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Conjoint Therapy for PTSD with 3,4-
Methylenedioxymethamphetamine (MDMA): A
Anne C. Wagner, Michael C. Mithoefer, Ann T. Mithoefer & Candice M.
To cite this article: Anne C. Wagner, Michael C. Mithoefer, Ann T. Mithoefer & Candice
M. Monson (2019): Combining Cognitive-Behavioral Conjoint Therapy for PTSD with 3,4-
Methylenedioxymethamphetamine (MDMA): A Case Example, Journal of Psychoactive Drugs, DOI:
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Combining Cognitive-Behavioral Conjoint Therapy for PTSD with
3,4-Methylenedioxymethamphetamine (MDMA): A Case Example
Anne C. Wagner
, Michael C. Mithoefer
, Ann T. Mithoefer
, and Candice M. Monson
Department of Psychology, Ryerson University, Toronto, Canada;
Remedy, Toronto, Canada;
Private Practice, Charleston, SC, USA
Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years.
From what was historically viewed as a pervasive, intractable condition have emerged multiple
evidence-based intervention options. These treatments, predominantly cognitive behavioral in
orientation, provide significant symptom improvement in 50–60% of recipients. The treatment of
PTSD with MDMA-assisted psychotherapy using a supportive, non-directive approach has yielded
promising results. It is unknown, however, how different therapeutic modalities could impact or
improve outcomes. Therefore, to capitalize on the strengths of both approaches, Cognitive
Behavioral Conjoint Therapy for PTSD (CBCT) was combined with MDMA in a small pilot trial.
The current article provides a case study of one couple involved in the trial, chosen to provide
a demographically representative example of the study participants and a case with a severe
trauma history, to offer a detailed account of the methodology and choices made to integrate
CBCT and MDMA, as well as an account of their experience through the treatment and their
treatment gains. This article offers a description of the combination of CBCT for PTSD and MDMA,
and demonstrates that it can produce reductions in PTSD symptoms and improvements in
Received 30 November 2018
Accepted 21 February 2019
MDMA; couples; CBT;
couples; MDMA; PTSD
The field has made enormous strides in the treatment
of PTSD in the past 30 years. From what was once
viewed as a pernicious, intractable disorder deserving
a palliative treatment course, PTSD is now considered
a treatable condition with various evidence-based inter-
vention options. The majority of these interventions are
cognitive-behavioral in approach (e.g., Cognitive
Processing Therapy, Resick, Monson, and Chard 2016;
Prolonged Exposure, Foa, Hembree, and Rothbaum
2007; Cognitive Behavioral Conjoint Therapy (CBCT)
for PTSD, Monson and Fredman 2012). Cognitive-
behavioral interventions for PTSD have been found
effective in meta-analyses (e.g., Watts et al. 2013),
adopted throughout healthcare systems (e.g., Karlin
et al. 2010), and thousands of clinicians have been
trained through ongoing dissemination efforts (e.g.,
Chard et al. 2012; Foa, Gillihan, and Bryant 2013;
Monson et al. 2018). Cognitive Processing Therapy
(CPT) and Prolonged Exposure (PE) have received
support as strongly recommended in treatment guide-
lines (e.g., APA 2017; ISTSS 2018).
These treatments, however, do not work for all of
those who receive them. For example, 50–60% of
people no longer meet criteria for PTSD in the most
successful treatment trials (Foa et al. 2005; Monson
et al. 2006; Resick et al. 2002), yet this leaves millions
of people every year who do not respond adequately to
existing treatments. Additionally, the current model of
individual weekly or biweekly psychotherapy does not
fit the needs of all individuals with PTSD. Alternative
approaches are needed, both to improve treatment out-
comes and to address participant interest in alternative
modes of treatment administration. The current study,
illustrated through the use of a case example, combines
CBCT for PTSD with MDMA, a medication with grow-
ing evidence for its efficacy for treating PTSD.
PTSD has been conceptualized as an interpersonal dis-
order, given the impact it has on interpersonal relation-
ships, and also the interpersonal nature of meaning making
post-trauma that occurs when PTSD is present (Monson,
Fredman, and Dekel 2010). Cognitive-Behavioral
Interpersonal Theory (C-BIT) outlines the relationship
between PTSD symptoms for an individual and for close
others in their psychosocial system (Monson, Fredman,
and Dekel 2010). PTSD impacts the functioning of not
only the individual with PTSD, but also their relationships.
