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By: Paula J. Caplan and Lisa Cosgrove
From: Bias in Psychiatric Diagnosis, Edited by Paula J. Caplan and Lisa Cosgrove, 2004, New York, Jason Aronson, Publisher, pp 19-34.
Posted by permission. Copyright by Jason Aronson, Publisher
The judges of normality are present everywhere.
–Michel Foucault, Discipline and Punishment, 304
an official announcement [reads that] . . . nearly half of all Americans experiencea psychiatric disorder. . . . does that mean no one is normal . . . ?Or [do] we live in such a crazy-making, sick, impersonal society that itdoes serious psychological damage to half of us? . . . should we be calling[people the] mentally ill, . . . or . . . society’s wounded?
— Paula J. Caplan, They Say You’re Crazy: How the World’sMost Powerful Psychiatrists Decide Who’s Normal, 6
The word “name-calling” provokes negative associations, but the term “diagnosticlabeling” has an aura of scientific precision, objectivity, and professionalismthat lends it tremendous power. Language confers power (Miller andSwift 1977), and that power is “not distributed equitably across the social hierarchy”(Hare-Mustin and Marecek 1997, 106), a fact that has had tremendousimpact on those who have sought mental health services. Diagnosis ofphysical problems has often been extremely useful,1 and in principle, psychiatricdiagnosis can be helpful, too (e.g., Emily J. Caplan, chapter 5 in this volume).Unfortunately, psychiatric labeling has been conceived of and applied inextremely biased ways and is surprisingly unwarranted by scientific research,and thus it can result in serious harm (P. Caplan 1995). As Hare-Mustin andMarecek note: “a diagnostic label . . . has a profound influence on what wethink of people so labeled and how they think about themselves” (1997, 105).In addition, diagnostic labels often create problems with employers and themilitary and can potentially result in the loss of child custody, health insurance,and the right to make decisions about one’s legal affairs and medical care(Emily J. Caplan, chapter 5). Furthermore, the topics deemed important for aclient’s therapy sessions can be heavily determined-sometimes for better butoften for worse-by the diagnostic system and the label(s) given to that client.These dangers and others, combined with many forms of bias, help to determinewho gets diagnosed and with what labels.
In the United States, distress is intensely psychologized,2 including the proliferationof diagnoses and therapists, drugs marketed for every psychologicalstate imaginable, cocktail party conversation in which laypeople analyzetheir own behavior and that of others, increasing use of mental health expertsand social scientists as witnesses in court, and even New Age practices thatinvolve psychological concepts. Thus, it is all the more alarming that, as AutumnWiley shows (2001), authors of abnormal psychiatry textbooks almostor entirely ignore the extensive critiques of bias that have been published foryears in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is not surprising, then, that undergraduate psychology majors “learn” aboutforms of alleged mental illness that have never been proven to exist and aboutdiagnostic terms but do not learn about the biases involved in their creationand use. It is not that assigning a psychiatric diagnostic label is never helpful,but it is widely-and wrongly-believed that diagnostic labels are very helpfulto therapists for choosing treatments and predicting treatment outcome.Unfortunately, in the realm of mental disorders, this is rarely true.3
The terms “mental illness,” “mental disorder,” “abnormality,” “normality,”and even “insanity” are constructs, terms that do not correspond to clearlyidentifiable, “real” objects. Constructs are defined by whoever does the defining,and the power to make a definition stick resides usually in groups thathave the most social, political, and/or economic power. Beginning in the lasttwenty years of the twentieth century, the small number of primarily white,high-status, male psychiatrists who make the ultimate decisions about whatgoes into the therapists’ diagnostic “Bible,” the Diagnostic and StatisticalManual of Mental Disorders (DSM), have had more power than any group todecide who is and is not psychologically normal. But the DSM authors are notthe only creators of diagnostic categories, for drug companies and book authorswith “M.D.” or “Ph.D.” after their names have also been granted authorityby the media and the wider public.
