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Conroy K, Kehrer SM, Georgiadis C, Hare M, Ringle VM, Shaw AM. Learning from Adolescents and Caregivers to Enhance Acceptability and Engagement Within Virtual Dialectical Behavior Therapy for Adolescents Skills Groups: A Qualitative Study. Child Psychiatry Hum Dev 2024:10.1007/s10578-023-01641-7. [PMID: 38183575 DOI: 10.1007/s10578-023-01641-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 01/08/2024]
Abstract
Despite the significant increase in adolescent mental health challenges in recent years, structural barriers continue to limit access to and engagement in mental health services. As such, opportunities to learn directly from adolescents and their families on how to best structure and deliver services are paramount. The current study assumes a multi-informant approach and reports on adolescents' and caregivers' (N = 33) experiences in an adapted telehealth/hybrid Dialectical Behavior Therapy for Adolescents (DBT-A) program. Focus groups were conducted across two cohorts of families who participated in DBT-A skills groups, to collect family-centered data on the acceptability of program modifications, engagement in the adapted telehealth/hybrid DBT-A, and recommendations for improvement. Participants were predominately Latine White and were from a broad range of socioeconomic backgrounds. Additionally, 45.5% of the adolescents identified as LGBTQ + . Focus group findings emphasized how the telehealth platform was both convenient and disengaging, and how in-person sessions offered improved group connection and content engagement. Participants underscored the importance of balancing multi-family group sessions with adolescent- and caregiver-only group sessions in the program, and adolescents emphasized a need for the DBT-A program to better center adolescents' unique experiences and voices throughout sessions. Both adolescents and caregivers suggested modifications to synthesize the content and improve generalizability of the DBT-A skills to their real lives. Overall, these findings add to a new and evolving branch of DBT-A qualitative inquiry, as well as the growing body of work that recommends incorporating the voices of people with lived experiences into the development and modification of psychological services.
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Affiliation(s)
- Kristina Conroy
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA.
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Sabrina M Kehrer
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA
| | - Christopher Georgiadis
- Center for Children and Families, Department of Psychology, Florida International University, Miami, FL, USA
- The Warren Alpert Medical School, Department of Psychiatry, Brown University, Providence, RI, USA
| | - Megan Hare
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Vanesa Mora Ringle
- Counseling Psychology Program, Department of Education and Human Services, Lehigh University, Bethlehem, PA, USA
| | - Ashley M Shaw
- School of Social and Behavioral Sciences, University of New England, Biddeford, ME, USA
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Orlowski EW, Chen JI, Breznik LH, Gleason LDL, Karver MS. Psychotherapist perceptions of engagement-building behaviours with youth clients across developmental levels. Clin Psychol Psychother 2024; 31:e2962. [PMID: 38404160 DOI: 10.1002/cpp.2962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/27/2024]
Abstract
Building a positive therapeutic relationship is a challenging, yet critical, first step in conducting youth psychotherapy. A number of studies in the youth treatment literature have indicated that a positive therapeutic alliance is related to increased treatment attendance, participation, and outcome. Some research has examined therapist behaviours for engaging therapy clients; however, developmental differences in alliance formation have had limited exploration. The current study surveyed clinicians about their use of specific engagement strategies and the developmental stage of their youth clients. It was hypothesised that participants would differentially rate the importance of different aspects of therapeutic engagement based upon a youth client's developmental stage and that these would correspond with differences in specific engagement strategies. A total of 64 clinicians with experience treating youth completed the study. The participants completed a questionnaire administered online that asked them to rate the importance of developmental differences to forming a therapeutic relationship and provide example client behaviours from their clinical experience for each developmental stage. Results showed clinicians felt the relative importance of collaboration, advocacy, and trustworthiness increased with age. These differences were also evidenced in the specific strategies clinicians endorsed in relation to each engagement factor across developmental stages. This program of research will eventually aid in the development of new guidelines for engaging clients in youth psychotherapy. In addition, the results may be used to enhance psychotherapy training for those working with children and adolescents.
