Alcoholics Anonymous: 75 Years Of 12 Steps

NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington.

You probably know the story about a drunk named Bill Wilson who saw God in his hospital room and never took another drink. Wilson also vowed to help others to stop the same way he did, and Alcoholics Anonymous marks its foundation from the day Bill W. made his first convert 75 years ago last month.

Meetings in church basements and the 12 steps have since been adapted to any number of addictions from narcotics to overeating because it works, not for everybody, not all the time, not most of the time maybe, but better than anything else.

But after 75 years, no one knows exactly how it works. If you've been in AA, how has it worked for you? Call and tell us your story. 800-989-8255 is our phone number. Email is talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, one of the most prolific and most successful composers in the film business, Hans Zimmer, joins us. "Inception" is his latest. But first, 75 years of AA.

Brian(ph) Koerner joins us via Skype from his home in Harlem. He's a contributing editor for Wired magazine and wrote a piece on AA for the July issue, and nice to have you with us today.

Mr. BRENDAN KOERNER (Contributing Editor, Wired): Thanks for having me.

CONAN: And this organization, it is so important to so many people. It's so interesting to me that, well, some of the statistics you cited in your story said the studies of its effectiveness range from five percent to 75 percent.

Mr. KOERNER: That's right. It's a very difficult organization to study for many reasons, but the chief one is you can't really subject it to clinical trials in the same way you would a pharmaceutical device.

You can't randomize people to AA because it's so widely available, and you can't really force people to go. Many people have very negative reactions to AA and drop out quite quickly. So we're left with kind of a hazy idea of its efficacy.

CONAN: And Brendan Koerner, what's the best guess as to how often it does work?

Mr. KOERNER: I think the best thing we can say is there is definitely a correlation, a mild correlation but certainly there, between meeting attendance and organizational involvement and long-term sobriety.

CONAN: And it's interesting also that you cited a study of different types of therapies that were attempted with alcoholics, you know, cognitive therapy and others, more recent, more modern techniques, and it turns out that the 12 steps developed by an amateur 75 years ago are at least as, probably more effective than those others.

Mr. KOERNER: Well, this is one data point we do have. It was a study called Project Match. This was a multi-year, multi-center study, where they investigated how the 12 steps, which are the foundation of AA, how those performed when they were administered in clinical settings rather than church basements, where most AA meetings take place.

And they did find, as you note, that the 12 steps performed about as well as things like cognitive behavioral therapy and other methods that have been developed since AA's founding.

But the caveat there, of course, is that none of them performed particularly well. They all had success rates well below 50 percent. Relapse rates for alcoholism is very high, about 90 percent over the course of someone's trying to gain sobriety.

CONAN: That doesn't necessarily mean, though, that they're in the gutter.

Mr. KOERNER: No, it doesn't, but that's actually one of the tenets of AA is that, you know, one drink, one drunk is what they say. And they have this notion that alcoholism is a progressive disease that will kill you eventually unless you do not drink at all, avoid alcohol on all forms.

So to a lot of AA members, you know, relapse is the same thing as danger of death.

CONAN: And it's interesting, that insistence on prohibition - to use a word -that was one of the revolutionary aspects of AA when it started. There were other programs at the time, but they were trying - they focused on controlling the amount of alcohol, not cutting it off completely.

Mr. KOERNER: Yeah, that's exactly right. It's interesting. In the course of doing the research on the history of AA, I actually found that in the early '40s, when AA was first taking off, there was a lot of debate as to whether people - some meetings were having people drinking beer at the meetings, saying beer was okay. It was hard liquor was the real demon.

So I think that total prohibition, total sobriety thing, although it was part of Bill Wilson's original conception, was kind of much under debate in the early going of AA.

CONAN: And also one of the revolutionary aspects of this organization was anarchy.

Mr. KOERNER: That's exactly right. This is what perhaps struck me most about the organizational aspect of AA. Going back again to its formative days in the '40s, there was a lot of debate as to how best to grow the organization.

And ultimately, Bill Wilson and his cohorts decided to opt for anarchy and to basically say we're going to make the 12 steps, and anyone can start a meeting based on the 12 steps pretty much at any time. We're not going to do quality control. We're not going to come in and make sure you're doing it right.

