment-resistant drinkers.
ment context, in which the client is Journal of Substance Abuse Treatment 14:467–472, AOD-abuse treatment. The trials were seen weekly at a clinic. Furthermore, conducted in a variety of geographic in outpatient studies that demonstrated regions, treatment settings (e.g., inpa- MEYERS, R.J.; MILLER, W.R.; HILL, D.E.; AND good treatment outcomes with CRA, tient and outpatient), and individual TONIGAN, J.S. Community reinforcement and fam- alcohol-dependent patients received ily training (CRAFT): Engaging unmotivated drug and family therapy approaches. Further- users in treatment. Journal of Substance Abuse 10(3): an average of five to eight CRA sessions more, the clients in those studies suffered 1–18, 1999.
(e.g., Azrin et al. 1982). Similarly, the from various AOD-related problems study by Miller and colleagues (in press) and included homeless people as well MILLER, W.R., AND PAGE, A. Warm turkey: Other demonstrated that approximately five routes to abstinence. Journal of Substance Abuse as people of different ethnic or cultural Treatment 8:227–232, 1991.
CRAFT sessions with a concerned sig- backgrounds. Consistently, CRA was nificant other frequently resulted in the more effective than the traditional MILLER, W.R., AND ROLLNICK, S. Motivational drinker's entry into treatment. This approaches with which it was compared Interviewing: Preparing People to Change AddictiveBehavior. New York: Guilford Press, 1991.
treatment duration is well within the or to which it had been added. Because guidelines of most managed care systems.
the scope and duration of CRA are MILLER, W.R.; ANDREWS, N.R.; WILBOURNE, P.; Although CRA is based on a compre- compatible with the guidelines of most AND BENNETT, M.E. A wealth of alternatives: Effectivetreatments for alcohol problems. In: Miller, W.R., hensive treatment philosophy, its proce- managed care services, this approach may and Heather, N., eds. Treating Addictive Behaviors: dures generally are familiar to clinicians play an increasingly important role in Processes of Change. 2d ed. New York: Plenum Press, who have been trained in cognitive- the treatment of people with alcoholism.
1998. pp. 203–216.
behavioral treatment approaches. For MILLER, W.R.; MEYERS, R.J.; AND TONIGAN, J.S.
example, CRA involves a functional Engaging the unmotivated in treatment for alcohol analysis and the individualized applica- problems: A comparison of three strategies for tion of specific components chosen intervention through family members. Journal of BBOTT, P.J.; WELLER, S.R.; DELANEY, H.D.; AND from a menu of problem-solving pro- MOORE, B.A. Community reinforcement approach Consulting and Clinical Psychology, in press. cedures. Furthermore, CRA can be in the treatment of opiate addicts. American Journal SANCHEZ-CRAIG, M.; ANNIS, H.M.; BORNET, A.R.; of Drug and Alcohol Abuse 24:17–30, 1998.
combined with other treatment meth- AND MACDONALD, K.R. Random assignment to ods. For example, at CASAA, CRA has AZRIN, N.H. Improvements in the community- abstinence and controlled drinking: Evaluation of a reinforcement approach to alcoholism. Behavior cognitive-behavioral program for problem drinkers.
recently been combined with motiva- Research and Therapy 14:339–348, 1976.
Journal of Consulting and Clinical Psychology 52: tional interviewing to form an integrated 390–403, 1984.
treatment. Similarly, CRA is consistent AZRIN, N.H., AND BESALEL, V.A. Job Club Counselor'sManual. Baltimore: University Park Press, 1980.
with involvement in 12-step programs.
SISSON, R.W., AND AZRIN, N.H. Family-memberinvolvement to initiate and promote treatment of Finally, combinations of CRA and AZRIN, N.H.; SISSON, R.W.; MEYERS, R.; ANDG problem drinkers. Journal of Behavior Therapy and ODLEY, M. Alcoholism treatment by disulfiram other treatment approaches can be tai- and community reinforcement therapy. Journal of Experimental Psychiatry 17:15–21, 1986.
lored to address the needs of particular Behavior Therapy and Experimental Psychiatry SMITH, J.E.; MEYERS, R.J.; AND DELANEY, H.D.
client populations (for an example of 13:105–112, 1982. Community reinforcement approach with homeless such an approach targeted to a specific HIGGINS, S.T.; DELANEY, D.D.; BUDNEY, A.J.; alcohol-dependent individuals. Journal of Consulting population, see sidebar, p. 121).
BICKEL, W.K.; HUGHES, J.R.; AND FOERG, F.
and Clinical Psychology 66:541–548, 1998.
Alcohol Research & Health



CRA and Special Populations
clients from this cultural group, alcoholism treatmentprofessionals should work with both the family andcommunity networks using traditional Native Americanceremonies and extended clan ties. The NCI programconnects or reconnects the clients with Native Americanspirituality through the Hiina'ah Bits'os (Eagle Plume)Society. For example, traditional practices, such as thetalking circle (i.e., the passing of an object that designateswho is speaking while all others listen) and the sacred use of tobacco, are integrated into the treatment program,replacing alcohol with the Dine' way of seeking harmonywith all of creation (i.e., "walking in beauty"). A special The community-reinforcement approach (CRA) is a compound built adjacent to the Na'nizhoozhi Center highly flexible treatment approach that allows therapists includes ceremonial grounds, tepees, and sweat lodges. and clients to choose from an extensive menu of treatment For many NCI clients, the path into this program options to meet the specific needs of the client. This has been long and painful. Most clients are unemployed, flexibility also enables CRA to be adapted easily to client destitute, hopeless, physically ill, and depressed after populations with special needs, such as ethnic or cultural multiple treatment failures. Researchers have begun to minorities. For example, CRA has been adapted creatively evaluate the effectiveness of the modified CRA approach at the Na'nizhoozhi Center, Inc. (NCI) in Gallup, New practiced at the NCI in this challenging patient popula- Mexico, a treatment facility that primarily serves the Dine' tion. Preliminary results indicate that at the 6-month (Navajo) Native Americans. The NCI staff has developed followup, a substantial portion of clients have achieved an intensive, 16-day residential program for alcohol- continuous abstinence and many other clients are free dependent Native Americans who have not responded of alcohol-related problems, despite occasional drinking, to treatment programs based on the Minnesota model, or have improved considerably even if they have experi- which emphasizes a loss-of-control disease methodology enced some ongoing problems. These initial indications and a 12-step approach to recovery.
of effectiveness bear witness to the Hiina'ah Bits'os Among the Dine', clan ties remain strong even when Society's motto, "Against all odds, we walk in beauty." the trust between the drinker and his or her family has —William R. Miller and Robert J. Meyers with been broken repeatedly. Accordingly, when treating Vol. 23, No. 2, 1999

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