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Psychological Medicine, Page 1 of 10. f Cambridge University Press 2011 Motivational interviewing and interaction skillstraining for parents to change cannabis use in youngadults with recent-onset schizophrenia: a randomizedcontrolled trial M. Smeerdijk1*, R. Keet2, N. Dekker1, B. van Raaij3, M. Krikke1, M. Koeter1,4, L. de Haan1,C. Barrowclough5, G. Schippers1,4 and D. Linszen1 1 Department of Psychiatry, Academic Medical Centre, Amsterdam, The Netherlands2 Mental Health Service North Holland North, Alkmaar, The Netherlands3 Training Company ‘ Bureau de Mat ’, Haarlem, The Netherlands4 Amsterdam Institute for Addiction Research, Amsterdam, The Netherlands5 School of Psychological Sciences, University of Manchester, UK Background. Cannabis use by people with schizophrenia has been found to be associated with family distress andpoor clinical outcomes. Interventions to reduce drug use in this patient group have had limited efficacy. This studyevaluated the effectiveness of a novel intervention for parents of young adults with recent-onset schizophreniaconsisting of family-based motivational interviewing and interaction skills (Family Motivational Intervention, FMI) incomparison with routine family support (RFS).
Method. In a trial with 75 patients who used cannabis and received treatment for recent-onset schizophrenia, 97parents were randomly assigned to either FMI (n=53) or RFS (n=44). Assessments were conducted at baseline and 3months after completion of the family intervention by an investigator who remained blind throughout the studyabout the assignment of the parents.
Results. At follow-up, patients’ frequency and quantity of cannabis use was significantly more reduced in FMI thanin RFS (p<0.05 and p<0.04 respectively). Patients’ craving for cannabis was also significantly reduced in FMIwhereas there was a small increase in RFS (p=0.01). There was no difference between FMI and RFS with regard topatients’ other substance use and general level of functioning. Both groups showed significant improvements inparental distress and sense of burden.
Conclusions. Training parents in motivational interviewing and interaction skills is feasible and effective in reducingcannabis use among young adults with recent-onset schizophrenia. However, FMI was not more effective than RFS inincreasing patients’ general level of functioning and in reducing parents’ stress and sense of burden.
Received 13 July 2011 ; Revised 10 November 2011 ; Accepted 10 November 2011 Key words : Cannabis, family intervention, interaction skills, motivational interviewing, schizophrenia.
that carers tend to be more critical and hostile if theirfamily member with schizophrenia uses drugs (Lopez Cannabis use is highly prevalent in people with the et al. 1999 ; Barrowclough et al. 2005). A critical attitude diagnosis of schizophrenia (Mueser et al. 1990). In this approach has been thought to increase patients’ population, the use of cannabis has been consist- defensive reactions and to reduce the likelihood that ently associated with treatment non-adherence and they would change their behaviour (Miller et al. 1993).
increased risk of psychotic relapse (Linszen et al. 1994 ; Studies have also found that a critical attitude in carers Zammit et al. 2008). Given these negative relationships, is associated with an increased risk of psychotic re- it is likely that there are high levels of interpersonal lapse (Butzlaff & Hooley, 1998). One study showed that conflicts in households in which a family member high levels of criticism within the family were the main with schizophrenia uses cannabis. It has been found predictor of psychotic relapse (Linszen et al. 1997).
Although there is clear need for interventions that help patients with schizophrenia to reduce their * Address for correspondence : M. Smeerdijk, M.Sc., Department of substance use, currently the evidence for effective Psychiatry, Academic Medical Centre, Meibergdreef 5, 1105 AZ, interventions is very limited (Cleary et al. 2009), and there has been little attention paid to family-based approaches (Mueser et al. 2009). Motivational inter- standard treatment programme for recent-onset viewing (MI) is a well-studied method to overcome schizophrenia, consisting of in-patient treatment last- resistance and increase the motivation to change ing 2 months, followed by out-patient treatment for a substance use (Hettema et al. 2005). Although MI maximum of 12 months. The content of the patients’ was originally developed for use by professionals treatment programme has been described elsewhere (Miller & Rollnick, 2002), training parents in MI might (Linszen et al. 1996), and included psycho-education, change their critical response to cannabis use and medication management, stress reduction and relapse help them to overcome patients’ resistance to change.