And that's really what helped the organization grow so quickly, I believe, is that right now, we have over 50,000 meetings that take place in the U.S. alone. Anyone can start a meeting. If you're in a meeting and don't like it, you can start your own.

CONAN: And nobody makes a profit on it.

Mr. KOERNER: Nobody makes a profit. I think that opting for deliberate corporate poverty was a good move on AA's part in the early going because it really allowed them to have more legitimacy that other organizations that have opted for for-profit status or to at least have a central body that brings in revenue don't have that same kind of legitimacy.

CONAN: And it also - there are structures. I think that one of the things that you write about that Bill W. was concerned about was that people would set themselves up as commanders somehow, blow themselves up.

Mr. KOERNER: Yeah, this was interesting to me. I thought the anonymity aspect of AA came from the fact there was a stigma against alcoholism at the time. But in fact, when Bill Wilson described why he chose that, he said his fear was that if people were doing this in public and were known to be in the organization and, you know, held themselves up as being these great people who triumphed over their addiction, well when they almost inevitably relapsed at some point in their lives, people would point fingers and say, well, look, AA doesn't work.

CONAN: Right. It also seems to be a self-protection against charismatic leaders who can form cults.

Mr. KOERNER: Sure.

CONAN: Yeah. Let's get some callers in on the conversation. Our guest is Brendan Koerner, a contributing editor for Wired magazine, 800-989-8255. Email us, talk@npr.org. David's on the line, calling from Salt Lake City.

DAVID (Caller): Yes, hello. Thanks for taking my call.

CONAN: Sure.

DAVID: I would like to tell you about my two brothers, both of whom have struggled with alcohol abuse for some time. They are absolute contrasts.

One, who's been sober for five or six years now, stopped one day, went to AA and has stuck with it and hasn't had a drop since. The other has fallen in and out of the program, and one of the problems is that he knows too much about the statistics.

He seems to be overthinking it in the sense that he can quote you, chapter and verse, why it doesn't work. And I think that's why he keeps relapsing and not sticking with the program is he thinks, well, it's not going to work for me.

CONAN: Because he knows the success rate is relatively low.

DAVID: Correct.

CONAN: But yet your other brother probably knows those same statistics, and it works for him.

DAVID: It's the community for him, I think. He's just embraced the community.

CONAN: And Brendan Koerner, a lot of the people you talk to in the piece, well, I think that we can - speaking to David's point, and we hope that his second brother does better, but people who are determined to drink will find a reason to continue drinking.

But in terms of the success with the group, that seems to be right at the core of a lot of the reason it does succeed when it does.

Mr. KOERNER: Yeah, I think the caller is exactly right. So many people I talk to cite the fellowship of Alcoholics Anonymous being key to what they get out of it and what helped them stop drinking.

And I think it comes down to social networks and that a lot of times, the people with very serious alcohol and addiction problems are inside social networks, surrounded by friends and family, who either overtly or tacitly encourage their drinking.

And what AA provides is a whole new set of relationships and a whole new fellowship to be part of in which sobriety is by far the number one goal.

So you'll see a lot of people become very deeply involved, especially very early on in their sobriety, with AA activities, not just going to the meetings but helping out, setting up, you know, bringing baked goods and coffee, going to AA events and dinners. That's very important for many people very early on in their sobriety.

CONAN: David, thanks again.

DAVID: Thank you.

CONAN: Bye-bye. Let's go next to - this is Janine(ph), Janine with us from San Antonio.

JANINE (Caller): Hi, I'm Janine, and I'm an alcoholic.

CONAN: Hi, Janine.

JANINE: And AA has been a lifesaver for me. I'm the first one in my family of a history of alcoholism, I mean, I don't even know how far back it goes, mostly on my father's side of the family, and my father died of alcoholism.

And my sister, who is eight years older than I am, and her husband are what we call in AA the walking dead because they're going to die from the disease and -because they're just so far gone.

And so I am the first one, and it's also an example to my son because my son's father is an alcoholic and drug addict. He's not active in the disease anymore, but he doesn't participate in program.

So it was a real important thing. My son's 23, and that's a real important thing. And the other thing to me is that the higher power is absolutely essential to this program. And it's the - it's God as we understand him, and for people who aren't religious, we are absolutely accepting of that and let people come in. And if we are - if the group becomes a higher power for them, whatever it takes.

