# Tell your psychiatrist and therapist to read this



## Methusala (Dec 22, 2005)

The psychiatric journal 'Psychiatric Clinics of North America' covers dissociation in its current edition. It provides a basic education for treating people with dissociative disorders, apparently including dp and dr. Note this line: 'I believe the vast majority of our 
patients can do this work when their clinicians are well educated.' Here are some excerpts from the introduction:

Why Should You Read These Articles 
on Dissociative Processes? 
Guest Editor

Most mental health clinicians have not had formal training in dissociation 
or dissociative disorders, a sad fact of current professional life-sad because it means that if you are a mental health clinician, your treatment of people with the following histories (among others) may lack full efficacy: 
 all self-harming behaviors; 
 all addictions; 
 eating disorders; 
 conversion disorders; 
 pseudoseizures; 
 childhood sexual abuse; 
 childhood physical abuse; 
 childhood neglect and emotional abuse; 
 growing up in a household as a witness to repeated violent behaviors; 
 hearing voices with goal-directed, nonbizarre messages or conversation; 
 ??rapid-cycling?? mood change occurring multiple times in a day or hour; 
 attention-deficit problems that are inconsistent or situational; 
 chronic posttraumatic stress disorder; 
 chronic depersonalization or derealization; 
 prolonged or multiple life-threatening hospitalizations in childhood; 
 profound body dysmorphic symptoms; and 
 borderline personality adaptations. ..

....
A new model of mind for the twenty-first century: states of mind 
Over 100 years ago, Sigmund Freud collaborated with Joseph Breuer to 
write a treatise on hysteria [3] at about the same time that Pierre Janet picked 
up his own pen [4]. Hysteria baffled contemporary neurologists. No wonder! 
With a name that meant ??wandering womb,?? hysteria seemed to be 
a disease of women that men could not understand. Janet wrote about the 
disaggregation of the personality, while Freud and Breuer took him on in 
the preface of their Studies on Hysteria, declaring that what was a so-called 
??double consciousness?? was essentially a mistaken description of the process 
of repression and a weakness of the ego. Freud?s disciples, including 
James Strachey and Joan Riviere, brought psychoanalysis to the Englishspeaking 
world at the same time that Eugene Bleuler coined the term schizophrenia 
(??split mind??) [5], and the work of Janet was eclipsed as the 
divisions in the dissociative mind became conflated with schizophrenia. It 
was not until the 1980s that this error began to be corrected with a new literature 
on what was then called multiple personality disorder [6,7]. Now, over 
100 years later, there are no good experimental models of repression, while 
evidence for disaggregation of mental processesdor dissociationdis a rapidly 
xvii PREFACE

enlarging scientific and clinical literature. Contemporary psychoanalysis 
and psychiatry are moving far away from Freud?s structural theory, id, ego, 
and super-ego, and embracing studies on the self and relational psychology, 
and an exploding literature on attachment. The study of the dissociative 
disorders is opening a large door into the study of mind. A confluence 
of work in a number of disciplines has arrived at the conclusion that a parsimonious 
??model of mind?? is that of ??states of mind?? as the basic building 
blocks of mind [8?21]. The advantages of a ??states of mind?? or ??states of being?? 
model, are spelled out in the articles presented in this issue. Of particular 
importance is that with attention to the language of the therapy (see the article 
by Wayin this issue), patients with dissociative and other psychiatric disorders 
immediately understand what their therapists are saying about their minds. 
Some important questions

....

The growth of this field in the last 15 years has been extraordinary. 
I look forward to the next 15 years, and to the advances that 
will lead to better treatments, faster healing, and resolution of pain for 
our patients. We need to assure, as best we can, that our patients can complete 
treatment and then go on to lead productive lives in a growth-promoting 
community. Fantasy? No, not at all. I believe the vast majority of our 
patients can do this work when their clinicians are well educated. Time to 
get back to work and make this belief a reality. Please join me.