prevention. The primary hypothesis was that FMI Accordingly, we developed an intervention pro- would be more effective than RFS in reducing patients’ gramme consisting of family-based motivational cannabis use. The secondary hypotheses were that FMI interviewing and interaction skills, called Family Moti- would be superior to RFS in (1) decreasing patients’ vational Intervention (FMI), for parents of patients substance use other than cannabis, (2) decreasing with recent-onset schizophrenia and co-occurring craving for cannabis use, and (3) increasing patients’ cannabis use. The programme was adapted from the quality of life. With regard to parents, the secondary Interaction Skills Training (IST) programme for hypothesis was that FMI would be superior to RFS in schizophrenia (Kuipers, 2003 ; van Meijel et al. 2009) to decreasing parents’ distress and sense of burden re- provide parents communication and problem-solving sulting from their child’s symptoms and cannabis skills to reduce stress and resolve conflicts within the family. This was combined with training parents inskills from MI to enhance patient motivation for changing cannabis use. FMI was delivered in additionto mental health standard care for patients. The aim Patients were invited to participate after being fully of the present study was to determine whether FMI informed about the content and aims of the study.
would be more effective than routine family support Parents were not approached for the study before the (RFS) in reducing patients’ cannabis use. Several sec- patient had given written informed consent. Patients ondary outcomes were also examined, including and parents were assured that family support would (1) patients’ substance use other than cannabis, their continue to be offered regardless of whether they craving for cannabis use and their quality of life, and agreed or refused to participate in the study. Although (2) parents’ distress and sense of burden.
both parents were approached about participating, itwas possible for only one of them to do so. After in-formed consent had been given, parents and patients were assessed separately at two time points : within 4 weeks before the start of FMI and RFS (baseline) and 3months after FMI and RFS had ended (follow-up : 9 Patients were recruited from two psychiatric services months post-baseline). The baseline assessment was in The Netherlands : the Academic Medical Centre of planned within the first month of hospitalization.
the University of Amsterdam (AMC-UvA) and the Allocation of the parents to FMI or RFS was based on Mental Health Service North Holland North (GGZ- the randomly assigned condition of their child. The NHN). Patients with the following selection criteria assessments were conducted by the first author, who were eligible : (1) DSM-IV diagnosis (APA, 1994) of was blind to participants’ treatment allocation. Efforts schizophrenia or psychotic-related disorder, based on were made to maintain blindness, including the use of the Comprehensive Assessment of Symptoms and separate locations for therapy and research staff and History (CASH ; Andreasen et al. 1992) ; (2) age 16–35 reminding participants before and at the start of the years ; (3) onset of schizophrenia or psychotic-related follow-up assessment not to disclose their treatment disorder within the previous 5 years ; (4) antipsychotic allocation. As a standard component of our treatment medication prescribed or indicated ; (5) cannabis use programme, all parents were invited for two sessions for at least 2 days/week in the previous 3 months ; and of group psycho-education, which were given in the (6) having contact with a parent for at least 10 h/week first month of hospitalization. After psycho-education, parents received either FMI or RFS over a period of6 months.
A single-blind randomized controlled trial was con- ducted in which parents were allocated to either FMI(the experimental condition) or RFS (the control Patients’ use of cannabis, alcohol, cocaine, ampheta- condition). In both conditions patients received a mines, opiates and psychedelic drugs was assessed Skills training for parents to change cannabis use in young adults with the Timeline Followback (TLFB-90) interview With this method the following key skills were prac- (Sobell & Sobell, 1992). This structured interview uses tised : active listening, sending clear signals, and a calendar method to identify and quantify the re- maintaining boundaries. MI was based on counselling spondent’s self-reported alcohol and drug use during techniques and addressed stages identified as those the previous 90 days. For the present study, measures that trainees needed to become competent in MI derived from the TLFB-90 were the mean frequencies (Miller & Moyers, 2006). Parents were trained in the of use in days for cannabis, alcohol and other sub- following techniques : asking open questions, using stances, the mean amount of use in grams for cannabis reflections, providing summaries, and overcoming and in glasses for alcohol and percentage of patients resistance. Parents were allowed to practise these in each condition being abstinent from cannabis at techniques by focusing on identifying and eliciting follow-up. To validate the patients’ self-reports, urine patients’ self-motivational statements (i.e. ‘ change samples were taken for cannabis, cocaine and amphet- talk ’) about changing cannabis use. Full details of the interventions can be found in the manuals for IST As an important mediator of continued substance (Kuipers & Raaij, 2006) and MI (Smeerdijk et al. 2007).