But it's just acknowledging that there's something bigger than us out there and that we are, our lives are unmanageable without our higher power. And so anyhow...

CONAN: Janine, hang in there.

JANINE: Oh, I'm so happy, and I'm - it's just a wonderful way - it gives you the tools to manage your life and to - I mean, I have days where I'm happy, and that's never been before. So - and I hope the fellow who just called, I hope his brother keeps coming back because hopefully, one day it'll click for him.

CONAN: All right, Janine, thanks very much, we appreciate it.

JANINE: Thanks a lot.

CONAN: Bye-bye. And Brendan Koerner, the higher power, different groups, as she describes it, define it different ways.

Mr. KOERNER: Yeah, it's not just different groups, it's people within a group. I remember going to one meeting here in New York, and there was one speaker who got up and was crediting Jesus Christ with getting him sober.

And there was a guy in the corner who was just shaking his head, and he spoke next and said that I'm an atheist, and I'm used to hearing that, but I don't believe that. My higher power is actually the room that we're sitting in. I made that my higher power because I don't believe in the supernatural.

So it's not by group. It's actually within groups themselves you'll find a wide variety of beliefs, ranging from atheists to people who are quite devout.

CONAN: AA turns 75 this year. How is working out for you? Give us a call, tell us your story. Stay with us. I'm Neal Conan, TALK OF THE NATION, NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. Im Neal Conan in Washington.

Alcoholics Anonymous has been helping people kick their addictions for 75 years now. The venerable institution has become a cornerstone of addiction treatment in this country. After all this time, though, we still don't know all that much about how AA works or how often it works.

We're talking with Brendan Koerner, a contributing editor at Wired. He wrote an article for that magazine titled "The Secret of AA: After 75 Years, We Don't Know How It Works." You can find a link to it on our website, at npr.org.

Of course, we want to hear from you, too. If you've been in AA, how did it work for you? Tell us your story. Email us, talk@npr.org. Call us, 800-989-8255. You can join the conversation on our website. Thats at npr.org. Click on TALK OF THE NATION.

And joining us now is Dr. Marvin Seppala, the chief medical officer at Hazelden, an addiction treatment center in Center City, Minnesota, and he joins us from his office there. Nice to have you with us today.

Dr. MARVIN SEPPALA (Chief Medical Officer, Hazelden Foundation): Hello. Thanks, Neal, I'm glad to be involved.

CONAN: And as I was reading in Brendan Koerner's article, I think Hazelden was the first institution to adopt the 12-step program.

Dr. SEPPALA: Yeah, in Minnesota, that's true. We started actually in 1949 and adopted the use of the 12 steps because it was noted that people who attended AA around Minneapolis-St. Paul actually got sober and stayed sober, and no one in the helping professions at that time had really seen alcoholics get sober.

CONAN: And does it continue to work? I think you're the author of a "Clinician's Guide to the 12-Step Principles." So I suspect you do think it works.

Dr. SEPPALA: I do think it works, and we certainly support it here at Hazelden. It's still the foundation of our treatment program, especially as we look at the long-term care of people as they leave our programs and go off on their own.

I think it's really a fair article, examining AA in the 75 years and some of the research, and yet there's a lot of information that does suggest that it works in other ways.

You know, 75 years of any activity that actually grows and people support is unusual unless it's actually working. Certainly not a study of any kind, but you have to take that into account.

My own personal and professional experience reveals dramatic change in people that attend AA, and significant sobriety. The fact that it is incredibly difficult to study has been addressed. Brendan wrote about that, and it's certainly true, and it limits exactly what we know about AA. But we actually don't know how successful it is.

It's real easy to focus on the opposite, that we don't know how unsuccessful it is, but the truth is, we have no idea how really successful it is.

George Valliant, a Harvard psychiatrist, has a study that he examined over 70 years of people that entered a study at age 18. About half are Harvard freshmen, the other half Boston-area youth. He ended up looking at those that became alcoholic over time. So it's a prospective study, a naturalistic study, in that it follows these people over their lifespan.

And those who attended - those who became alcoholic and attended AA, remarkable recovery rates. Those who became alcoholic and did not attend AA, remarkable tragedy. Very straightforward. You don't have to be a scientist to see just how different those results are in his data.

