Aggression: From Fantasy to Action

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This book is a result of the 2nd International Psychoanalytic Conference: "Aggression: From Fantasy to Action", held in May 2010.It contains papers that were delivered to the conference, together with edited summaries of discussions from the floor that followed each paper. The standard of the papers given was extremely high. What was noticeable from the outset of the conference was the intensity of focus on understanding the origins of aggression and violence, from a psychoanalytic perspective. This intensity persisted throughout the two days, leading to a number of the fascinating discussions that are summarized in this book.

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CHAPTER ONE: The nature and function of aggression

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Donald Campbell

Dr Richard Ingram introduces Mr Donald Campbell

W“ell, it is an unexpected pleasure for me, in the absence of Siobhan O’Connor, to introduce our keynote speaker, Don Campbell. For those of you who do not know about Don’s career, it is a very distinguished psychoanalytic career. Don has been a past president of the British Psychoanalytic Society, Secretary General of the International Psychoanalytic Association and has worked for over thirty years in the National Health Service at the Portman Clinic in London. Within the British Society, he is a training analyst, and he has published widely on a range of topics, including violence, suicide, perversion, and adolescence. It is with great pleasure that I pass over to Don to speak to us today.”

Donald Campbell: “Good morning everyone. I hope you can all hear me and get used to this way of communicating with each other. When I thought about having to present my paper to you over the phone, I thought back to my days as a child listening to the radio, and I hope this will be a bit like listening to a good radio programme. I want to thank the organizers for inviting me to present this keynote address to what I think is an unusually well organized conference. By that I mean it has brought together people who have had clinical experience with violent and aggressive patients and this is true, I think, of everyone who is presenting. I am very impressed with the way this conference has been organized. I want to thank Nora McNairney and Lisa Losty for their really stalwart efforts to pull things together when the volcanic ash curtailed our flights to Belfast and to give you my apologies for not being with you today. I have not only had my flight cancelled, but I have been extremely anxious about being able to get back from Belfast, even if I had got to see you there, in order to get back for my son’s wedding, which is this weekend. So it has been a fraught time on many fronts.”

 

Discussion of Donald Campbell’s paper

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Richard Ingram: “Thank you very much indeed, Don. We now have about fifteen minutes for questions. There is a roving mike, so if you’d like to put your hand up, stand up and introduce yourself, we’ll get the mike over to you. While we’re waiting for questions, I was wondering, Don, about your initial comment about your reaction to the patient, where you removed the ashtray from the room? I was wondering—are there some necessary adaptations to the clinical setting that need to be thought about in dealing with potentially violent patients, or do you think this is something that could be quite destructive or negative in the process?”

Don Campbell: “Yes, I think there definitely are some limitations that need some technical and very practical considerations to be made: in fact, Carine can tell you about some of her experiences at Broad-moor in this respect, with the use of panic buttons and so forth. In an outpatient setting, and I think this probably says more about the type of patients we see at the Portman Clinic than necessarily the setting itself, we often debate whether we should have a panic button in the room in case the patient becomes violent. What is interesting is that, and I hope, Richard, that I am answering your question by going in this direction, because I couldn’t quite hear it. Is that what you had in mind?”

 

CHAPTER TWO: Which violence and whose violence? Questions arising in the psychotherapy of aggressive children

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Anne Alvarez

Dr Maria O’Kane introduces Dr Anne Alvarez

Dr Alvarez hoped to come to Belfast today, but unfortunately she has been a victim of the ash, as other people have been, but she has very kindly agreed to do the presentation by audio link from her base in London. I’m sure she is well known to most of you. I think it is very important for those of us who work in adult psychiatry to understand the importance of the development of the child when we are trying to understand the adult, and I think you will agree that Anne Alvarez has helped us enormously in understanding very disturbed mental states and how they extend from childhood into adulthood. You will see from the description she has provided of herself that she is a consultant child and adolescent psychotherapist; she trained as a clinical psychologist in Canada and the USA before training as a child and adolescent psychotherapist in the UK. She is a consultant child and adolescent psychotherapist, and retired co-convener of the autism service, child and family department at the Tavistock Clinic in London. She is also the author of Live Company, a book I would recommend, Psychotherapy with Autistic Borderline Deprived and Abused Children, and has edited, with Susan Reid, Autism and Personality. A book in her honour was published in 2002, edited by Judith Edwards, and titled Being Alive: Building on the Work of Anne Alvarez. She was Visiting Professor at the San Francisco Psychoanalytic Institute in November 2005.