Biases in diagnosis of “mental disorder” take effect on shifting sands onshifting sands, because no one has ever been able to come up with a definitionthat they considered satisfactory, as the DSM authors have courageouslyacknowledged (Kirk and Kutchins 1992). The subjectivity is evident in thefollowing italicized terms: mental disorder, they say, is a clinically significantsyndrome or pattern that is associated with distress or disability or with significantlyincreased risk of suffering, death, pain, disability, or an importantloss of freedom and must be considered a manifestation of a behavioral, psychological,or biological dysfunction in the individual. The further proviso,that it must not be an expectable and culturally sanctioned response, presentsparticularly thorny problems in light of the richly multicultural world inwhich we live. The problems with this definition remind us poignantly that”mental disorder” is, after all, a construct.
The fact that psychiatric diagnosis is ubiquitous (in the mental health systemand in noninstitutional contexts like social gatherings and the media) hastremendous impact on psychiatrists, social workers, pastoral counselors, guidancecounselors, psychologists, family therapists, nurse practitioners, psychiatricnurses, and others. As many clinicians realize, demonstrably far morehelpful than labeling in mental health settings is an intense focus on any or allof the following: therapists’ and others’ provision of listening ears, support, respect,familiarity with relevant research and with effective clinicians’ experiences,and a questioning approach to the literature and clinical narratives (P.Caplan 1995). Another helpful tool that is far too rarely used is formulation, the working out of the most likely explanations, insofar as one can tell, of thecauses or perpetuating factors of the person’s problems (Block 2002).
When DSM began increasing in size because of its skyrocketing number ofcategories and subcategories, its authors claimed that their labels were “atheoretical,”not tied to any theory or treatment, and solidly based in empiricalresearch (American Psychiatric Association 1980). Partly because of thisatheoretical approach, the formulation that had been so important in psychoanalysisand many other “talk” therapies has become dwarfed and, in somecases, replaced by an emphasis on diagnosis. This change was impelled by theprominence of the DSM, the American Psychiatric Association’s aggressivemarketing strategy for it, and the ready acceptance of its hundreds of categoriesand subcategories, by many therapists and researchers. The number ofDSM labels has skyrocketed over the past fifty years. With each subsequentrevision, new diagnostic categories have been added and others sometimeschanged or deleted. In the seven years between the 1987 and 1994 editions,for example, the number of categories and subcategories increased from 297to 374 (P. Caplan 1995). In addition to growing in size, this manual has becomeincreasingly influential, due to the fact that third-party reimbursementnow requires that patients receive a DSM diagnosis. Increased emphasis ondiagnosis was impelled by insurance groups and health maintenance organizations(that want therapy to be brief and therefore want particular problemsmatched with particular drugs and quickly cured), by those media people whoare too impressed by the psychiatric establishment to do real investigativejournalism, and by laypeople who understandably want to believe that, aswith a broken bone, diagnosis can lead to cure.
In addition to these concerns, six other factors inspired this book:
Therapists who, uncritically following the medical model, believe that allemotional problems are caused by factors within the individual make whatsocial psychologists call the fundamental attribution error (Ross 1977;Wiener and Marcus 1994), failing to consider the effects of social factors.Therapists working within the mental health system have developed alternativesto the medical model. For example, in 1987 Janet Stoppard led theWomen and Mental Health Committee of the Canadian Mental Health Asso-ciation (CMHA) in producing a report called Women and mental health inCanada: Strategies for change (Women and Mental Health Committee 1987).They dispensed with unvalidated systems of diagnostic labels, instead namingmany of the known and proven causes of women’s suffering, includingpoverty, violence, and lack of social and political power and resources. Theyproposed that money and energy be channeled into eradicating these causes,ending the report with point-by-point recommendations for action in therapists’training programs, various levels of government, and the CMHA itself.Unfortunately, the CMHA allowed the report to go out of print shortly after itwas published, and neither the CMHA nor any other group or individual hasreported having tracked whether any recommendations were followed. Thereis little evidence that they were, and there is little evidence in Canada or theUnited States that attempts to call attention to these major sources of emotionaldifficulty have permeated the mental health system. Clinicians and researcherscould advocate for replacement of current diagnostic labels with descriptorslike “the consequences of poverty,” “the consequences of violence,””the effects of homelessness,” “the damage done by interpersonal discrimination/demeaning treatment,” and so on. The DSM authors provide one axison which “psychosocial stressors” are to be listed, but the terms on Axes I andII are the focus of diagnosis and practice, and psychosocial stressors are oftenleft out entirely.