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Affiliation(s)
- Edmund W Orlowski
- Department of Educational and Counseling Psychology, University at Albany/SUNY, Albany, New York, USA
| | - Jason I Chen
- VA HSR&D Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon, USA
| | | | - La Donna L Gleason
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Marc S Karver
- Department of Psychology, University of South Florida, Tampa, Florida, USA
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Hildebrand-Burke C, Davey C, Gwini S, Catania L, Kazantzis N. Therapist competence, homework engagement, and client characteristics in CBT for youth depression: A study of mediation and moderation in a community-based trial. Psychother Res 2024; 34:41-53. [PMID: 37963351 DOI: 10.1080/10503307.2023.2267166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVE Prior studies of Cognitive Behavioral Therapy (CBT) have focused on the quantity and quality of clients' homework completion and only rarely have considered the role of therapist competence. METHODS The present study examined (a) therapist competence across the entire process of integrating homework into CBT, including the review, design, and planning of tasks; (b) homework engagement, including client appraisals of the difficulty and obstacles encountered in task completion using the Homework Rating Scale - Revised (HRS-II); (c) pre-post symptom reduction as the index of outcome; and (d) considered client factors such as suicide risk in a community-based trial for adolescent depression. Trained independent observers assessed therapist competence and engagement with homework at two consecutive sessions of CBT for N = 80 young people (Mage = 19.61, SD = 2.60). RESULTS Significant complementary mediation effects were obtained; there was an indirect mediation effect of HRS-II Beliefs (b = 1.03, SE B = 0.42, 95% BCa CI [0.35, 2.03]) and HRS-II Perceived Consequences on the Competence-Engagement relationship (b = 0.85, SE B = 0.31, 95% BCa CI [0.39, 1.61]). High levels of suicidal ideation were also shown to moderate this relationship. CONCLUSIONS The present findings contribute to the growing body of CBT process research designed to examine the complex interrelationships of client and therapist variables, in a manner that reflects the actual process of therapy, and advances beyond studies of isolated predictors of symptom change.
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Affiliation(s)
- Craig Hildebrand-Burke
- Cognitive Behavior Therapy Research Unit, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | | | - StellaMay Gwini
- Cognitive Behavior Therapy Research Unit, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Lisa Catania
- University of Melbourne, Melbourne, VIC, Australia
| | - Nikolaos Kazantzis
- Cognitive Behavior Therapy Research Unit, Melbourne, VIC, Australia
- Beck Institute for Cognitive Behavior Therapy, Philadelphia, PA, USA
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Bose D, Pettit JW, Silk JS, Ladouceur CD, Olino TM, Forbes EE, Siegle GJ, Dahl RE, Kendall PC, Ryan ND, McMakin DL. Therapeutic Alliance, Attendance, and Outcomes in Youths Receiving CBT or Client-Centered Therapy for Anxiety. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023:1-11. [PMID: 37796228 PMCID: PMC10995113 DOI: 10.1080/15374416.2023.2261547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Positive associations between therapeutic alliance and outcome (e.g. youth symptom severity) have been documented in the youth anxiety literature; however, little is known about the conditions under which early alliance contributes to positive outcomes in youth. The present study examined the relations between therapeutic alliance, session attendance, and outcomes in youths (N = 135; 55.6% female) who participated in a randomized clinical trial testing the efficacy of cognitive-behavioral therapy or client-centered therapy for anxiety. METHOD We evaluated a conceptual model wherein: (1) early alliance indirectly contributes to positive outcomes by improving session attendance; (2) alliance-outcome associations differ by intervention type, with stronger associations in cognitive-behavioral therapy compared to client-centered therapy; and (3) alliance-outcome associations vary across outcome measurement timepoints, with the effect of early alliance on outcomes decaying over time. RESULTS Contrary to hypotheses, provider ratings of early alliance predicted greater youth-rated anxiety symptom severity post-treatment (i.e. worse treatment outcomes). Session attendance predicted positive youth-rated outcomes, though there was no indirect effect of early alliance on outcomes through session attendance. CONCLUSIONS Results show that increasing session attendance is important for enhancing outcomes and do not support early alliance as a predictor of outcomes.