 

Discussion of Anne Alvarez’s paper

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Maria O’Kane: “Professor Alvarez, thank you very much. You’ve certainly given us plenty of food for thought. I have been fortunate to have access to the paper before the conference, but what you have done is try to get us to think about which violence and whose violence, essentially sub-categorizing different ways of thinking about violence and then to think about violence in the context of object relationships. You’ve talked about children and their violent activities towards things and towards other people, but I wondered whether or not you feel the model you are suggesting would work in the context of self harm.

Anne Alvarez: “Yes, I realize I didn’t say anything about masochism and self harm and I’m sorry about that, it ought to be there, because you can get all three factors. Once the self harm becomes very addictive, and even sexually exciting, there are some people who say they like to see the blood flow and it can begin as wanting to bring to life a dead object, and a dead self, a depersonalized self, but, of course, it can gather other motivations to it. That’s the problem with every symptom: it can start gathering other, secondary motivations and begin to take over the whole personality and I agree with you about that.”

 

CHAPTER THREE: Violence to body and mind: treating patients who have killed

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Carine Minne

The nature and function of aggression, described so elegantly by Don Campbell in his chapter, and the theme of the conference, “Aggression: from fantasy to action”, are subjects that have intrigued me for many years and caused so much suffering to the patients I have seen, and to those around them, particularly their victims. In particular, I have wondered what is it that makes a mind that entertains an aggressive fantasy, a common occurrence, transform into a violent muscular action, a much less common occurrence. When violent patients have psychoanalytic psychotherapy as part of their treatment plan, and the prospect of understanding develops, what does one need to indicate has changed in the patient and, indeed, how can one demonstrate any changes that may have arisen which would mean the patient is now less at risk of being violent again? Generally, clinical risk assessments on patients who have been violent tend to focus on the patients’ behaviour, combined with a psychiatric mental state examination. This often neglects what, if any, changes may have arisen in the patients’ internal worlds, and it is here that a psychoanalytic approach can contribute to clinical risk management, one that emphasizes the fluidity of risk as opposed to presenting a snap-shot.

 

Discussion of Carine Minne’s paper

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Richard Ingram: “Thank you very much indeed, Carine, for a wonderful paper and an insight into working with this level of disturbance in a very high secure setting. I’m sure we have lots of questions we would like to put.”

Question from the floor: “Would psychotic transference be an appropriate for Mr A’s thinking in the immediate build up to the killing of his victim?”

Carine Minne: “Definitely, yes.”

Question from the floor: “Is it a term you would use nowadays?”

Carine Minne: “Yes, it would still be used and I think it makes sense to use it because it’s quite clear what it means.”

Question from the floor: “It reflects the intensity?”

Carine Minne: “Absolutely, what I was trying to describe was how at that moment, that’s when he became overtly psychiatrically psychotic and not just psychoanalytically psychotic.”

Brian Martindale: “Thank you very much, Carine, for a wonderful paper, very rich and easy to follow as well this horrendous psychopathology you are working with. My question is about your work with the other staff. I’ve a feeling we know that in hospitals and in outpatient services there are all kind of complex relationships between our colleagues and I think there is a tendency to idealize them at times and not perhaps come to ground with a range of things that go on. So, what I’d like you to comment on is the nature of your work with the staff who work alongside you with these patients and how you help them look at some of the things that happen in these places between patients and staff.”