CONAN: Sure, but the people who went to AA wanted to stop, maybe the other people didn't.

Dr. SEPPALA: Always possible. However, when you look at some of the newer studies, Moos, Rudolf Moos out in the Bay Area, and Kaskutas, who's mentioned in Brendan's article also, have studied broader groups of folks. In fact, one of the studies examined all of the referrals from the treatment system within a certain county in California, whether they went to AA or not, whether they went to treatment or not, and found distinct evidence of improved outcomes for folks that went to AA.

In a study by Timko and Moos published in 2000, they found one- and three-year abstinence rates twice as often if people did formal treatment and AA versus just treatment alone.

CONAN: Let's get another caller in on the conversation. Let's go to Rich(ph), and Rich with us from Charlotte.

RICH (Caller): Hi, yeah, this is Rich. I'm an alcoholic. I've been sober for about four years now. Earlier, you were speaking about the fellowship and the importance of the fellowship, and I certainly agree, and it's helped me quite a bit.

However, what's been more important for me is the fact that AA has really taught me how to live. You know, as an alcoholic, I had done a lot of bad things and carried around a lot of guilt and shame, and working the steps has really helped me to deal with that.

And so, you know, I've learned in this process that, you know, liquor is really just the symptom of my problem, and my problem is how I react to life, and I don't react to it very well. And AA has really taught me how to deal with that.

CONAN: Brendan Koerner wrote in his piece that a lot of people find that the requirement - and it's one of the steps - to come out and publicly confess is very helpful, and hearing other people do it too, that indeed, it does help overcome that great sense of guilt.

RICH: Absolutely, and in fact, you know, when I sat down with my sponsor and went through some of the things that I had done, what was most encouraging was that he had done some of the same things. And so all of a sudden, I don't feel so unique. You know, I don't feel like it's just my problem.

And the other part of that is that in that process, he's also telling me what's good about me, and that's not, you know, something that you hear often as a practicing alcoholic. And so that whole process is just extremely cathartic and therapeutic.

CONAN: Rich, congratulations. Did you get a four-year chip?

RICH: I did, yes.

CONAN: Congratulations.

RICH: Thank you very much.

CONAN: Bye-bye. Thanks very much for the call. Here's an email from S. Geary(ph): A key tenet of AA is that it is not promoted as the way. Neither is it advertised or anything similar. One difference in AA is that most of us are not gerrymandered into it. Most try it out, and many stay, because they reach what we call a bottom, i.e., are desperate to change their life. People come to it because they want, need, hope, et cetera, not because someone or something has marketed it. This adheres to AA's overall tenor of honesty.

And indeed in your story, Brendan, there was - people who are sentenced to go to AA are not very successful.

Mr. KOERNER: Yeah, that's been the finding. I talk about a study in the piece that kind of found against AA's efficacy, but the big caveat, which the authors acknowledged, is that a large percentage of the people they studied had been sent to AA as part of court-mandated sentencing for things like DUIs or drunk and disorderlies.

It does kind of bring up an interesting issue, which you raised, which is the selection effect. We do know that AA tends to work for people who have hit rock bottom, who are the most desperate alcoholics. But that does bring up the question of: Had these people already made up their minds to no longer drink because of the terrible havoc they have wreaked before they ever set foot inside a church basement?

CONAN: Here's another email, this from Amy(ph) in Tulsa: My personal problem, as well as others that I know, with AA is that the courts often require people with alcohol-related offenses to go to AA, when AA requires participants to claim only a higher power can help you. The courts and others should be aware of more secular organizations for those who wish not to profess to a supernatural power.

Dr. Seppala, I wonder: Does this come up often in your experience?

Dr. SEPPALA: It does come up on a regular basis but not frequently. And it's true that I think that the courts do need to provide options for people because some folks are just not going to accept examination of a medical disease through a spiritual means.

CONAN: But is it also your experience that sometimes people use that as, well, one of the rationales to continue drinking?

Dr. SEPPALA: Absolutely. You know, people use almost - this is a remarkably powerful illness, drives people to do pretty crazy things during their lifetime, and they don't really recognize it. The denial is tremendous. The drive to continue use is tremendous, and so people use almost any reason to avoid treatment or abstinence.