use and relapse after abstinence, craving was assessed The intervention was conducted by two highly ex- with the self-report Obsessive Compulsive Drug perienced family therapists who were trained by cer- Use Scale (OCDUS ; Anton et al. 1996 ; Schippers et al.
tificated professionals in IST and MI. To facilitate 1997). The OCDUS measures three factors of craving treatment fidelity, six pilot sessions of FMI were car- for cannabis in the past 7 days : (1) thoughts about ried out and recorded on videotape. These tapes were cannabis and interference they cause, (2) desire to use then viewed in supervision sessions to discuss with cannabis and control over the desire, and (3) resistance the trainers their compliance with the treatment man- to thoughts about cannabis and intentions to use.
uals. Supervision sessions were continued throughout Patients’ subjective quality of life was measured with the short form of the widely used World RFS consisted of individual meetings between the Health Organization Quality of Life self-report ques- parent(s) and an experienced family therapist. RFS tionnaire WHOQOL-BREF (de Vries & van Heck, was designed to be supportive and encouraging for the parent(s) and consisted of providing the oppor- For the assessment of stress in relation to caring tunity to talk freely about their feelings, answering for someone with a schizophrenic disorder who uses cannabis, parents completed three self-report Meetings were commonly focused on topics such as questionnaires : the Experience of Caregiving In- emotional processing of grief and loss, medication and ventory (ECI), the Family Questionnaire (FQ) and crisis management, and social rehabilitation. Parents the General Health Questionnaire 28 (GHQ-28). The determined their own topics and there were no formal ECI (Szmukler et al. 1996) measure the positive and skills provided during the intervention period. In ac- negative appraisal of caring for someone with mental cordance with the FMI, RFS was held twice a month, health problems. The FQ (Quinn et al. 2003) measures three dimensions of parents’ perception : frequencyof symptoms, concern about symptoms and ability to cope with symptoms. The GHQ-28 (Goldberg &Hillier, 1979 ; Koeter & Ormel, 1991) is an established All data were analysed using SPSS version 17 for brief self-report questionnaire that screens for Windows (SPSS Inc., USA). To compare the conditions on baseline characteristics, continuous data were ana- assessing the person’s mental health during the lysed using independent t tests (normally distributed data) and Mann–Whitney U tests (non-normally dis-tributed data). Categorical data were analysed withPearson’s x2 test or with Fisher’s exact test when fre- quencies were low. All analyses of changes from FMI consisted of 12 group sessions scheduled every baseline to follow-up were conducted on an intention- other week. The training provided parents with skills to-treat (ITT) basis. Missing data from the TLFB, adapted from the IST and MI. The IST programme was developed by the training company Bureau de Mat1.
means of the multiple imputation method for missing The purpose was to help parents to practise interac- values. Consistent with the standard practice in sub- tion skills and problem-solving techniques by using a stance abuse trials, missing urine samples were red- and green-coloured mat to visualize interaction imputed as positive. To assess patients’ improvement problems between child and parent (Kuipers, 2008).
from baseline to follow-up, independent t tests were parents refused participation, n=32 Fig. 1. CONSORT diagram. FMI, Family Motivational Intervention ; RFS, routine family support.
conducted comparing the experimental and control approve of their parent’s participation. Of the 75 conditions on patients’ change scores in self-reported remaining patients who were randomized, 25 (33 %) substance use, craving for cannabis use and quality of refused to take the baseline assessment but agreed that life. Differences in urine values between the conditions their parent(s) would participate. Of the participating at follow-up were analysed with the x2 test. With patients, nine partners and 16 single parents were in regard to the parents’ outcomes, a linear mixed model the FMI group, and seven couples and 16 single par- was used to correct for differences between patients in ents were in the RFS group. Of the non-participating the number of participating parents. The level of sig- patients, five couples and nine single parents were in nificance (a) was set for all outcomes at p<0.05, using the FMI group, and three couples and eight single two-sided tests. Effect sizes (Cohen’s d) were calcu- parents were in the RFS group. Of the 53 parents as- lated for significant outcomes, with d=0.2, 0.5 and 0.8 signed to FMI, 92 % attended at least eight of the 12 considered to be a small, medium or large effect sessions. Of the 44 parents assigned to RFS, 89 % attended at least eight sessions over the 6-month per-iod of the trial. Baseline and follow-up data were col-lected from 46 carers (87 %) in the FMI group and from32 carers (73 %) in the RFS group. For the patients, the follow-up rates were 17 patients (71 %) in the FMI group and 20 patients (77 %) in the RFS group.