Richard A. Chefetz, MD

http://www.issd.org

M


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## Methusala (Dec 22, 2005)

Here's the whole article from the front page of http://www.issd.org

Preface 
Why Should You Read These Articles 
on Dissociative Processes? 
Guest Editor 
Most mental health clinicians have not had formal training in dissociation 
or dissociative disorders, a sad fact of current professional lifedsad because 
it means that if you are a mental health clinician, your treatment of people 
with the following histories (among others) may lack full efficacy: 
 all self-harming behaviors; 
 all addictions; 
 eating disorders; 
 conversion disorders; 
 pseudoseizures; 
 childhood sexual abuse; 
 childhood physical abuse; 
 childhood neglect and emotional abuse; 
 growing up in a household as a witness to repeated violent behaviors; 
 hearing voices with goal-directed, nonbizarre messages or conversation; 
 ??rapid-cycling?? mood change occurring multiple times in a day or hour; 
 attention-deficit problems that are inconsistent or situational; 
 chronic posttraumatic stress disorder; 
 chronic depersonalization or derealization; 
 prolonged or multiple life-threatening hospitalizations in childhood; 
 profound body dysmorphic symptoms; and 
 borderline personality adaptations. 
Richard A. Chefetz, MD 
0193-953X/06/$ - see front matter  2005 Elsevier Inc. All rights reserved. 
doi:10.1016/j.psc.2005.12.001 psych.theclinics.com 
Psychiatr Clin N Am 29 (2006) xv?xxiii

I am not saying that everyone with these kinds of histories will have a dissociative 
disorder. What I am saying is that dissociative processes are often 
the engine that drives these histories into childhood and adult psychopathologies. 
To borrow from a favorite childhood story, the dissociative process is 
the ??little engine that could.?? If you don?t know how dissociative processes 
work, then you don?t know how to ask your patients about some of the central 
symptoms of their livesdand because most of these symptoms have 
been lifetime experiences, these people are not likely to volunteer that they 
are troubled by what they consider normal for them. If they do become conscious 
of their dissociative symptoms, they often believe their symptoms are 
a sign of ??craziness?? that would cause them to be ??locked up in the loony 
bin?? rather than be taken seriously, respected, and helped. People will most 
often hide their dissociative processes if they are aware of them. If they are 
not aware, then you will have to be smart enough to ask about these processes 
before you will have a chance of gently openingdjust a littledthe 
lid of their very own private Pandora?s box, in which their mind is hidden. 
What are dissociative processes? 
 Depersonalization (defined below) 
 Derealization (feeling that the world is unreal) 
 Microamnesia (repeatedly forgetting what was just said, or somehow 
knowing what was just said by recalling it as if it had been read in 
a newspaper rather than just experienced as a ??lived?? event) and macroamnesia 
(includes forgetting ??outside the range of normal experience?? 
[1]) 
 Identity confusion (not knowing one?s name) 
 Identity alteration (??I?m Mary, not Jane.??) 
Dissociation is that process in which normally related psychologic experiences 
and events are detached from each other and result in a distortion of 
experience with both subtle and profound alterations in interpretation of the 
meaning of personal and interpersonal events. For example, depersonalization 
(an out-of-body experience or feeling ??unreal??) [2] is generated by a psychologic 
detachment for sensing being embodied, being located in ??my 
body.?? When a person cannot feel their bodily senses, then they can?t feel 
their feelings either; they become emotionally numb, a hallmark of posttraumatic 
disorders. Depersonalization can be thought of as a desperate unconscious 
control mechanism for squelching overwhelming effects like terror, 
horror, utter helplessness, and so forth. A standarddand saddreport of depersonalization 
is having a recollection of floating on the ceiling watching 
??as I was raped. The person below was me, sort of, but I wasn?t there. 
But I was. It was all very confusing. I just feel numb about it now.?? 
When knowledge is isolated (corollary to isolated affect, emotional 
numbness), a person may experience a storm of painful effect, complete with 
xvi PREFACE