CONAN: Let's go next to Richard(ph), Richard with us from Sacramento.

RICHARD (Caller): Hi, greetings. I first encountered these 12-step groups a number of years ago, and I found that while they are helpful for a lot of the people, and particularly the people who keep coming back to them, there are some people that that's the only way that they're going to get sober.

But in my case, I found that the groups were somewhat dogmatic. And even though they claim that they're not necessarily religious, there's a very strong cultlike behavior in these groups. And they tend to be dismissive of other options that are out there. Not everybody necessarily is that way, but some of the behavior of these groups does lean towards that.

CONAN: And you've obviously tried different groups. Have you...

RICH: Right. Well, one thing I've learned about since then is, because I had issues with drugs and alcohol in the past, is that there's two ways of looking at issues of drugs and alcohol.

One is the disease model, which they have, that AA buys into, is that if you -you're an alcoholic, and you're always an alcoholic and that you're going to have this issue for the rest of your life.

But the other model that they also, that other groups have proposed is what's called the behavioral model. Groups like Rational Recovery, they say it's not a disease, and if you buy into the notion that it is a disease, you're going to fall prey to it as an excuse to keep drinking and to keep - use it as an excuse to relapse.

But if you look at it as more of a behavior and that you have a choice not to do it, then just simply don't do it.

CONAN: Well, Dr. Seppala...

RICHARD: Obviously that doesn't work for everybody, but...

CONAN: Well, nothing works for everybody. But, Dr. Seppala, can you help us out here?

Dr. SEPPALA: Yes. Yeah. A 12-step program certainly doesn't work for everyone, and yet it's the only studied, you know, program of its kind. None of the other kind of secular programs, Rational Recovery and the like, have been studied in the same manner. So this is an evidence-based examination of recovery. And in regard to the groups - earlier you mentioned the word anarchy related to AA.

CONAN: Mm-hmm.

Dr. SEPPALA: And Bill Wilson's start of it. And there's multiple types of groups available. And if people don't like a certain group or can't find one they really like, they can go off and start their own. They can have the, you know, the above 50, bald-headed biker group of AA or the, you know, physician AA group or anything. Any sort of belief system can be used to start your own AA meeting.

CONAN: Richard, good luck to you.

RICHARD: Okay. Thanks a lot.

CONAN: Thanks very much. Here's an email from Lauren(ph) in Rochester, New York. I'm a nurse working in detox and an Al-Anon member. Al-Anon helped me live with folks who I think would benefit from AA. I love the down-home feel of most of the meetings and supportive folks from all walks of life. I encourage folks to try several meetings, and I think the community is a big deal. I appreciate Al-Anon taking away my guilt and giving me tools to feel at peace with my life.

An Al-Anon is for people who are in the families of alcoholics. And as you note in your piece, Brendan, there's all kinds of blank anonymous, from Narcotics Anonymous and several variants of that to people who have eating disorders.

Mr. KOERNER: Yeah. Basically, very early on, AA made the decision to kind of turn the 12 steps into a piece of open-source code. Anyone could build off of it to address any sort of addiction. And I think that was very wise on their part because it caused all Americans, whether they are involved in these groups or not, to have a basic familiarity with the 12 steps because they have become so pervasive and so prevalent to treat a range of addictions. The 12 steps in AA are really part - they're really ingrained in our culture, in our popular culture right now.

CONAN: Yeah. You mentioned that almost anybody, even if they've never had a problem with alcohol or been to a meeting, they probably know one or two of the steps.

Mr. KOERNER: If you've seen TV or seen a movie, as - you know, going to the movies, you've seen 12-step groups and AA represented a thousand times over the years.

CONAN: Brendan Koerner is a contributing editor for Wired and a columnist for the New York Times and Slate. His article, "The Secret of AA: After 75 Years, We Don't Know How It Works," is in the July issue. There's a link to it on our website at npr.org. Our other guest is Dr. Marvin Seppala who's the chief medical officer at Hazelden, an addiction treatment center in Center City, Minnesota, the author of the "Clinician's Guide to the 12-Step Principles." You're listening to TALK OF THE NATION from NPR News.

And Jacob is on the line, Jacob with us from Nashville.