Figure 1 shows the progress of the patients and par-ents through the trial. Of the 149 patients meeting the inclusion criteria, 74 did not participate because : (1)they were not willing to take part in the study or (2) The demographic and clinical characteristics of they were excluded because their parents were not patients and parents at baseline are shown in Table 1.
willing to participate. Of the 194 eligible parents, 97 At baseline, patients in the two conditions were not did not participate because : (1) they were not willing significantly different on the following variables : age, to take part in the study or (2) the patient did not gender, race, marital status, years of secondary Skills training for parents to change cannabis use in young adults Table 1. Participants’ characteristics at baseline for Family Motivational Intervention (FMI) and routine family support (RFS) First treatment for schizophrenia, n ( %) education, employment status, primary schizophrenia number of days in treatment before the baseline as- diagnosis, prior treatment experience for schizo- sessment point between the FMI group [33.08 phrenia, treatment status and duration, or type of (¡22.80)] and the RFS group [31.54 (¡21.49)]. Because medication use (all p’s>0.05). Parents in the two con- the follow-up assessment was planned to occur 3 ditions did not significantly differ in terms of gender, months after the end of the 6-month family inter- marital status or number of contact hours with the ventions, it was possible for patients to still be in patient (all p’s>0.05). Within the conditions, patients treatment at this evaluation point. However, none of who were lost to follow-up did not significantly differ the patients were still receiving the out-patient phase from those who completed the follow-up assessment of the intervention when they were seen at the follow- with respect to any of the demographic and clinical up. During the 9-month study period, one patient in characteristics. Because the opportunity was given to the FMI group and one patient in the RFS group participate in the study at a later time in the patients’ were readmitted to hospital. With regard to the other treatment programme, 28 % (n=14) of the patients and patients, there was no significant difference in the 25 % (n=24) of the parents had the baseline assess- mean number of treatment weeks from baseline to ment after the first month of the in-patient admission.
out-patient discharge between the FMI group [20.71 There was no significant difference in mean (S.D.) (¡5.73)] and the RFS group [18.75 (¡5.16)]. In Table 2. Patients’ cannabis, alcohol and other drug use from the Timeline Followback (TLFB-90) Standard deviations are given in parentheses.
addition, no significant difference was found in the (58.8 % v. 25.0 %, x2=3.07, p=0.08). In addition, at mean number of weeks from out-patient discharge to follow-up there was no significant difference between follow-up between the FMI group [20.54 (¡6.65)] and the groups in abstinence rates for alcohol use and drug use other than cannabis. Among the patients seen atfollow-up, seven patients (41 %) in the FMI group and nine patients (45 %) in the RFS group refused to givea urine sample. All missing urine samples were im- Table 2 shows the baseline and follow-up mean scores puted as positive for cannabis. There was no signifi- on the patients’ self-reported frequency and quantity cant difference between the FMI and RFS groups at of cannabis, alcohol and other substance use prior to follow-up with regard to the proportion of patients the multiple imputation analyses. At baseline, there with a negative urine test result for cannabis use were no significant differences between the groups (28.0 % v. 17.9 %, x2=0.78, p=0.51).
in mean days of use of cannabis, alcohol and other Scores on the OCDUS at baseline revealed no sig- substances during the 3-month period preceding the nificant difference between the FMI group and the RFS assessment (all p>0.05). On change scores in mean group in patients’ craving for cannabis use. Change days of cannabis use from baseline to follow-up, a scores on the OCDUS from baseline to follow-up, significant difference was observed between the however, showed a significant difference between the groups (t51=2.00, p<0.05, Cohen’s d=0.56). Specifi- groups (t51=2.75, p=0.01, d=0.77) ; there was a de- cally, the mean number of days of cannabis use crease in craving in the FMI group [x8.13 (¡8.29) was decreased in the FMI group by 40.89 (¡36.47) points] and a very small increase in craving in the RFS days and in the RFS group by 12.83 (¡33.25) days.