Much current research is based on DSM categories, even when those categorieshave not been shown to represent real entities (P. Caplan 1995; Eli Lillyand Company Limited, 2003), and use of DSM categories can appear to somegrant proposal reviewers to legitimize the proposed research. Futhermore, researchreports in which DSM categories were used provide further apparentsupport for the legitimacy of the DSM, even if the study has no bearing on thevalidity or practical usefulness of a DSM category. However, as discussed in anumber of chapters in this volume (e.g., Olio; Javed and Gerrard; P. Caplan,chapter7 in this volume; Caplan and Profit, chapter 32 in this volume), non-DSM labels can have tremendous power and be used in biased ways. For instance,labeling people as “stressed” has become so nearly ubiquitous that itthreatens to lose its meaning. Often, the word is used when accurate labelsshould be, for instance, “ashamed” or “terrified.” Paula J. Caplan heard a psychologistdescribe a woman recently diagnosed with late-stage breast canceras feeling “stressed” by the news. It is troubling enough when the label”stressed” masks the intensity or character of any emotion, and it is even moredisturbing when it masks the effects of oppression and violence. A brilliantdramatization of labeling’s masking effect is evident in Carolyn Gage’s play,Harriet Tubman Visits a Therapist, in which runaway slave Tubman tells atherapist about the tragedy and horror of slavery, and the therapist respondswith the recommendation that Tubman perform stress-reduction exercises(Gage 1999). Sadly, this mimics what sometimes happens today with labelingthe consequences of oppression.
By and large, research on human behavior tends to be conducted by individualswho interpret their results in ways that are consistent with prevalentforms of bias (Caplan and Caplan 1999). Racism, sexism, classism, ageism,mother-blaming, ableism, and other forms of bias are sustained both withinand outside the social sciences and mental health fields (Burman 1998; Fine1992; Wilkinson and Kitzinger 1995; Caplan, 2000). Further, drug companiesfund much research that is used to advocate new diagnostic categories, becausefinding or creating a diagnostic label for a drug maximizes the likelihoodof FDA approval and simplifies marketing. In the recent proliferation oftelevision commercials for prescription drugs, many include a description ofan ordinary phenomenon (such as shyness), the relabeling of it (shyness becomes”Social Anxiety Disorder“) in ways that alarm people because themessage is that they are mentally ill, and finally the announcement that abrand-name drug is just what the “disordered” person needs. research onthese and other drugs is frequently performed by their own in-house drugcompany researchers and sometimes by “independent” scientists. Drug companiesdo not pay these scientists’ salaries but the scientists are given drugcorporations’ research money and often prohibited from publishing resultsthat show the drugs to be ineffective or dangerous. Researchers and, indeed,at least one editor of a major medical journal are concerned about the associationbetween funding source and study outcome (e.g., Angell 2000; Bodenheimer2000; Davidson 1986; Friedberg, Saffran, Stinson, Nelson, and Bennett1999; Korn 2000). Former New England Journal of Medicine editor, Dr.Marcia Angell, reports that finding a research psychiatrist to write an editorialon treatment of depression was difficult because “we found very few whodid not have financial ties to drug companies that make antidepressants” (Angell2000, 1516).
Therapists who choose or are required to diagnose their patients, are likelyto read research reports in “scholarly” journals, the media, or both; and research-supported biases tend to affect the diagnoses they select for their patients.One example is the tendency to label abused women as “masochistic”based on poorly designed and misinterpreted research supposedly provingthat aggression is biologically impelled and thus nonpathological in men (Caplanand Caplan 1999; Caplan 1993a; Fausto-Sterling 1992). But the existenceof even greater bias against women is evident in this example, becauseof the powerful catch-22 situations in which they are placed: Women victimsof violence are diagnosed as “masochistic,” but because aggression is codedas naturally masculine, women perpetrators of violence, even in self-defense,are often labeled pathological for being “unwomanly,” “castrating,” or “psychopathic.”Similarly, women who stay with abusive partners are labeled”masochistic,” but women who leave are labeled “rejecting and cold” (P. Caplan1993a; Stahly 2003; Fausto-Sterling 1992).