sobbing, hyperventilation, and so forth, but not have any sense of a context 
for why they are feeling so distressed. (??It makes me feel crazy to be taken 
over by all this weeping and not have a clue why I?m even crying!??) Similarly, 
veterans from military conflicts return home to people they have loved, 
know they should feel more ??moved?? emotionally, but simply ??feel nothing??
dthe affect is isolated, and they have posttraumatic numbness, a dissociative 
symptom. Likewise, a powerfully successful businessman is rarely 
able to sleep when traveling. Unconsciously he experiences his hotel room, 
one of many on a long hallway, as too close a match for one of many hospital 
rooms he occupied as a child with recurrent near-fatal medical events. 
He spends his nights depersonalized, feeling unreal, in a panic, sleepless. A 
drug-addicted housewife can?t remember why she snorted another round of 
cocaine. ??I told myself I wasn?t going to do it, and then I watched myself 
reach for that line and lift it to my face, the whole time yelling inside my 
mind to stop, but my arms weren?t under my control!?? The teenage girl in 
the emergency room, after cutting her upper arm, reported that ??It?s nothing. 
It stopped bleeding, so who cares? I didn?t feel anything. I just got calm 
and felt better after I saw the blood. I don?t remember cutting my arm, but 
I do know I didn?t feel it.?? The bulimic says, ??My stomach was so painfully 
full that my whole body hurt. That?s when I went to throw up, and this 
weird and wonderful fog filled my head like everything was just a dream. 
I must have fallen asleep. When I woke up I knew what I had done, but in 
a weird way it didn?t feel like I had done it, I just knew I felt better, calm. 
Finally. It?s what always happens. I hate throwing up, but the calm afterward 
is just fine with me.?? 
A new model of mind for the twenty-first century: states of mind 
Over 100 years ago, Sigmund Freud collaborated with Joseph Breuer to 
write a treatise on hysteria [3] at about the same time that Pierre Janet picked 
up his own pen [4]. Hysteria baffled contemporary neurologists. No wonder! 
With a name that meant ??wandering womb,?? hysteria seemed to be 
a disease of women that men could not understand. Janet wrote about the 
disaggregation of the personality, while Freud and Breuer took him on in 
the preface of their Studies on Hysteria, declaring that what was a so-called 
??double consciousness?? was essentially a mistaken description of the process 
of repression and a weakness of the ego. Freud?s disciples, including 
James Strachey and Joan Riviere, brought psychoanalysis to the Englishspeaking 
world at the same time that Eugene Bleuler coined the term schizophrenia 
(??split mind??) [5], and the work of Janet was eclipsed as the 
divisions in the dissociative mind became conflated with schizophrenia. It 
was not until the 1980s that this error began to be corrected with a new literature 
on what was then called multiple personality disorder [6,7]. Now, over 
100 years later, there are no good experimental models of repression, while 
evidence for disaggregation of mental processesdor dissociationdis a rapidly 
xvii PREFACE

enlarging scientific and clinical literature. Contemporary psychoanalysis 
and psychiatry are moving far away from Freud?s structural theory, id, ego, 
and super-ego, and embracing studies on the self and relational psychology, 
and an exploding literature on attachment. The study of the dissociative 
disorders is opening a large door into the study of mind. A confluence 
of work in a number of disciplines has arrived at the conclusion that a parsimonious 
??model of mind?? is that of ??states of mind?? as the basic building 
blocks of mind [8?21]. The advantages of a ??states of mind?? or ??states of being?? 
model, are spelled out in the articles presented in this issue. Of particular 
importance is that with attention to the language of the therapy (see the article 
by Wayin this issue), patients with dissociative and other psychiatric disorders 
immediately understand what their therapists are saying about their minds. 
Some important questions 
How do dissociative processes work? What is the neurobiology that underlies 
dissociative experience? What happens to an individual?s subjectivity in 
dissociative experience? What does ??I?? feel like when you can?t remember 
what your name is? Is there some kind of normal dissociative process? 
Wouldn?t these processes, when unrecognized, skew psychiatric research 
through misdiagnosis? If borderline adaptations are filled with dissociative 
process, wouldn?t it be more useful to reformulate borderline and posttraumatic 
processes with a knowledge of dissociative processes? How do I learn 
to think intuitively about these processes so that I can ??get into the mindset?? 
of my patients and use these processes to their advantage, or at least halt their 
destructiveness? What about intervening with the out-of-control, self-destructive 
patient with a full-blown dissociative disorder and altered personalities? 
You don?t expect me to believe there are other people inside my patients, do 
you? (Not only is that not expected of you, it would simply be wrong to reify 
a subjective experience rather than call that shift in subjectivity to the patient?s 
attention and study their experience with them.) How do I intervene to work 
with a potentially violent dissociative patient? How do I understand and work 
with alter phenomena? Is it really appropriate to agree with the patient when 
they tell me their name is different than their given name? Doesn?t that just 
make things worse? Aren?t I feeding a delusion? Is there something about 
the particular use of language, descriptive metaphor, in the treatment of the 
dissociative disorders that predicts or limits what we understand about a mind, 
or how to help someone with these problems? 
What can you learn about in the pages that follow? 
The 16 articles in this issue are organized into three main sections: theory, 
research and evaluation, and technique. The theory section is led by Paul 
Dell?s revisionist model of the dissociative disorders as the picture of a mind 
xviii PREFACE