CONTACT Anne C. Wagner email@example.com Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, Ontario,
M5B 2K3, Canada
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ujpd.
JOURNAL OF PSYCHOACTIVE DRUGS
© 2019 Taylor & Francis Group, LLC
Conversely, the functioning of close others and relation-
ship functioning impact PTSD (e.g., Bradley et al. 2005;
Lambertetal.2012;Shnaideretal.2014). CBCT for PTSD
makes use of this interpersonal dynamic in the treatment of
PTSD, and notably addresses the desire for close others to
be involved in treatment. CBCT for PTSD targets both
PTSD symptoms and relationship satisfaction by increas-
ing understanding of PTSD within the context of the
relationship, dyadic skills (e.g., communication, problem
solving, and conflict management), behavioral approach
tasks, and dyadic cognitive restructuring of thoughts that
are preventing recovery (Monson and Fredman 2012).
Because of the nature of avoidance with PTSD, along
with stigma regarding seeking mental health care and
concern regarding treatment (e.g., Stecker et al. 2013),
involving close others in PTSD treatment can be useful.
There may be strong investment in engaging in care for
the sake of the relationship, if not only for the indivi-
dual (e.g., Meis et al. 2013). There is growing evidence
for the effectiveness of CBCT, with strong outcomes for
the reduction of PTSD symptoms, as well as improve-
ments in partner functioning and in relationship func-
tioning (Monson and Fredman 2012; Monson et al.
2004; Shnaider et al. 2014). CBCT has been found to
be effective with distressed and non-distressed dyads
(Monson and Fredman 2012; Shnaider et al. 2014).
MDMA, an atypical psychedelic compound, was used as
a therapy-facilitating tool before it was placed in Schedule 1
in the United States (Greer and Tolbert 1986;Passie2018;
Passie and Benzenhofer 2016; Riedlinger and Riedlinger
1994). MDMA has shown promise in the treatment of
PTSD when coupled with non-directive, supportive psy-
chotherapy (Mithoefer et al. 2011,2013,2018b). MDMA’s
neurobiological effect includes activation of the prefrontal
cortex and dampening of activity in the amygdala, as well
as release of neurotransmitters such as serotonin, dopa-
mine, norepinephrine, and hormones such as oxytocin,
cortisol, vasopressin, and prolactin (Carhart-Harris et al.
2015; de la Torre et al. 2000;Dumontetal.2009; Emanuele,
Arra, and Pesenti 2006; Feduccia and Mithoefer 2018).
Coupled with the intentional creation of a therapeutic con-
text, set, and setting, this neurobiological effect enables
what has been theorized as an optimal zone of arousal, as
well as possibly allowing for a type of fear extinction
(Feduccia and Mithoefer 2018).Wepositthattheneuro-
transmitter release and changes in brain activity may also
allow for flexibility in cognition, given the altered affective
and sensory state, as well as increased feelings of empathy
(Kuypers et al. 2014), positive or clear affect (Green et al.
2003), openness (Gamma et al. 2000), and less constrained
cognitive processing (Carhart-Harris et al. 2015), which
may address elements of trauma reappraisal targeted in
cognitive therapies. Additionally, it is posited that the
experimental expectancy effect of taking a psychedelic
compound, as well as the “special”nature of the context
of therapy (massed dosing, full-day sessions, significant
pre-treatment discussion and consent, contact with thera-
pists daily following MDMA sessions), may allow for opti-
mal treatment gains. The sense of empathy produced
extends to therapists, partners, and also to the client, allow-
ing for more thorough examination of thoughts and emo-
tions with a sense of care and understanding, as opposed to
fear. The MDMA session experience may create a salient
example of what it may feel like to no longer have PTSD,
and therefore offer a scaffold on which to continue to
a detailed account of the methodology and choices made to
experience through the treatment and their treatment
CBCT protocol and session flow
CBCT is a 15-module, three-phase, protocol-based, dya-
dic treatment for PTSD (Monson and Fredman 2012).