As human beings, mental health professionals who conduct psychologicalor psychiatric assessments and apply diagnostic labels can never can be totallyfree from bias (Caplan and Wilson 1990; Fox 1997). However, manylawyers and judges operate as though assessors were infallible professionalswhose work is objective science, and in this context therapists’ biases canlead to infringement of the legal rights-even constitutional protection-ofmembers of marginalized groups. When making diagnoses and recommendations,a therapist can choose which theoretical or interpretive framework touse. To simplify only a little, there are two kinds of theories, one of whichtends not to be supported by good research and (probably not coincidentally)to be racist, sexist, or otherwise negatively biased, and the other tends to bebased on good research and not to be negatively biased. Serious legal principlesare ignored when an assessor chooses to bring one of the former into play(P. Caplan 1993b).The courtroom is a stage on which some of the tragic consequencesof diagnostic labeling are frequently played out through judicialedicts that basically constitute the rubber-stamping of a therapist’s diagnosticreport. Consider this case: A woman and man divorce soon after their daughteris born. He has physically abused his wife. They agree that the mother willhave care and custody of the child. When the daughter is a preschooler, sheshows signs of having been sexually abused. The mother is alarmed but fearswhat her ex-husband will do if she contacts the relevant authorities. She callsher lawyer, who advises her to make a formal report of suspected abuse,which she does. Informed about this report, the judge remarks in a conferencewith the lawyers that if the Department of Child and Family Services fails tofind that the child was abused, he will transfer custody to the father. Themother’s lawyer tells her what the judge says, and she is beside herself, feelingterrified and helpless. The next day, the mother has her first appointmentwith the psychologist whom the judge has ordered to conduct psychologicalassessments of both parents. The psychologist administers her a MinnesotaMultiphasic Personality Inventory, and, although all her scores fall within the”normal” range, he writes in his report that her MMPI profile showed her tobe extremely defensive and that her claim that the daughter might have beenabused proved her to be an hysteric, a category almost always applied towomen. In the “diagnosis” section of his report, on Axis II, he said that shehad “Self-defeating Features.”
This mother had sufficient resources to pay a good lawyer and two psychologistswho could testify that (1) nothing in the court-appointed psychologist’snotes or data suggested that she was defensive or hysterical, and (2) the assessorused DSM format and terminology to diagnose her, but the term “Selfdefeating”is not in the current DSM. This example appears here because thisscenario is tragically common.
The chapters in this book represent only a sampling of the huge number ofkinds of bias in mental health diagnosis, including sexism, racism, ageism,homophobia/heterosexism, and classism. We include papers about some individuallabels, as well as about problems that result from various manifestationsof bias in diagnosis. We hope that awareness of some of these issues willsensitize both trainees and faculty to the sorts of things to look for in other instances,since critical thinking is developed in part by questioning the assumptionswe are most likely to take for granted. Like K. Gergen (1994;2001), we believe that productive and constructive critique engenders dialoguerather than impeding it. When we transcend dichotomous and othersimplistic forms of thinking (e.g., science/politics; normal/abnormal), andwhen we dare to envision new ways of understanding the world, educationbecomes “the practice of freedom”(hooks 1994, 12), an aim that informs thespirit and content of this book.
Some of the chapters in this collection are about forms of bias-such asracism, ageism, sexism, heterosexism, classism-that affect large numbers ofdiagnostic categories. Some are addressed to such general topics as the “deepstructure” (different levels) of bias in diagnosis or case studies of the historyand politics of particular categories. Still others are about particular diagnosticcategories. At the end of this chapter is a list of some of the useful journalsand references for general readers or professionals who wish to read further.We hope clinical faculty will interweave their courses and caseconferences with discussions of the ways biases interfere with clinical treatment,we hope students may form informal discussion groups about thesematters, and we hope that general readers will discuss these matters with family,friends, and clinicians.
PIONEERS
It is important to review some of the classic work by those who have writtenabout bias in “mental illness” diagnosis. Writing in 1923, when SigmundFreud’s theories were becoming well known and in some quarters treated asgospel, psychiatrist and psychoanalyst Karen Horney had the courage to challengetwo of the most central psychoanalytic diagnoses (Horney 1973). Shequestioned Freud’s notion of “penis envy” as a label for much of women’sand girls’ behavior and his claim that all females have not only “penis envy”but also the wish to castrate the “favored male” (Horney 1973, 37). Criticizedand ridiculed by Freud and his inner circle, Horney had suggested that females’envy of or anger at males came not from wishing to have a penis butfrom understanding that males had more power and influence in many realmsand fewer restrictions than did females. The “penis envy” and castration wishthat Freud claimed as universal were examples, she said, of psychoanalysis’sown revelation “that much that we have regarded as constitutional merelyrepresents a blockage of growth, a blockage which can be lifted” (Horney1973, 13).
