Psychotherapy © 2014 American Psychological Association

2015, Vol. 52, No. 2, 169 –173 0033-3204/15/$12.00 http://dx.doi.org/10.1037/a0037596

Alliance-Focused Training

Catherine Eubanks-Carter J. Christopher Muran

Yeshiva University Adelphi University

Jeremy D. Safran
New School for Social Research

Alliance-focused training (AFT) aims to increase therapists’ ability to recognize, tolerate, and negotiate
alliance ruptures by increasing the therapeutic skills of self-awareness, affect regulation, and interper-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sonal sensitivity. In AFT, therapists are encouraged to draw on these skills when metacommunicating
This document is copyrighted by the American Psychological Association or one of its allied publishers.

about ruptures with patients. In this article, we present the 3 main supervisory tasks of AFT: videotape
analysis of rupture moments, awareness-oriented role-plays, and mindfulness training. We describe the
theoretical and empirical support for each supervisory task, provide examples based on actual supervision
sessions, and present feedback about the usefulness of the techniques from trainees in our program. We
also note some of the challenges involved in conducting AFT and the importance of maintaining a strong
supervisory alliance when using this training approach.

Keywords: alliance, alliance ruptures, supervision, training, therapist skills

Given the importance of the alliance as a predictor of outcome client, and observer ratings of ruptures show that therapists often
(Horvath, Del Re, Flückiger, & Symonds, 2011), and evidence that miss ruptures, and that failure to address ruptures is linked to
therapists vary in their abilities to maintain strong alliances (Bald- patient dropout (Eubanks-Carter, Muran, & Safran, 2010).
win, Wampold, & Imel, 2007), there is increasing interest in In addition to recognizing that a rupture is occurring, therapists
training and supervision approaches to enhance therapists’ abilities must be able to tolerate the difficult emotions that may be
to improve the alliance (see Safran, Muran, & Eubanks-Carter, involved— both their own and their patients’. The skill of affect
2011 for a review). Based on our ongoing research program on the regulation is essential for responding empathically and resisting
alliance (see Muran, 2002 for a description), our group has devel- the urge to answer patient hostility with counterhostility or to use
oped an approach to training that focuses on increasing therapists’ avoidance behaviors to reduce one’s own anxiety. There is pre-
skills for negotiating problems, or ruptures, in the alliance. Our liminary evidence that therapists’ abilities to regulate their emo-
approach, alliance-focused training (AFT), has also been studied in tions predict treatment outcome (Kaplowitz, Safran, & Muran,
the form of a manualized treatment called brief relational therapy 2011).
(BRT). Finally, in addition to recognizing the rupture and managing
AFT is focused on developing three interdependent therapist their affect, therapists need to be able to communicate with the
skills: self-awareness, affect regulation, and interpersonal sensitiv- patient about what is transpiring without exacerbating the rupture.
ity. Self-awareness is critical for recognizing that a rupture is The skill of interpersonal sensitivity refers to this ability to express
occurring. By becoming more attuned to their own immediate accurate empathy and to address the rupture in a way that enhances
experience, therapists become better able to detect strains in the
the patient’s awareness of his or her own experience and his or her
alliance. The ability to detect ruptures is important: evidence from
impact on others.
qualitative patient interviews as well as comparisons of therapist,
We recognize that there are many ways that therapists can use
these skills to address a rupture, including methods in which the
rupture is not explicitly discussed or explored (see Safran &
This article was published Online First August 25, 2014.
Muran, 2000). However, the focus of AFT is the resolution strat-
Catherine Eubanks-Carter, Ferkauf Graduate School of Psychology, egy of metacommunication (Kiesler, 1996), or communicating
Yeshiva University; J. Christopher Muran, Derner Institute for Advanced about the patient–therapist interaction. When teaching metacom-
Psychological Studies, Adelphi University; Jeremy D. Safran, Department munication, we encourage trainees to collaborate with their pa-
of Psychology, New School for Social Research. tients, to try to be curious together about what is happening
The research on alliance-focused training was conducted at the Psycho- between them. Therapists are also encouraged to take responsibil-
therapy Research Program, Mount Sinai Beth Israel, and supported by a ity for any ways in which they have contributed to the rupture.
grant from the National Institute for Mental Health [MH071768] (Principal
Metacommunication may include drawing links between the
Investigator: J. Christopher Muran).
Correspondence concerning this article should be addressed to Catherine patient–therapist interaction and other relationships in the patient’s
Eubanks-Carter, Ferkauf Graduate School of Psychology, Yeshiva Univer- life in the form of transference interpretations. However, we gen-
sity, 1300 Morris Park Avenue, Bronx, NY 10461. E-mail: catherine erally recommend that trainees keep the focus of the metacommu-
[email protected] nication on the here and now, with the goal of increasing their own