Each module is typically delivered in a 75-minute psy-
chotherapy session. The relationship between the mem-
bers of the dyad is considered the client in therapy, and
all interventions are designed to address both people.
Phase one of the treatment (two modules) includes psy-
choeducation about PTSD and addresses barriers to
safety, including understanding and working with
anger and irritability. Phase two (five modules) empha-
sizes the development of communication and problem-
solving skills, and introduces behavioral approach tasks
aimed at reducing avoidance. Phase three (eight mod-
ules) consists of dyadic cognitive work to address stuck
thoughts related to the trauma, including areas related to
acceptance and blame, trust, power, control, emotional
intimacy, physical intimacy, and posttraumatic growth.
Out-of-session assignments are used to practice skills
and techniques learned in session.
In this case study, two full-day MDMA sessions were
added to the CBCT protocol, during which both mem-
bers of the dyad were given MDMA. The first MDMA
session was placed after module 5 of CBCT, which is
mid-way through phase two (see Figure 1). This place-
ment was selected in order to place the MDMA session
directly after the couple had learned and practiced
communication skills, as we wanted the couple to
have these skills in order to share their experiences
and be able to communicate effectively during their
MDMA session and afterwards. The second MDMA
2A. C. WAGNER ET AL.
session took place after module 9 of the CBCT proto-
col, which is near the beginning of phase three of the
protocol, and in the heart of the trauma processing
around themes of acceptance and blame. The rationale
for placing the second MDMA session there was to
facilitate trauma processing and to prime the partici-
pants with self-referential, trauma-related content.
The first three modules of CBCT were delivered in
one day (see Figure 1), with time during breaks for the
couple to complete homework exercises. This procedure
was both feasible and acceptable to the participants.
Subsequently, two modules of CBCT were condensed
the next morning prior to the first MDMA administra-
tion. Four modules of CBCT were delivered over video-
conference over the following three weeks, and then two
modules of CBCT were conducted in person the day
before the second MDMA session. The final four mod-
ules of CBCT were delivered weekly over videoconfer-
ence after the second MDMA session. The CBCT
modules that were delivered over videoconference were
done so due to pragmatic considerations; the couples and
therapists often did not live in the same city and all would
travel to meet for the in-person sessions. CBCT has been
demonstrated to be effective when delivered over video-
conference (Morland et al. 2018).
The design of CBCT + MDMA includes a team of two
therapists, with no specification as to the gender of the
therapist, deviating from the norms of a male and female
therapist dyad used with MDMA-assisted non-directive,
supportive psychotherapy (Mithoefer et al. 2018a). The
therapists were present with the dyad throughout all
components of the therapy. During the MDMA sessions,
the participants, who were seated in reclining lounge
chairs, were encouraged to spend time “inside”(e.g.,
with headphones on with pre-selected instrumental
music playing and with eyeshades). This time “inside”
alternated with time “outside”(e.g., headphones and
eyeshades off, speaking with the partner and therapists).
The alternating pattern of time spent inside and outside
lasted for approximately six hours, during which time
hourly subjective units of distress (SUDS) ratings were
recorded and blood pressure and temperature were
checked per the safety protocol.
Participants stayed overnight at the study facility the
night of the MDMA session with a night attendant, and
then met with the therapists the following morning to
debrief and assign out-of-session assignments. Daily
phone check-ins ensued for seven days to maintain
supportive contact and check in on any adverse reac-
tions to the medication. The second MDMA session
followed the same procedure as the first.
Participants were given 75 mg of MDMA for the first
session, with an optional supplemental half-dose
(37.5 mg) offered at 90 minutes post-administration to
elongate the session (the participants in this case study
both took the supplemental half-dose). Ninety minutes
post-administration was chosen as this is the time where
the MDMA has reached full effect for the majority of
participants. For the second MDMA session, participants
were offered the choice of 75 mg or 100 mg as their initial
dose of MDMA (in the case described here, both mem-
bers of the dyad chose 100 mg), and therefore the supple-
mental half-dose was 50 mg. The choice to offer an
increase in dose was done based on the option to create
a stronger felt effect of the MDMA, as 75 mg is the lowest
of CBCT, in
of CBCT +
of CBCT over
15 of CBCT
Figure 1. CBCT+MDMA Treatment Flow.