Another diagnostic term that psychoanalysts claimed to be fundamentally,immutably female was “masochistic.” Nevertheless, Horney pointed out thatwhat was called masochism was actually women’s silent acceptance of thesocially imposed conditions that made them unhappy (Horney 1939). In fact,she wrote that what was called masochism was in fact an effort to avoid suffering,to find safety and satisfaction by not making demands or being noticeable.As the liberation movements began forty and fifty years ago, sociologistAugust B. Hollingshead and psychiatrist Fredrick C. Redlich had found intheir classic work, Social class and mental illness (1958), a strong relationshipbetween individuals’ socioeconomic class and the psychiatric diagnosesthey were likely to receive.4 Hollingshead and Redlich pointed out the waysthat the beliefs of staff members in different clinical settings led to differentviews of patients,5 but their findings were striking. They assigned participantsto social class, using an index combining the person’s area of residence, occupation,and education. People in the “lowest” class, Class V, had the leasteducation and lowest incomes and lived in the least expensive neighborhoods.They found:
Hollingshead and Redlich attributed these class differences in diagnosis andtreatment to social factors and wrote that “the measure of mental health or illnessis not who is ‘normal’ or ‘abnormal’ but who is normal for what and forwhom in each class” (360). They note, for instance, that “the external problemsof lower class individuals, as well as threats to their economic, social,and physical security, are much stronger than to members of the higherclasses” and recommend “that psychiatrists need to understand the social systemof the community if they are to diagnose accurately” (365 and 371).Reporting a ten-year follow-up of the Hollingshead and Redlich study,Jerome K. Myers, Lee L. Bean, and Max P. Pepper note “the very process ofdiagnosis and treatment provides a social definition-that of mental patient”(1968, 13). They found a strong association between diagnosis and the treatmentagency to which a patient goes, therefore the greater likelihood of peoplein Classes IV and V being diagnosed with severe mental illnesses couldwell explain the differences in ongoing hospitalization.
In The politics of therapy, Seymour L. Halleck (1971) addresses the socialand environmental factors that give rise to problems, the expression of whichoften leads people to being psychiatrically diagnosed with labels that eithercarry implicit or explicit attributions of the problems to individual, intrapsychicfactors. Halleck expressed concern that people might be simply diagnosedas “mentally ill” rather than listened to and understood to be exhibiting”behavior that is defined as symptomatic or unreasonable” by those aroundthem in attempts to influence environments that are causing them harm (69).Halleck warned against therapists’ attempts to remove symptoms (so thatpeople would no longer appear diagnosable) without giving careful thoughtto the role those “symptoms” played in the patients'” attempts to improvetheir environments. He noted the risk of rendering the person even more powerless”to cope with the forces of oppression” (70); otherwise, the therapistrisked functioning only as “an agent of political control” (71). Halleck suggeststhat instead of diagnosing old people as depressed and treating the depressionas though it were the source of their problems, “the psychiatristshould try to identify those factors . . . that help to make old age a nightmare. . . not only to care for the victims of a brutal process, but to prevent thisprocess from becoming worse” (114). Halleck did not claim that all severeemotional problems were environmentally caused, but he made an impassionedplea with regard to the diagnosis and treatment of people whose primarystruggles had such causes.
“Obviously if enough tranquilizing medication were dispensed, blackprotest could be eliminated” (74). He observes that the people who have beenmost concerned and militant about oppression tend to be prone to periods ofanxiety and depression, even to “intense despair” (75). But, he asks, “what ifwhile they were in jail Henry Thoreau, Eugene Debs, Martin Luther King,and Malcolm X had been given the opportunity to improve their mental outlookby taking a powerful antidepressant?” (75). Furthermore, in words thatare powerful in their prescience, Halleck says that therapists ought to urgedrug companies to “curb their merchandising fervor [which led to advertisements that would often] depict patients who are overwhelmed with socialproblems; then they recommend dealing with these patients by simply tranquilizingor stimulating the patient” (77).