 

CHAPTER FOUR: The interpretation of violence

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James Gilligan

Carine Minne: “It’s a huge pleasure for me to introduce James, whom I’ve known for many years, and we’re very privileged to have him here. It’s great that he has made it. I think James was the only man who caught the flight from London to Belfast on Wednesday morning. It was the one and only flight that went that day.

“James is a world expert on violence and on the psychoanalytic understanding of violence, and has been in the field working for over forty years and probably seen more people who have killed, more murderers, than anybody else on the planet. James is Clinical Professor of Psychiatry at the School of Medicine, an Adjunct Professor at the School of Law and Collegiate Professor at the School of Arts and Science at New York University, and I won’t say all the other things that he has done, but he has published profusely, he is writing all the time, his books are wonderful, his papers are fantastic, and we are going to be thrilled by what he is going to say this morning. I am sure it’s going to lead to a very rich discussion afterwards. Over to you, James, and thank you very much.”

 

Discussion of James Gilligan’s paper

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August Ruhs, Vienna: “If no act without language has a meaning, there are maybe acts which have no meaning. I think of the differentiation between acting in and acting out and what the French call a kind of action without signification, no symbolized action. For example, when Freud discussed the case of the nineteen-year-old homosexual girl and he tried to interpret the jump into the ditch, the suicidal act, he said it was a significant act translating the wish to be pregnant by jumping down, which means in German niederkommen, like to give birth. Then there was a rereading of this by Lacan, who said no, it’s not, it’s out of the symbolic—it’s when she as a subject is disappearing, she’s identifying with a falling object and now it’s going into the Real and in the Real there is no symbolic. I wanted to discuss whether the sentence is true that there is no act without meaning.”

James Gilligan: “It’s a good theoretical question. I’ve implicitly been trying to distinguish between behaviour that I think does have a symbolic meaning the way that rituals have a symbolic meaning— for example, religious rituals such as the holy communion. Giving the wine and bread is meant to symbolize the body and blood of Christ, or in a courtroom, standing up when the judge enters the courtroom is a symbol of one’s respect for the law and, by implication, for the court and the judge. So, there are many kinds of rituals in our society that permeate all aspects and all institutions in it and they really do have a symbolic meaning. All of what we call courtesy and politeness, standing up when someone enters the room, all of these are symbols of respect or similar messages. I’ve asked myself the question: are there some behaviours that are just behaviours that have no meaning that can be put into words? We do things all day long, we tie our shoes, does that have a symbolic meaning? It does and it doesn’t; it’s a symbol purely of being an adult with a certain competence. I have grandchildren who are learning to tie their shoes and they become very proud when they show they can tie their own shoes—a symbol of competence, adulthood, of being a worthwhile human being. The more I think about it, the more I’m beginning to think that almost all behaviour can be translated into some kind of symbolic meaning. If we drink a cup of coffee, it symbolizes something that we choose coffee rather than tea. They have different social connotations in our minds. Let me get to what I think is the essence of psychopathology. I think Freud says this repeatedly: the essence of psychopathology is, or one of the criteria is, dissociation. Freud talked about, in most of his descriptions of neurosis, obsessive compulsive neurosis, a consequence of isolation of thoughts from affects in which you over-emphasize thoughts producing intellectualization and you de-emphasize affects, make them unconscious. His theory is more the opposite: you repress thoughts and become flooded with affect. Another way to think about the human psyche is that the psyche is divided into three parts but they are not geographical areas, they are three areas of function, cognition, affection, or emotion and action. Ordinarily these are integrated and synthesized in the “normal” psyche. We act according to thoughts and feelings that we can explain and that we are consciously aware of. Psychopathology results when these get dissociated from each other. If you think about diagnostic categories, we speak of affective disorders like depression and mania and we speak of thought disorders, schizophrenia, paranoia, and the like. I would say that character disorders or personality disorders could be seen as action disorders, that is, “people behaviour” is the pathological symptom. I put the violent person in the realm of character disorder and action disorder. The problem with the violent is that they have dissociated their actions from their thoughts and feelings. That is putting it very abstractly, so let me be concrete: when I worked with prisoners the first thing that struck me about them was that any time I walked into a prison and started talking to a criminal, I got the impression that I was talking to somebody who responds with actions, without the actions passing through the filters of thought and feeling, which they do for most of us. In other words, when I work with violent criminals I get the impression that it’s almost as if they have a short-circuit in their brains so that everything immediately goes straight to action rather than being slowed down by thoughts or being accompanied by feelings. They’ve dissociated action from thoughts and feelings, and what I’m trying to do is to undo that dissociation by showing the association between the thoughts and the feelings that they have not developed, or else they have lost the capacity for. That’s not putting it in Lacanian language, but it’s ordinary English, which is the way I understand it.”