JOURNAL OF PSYCHOACTIVE DRUGS 3
dose used in other studies of MDMA for the treatment of
PTSD (e.g., Mithoefer et al. 2018b). All MDMA doses
were administered via oral capsule. Participants were
required to refrain from eating from midnight the night
before the MDMA session, and the MDMA was adminis-
tered by 11 AM on the day of the session.
Assessment and inclusion
Ethics approval was obtained from the Copernicus Group
in the US and Ryerson University in Canada, and written
informed consent was obtained from participants. The
study took place in a private practice facility in the
Southern United States. Assessments were conducted by
an independent rater pool. Participants completed assess-
ments at baseline, post-treatment, three-month follow-up,
and six-month follow-up, and completed the PTSD
Checklist (PCL-5, patient or partner version; Weathers
et al. 2013b) and a one-item rating of relationship satisfac-
tion (Couples Satisfaction Index, CSI; Funk and Rogge
2007) at every session. Participants were assessed on the
Clinician-Administered PTSD Scale-5 (CAPS-5; Weathers
et al. 2013a) at each assessment time point, and the
Structured Clinical Interview for the DSM-5 (SCID-5;
First et al. 2015) at baseline to determine eligibility. PTSD
symptoms and relationship satisfaction scores are consid-
ered the primary study outcomes.
Participants had to be over 18 years of age, and one
member of the couple had to have a diagnosis of PTSD.
The partner could not have a diagnosis of PTSD. Current
substance use disorder, active suicidal planning or intent,
mania, and psychosis were psychiatric exclusionary cri-
teria for both partners. Severe partner aggression was also
an exclusionary criterion. Participants were medically
screened for safe inclusion, including of heart rate, car-
diac functioning, blood pressure, and any major medical
condition, and participants were required to taper off of
all psychiatric medications.
Case background, assessment, and therapists
The participants, Stuart and Josie,
were recruited as part
of a pilot study of CBCT + MDMA. They were referred
to the study by Stuart’sindividualtherapist.Stuarthad
been attending therapy for several years to address his
trauma-related symptoms. While he had experienced
periods of symptom abatement, the symptoms returned
and, within the past three years, they had become
increasingly problematic for him and for his relationship
with his wife, Josie, and their three grown children.
Stuart and Josie were both in their mid-50s at the time
of treatment. They were both Caucasian and were
employed full-time. Stuart had not previously received
a cognitive-behavioral treatment for PTSD. He had
received a course of Eye-Movement Desensitization
and Reprocessing (EMDR; Shapiro 2001). Stuart had
not shared much regarding his traumatic experiences
with Josie, because Josie reported being concerned
about the effect they might have on her if she should
At baseline, Stuart’s CAPS-5 score was 43 (range 0 to
80; Weathers et al. 2013a), his PCL-5 score was 66 (all
versions range 0 to 80; Weathers et al. 2013b), and his
baseline relationship satisfaction on the one-item CSI
measure was 3 (on a scale of 0 to 6, with 0 being
Extremely Unhappy and 6 being Perfect). He did not
have any current comorbid disorders on the SCID-5,
and met criteria for past Major Depressive Disorder and
past Alcohol Use Disorder. Josie had no psychiatric diag-
noses per the SCID-5, and rated Stuart’s posttraumatic
symptoms as a 53 on the PCL-5. Her relationship satisfac-
tion was a 3.
The therapists consisted of one female, early-career
clinician who took the role of CBCT expert, and one
male, late-career clinician who had extensive experience
with MDMA-assisted psychotherapy. Both clinicians
underwent training in the other modality in order to
facilitate treatment development and create a common
understanding of the administration of MDMA in
Stuart’s traumatic event was repeated sexual assault
in childhood by his father and his father’s work collea-
gues. Through the course of therapy, Stuart came to
realize that he had been groomed by his father’s friends,
and that his father had been coerced and blackmailed
into sexual acts with Stuart by his friends. Stuart
reported immense guilt and shame surrounding the
events, particularly because he recalled always wanting
to go to work with his father, and desperately wanting
his father’s approval. Stuart’s confusion about his early
sexual experiences resulted in what he described as an
unwanted focus on being submissive and seeking out
sexual scenarios consistent with that experience. This
created strain in the relationship with Josie, because
this was not a dynamic she enjoyed.