169
 170 EUBANKS-CARTER, MURAN, AND SAFRAN

and the patient’s awareness of their immediate experience. Finally, ysis, the authors found that the use of audio- or videotaping in
we encourage trainees to expect that attempts to explore ruptures supervision demonstrated a moderate, though nonsignificant, ef-
may lead to more ruptures. Rupture–repair is an ongoing process, fect on the relationship between therapist affect focus and patient
and trainees need to be able to move fluidly as the nature of the outcome. The authors observed that the use of taping may help to
interaction shifts. maximize treatment effects.
In our studies at the Mount Sinai Beth Israel Brief Psychother- In our use of video, we emphasize difficult moments—moments
apy Research Program, AFT is conducted as weekly group super- of rupture. We encourage our trainees to purposely select video
vision with trainees who are primarily seeing patients with Cluster segments where they felt stuck, frustrated, confused, or anxious.
C personality disorder diagnoses for 30 sessions of therapy. At the When watching those difficult moments in supervision, our focus
beginning of the supervision, trainees are provided with readings is not on helping trainees to problem-solve or identify better
that introduce them to the approach, including excerpts from the interventions to use next time, although these tasks may be part of
book Negotiating the Therapeutic Alliance: A Relational Guide the discussion. Rather, the emphasis is on enhancing trainees’
(Safran & Muran, 2000), which functions as our training manual. awareness of what they were experiencing in the moment with the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

This book describes our empirically based rupture resolution patient. Our hope is that therapists will become more aware and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