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Affiliation(s)
- Deepika Bose
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Jeremy W. Pettit
- Department of Psychology and Center for Children and Families, Florida International University, Miami, FL
| | - Jennifer S. Silk
- Department of Psychology, University of Pittsburgh, and Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, PA
| | - Cecile D. Ladouceur
- Department of Psychology, University of Pittsburgh, and Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, PA
| | - Thomas M. Olino
- Department of Psychology, Temple University, Philadelphia, PA
| | - Erika E. Forbes
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, PA
| | - Greg J. Siegle
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, PA
| | - Ronald E. Dahl
- School of Public Health, University of California at Berkeley, Berkeley, CA
| | | | - Neal D. Ryan
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, PA
| | - Dana L. McMakin
- Department of Psychology and Center for Children and Families, Florida International University, Miami, FL
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Rabner J, Norris LA, Crane ME, Klugman J, Kendall PC. Impact of youth and caregiver worries about treatment on therapeutic process factors and posttreatment outcomes. J Anxiety Disord 2023; 98:102741. [PMID: 37348261 PMCID: PMC10527968 DOI: 10.1016/j.janxdis.2023.102741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 05/31/2023] [Accepted: 06/14/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE To examine the impact of youth- and caregiver-reported pretreatment worries about treatment (i.e., concerns about the effect of, perceptions of, or aspects involved in treatment) before cognitive behavioral therapy for anxiety on (1) clinician-rated therapeutic process factors (i.e., client engagement, client-therapist alliance, content mastery, and homework completion) and symptom change (i.e., improvement, anxiety severity) assessed throughout treatment and (2) independent evaluator-rated posttreatment outcomes (i.e., response, remission, and functional impairment). METHODS Participants were 128 youth, aged 7-17 years, who sought treatment for a principal anxiety disorder, and their primary caregiver. Multilevel models were estimated to examine the relationship between worries about treatment and the set of therapeutic factors. Regression models examined the relationship between worries about treatment and posttreatment outcomes. RESULTS Results indicated that greater youth-reported worries about treatment flattened/lessened improvement trajectories throughout treatment and had a positive association with higher anxiety severity and lower content mastery. Greater caregiver-reported worries about treatment were associated with greater homework completion, client engagement, and content mastery throughout treatment. Youth- and caregiver-reports of worries about treatment did not impact independent evaluator-rated posttreatment outcomes. CONCLUSIONS Findings support the notion that worries about treatment do not prevent youth from achieving favorable posttreatment outcomes, but do impact various therapeutic factors differentially across youth and caregiver report (e.g., content mastery, client engagement, and homework completion). The value of addressing worries about treatment at the start of therapy is discussed.
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Affiliation(s)
- Jonathan Rabner
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA, USA.
| | - Lesley A Norris
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA, USA; Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
| | - Margaret E Crane
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA, USA; Department of Psychiatry, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Joshua Klugman
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA, USA; Department of Sociology, Temple University, Philadelphia, PA, USA
| | - Philip C Kendall
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA, USA
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Kendall PC, Ney JS, Maxwell CA, Lehrbach KR, Jakubovic RJ, McKnight DS, Friedman AL. Adapting CBT for youth anxiety: Flexibility, within fidelity, in different settings. Front Psychiatry 2023; 14:1067047. [PMID: 36937729 PMCID: PMC10014836 DOI: 10.3389/fpsyt.2023.1067047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/30/2023] [Indexed: 03/05/2023] Open
Abstract
Anxiety disorders are common in youth, associated with impairments in daily functioning, and often persist into adulthood when untreated. Cognitive behavioral therapy (CBT) for youth anxiety is a well-established intervention and has been modified to fit several treatment settings. Despite decades of results supporting the efficacy of CBT, there is a large gap in access to this treatment and a need to consider how it can best be administered flexibly to increase uptake and personalization. We first discuss the core components of treatment for CBT through the lens of the Coping Cat treatment. Next, we review the empirical findings regarding adjustments made for CBT for youth anxiety delivered (a) in schools, (b) in community settings, (c) through telehealth, (d) through online computer programs, and (e) by caregivers at home. In each setting, we provide specific suggestions for how to implement CBT with flexibility while maintaining fidelity.