The two groups did not differ significantly in the At baseline, there was no significant difference in change in alcohol and other substance use from base- scores on quality of life between the FMI group and line to follow-up (p>0.05). At baseline, there were the RFS group. There was also no significant difference no significant differences between the groups in in the increase in scores on quality of life from baseline mean daily cannabis or alcohol use. There was, how- to follow-up between the FMI group [+6.19 (¡10.02) ever, a significant difference between the groups in points] and the RFS group [+6.26 (¡14.32) points].
changes from baseline to follow-up in mean gramsof cannabis used (t51=2.06, p=0.04, Cohen’s d=0.58).
Specifically, in the FMI group the mean use ofcannabis was reduced by 0.53 (¡0.67) g whereas in There were no significant differences between the FMI the RFS group there was a small increase by 0.08 group and the RFS group in baseline scores on the (¡0.62) g. The groups did not differ in change from GHQ, the FQ and the ECI. After imputation of missing baseline to follow-up in mean number of glasses of values, linear mixed model analyses revealed that there were also no significant differences between the Complete abstinence from cannabis during the groups in change scores from baseline to follow-up 3-month period preceding the follow-up assessment on any of these questionnaires. More specifically, there was reported more frequently in the FMI group than was a significant decrease in both groups in total in the RFS group, although this was not significant scores on the GHQ and the FQ, and on the negative Skills training for parents to change cannabis use in young adults Table 3. Parents’ means scores at baseline and at the 10-month follow-up, and comparison of their change scores FMI, Family Motivational Intervention ; RFS, routine family support ; ECI, Experience of Caregiving Inventory ; GHQ-28, General Health Questionnaire 28 ; FQ, Family Questionnaire ; df, degrees of freedom.
Values given as mean (standard deviation).
scale of the ECI (Table 3). These scores indicate that long-term efficacy of FMI, as craving is an important both parents groups improved from baseline to mediator of relapse after abstinence from cannabis follow-up on their levels of distress and sense of bur- (Anton et al. 1996). No consistent evidence exists to den. Exploratory analyses with dependent t tests date to support the effectiveness of pharmacological revealed that these improvements were all significant and psychosocial interventions to reduce cannabis use for the FMI parent group (GHQ : p<0.01, FQ : p=0.01, by people with schizophrenia (Cleary et al. 2009 ; ECI : p<0.01) and also for the RFS parent group (GHQ : Hjorthøj et al. 2009). Although randomized trials have p=0.02, FQ : p=0.02, ECI : p<0.01).
repeatedly shown that family interventions are effec-tive for persons with schizophrenia (Pharoah et al.
Relationship between patients’ and parents’ 2006) and for persons with substance use (O’Farrell & Fals-Stewart, 2006), to our knowledge only two otherstudies have evaluated a family intervention pro- Pearson’s correlation coefficient (r) was computed to gramme for their co-occurrence (Barrowclough et al.
examine the relationship between the significant out- 2001 ; Mueser et al. 2009). The first study demonstrated comes for patients and parents. To correct for differ- that a 9-month programme that included psycho- ences between patients in the number of participating education and support for carers resulted in a signifi- parents, parents’ mean change scores were used if cant increase in the percentage of days participants both parents had participated. Contrary to expec- were abstinent from alcohol and other drug use over a tation, improvements in parents’ levels of stress and 12-month period from baseline to follow-up. The sense of burden (as measured by the GHQ, FQ and second study also included psycho-education and ECI) were not significantly related to reductions in support for carers and, like the present study, trained either patients’ frequency or amount of cannabis use.
carers in communication and problem-solving skills. It These associations were not found for the sample as a revealed that successful involvement of carers in the whole or for the FMI and RFS group separately.