Course of treatment and outcomes
In phase one of CBCT, Josie and Stuart identified that
emotional numbing and irritability, as symptoms of
PTSD, had impacted their relationship. They were able
to identify how the different symptom clusters interplayed
together to maintain PTSD, and noted particularly how
avoidance of emotion fed that cycle. Work was done early
4A. C. WAGNER ET AL.
on in the treatment to work through Josie’s concerns
about hearing traumatic information, based on the under-
standing that how the information is shared in therapy
would not be traumatizing for her and that she would be
supported in responding to Stuart.
In phase two of CBCT, Stuart and Josie worked to
develop skills such as paraphrasing. They were also taught
skills to express specific thoughts and feelings related to
PTSD that created strong emotion for them both. The
development of those skills was used to prime the couple
before their first MDMA session, and the couple was
prompted to use the skills during the session when they
wanted to share thoughts and emotional experiences.
Prior to the first MDMA session, both partners
expressed anxiety, having never used any type of
non-ordinary state of consciousness-inducing medi-
cation before, and not knowing what the experience
would bring up cognitively and emotionally. During
the first MDMA session, Stuart, unprompted, went
chronologically through his traumatic experiences.
He reported staying with the memories and sensory
details, much of which he had previously avoided.
Stuart experienced strong emotional reactions, such
as crying and grief in the sessions, and did not try
to stop or escape those experiences. Stuart also had
strong visceral reactions in the MDMA session,
including muscle tightening and sweating as he
reviewed traumatic memories while “inside.”
Following this session, Stuart reflected, “There’sno
easy fix—I need to work through the darkness.”
Josie was able to discuss her challenges in coping with
Stuart’s PTSD and the impact on their relationship, her
mental wellness, and their family more generally, in the
MDMA sessions. She reported strong positive experi-
ences and the sensation of finally being able to relax,
which she reported as being atypical for her. Josie
reported that “I just have overall inner peace—it’samaz-
ing. There is no price anyone can pay for that.”
Stuart and Josie are religiously devout, and cited their
faith as a key ingredient in their individual lives and
relationship. Religious symbolism was rife throughout
their MDMA sessions, including Josie reporting that
she felt as if “Jesus is holding my hand and walking
with me.”Stuart and Josie used this type of referent
frequently in therapy, although the sensation appeared
heightened and comforting in the MDMA sessions.
Following the first MDMA session, neither Stuart
nor Josie reported significant emotional or physiologi-
cal challenges in the subsequent days. Stuart reported
feeling fatigued, but emotionally and psychologically
much lighter. Stuart’s self-reported PTSD symptoms
reduced markedly following the first MDMA-
facilitated session; he attributed this to “a new under-
standing of the traumatic experiences and acceptance.”
Josie and Stuart completed behavioral approach
tasks in the three weeks between the two MDMA
sessions, such as organizing to spend time with
Stuart’s sister and having conversations about emo-
tions. Moving into phase three of the treatment,
Stuart and Josie tackled stuck thoughts, which are
dysfunctional cognitions that maintain the cognitive
loop that contributes to the cycle of PTSD symp-
toms. They worked through stuck thoughts related
to themes of blame, trust, and control for Stuart
(such as “Ididn’t do enough to stop what happened.
It was my fault,”which resulted in the alternative
thought “It wasn’t my fault, I know that now. I was
a little kid and I didn’t have a choice”), and related
to emotional intimacy for Josie (such as “We can’t
let other people into our lives,”which resulted in
the alternative thought “I can learn to let other
people in and become close to them”).
The second MDMA session closely resembled the
first, although Stuart did have some time of peace and
gentle pleasurable experience by the end of his second
session. Josie continued to have a supportive, relaxing,
and engaged experience during the second session.
Following the second session, Stuart’s symptoms were
almost non-existent, and remained so through follow-
up, with several waves of strong emotions over the
months that he attributed to paying attention to differ-
ent memories from his childhood that he had avoided
previously. At post-treatment, Stuart’s CAPS-5 score
was 1, and his PCL-5 score was 4. Josie’s PCL-5 score
of Stuart’s symptoms was 1. They both rated their
relationship satisfaction as 5. These gains were main-
tained at three- and six-month follow-ups.