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Casline EP, Ogle RR, Peris TS, Kendall PC, Piacentini J, Compton S, Keeton C, Ginsburg GS. Client-rated facilitators and barriers to long-term youth anxiety disorder recovery. J Clin Psychol 2022; 78:2164-2179. [PMID: 35687807 PMCID: PMC9561069 DOI: 10.1002/jclp.23400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/10/2022] [Accepted: 05/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study examined client ratings of 26 facilitators and barriers to anxiety improvement approximately 6 years after randomization to treatment for anxiety. METHOD 319 youth (average 17.12 years old; 82.1% Caucasian; 58.6% female) participated in the longitudinal follow-up study to child and adolescent anxiety multimodal study (CAMS), a randomized controlled trial of medication, cognitive-behavioral therapy (CBT), combination, and placebo. RESULTS Correcting for multiple comparisons, CBT components (i.e., problem solving, changing unhelpful thoughts, relaxation skills) were rated significantly more helpful among youth without, versus with, an anxiety disorder at follow-up. Barriers that differentiated youth with and without an anxiety disorder included being bullied and difficulty applying therapy content to new situations. Comparisons between youth with different anxiety disorder trajectories (e.g., stable remission, relapsed, or chronically ill) also revealed several differences. CONCLUSION Findings suggest that client-rated facilitators and barriers covary with anxiety disorder recovery and may serve as useful tools when evaluating long-term treatment efficacy.
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Affiliation(s)
| | - Robert R. Ogle
- Counseling Center, Yeshiva University, New York, NY, USA
| | - Tara S. Peris
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA
| | | | - John Piacentini
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA
| | - Scott Compton
- Department of Psychiatry and Behavioral Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney Keeton
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Golda S. Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
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Piacentini J, Wu M, Rozenman M, Bennett S, McGuire J, Nadeau J, Lewin A, Sookman D, Lindsey Bergman R, Storch E, Peris T. Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2021; 299:113854. [PMID: 33765492 DOI: 10.1016/j.psychres.2021.113854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.
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Affiliation(s)
- John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA.
| | - Monica Wu
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA.
| | | | - Shannon Bennett
- Department of Psychiatry, Weill Cornell Medical College, NY, NY USA
| | - Joseph McGuire
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Josh Nadeau
- Department of Pediatrics, University of South Florida, St. Petersburg, FL, and Rogers Memorial Hospital, Oconomowoc, WI, USA
| | - Adam Lewin
- Departments of Psychiatry and Behavioral Neurosciences and Pediatrics, University of South Florida, St. Petersburg, FL, USA
| | - Debbie Sookman
- Department of Psychology, McGill University Health Center, and Department of Psychiatry, McGill University, Montreal, Quebec, CANADA
| | | | - Eric Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX USA
| | - Tara Peris
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA
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In-Session Involvement in Anxious Youth Receiving CBT with/without Medication. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2020. [DOI: 10.1007/s10862-020-09810-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Miles to Go Before We Sleep: Advancing the Understanding of Psychotherapy by Modeling Complex Processes. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9893-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Introduction to the Special Issue on Processes of Cognitive Behavioral Therapy: Does “Necessary, But Not Sufficient” Still Capture It? COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9891-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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