model, as well as other conceptual lenses (e.g., resistance, multiple accepting of their experience, and that this enhanced awareness
selves) that can help therapists to understand and organize their and acceptance will enable them to intervene in a genuine, em-
experience. AFT can also include use of process measures to help pathic, and flexible way.
sensitize trainees to subtle changes across a therapy session (see In the following example, a trainee, Sam, shows the supervision
Muran, Safran, & Eubanks-Carter, 2010; Safran & Muran, 2000; group a segment of a session in which he raised the possibility that
Safran, Muran, Stevens, & Rothman, 2008, for more detailed perhaps the patient had some disappointment about the treatment,
descriptions of the supervision model). This article will focus on and the patient quickly responded that she found therapy helpful.
the three tasks that are most central in AFT: videotape analysis of The supervisor stops the tape and asks Sam what he is experienc-
challenging moments in the session, awareness-oriented role- ing as he watches it. A second trainee, Jess, then shares her
plays, and mindfulness training. experience of watching the tape.
To date, research done by our group offers some support for Sam: I’m experiencing myself as being a little more defensive
AFT. In a randomized, controlled trial comparing a treatment than I thought I was at the time.
condition in which trainees received this form of supervision Supervisor: Defensive in what way?
(BRT) with cognitive behavior therapy (CBT) and a short-term Sam: Just my facial expression. I’m very tepid about saying,
dynamic treatment, all three treatments were equally effective at “perhaps this has been unhelpful.” Something about my face felt
improving symptoms and interpersonal functioning, and BRT was like I was—I was trying too hard to not be defensive, and it didn’t
more effective at retaining patients in treatment (Muran, Safran, come across as genuine. Whereas at the time, I felt I was being
Samstag, & Winston, 2005). Preliminary findings from an ongoing very conscientious.
study (Muran, Gorman, Safran, Eubanks-Carter, & Winston, 2014; Supervisor: I’m not sure I understand. In what way were you not
Safran et al., 2014) show that when therapists trained in CBT then being genuine?
switch to AFT following a multiple-baseline design, there is a Sam: I was trying to find a way of saying “perhaps you didn’t
positive impact on interpersonal process plus some evidence sug- find this helpful” that didn’t come across as a criticism, or like I
gesting that this impact has implications for better outcome. There was trying to defend the work. At the time, it felt neutral, but just
is also evidence that AFT improves therapists’ abilities to reflect now when I was watching this, it felt like I was a little more
on their emotional involvement with their patients. defensive than I remembered.
In the following sections, we will describe in more detail the Supervisor: So to bring up the possibility that the therapy is not
three main supervisory tasks in AFT and the theoretical and helpful feels threatening?
empirical support for their use. We will illustrate each task with an Sam: I wouldn’t say threatening. I was happy that she said that
excerpt based on actual supervision sessions we have led (trainees’ because it was the first time she’s articulated something like that,
names have been changed to preserve confidentiality). We will where she’s been able to verbalize her ambivalence. But I do
also provide some excerpts from interviews with trainees, drawn remember feeling a twinge.
from an ongoing qualitative study (Eubanks-Carter, Silberstein, & Supervisor: It’s perfectly natural to feel a twinge, and it’s good
Muran, 2014). that you’re able to notice and acknowledge that.
Jess: As I was thinking about how I would feel if I were in your
position, I felt defensive. The patient was so quick to say that
Videotape Analysis
therapy was helpful. It was very quick for someone who usually
A central focus of our supervision sessions is the analysis of takes a long time to express herself. That brought up defensive
videotapes of trainees’ therapy sessions. As Haggerty and Hilsen- feelings in me.
roth (2011) noted in their review, the use of video overcomes the Sam: Yes. When the patient and I first started talking about the
limitations of relying on selective memories and allows for a question of whether therapy has been helpful for her, I pursed my
greater focus on nonverbal behavior. There is some evidence that lips a little bit. But then when she said that it was helpful, I relaxed
the use of video in supervision benefits clients. For example, a visually. I didn’t realize that I did that at the time, but I can see it
meta-analysis by Diener, Hilsenroth, and Weinberger (2007) ex- now watching the tape.
amined the relationship between therapist focus on patients’ emo- Observing his own nonverbal behavior helped Sam become
tion and outcome in psychodynamic therapy. In a moderator anal- more aware of the defensiveness he experienced—and unwittingly
 ALLIANCE-FOCUSED TRAINING 171

displayed—in his interaction with his patient. The supervisor en- The trainee, Sarah, showed a video segment of a recent session and
couraged Sam to explore these feelings in a nonjudgmental way. shared her growing frustration with her patient. The supervisor
Participation by fellow trainees who could validate Sam’s experi- suggested a role-play with Sarah playing her patient, and another
ence also helped to create an atmosphere in which Sam felt safe to trainee, Anna, playing the therapist.
be open and curious, rather than defending against his defensive- Sarah: OK, I’ll start the way she did in the segment I just
ness. showed you. [as patient]: What session is this, is this Session 21?
Creating a safe space for trainees to show videos of rupture Anna [as therapist]: Yes, this is session 21, so we have 9 left.
moments can be challenging. As one trainee noted: “I never Sarah [as patient]: (Loud, sharp laugh.)
completely forgot that there was a camera in that room . . . and Anna [as therapist]: Do you have some thoughts or feelings
always knowing that I was going to be showing tape would make about that?
the session sort of a little more stressful.” Another trainee ob- Sarah [as patient]: No, no, I just was trying to keep track. It’s not
served: “If you’re feeling uncomfortable you can sort of hide a enough.
little bit in supervision, and not necessarily show your tape if you Anna [as therapist]: It’s not enough? Do you feel disappointed?
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

had a really tough session, and you’re not quite sure how you feel Sarah [as patient]: (Loud, sharp laugh again, dramatically rolls
This document is copyrighted by the American Psychological Association or one of its allied publishers.

about it yet.” her eyes. The group laughs.)