suffering from relentless intrusions of dissociated affects, knowledge, and so 
forth. Over a decade of work on his multidimensional inventory of dissociation 
has informed this view that emphasizes how individuals suffer from intrusive 
experience into every aspect of executive functioning. Whether you 
agree with him or not, he sifts dissociative experience through a very fine 
mesh and provides a marvelous tour of the dissociative mind. Karen Way 
then provides a unique vantage point from which to consider dissociative 
phenomena and experience by understanding how the metaphors that describe 
persons with dissociative disorders influence our views of mind as 
subject and object. She explores the notions of the self as a thing that is divided 
versus the self as an agent in the world that turns inwardly, away from 
traumatic experience and relatedness, but nevertheless cannot escape the 
past. She discusses her conclusion in detail: verb-based metaphors are more 
consistent with the goals of treatment. Lisa Butler explores the realm of 
normative dissociation. She combines her knowledge of dissociation and 
hypnosis to develop a line of inquiry that exposes the extent to which 
dissociative processes are part of our everyday lives. Being absorbed in reading 
this paragraph and having lost track of your surrounding environment is 
an example of everyday dissociation. Check out what she has to say. You?ll 
learn that a dissociative process is not just something that occurs as a result 
of a traumatic experiencedit is part of the basic operating systems in our 
mind. Dissociation helps us to focus and concentrate. The challenge is to 
not lose our bearings. Of course, paradoxically, in the face of trauma, losing 
one?s bearings may be preferable to staying focused on unbearable trauma 
from which there is no escape. Lyons-Ruth and colleagues discuss how it 
is the specific qualities of the parent?infant dialog that are most predictive 
of adult dissociative disorders. The notion that traumatic experience is always 
at the root of dissociative adaptation seems not so sure in the face of 
this work. Trauma may be associated with adult and childhood dissociation, 
but it is the particular quality of the patterns of parent?child communication 
that are most predictive of dissociative coping styles. It is the ??hidden trauma?? 
of profound interpersonal emotional dysfunction that may fuel basic 
dissociative processes. It is within this context that Catherine Classen and 
colleagues responded to my invitation and wrote a reformulation of borderline 
and posttraumatic disorders by describing a posttraumatic personality 
disorder. Based on an exploration of insecure attachment that is disorganized 
versus organized, this article is a marvelous font toward understanding 
a confluence of conditions that are related to both trauma and profound 
relational failures. Whereas type D attachments (disorganized/disoriented 
pattern) are clearly consistent with the phenotype of adult dissociative disorders, 
the emotionally dismissive parent of the type A attachment (avoidant 
pattern) and the preoccupied parent of the type C attachment (anxious/ 
ambivalent pattern) clearly show up in the behavior of borderline and posttraumatic 
patients. With trauma histories so prevalent in our borderline 
patients, isn?t it time to think about reformulating the borderline construct 
xix PREFACE