programme was strongly associated with less severe Parents’ attendance rates at FMI and RFS sessions drug abuse among patients ; however, the impact of were also not significantly correlated with patients’ the intervention on patients’ substance use has not yet changes in frequency or amount of cannabis use or with parents’ improvements in levels of stress and On the other outcomes, no additional benefits were obtained in the FMI group beyond those achieved inthe RFS group. In both groups there were no effects onpatients’ alcohol use and drug use other than canna- bis. However, on these outcome measures it was This study demonstrated that training parents of difficult to establish any changes because excessive patients with the diagnosis of recent-onset schizo- alcohol use and substance use other than cannabis was phrenia in FMI led to significantly greater reductions rare among the patients in this present study. In in patients’ frequency and amount of cannabis use addition, both FMI and RFS led to significant im- than providing parents RFS for at least 3 months. In provements in patients’ quality of life status and in addition, patients’ craving for cannabis decreased to a parental sense of burden and stress. These improve- significantly greater extent in the FMI group than in ments could be due to short-term benefits achieved the RFS group. These results offer promise for the with the treatment that the patients had received before the follow-up assessment, which included use in people with a severe psychiatric disorder pharmacotherapy and psychosocial interventions. In (Carey et al. 2004 ; Stasiewicz et al. 2008). More specifi- this case, it would have been difficult to establish any cally, for patients with psychosis, the TLFB-90 shows benefits of FMI on the quality of life beyond those good concurrent validity (Barrowclough et al. 2001), and findings even suggest that it may be a more sen- The findings of this study should be discussed in sitive measure for detecting cannabis use in this the context of its limitations. First, 45 % of the patients patient group than hair analysis (Haddock et al. 2009).
meeting the inclusion criteria and almost one-third of In both groups there was an improvement in the parents who were asked to participate refused to patients’ quality of life status and in parents’ stress do so. However, those parents who did participate and sense of burden, but only FMI showed an im- showed a high level of commitment, which was provement on cannabis use and craving for cannabis shown in both groups. In addition, there was a high use. This is an important finding because FMI did response rate among patients and parents in both have a particular focus on changing cannabis use groups at follow-up. However, the high rate of initial whereas RFS did not. Therefore, it is recommended refusal opens the possibility that the sample was that, if cannabis use is present in schizophrenia, in- biased towards patients who were already considering terventions for family members should include train- changing their cannabis use and therefore found it ing in interaction and motivational skills that target meaningful to participate. This also raises the concern the cannabis use of the patient. Other authors also over the small sample size of patients, which makes it mention that psychosocial treatments for psychosis difficult to find any statistical differences and reduces should maintain a well-defined focus (Garety et al.
the statistical power. Given the high intensity of FMI 2008). It could be argued, however, that the effects on (12 sessions provided over a 6-month period, each cannabis use were due to the greater efforts parents lasting 3 h), it is understandable that the most often- made in the FMI condition rather than to the specific mentioned reason for parents not participating was skills they were taught. At the same time, parents’ ef- their inability to integrate the training into their daily forts to help patients abstain or cut down their canna- activities. This reflects the fact that FMI might not be bis use could be counterproductive, leaving the carers feeling frustrated and stressed because of their failed Second, because the follow-up assessment occurred attempts. FMI aims to teach parents to leave the re- 3 months after the end of the family intervention, more sponsibility for changing to the patient, and that at- research is warranted to determine whether the posi- tempts to argue with the patient and persuade them to tive results in changes in patients’ cannabis use and change only create resistance. Trainers’ anecdotal re- cannabis craving will be sustained after longer ports confirmed that changing carers’ attitude about, and their approach to, the patients’ cannabis use was Third, this study included only patients who had the major achievement of FMI. Further trials are nee- contact with a parent for at least 10 h/week. Therefore, ded to identify what the active and most important it is difficult to know whether the results can be gen- ingredients are in FMI, and to examine the long-term eralized to patients who have less substantial contact effects of the involvement of parents in the treatment with their families. Furthermore, because within the of patients with recent-onset schizophrenia.
patients’ family only the parents were asked to par-ticipate, it is unclear whether our intervention wouldhave similar benefits if family members other than Fourth, compared to treatment for schizophrenia in other countries such as the UK and the USA, the Organization for Health Research and Development, in-patient phase of our treatment programme is rela- grant no. 100003014) and by Eli Lilly. We are grateful tively long (2 months). Therefore, future studies are to all of the participants. We also thank K. Hulstijn, warranted to determine whether the observed benefits F. Lobban and T. Kuipers for their scientific contri- found in our study can also be attained by mental butions and A. de Jager for delivering the MI training.
health services with a short in-patient phase.
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