Other trainees acknowledged the evaluative pressure but also Anna: (laughing) Wow, you really don’t like your patient, do
reported that the use of videotape actually helped them to be more you?
accepting and less self-critical. As one trainee noted: “It’s really Sarah: I just get so frustrated with her avoidance maneuvers. I
raw to watch yourself on video, and in a way, you know, there are feel like she could do more than she does. I feel very critical of her.
times when you feel like you’re being critiqued, but there are times Does anyone else have that kind of reaction to her?
when it really brings to light maybe some dynamics you weren’t Supervisor: I think there’s another question behind that ques-
aware of in the room . . .. It helped me to pay attention more to my tion—is it OK that I feel this way?
own experience in the room instead of trying to be, you know, this Sarah: (Nods.)
perfect therapist.” Similarly, another trainee noted how the partic- Supervisor: And that is completely OK. What’s important is that
ipation of the other supervisees validated her own experience: is how you are feeling. So let’s stick with that for a moment. Let’s
“Hearing other people’s reactions to [the patient’s behavior in try the role-play again, but this time you play yourself and Anna
session] I think probably, maybe, freed me up a little bit more . . . will play the patient. And this time, tell her how you really feel.
hearing other people’s reactions to it made me feel more accepting Don’t worry about phrasing it nicely or how you would really talk
of my own reaction to it.” to a patient. Just tell her how you feel.
Anna [as patient]: What session is this? How many do we have
left?
Awareness-Oriented Role-Plays
Sarah [as therapist]: This is 21. We only have 9 more. Do you
The second key feature of AFT is the use of awareness-oriented have some thoughts about that?
role-plays. Trainees may take turns playing the roles of patient and Anna [as patient]: No, no thoughts, just curious.
therapist, or one trainee may be asked to switch back and forth Sarah [as therapist]: OK. But I wonder, maybe you do have
between patient and therapist roles. These awareness exercises are some thoughts. Maybe we should talk about that.
similar to the experiential techniques of two-chair and empty chair, Supervisor: Don’t hold back. You are being careful and cautious
and share their goal of focusing attention on the participant’s and talking like a therapist. Just tell her directly how you feel.
experience to increase awareness of implicit feelings, to express Don’t censor yourself.
unmet needs, and to gain greater understanding and acceptance of Sarah: OK. [as therapist]: I’m frustrated. I’m frustrated with
self and other. Research has found that the use of the two-chair you. I feel like you never work with me. You never let me in.
technique is effective in helping patients resolve intrapersonal (Turns to face the group.) This is really hard.
conflicts (Clarke & Greenberg, 1986). Emotion-focused therapy, Supervisor: What’s happening for you right now?
which uses empty-chair as a primary technique, has been found to Sarah: I feel judged by her. She’s been disappointed with me
be an effective treatment for depression, interpersonal problems, since we started. You know, the first time I went to meet her in the
and trauma, and is effective in promoting empathy (Greenberg & waiting room, she seemed disappointed to learn that I was her
Watson, 2006). therapist. But I can’t tell her that I feel judged by her—that will
In our use of role-plays in AFT, trainees do gain the opportunity just sound like more criticism.
to experiment with intervening in different ways, similar to the Supervisor: You’re both caught in this right now, feeling criti-
way in which role-plays may be used to practice interventions in cal, and feeling criticized. It’s a shared dilemma.
other forms of supervision such as CBT. However, the primary Sarah: Yeah, that’s true. That’s something I could say to her.
focus of role-plays in AFT is to help trainees explore their own Similar to the use of video, awareness-oriented role plays can
feelings and internal conflicts as they emerge. Supervisors inter- contribute to performance anxiety in trainees. In the trainee inter-
vene at critical points to encourage trainees to focus on and views, some trainees admitted that they avoided volunteering for
articulate their experience. The supervisor may encourage the role-plays due to anxiety. Most trainees, however, while acknowl-
trainee to verbalize his or her feelings and intuitions in the role- edging their anxiety, described the role plays as being the most
play as part of a metacommunication process. The supervisor may helpful part of supervision. As one trainee stated: “I love role
also encourage exploration of the therapist’s fears or frustrations plays. They’re nerve-wracking to do but I learn a lot from them . . .
that are contributing to the rupture, as in the following example. The reason why I like the role plays is because it’s like a dual track
 172 EUBANKS-CARTER, MURAN, AND SAFRAN