as well as chronic posttraumatic adaptations into something that is more 
parsimoniously structured? You will learn a lot from their careful 
reformulation. 
The research and evaluation section leads off with an article by clinicianscientists 
Frewen and Lanius. They review studies of the neural correlates of 
dissociative experiences, as assessed by positron emission tomography and 
functional MRI through the organizing principles of what some writers have 
called primary, secondary, and tertiary dissociation. They show how the key 
cortical structures involved in these processes include the medial prefrontal, 
anterior cingulate, somatosensory, and insular cortex, as well as the thalamus. 
Distinctive neural correlates of primary and secondary dissociative experiences 
in individuals who have posttraumatic stress disorder support 
state-phase models of animal defensive reaction to external threat. They 
speculate that disconnection of neural pathways normally linking selfawareness 
with body-state perception, occurring as a result of childhood 
trauma, may occasion the development of tertiary dissociative identities. 
In another article, Vedat Sar and Colin Ross discuss how the lack of attention 
to and knowledge about the dissociative disorders can lead to misadventure 
and misleading results in psychiatric research. It has always 
astonished me that even though the diagnosis of schizophrenia relies heavily 
upon hearing voices, most researchers do not screen for dissociative disorders. 
With psychotherapeutic interventions for schizophrenia de-emphasized, the 
tragedy of misdiagnosis of a dissociative disorder as a schizophrenic disorder 
is accentuated. Sar and Ross provide some interesting ideas to consider with 
regard to diagnosis and research. 
Brand, Armstrong, and Loewenstein discuss how psychologic assessment 
can assist in the diagnosis of dissociative identity disorder (DID) as well as 
treatment planning for dissociative patients. They outline a battery that can 
assess the extent of dissociation, review the research on dissociation on various 
psychologic tests, and present new Rorschach data on severely dissociative 
patients that can be useful in planning treatment. Their work is on the 
frontier of the best in clinical research. As a group, their clinical skill is extraordinary. 
I hope you will take some time to digest their wisdom. Likewise, 
Frankel and Dalenberg offer a sterling review of the forensic 
psychology literature that is designed to be a reference guide for study by 
the practicing clinician. They address the role of the forensic mental health 
professional in the context of court-related evaluations of claims of dissociative 
disorders, the possible relationships between such claims and the issues 
to be decided by the trier of fact, research developments that may bear on 
the forensic evaluation of DID from biological, psychologic, and social data 
sources, and provide a checklist of issues about which forensic evaluators 
should be prepared to respond on direct and cross-examination. 
For the consultation liaison clinician in you, spend some time looking at 
Elizabeth Bowman?s comprehensive review of the relationship between 
pseudoseizures and dissociative processes. Bowman is one of the world?s 
xx PREFACE

leading authorities on this topic. If you have ever treated a patient with 
pseudoseizures, then you know that moving the patient?s understanding of 
what ails them from a medical model of their problem to a psychologic model 
requires the utmost skill. Cross-reference this with the Turkish experience 
in the ubiquitous presentations of conversion disorder, and you begin to 
see the potential for understanding a whole range of neuropsychiatric presentations 
based on dissociative process. 
You will enjoy Eli Somer?s discussion of culture-bound syndromes related 
to dissociative process. The expression of dissociative process is guided 
somewhat by culture, and Dr. Somer discusses this in detail. There is 
a wide range of dissociative process visible in behavioral syndromes in 
both sophisticated and more primitive societies. To round out this section 
on research and evaluation, Vedat Sar starts with the Turkish experience 
and adds an international roster of literature and research on the dissociative 
disorders. While some critics have said that dissociative disorders were 
a North American phenomenon, all one might need do to end the controversy 
is to combine the insights of Somer and Sar. 
The last section will be a special treat for clinicians who are eager to learn 
more about the application of theory. Turkus and colleagues have put to paper 
many years? experience as they spell out the basics of a coherent treatment 
from psychoeducational approaches, through grounding techniques, 
to fostering inter alter communication. Their contribution is filled with clinical 
wisdom. Pain, Ogden, Fisher, and Ryder spell out an important element 
of treatment, how to integrate a knowledge of the sensorimotor neurobiologic 
processes into the treatment of trauma. Many clinicians focus on dissociation 
of affect and knowledge as the main topic of a treatment. These 
clinicians show how sensorimotor and even cerebellar dissociations are 
a powerful mode of inquiry into healing a mind filled with experience that 
outstripped the capacity to speak and describe overwhelming adversity with 
words. Somatic approaches to treatment are invaluable. While their approach 
may not seem immediately applicable to routine psychotherapy, read 
closely and you will see that even without special training, you can adapt 
their technique and still maintain appropriate clinical boundaries in the 
treatment of the traumatized person. 
The last two articles in this issue are both a tour de force. Rick Kluft has 
written a kind of ??everything you ever wanted to know about alter personalities 
but were afraid to ask?? article. In many ways, Kluft is the father of 
this field. His knowledge is extraordinary. I hope you enjoy reading his work 
as much as I did. Rich Loewenstein?s clinical wisdom comes alive in ??DID 
101.?? Having trained under his supervision, all I can say is that he continues 
to delight me with his creativity and his uncommon good sense. No matter 
what your level of skill, you will learn something from this blow-by-blow illustrative 
dialog of working with two particularly challenging patients, one 
initially in restraints, and the other skillfully self-destructive and previously 
impervious to intervention. 
xxi PREFACE