* * *
Please keep in mind that this book is specifically about diagnosis, becausemuch has been written about the wide variety of problems and biases intreatment. Some implications for treatment (or lack of) are mentioned or willbe obvious but are not explored here in detail. We hope that you will enjoythe range of voices and viewpoints that are represented in this book (e.g., academic,clinical, and explicitly political perspectives) as well as the broadrange of the authors’ formal and experiential qualifications. We want to emphasizethat no author in this book claims to have easy answers or all the answersfor preventing harmful biases.
WHAT TO DO
Clinicians often ask what they can do to try to insulate patients from negativeconsequences of receiving a diagnosis. Clinical judgments are always involvedin the process of diagnosis, whether in psychiatry or other fields. Insome cases, the patient clearly meets the requisite number of criteria for oneof the official diagnostic categories. However, there are cases in which questionsarise about which is the most accurate diagnosis, and in those cases, cliniciansmight take particular care to consider the effects of their diagnoses onclients’ lives outside of treatment, as well as of the treatment implications ofgiving a patient one diagnosis rather than another.6 For instance, insurancecompanies often provide reimbursement for more therapy sessions for patientswith certain diagnoses than with others. It is important to select a labelthat seems to accurately represent as many of the patient’s difficulties as possibleand does not misrepresent any dangers or increase the potential risk tothe patient or others. When there is any question about which diagnosis ismost appropriate, the clinician can record which labels beside the chosen onewere seriously considered and whether or not they were ruled out. Whateverdiagnosis one gives a particular patient, it is important to be aware that diagnosescan be helpful but not infrequently have negative effects on patients’rights to child custody, employment, health insurance, or the right to make decisionsabout their lives.
Clinicians who feel in a given case that it is consistent with their clinicalassessment and judgment to do so can write on the patient’s chart next tothe diagnosis such statements as, “The fact that this patient has received thisdiagnosis does not in and of itself indicate that the patient lacks such capacitiesas the ability to be a good parent, caretaker of others or employeeor to make decisions about their medical and psychological care, their legalaffairs, or other important aspects of their lives.” Some therapists offer togive their clients letters in which they make statements about the diagnosisthat are relevant to the particular person’s life situation and needs. For example,a therapist who had diagnosed a woman as having Chronic AdjustmentDisorder gave her a letter in which he stated that her disorder was aresult of severe, ongoing crises in her life and that it was likely, if the crisesabated, that she would be employable and that she would not necessarily alwayshave the disorder and be mentally ill if her life circumstances improved.
It is wise for clinicians to make sure that their words and actions are consistentwith the ethical standards of their respective professions and to checkwith attorneys about how best to choose to protect both the patient and theclinician.
Clinicians should also fully inform patients: (1) that they have to give thema diagnosis, (2) the reason that they have to do this (most often because requiredby their place of work and/or required for reimbursement by insurance companiesand because diagnoses are used in treatment planning), (3) that there arepotentially negative consequences of receiving a diagnosis and what these canbe, and (4) what the clinician is doing-or will do in the future, if relevant-totry to protect the patient as much as possible from those consequences.Finally, it is important to initiate and engage in ongoing discussions withcolleagues and consultants about the various potential and actual positive andnegative consequences of diagnosis, and it is important to educate the publicabout these matters, to make the realm of diagnosis more transparent to all.
Journals:
APA Division 44-Society for the Psychological Study of Lesbian, Gay, andBisexual Issues-Newsletter
SPSLGI Newsletter; Cultural Diversity and Ethnic Minority Psychology
Feminism and Psychology
International Journal of Critical Psychology
Journal of Feminist Family Therapy
Journal of Social Issues
Psychology of Women Quarterly
Radical Psychology
Theory & Psychology
Women and Therapy
Special issue, Independent Thinking Review, on “Critical Thinking About Psychology.” (1995). Volume 1, Number 4.
Websites:
Critical Psychology Homepage https://www.uws.edu.au/criticalpsychology/crit-psych-net.htm
Psychologists for Social Responsibility https://www.psysr.org/
Psychology of Women Resource List listserv@uriacc.uri.edu
Radical Psychology Network https://www.radpsynet.org/
NOTES
REFERENCES
Copyright (c) 2004 by Jason Aronson
Reprinted and posted by permission
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