 

CHAPTER FIVE: From action to communication: the transformation of aggression in childhood

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Marie Zaphiriou Woods

Introduction

This short paper outlines the development of aggression in childhood in the context of relationships which, when all goes well, enable the transformation from action to communication. My approach is rooted in a psychoanalytic understanding of normal development, emphasizing the interaction between the infant and young child’s evolving internal world, and that of the parents (caregivers). In line with Yakeley’s multi-dimensional viewpoint (Yakeley, 2010, p. 24), the role of trauma and loss, the capacity for representation and mentalization, unconscious fantasy, and the defensive system are also considered.

The development of aggression

There is a vast psychoanalytic literature on aggression. I will give a brief overview, starting with Winnicott (1950), who equated the infant’s aggression with activity, muscularity, a “life force”. Win-nicott describes how the mother’s capacity to survive, without retaliation, her infant’s ruthless instinctual expressions enables him to realize his full aggressive potential, to feel real, and, over time, to recognize that she is separate, outside his omnipotent control (1969). Combined with her empathy and readiness to perceive and receive his spontaneous reparative gestures, the mother’s survival also enables the fusion of aggressive and erotic drives, and the transformation of the infant’s anxiety about losing or destroying her into concern and a sense of responsibility (Winnicott, 1963). Aggression can then be integrated into the personality as a useful energy in work and play. When fusion does not occur, aggression is split off, leading to enactments of violence and destruction (see Abram, 1996).

 

CHAPTER SIX: Aggression and violence in adolescence

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Marianne Parsons

Introduction

Marie has given a very clear account of the normative development of aggression in childhood, with some vivid clinical material about a boy whose development went off track, leading him to enact in very aggressive ways until his anxieties could be worked through in psychotherapy. My task is to extend the theme into adolescence, and then I want to focus on a concept pertinent to untransformed aggression: the core complex. My interest in aggression was stimulated in the Portman Clinic Violence Research Group under the leadership of Mervin Glasser, and I will use material from one of my Portman Clinic patients, an adolescent boy, to illustrate how thinking about the core complex can help with understanding and working with a violent patient. I will begin with the impact of the adolescent process.

The developmental process of adolescence

Erikson (1956) defined adolescence as the years when the mind develops the capacity to integrate the profound physical changes that start in puberty in relationship to the self and to others. It is a “normative crisis situation” (Tonnesmann, 1980) and a time of necessary “developmental disturbance” (A. Freud, 1958), when the typical “fluctuations between extreme opposites would be deemed highly abnormal at any other time of life” (A. Freud, 1958, p. 165). It is like an age-appropriate transient madness in which everything is in a state of bewildering and unpredictable tension and change, with rapid shifts between wild excitement and deep depression. Such upheavals show that necessary internal adjustments are in progress.

 

Discussion of Marianne Parsons’ paper

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Brian Martindale (Chair): “We have about twenty minutes for discussion.”

Question: “Can I ask about how Tom came to you in the first place? I’m interested in his motivation. We heard about his motivation once he was seeing you, but I’m wondering about his motivation before his first appointment.”