No editor works in a vacuum. Everybody has a life. I particularly wish to 
thank my wife, Kathryn Chefetz, LCSW, a psychoanalyst who ??gets?? dissociative 
disorders and who has tolerated (mostly) the time that has been taken 
from our relationship and family for me to complete this project. I only 
hope to live up to the high standard she sets for intellectual honesty and 
compassionate involvment in doing the work of complex treatments. She 
is a valued colleague. Thank you for your support, Kathryn. I also want 
to thank my editor, Sarah Barth, for allowing me to put together 16 rather 
than the usual 14 papers for an issue of this type. I want to thank my authors 
for their hard work, and for their respectful challenges to my editorial 
input that made producing this publication both a pleasure and a learning 
experience. They are an extraordinary group of clinicians and researchers. 
Lastly, I wish to thank my colleagues at the International Society for the 
Study of Dissociation. You have provided me with many worthy challenges, 
but most of all with your warmth and friendship. When Rich Loewenstein 
edited the last issue of the Psychiatric Clinics of North America on this subject 
in 1991, many of the authors, and this editor, were still early on in the 
learning curve for understanding complex dissociative disorders and dissociative 
processes. The growth of this field in the last 15 years has been extraordinary. 
I look forward to the next 15 years, and to the advances that 
will lead to better treatments, faster healing, and resolution of pain for 
our patients. We need to assure, as best we can, that our patients can complete 
treatment and then go on to lead productive lives in a growth-promoting 
community. Fantasy? No, not at all. I believe the vast majority of our 
patients can do this work when their clinicians are well educated. Time to 
get back to work and make this belief a reality. Please join me. 
Richard A. Chefetz, MD 
4612 49th Street NW 
Washington, DC 20016, USA 
E-mail address: [email protected] 
References 
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[2] Simeon D. Depersonalizaiton disorder: a contemporary overview. CNS Drugs 2004;18: 
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[3] Breuer J, Freud S. Studies on hysteria. Volume 2. London: The Hogarth Press; 1895. 
[4] Janet P. The major symptoms of hysteria. New York: Macmillan; 1907. 
[5] Bleuler E. Dementia praecox or the group of schizophrenics. New York: International 
Universities Press; 1911. 
[6] Kluft RP, editor. Childhood antecedants of multiple personality. Washington, DC: American 
Psychiatric Press, Inc.; 1985. 
xxii PREFACE

[7] Putnam FW. Diagnosis and treatment of multiple personality disorder. New York: Guilford 
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[16] Gleaves D, May M, Cardena E. An examination of the diagnostic validity of dissociative 
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[17] Hilgard ER. Divided consciousness: multiple controls in human thought and action. New 
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[18] Horowitz MJ, Fridhandler B, Stinson C. Person schemas and emotion. J Am Psychoanal 
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[19] Krystal H. Integration and self healing: affect, alexithymia, and trauma. Hillsdale (NJ): Analytic 
Press; 1988. 
[20] Ledoux J. The emotional brain. New York: Simon & Schuster; 1996. 
[21] Liotti G. Disorganization of attachment as a model for understanding dissociative psychopathology. 
In: Solomon J, George C, editors. Attachment disorganization. New York: 
Guilford Press; 1999. p. 291?317. 
xxiii PREFACE


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## Guest (May 15, 2006)

Five English pounds to the person who fully reads all of this =P

*Waves ?5*

I would read it but ... It would TKO my eyes.

Cheers any how.


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