of learning at once. It’s like speed learning . . . I typically get more nondefensive fashion. We conceptualize metacommunication as a
insight into what the patient might be experiencing as I’m trying to form of “mindfulness in action” (Safran & Muran, 2000).
be in their position. That helps me to get them more. And also We encourage trainees to develop their own daily mindfulness
tracking [the therapist’s] responses helps me to understand better practices. We also incorporate mindfulness training into the super-
what I might do in that situation, and also what a patient might feel vision sessions. We may start a supervision session with an exer-
in relation to some of the responses that I might make.” cise such as the following:
Another trainee noted the importance of feeling supported when Supervisor: Get comfortable in your chair, and you can close
doing a role-play: “It was just real hard being a therapist in that your eyes or just lower your gaze. Focus your attention on your
moment because I could feel myself kind of reliving a lot of the breath. Pay attention to each inhale and exhale. Now start to count
uncomfortable, anxiety-like feelings I would experience when I each breath. Whenever you notice your mind wandering, just note
would be in the room with [my patient] . . .. It was difficult because this, no judgment, no criticism, just note that your attention has
other people were watching me, and the supervisor, and you knew wandered, and then gently refocus your attention on your breath
you were being critiqued in some ways. But it was also relieving, and start counting again, beginning again at one.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

knowing you were doing it in a safe environment, and that it was In the interviews, one trainee noted that mindfulness training
This document is copyrighted by the American Psychological Association or one of its allied publishers.

with the notion of receiving some feedback and some help with, was particularly helpful during a hectic internship year: “It really
you know, what they were seeing that maybe I could utilize at the did help me during this difficult year to, kind of ground me at
time, so I didn’t feel so alone in the process.” certain points, and when I wasn’t really able to get into it, then to
An important component of role-plays is the way in which they be mindful about what was going on that made it hard, and why I
actively involve other members of the supervision group and can felt distracted as well.” However, a number of interviewees ex-
help to foster an alliance among the group members. As one pressed some disappointment with mindfulness training. Concerns
trainee observed: “When you are watching a case unfold and you were raised that it was not sufficiently integrated with the rest of
are not in it, I think you really can kind of reflect on an experience AFT. As one trainee observed: “We started off doing a lot of
the therapist is having in a less judgmental way, and just kind of meditation, and I guess I was expecting that to kind of tie in more,
start to verbalize it. I found it really helpful when we inhabited and I don’t think that it did. I just feel like maybe it could have, in
each other’s spaces, as therapists, and tried to speak about what we terms of the actual moment-to-moment clinical material.” Another
might be feeling.” trainee observed how challenging it is to require mindfulness
training: “I really like mindfulness meditation quite a bit, and I do
it on my own, and I know it’s a component of the treatment, and
Mindfulness Training I think it’s a good one. I think it’s kind of the sort of thing that’s
The third key feature of AFT is mindfulness training. Mindful- hard to enforce upon a group. Everybody’s got to maybe figure it
ness is commonly defined as the ability to attend to one’s experi- out on their own.”
ence in the present moment with an attitude of nonjudgmental
acceptance (Aronson, 2004). Mindfulness has become an impor-
Discussion
tant component of a number of psychotherapy treatments, includ-
ing acceptance and commitment therapy (Hayes, Strosahl, & Wil- Our alliance-focused training approach aims to increase thera-
son, 1999), dialectical behavior therapy (Linehan, 1993), and pists’ ability to recognize, tolerate, and negotiate alliance ruptures
mindfulness-based cognitive behavioral therapy (Segal, Williams, by enhancing their self-awareness, affect regulation, and interper-
& Teasdale, 2002). Therapists practicing these treatments are sonal sensitivity. Through the use of videotape analysis of rupture
encouraged to develop their own mindfulness skills (Wilson & moments, awareness-oriented role-plays, and mindfulness train-
Dufrene, 2008). In their review, Davis and Hayes (2011) report on ing, we encourage trainees to develop an open, accepting, non-
findings that provide some evidence (albeit based primarily on judgmental curiosity about their own experience and the experi-
trainee self-report) that mindfulness training for trainees leads to ence of their patients, and to begin to articulate their experience via
increased empathy toward clients and greater attention to therapy metacommunication.
process; increased self-compassion, self-awareness, and self-efficacy; Our research program has produced evidence that suggests that
and decreased stress and anxiety. AFT helps trainees to treat challenging patients effectively. Addi-
In AFT, the goal of mindfulness training is to help therapists tional research is needed to tie particular supervisory actions to
refine their capacity to observe their inner experience as well as client outcomes. Interviews with trainees suggest that they find
their contributions to the interaction with the patient. Our hope role-plays and the use of video anxiety-producing but helpful.
is that mindfulness training will enhance trainees’ abilities to Their feedback also suggests that we need to explore different
attend to the here and now with an attitude of curiosity and ways to integrate mindfulness into AFT. One possibility is to
nonjudgmental acceptance. In other words, mindfulness training develop a brief mindfulness exercise that therapists could engage
will help therapists to decenter, to observe their thoughts and in prior to seeing a patient. There is evidence that practicing
feelings as temporary mental events rather than unalterable truths mindfulness right before a session may be beneficial. Dunn, Cal-
(Safran & Segal, 1990). Taking this observing stance helps ther- lahan, Swift, and Ivanovic (2013) randomly assigned therapists to
apists to disembed from a rupture—to step out of a vicious cycle either complete a 5-min acceptance and commitment therapy cen-
of patient hostility and therapist counterhostility, or of patient tering exercise right before a session, or engage in common pre-
withdrawal and therapist pursuit, for example. Therapists are then session routines such as checking email. When therapists engaged
better able to metacommunicate about the rupture in a noncritical, in the centering exercise, they rated themselves as being more
 ALLIANCE-FOCUSED TRAINING 173