JACOB (Caller): Hello. I'm Jacob Casset(ph). I've been sober off alcohol since '74 and I've had two or three years of marijuana smoking, intermittent during that period, so I can't call me totally sober since '74. And a couple of comments is when I go to meetings, if there's something going on with me like a resentment or whatever, usually, if I bring it up, there'll be enough opinions in that meeting to raise my awareness and free me up for that period of time. Unfortunately, it's like cleaning your house. You can't clean your house and expect for it to stay clean. AA is the type of thing that you really can't stay sober, in my opinion, unless you continually go. I've been going to two or three meetings minimum for that length of time.

CONAN: Two or three meetings a week, you're saying?

JACOB: Yeah, for that length of time. And the guy that was talking about dogmatic, when I first got in, I had a sponsor in NA at that time and he works at a treatment center here called Cumberland Heights, which is a wonderful treatment center here in Nashville. And I was bitching and moaning about having to say the Lord's Prayer after the meeting because I was - my parents were atheist. I was agnostic, whatever. And I said why the hell do I got to hold hands and say the Lord's Prayer after meeting? He said because it works. And really and truly, that was the last time - and that had to have been in the '80s - that was the last time that I ever really questioned any of the tenets. I don't swallow anything piecemeal. I question things.

But this program here, it, you know - like somebody will come in, they're fixing to kill somebody, and they get defused just for that one period of time. And they leave there and maybe it defuses it just for that day. So any questions you have to ask me, I'll be glad to answer.

CONAN: Oh, well, thank you very much. I just wanted to ask Brendan to comment. The 12th step is the commitment to stay with it. You never graduate from AA.

Mr. KOERNER: No. The idea is that you practice the steps and live the steps every day for the rest of your life. And not only that, but you try to spread the message and go to others who may be in desperate straits and tell them how the program worked for you as well. So it really is, theoretically at least, a lifelong commitment.

JACOB: It's a program of attraction, though, not conversion. That's in the traditions. There are 12 traditions and 12 steps.

Mr. KOERNER: Right.

JACOB: So it's a program of attraction. You don't go - you're not going to convert an alcoholic. They're too hardheaded.

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Mr. KOERNER: Well, you let them know that when they do hit rock bottom that they should show up for a meeting.

JACOB: Oh, yeah. You can be assertive. I understand what you're saying there. But what drew me to it was there was no credentials to become a member and there were no leaders, because I was resentful against authorities, so I qualified, you know? It was pretty loosey-goosey program for me. And just in my opinion, alcoholics wouldn't fit into anything else.

CONAN: Jacob, thanks very much for the advice.

JACOB: Thank you very much.

CONAN: Appreciate the phone call.

JACOB: Okay.

CONAN: We'll end this email from Boone in - from Anonymous in Boone, North Carolina. I attended AA meetings for a while because my therapist insisted I do so. I know the group has helped many people, but as I sat there, I realized nothing anyone was saying applied to me. I was, am not a chronic drinker. On any given evening, I might have one beer or two or six or none, that all depends. Day after day, the same people were telling the same stories over and over. I stopped going and came back after a month or so. The same people were still saying the same things. It's wonderful for some. It is not for everybody.

And, Dr. Seppala, I think we do need to end with that thought. It is not for everybody, but sometimes you can have a problem with alcohol and not be willing to admit it.

Dr. SEPPALA: It's true. AA is not for everybody. It tends to work better for folks that have worse levels of alcoholism. However, of the things that are available, and in particular, if you look outside of treatment and what is available in the United States, AA works. It's accessible. It's in over 150 countries worldwide. There's multiple meetings per day in any city in our country. You just can't find anything so accessible with people that are willing to welcome you and help you out in such a manner.

CONAN: Dr. Seppala, thanks very much for your time. We appreciate it.

Dr. SEPPALA: Thank you.

CONAN: Dr. Marvin Seppala, chief medical officer at Hazelden, which is in Center City, Minnesota. Brendan Koerner, thank you for your time as well.

Mr. KOERNER: Well, thanks for having me.

CONAN: And again, Brendan Koerner is a contributing editor for Wired magazine. Coming up, Oscar-winning film composer Hans Zimmer will join us. Stay with us. It's the TALK OF THE NATION from NPR News.

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