For this couple, CBCT + MDMA had the intended effect
—resolution of PTSD symptoms and improvement in
relationship satisfaction. The intensive nature of the treat-
ment facilitated participant engagement and commit-
ment, and it can be posited that the context, set, and
setting of multiple full days together, as well as the empa-
thy-inducing effects of the MDMA, created strong ther-
apeutic bonds between the couple and the therapists. The
issue of homework completion early in treatment was
mitigated by condensing modules together and having
breaks within the therapy session itself to do homework.
Stuart attributed much of his reduction in symptoms
to a better, clearer understanding of the events that
occurred, and acceptance of both the events and himself.
JOURNAL OF PSYCHOACTIVE DRUGS 5
This understanding allowed the struggle around the
memories and experiences to cease, which resulted in
less numbing, avoidance, and irritability. Memories of
the traumatic events that entered his mind following the
therapy were often described as being examined with
curiosity and interest, as opposed to fear and displeasure.
Stuart and Josie both described feeling a strong sense of
this (the trauma, their journey together, this treatment,
Stuart’s recovery) having happened “for a reason,”and
felt bonded for having gone through the therapy together.
The salient, shared experience of the intervention, as well
as experiencing what it felt like not to have the overlay of
PTSD present during the MDMA sessions, created
a lasting impression for Stuart and Josie that they were
able to integrate and move forward.
For Stuart, the CBCT + MDMA experience offered
a new template to make sense of his traumatic experi-
ences, and allowed him the space to think and experi-
ence through the memories and assumptions he had
made about the event without the overlay of fear and
anxiety. That ability to take a nuanced look allowed
Stuart the opportunity to make meaning of the events
in a way that felt helpful to him, and unlocked the cycle
of PTSD symptoms. “I have my life back and for the first
time in my life I look forward to a renewed future….
I live my life now with hope where despair ruled before.
That is a pretty huge realization for me….It’s like a light
has been shined into the darkness of my soul”(Stuart, 11
months post-treatment in an email to the clinicians).
For Josie, the CBCT + MDMA experience allowed her
the opportunity to no longer feel she had to “walk on
eggshells,”and to experience relief from anxiety and
tension. Together, Stuart and Josie were able to share
the experience of Stuart’s traumatic memories, and face
them in a united and accepting manner. They both cited
having the template of the skills offered in CBCT, such as
the skills of paraphrasing and the tools of behavioral
approach and challenging thoughts, as helpful in creating
a common language and roadmap for them.
This case example demonstrates that the combina-
tion of CBCT + MDMA was feasible, effective for this
case, and well-tolerated by the couple. They were able
to follow the protocol as designed, and were engaged in
out-of-session work and all therapy sessions. This case
also demonstrates that the delivery of CBCT can be
condensed (e.g., having the course of therapy delivered
in two months as opposed to four to five months; see
also Fredman et al. 2018), elements can be delivered
effectively via videotherapy, and that the addition of
MDMA was viewed as useful to the clients.
Additionally, this case demonstrates that the use of an
evidence-based stand-alone treatment for PTSD can be
combined effectively with MDMA, as previous studies
of MDMA-assisted psychotherapy for PTSD have used
non-directive, supportive psychotherapy, which alone is
not considered an evidence-based PTSD treatment.
The specific setting created for the therapeutic use of
MDMA (a comfortable room, the ability to lie down,
the use of music and eyeshades) and set (the presenta-
tion of this medication as an adjunct that could help
facilitate therapy), as well as context (in the midst of
a trauma-focused PTSD intervention), are key elements
that need to be considered. The context prepares the
clients for engaging with trauma-related content in the
sessions. The set and setting are following principles
outlined in the early psychedelic-assisted psychotherapy
literature (Greer 1985; Grof 2001), and described in
a treatment manual used in recent MDMA clinical
trials (Mithoefer et al. 2018a). While appealing and
standardized in this context, their individual effect
and necessity is not yet known.
Although the findings from this case are positive, addi-
tional research is needed to explore whether this treatment
will be helpful for other couples presenting for treatment.
1. Names have been changed. Some identifying charac-
teristics have been changed in order to protect partici-
pant confidentiality, although all data are accurate.
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