Marianne Parsons: “It’s a very good question. He was referred by his probation officer, like many of the Portman adolescent patients. In my early years at the Portman we used to treat patients who were sent under a probation order and we stopped this because as soon as the probation order stopped, the patient stopped coming. It was like ‘you can take a horse to water but you can’t make it drink’. The patient would turn up and you would do your best and you might say a few things that were helpful. You might provide a different experience in the room with you, but most of it would go over their heads. By the time I was seeing Tom things had changed. He had a genuine wish to stay out of prison and I think he thought ‘I’ll go to that stupid effing place and see if they can make my fantasies disappear. He wasn’t worried about raping for moral reasons or out of concern for his victim, he was worried about going to prison, so there was some motivation in him of a very primitive kind, but at least it got him to us. However, he did leave when he reached an age when he could go off to university.”

 

CHAPTER SEVEN: The perverse fascination of destructiveness

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Paola Capozzi and Franco De Masi

The war of absolute enmity knows no bracketing. The consistent fulfillment of absolute enmity provides its own meaning and justification.

(Schmitt, 1962, p. 52)

Professor Paul Williams (Chair) introduces Dr Franco De Masi

It is with great pleasure that I introduce Dr Franco De Masi from Milan. Franco, as many of you know, participated in the first International Psychoanalytic Conference in Belfast, and it is a pleasure to have him back with us. He has long experience in treating patients with psychosis and severe disturbance, and has published widely on these subjects. He is a training and supervising analyst of the Milan Psychoanalytic Society. His paper today was written in collaboration with his wife, psychoanalyst Paola Capozzi, who, unfortunately, is unable to be with us today due to illness. We shall have a good amount of time to explore Franco’s paper, so please make a note of questions, as I am sure Franco will be pleased to respond. Dr De Masi …

* * *

 

Discussion of Paola Capozzi and Franco De Masi’s paper

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Paul Williams: “Thank you, that is food for thought.

Question from the floor: “I’m trying to reconcile Stoller’s title, Perversion: The Erotic Form of Hatred, with your comments that perversion has nothing to do with hatred. There seems to be a conflict there.”

Franco De Masi: “Stoller’s conception is that perversion is a defence against a trauma. Stoller thinks of the pervert as being a child who was submitted to traumas of being beaten, perhaps of receiving violent aggressive sexuality from an adult. I think that for my conception, the origin of perversion is more complicated. I think the perverse child [is one] who has withdrawn from reality and from emotions and has filled his mind with fantasies that are not necessarily the product of trauma in infancy.”

Questioner: “You don’t think it’s revenge against the object?”

Franco De Masi: “For me it is not, because there are many children who have not been submitted to trauma. For twenty years I have analysed a perverse, sadomasochistic, paedophile individual who was not a traumatized youngster but who lived in a good enough family, but without emotional bonds to the father or other people. It is not trauma in the way Stoller is thinking.”

 

CHAPTER EIGHT: Aggression: social and political aspects

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Lord Alderdice

Dr Philip McGarry (Chair): “Thank you for returning for the last session of the conference and I’m sure you’ll all agree we have had three tremendous sessions this morning. I am delighted to introduce my colleague and long-standing friend, Lord John Alderdice. John and I go back many years. John is a man of many parts and there are two particular roles that John has performed over the years. One is as a very distinguished consultant psychiatrist in psychotherapy. My first memory of John was as a medical student. I was a medical student at Holywell and he was a registrar. Tom Freeman was the consultant, and that’s where John’s interest in psychotherapy burgeoned, from that particular point. John has been an Honorary Fellow of the Royal College, he has been awarded many distinctions around the world, is a Visiting Professor in Virginia, Lima in Peru, and also Chair of the International Dialogue Institute in Istanbul. John was the founder of the Centre for Psychotherapy in Belfast, which is one of the key organizers of this meeting. The Centre for Psychotherapy in Northern Ireland has a very distinguished role in assessment, treatment, and, in particular, training of staff across a range of disciplines and is a very important institute for Northern Ireland. As well as being very distinguished as a psychiatrist, John has had another life as a politician. John was leader of the Alliance Party for many years and John and I spent some years in the City Hall chamber together during some interesting times. John was also the inaugural speaker at the Northern Ireland Assembly in 1998, once devolution was restored, and he managed a fantastic job of getting that fragile institution up and running. John also has been the President of Liberal International between 2005 and 2009 and, of course, he has a very active role in the House of Lords. There is nobody better placed to marry the principles of psychoanalysis and politics and social aspects. John, unusually for him, has written his presentation. One of the amazing things from the time when I was Chairman of the Alliance Party was the annual conference, in which the leader’s speech is viewed as extremely important. One year the TV journalists used the advance script of his speech to identify the highlights and so did not record the full forty-minute speech. The next year John turned up and I said to him, “Where’s the script for the journalists?” “No script, they’ll have to listen”, was his reply. He gave a forty-five-minute speech unscripted and it was the most coherent, constructed speech I’d heard in my life. No other politician I know has ever attempted to do this and no sensible politician should attempt to do it unless they are of John’s ability. Amazingly, today John does have a script, so I’ll leave you in the capable hands of John, Lord Alderdice.”