present in the subsequent session, and their patients rated the Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
sessions as being more effective. commitment therapy: An experiential approach to behavior change.
While we support our trainees’ efforts to attend to their alliances New York, NY: Guilford Press.
with their patients, we as supervisors must also build and maintain Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011).
Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psycho-
an alliance with our trainees. A strong supervisory alliance is
therapy relationships that work: Evidence-based responsiveness (2nd
essential in order for trainees to feel safe sharing difficult therapy
ed., pp. 25– 69). New York, NY: Oxford University Press. doi:10.1093/
experiences. We endeavor to be aware of and explore any ruptures acprof:oso/9780199737208.003.0002
that emerge in the supervision. However, from the trainee inter- Kaplowitz, M. J., Safran, J. D., & Muran, J. C. (2011). Impact of therapist
views, it is clear that we supervisors, just like therapists, can miss emotional intelligence on psychotherapy. Journal of Nervous and Men-
ruptures. Some trainees reported that they experienced moments of tal Disease, 199, 74 – 84. doi:10.1097/NMD.0b013e3182083efb
feeling criticized or misunderstood by their AFT supervisors, but Kiesler, D. J. (1996). Contemporary interpersonal theory and research:
that they did not share these feelings and the supervisors appeared Personality, psychopathology, and psychotherapy. Oxford: Wiley.
unaware of the ruptures. A future challenge for us will be to Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

continue to explore this phenomenon and see if there are additional personality disorder. New York, NY: Guilford Press.
Muran, J. C. (2002). A relational approach to understanding change:
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tasks that we should employ to increase our sensitivity to ruptures

Plurality and contextualism in a psychotherapy research program. Psy-
with trainees. In our work with patients, we have found that
chotherapy Research, 12, 113–138. doi:10.1080/713664276
ruptures present difficulties but also opportunities for growth— our Muran, J. C., Gorman, B. S., Safran, J. D., Eubanks-Carter, C., & Winston,
hope and expectation is that additional exploration of ruptures in A. (2014, June). Exploring changes in interpersonal process, intermedi-
supervision will also prove challenging but fruitful. ate, and ultimate outcome in a within-subject experimental study of an
alliance-focused training. Paper presented at the annual meeting of the
Society for Psychotherapy Research, Copenhagen, Denmark.
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Haggerty, G., & Hilsenroth, M. J. (2011). The use of video in psychotherapy Received March 31, 2014
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