 

Discussion of Lord Alderdice’s paper

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Philip McGarry: “Thank you, John, for that tour de force, everywhere from the Maze Prison to Katmandu to Lima. I’m sure we have plenty of questions.”

Question: “You referred to these political acts, the communicable act of a terrorist, but how would you describe the American government’s attack on Iraq or Afghanistan, that sort of ‘rescuing’ countries from violence?”

John Alderdice: “One of the things that’s terribly important for us, whether in medicine or psychiatry or psychoanalysis, is to try to be as clear as possible about the language we use. One of the problems about emotionally driven language is that it tends to expand to mean everything and nothing. The term terrorism is a description of a specific triangular tactic where people who don’t have the power to confront a power or authorities directly, because they would be destroyed, then attack a victim, but the victim is not the target of the attack. The target of the attack is the powerful government that is responsible for this victim, so it’s a triangular process. What an authoritarian government does, whether it is the USA attacking Iraq, or whoever, whatever you like to call it, it’s not terrorism because it’s a direct attack, the victim is the target, so it’s not the same kind of thing. It’s done because that authoritarian government or authority figure doesn’t feel any great fear that it can’t cope with any attack that comes back. So, I think it’s important to use the term terrorism not as a moral term, where, by using the very term, you are condemning it and everybody that’s involved with it simply by the use of the term. It’s emotionally loaded. I don’t use it in this way, I use it as a technical term that describes a very specific clear tactic that was developed quite strongly by the anarchists in the nineteenth century and we’ve seen it continuing on since. It’s not a question of whether you like or don’t like what they stand for, that’s not the issue; it’s a specific description of a tactic. The tactics that governments use, whether on their own citizens or on others, of spreading fear and terror, are no less frightening and I’m not setting one against the other in a moral sense, but it is a very different kind of tactic.”

 

CHAPTER NINE: Plenary session

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Chair, Brian Martindale

Brian Martindale: “We have got from 3.15 p.m. until 5.00 p.m. The idea is that the distinguished colleagues on my left and right will speak for some of the time, as this is a time for your questions, comments, etc. The plan is that Rosine Perelberg is going to be available from about 3.45 p.m. If you have questions for Rosine, it would be helpful to have them beforehand, although I would welcome your exchange with her when she comes online. I have a few questions here for four speakers already, but does anyone in the audience want to ask a question or make a comment about anything that has come up? Let’s start with a question to James Gilligan from Gabby Marks.”

Gabby Marks: “This in response to Professor Gilligan’s very interesting talk and the fact that he mentioned that recidivism was completely halted in prison by giving murderers a degree course and that the people who achieved a degree didn’t come back to prison. What sort of violence is perpetrated on serious offenders, murderers, by the state in not allowing them to re-educate their minds and their psyches by continuing to offer degree course and also intensive therapy? I’m not sure if that still holds that they took away all the services that were being offered, but what you said was frightening. I thought, in general, there is so little education while people sit in prison and each time I have tried to explain it or have written the odd letter to a newspaper they see you as protecting prisoners, being on the wrong side.”

 

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