Evolution not revolution: My thoughts on the DCP’s call for a paradigm shift

For those that don’t know, there has been a long standing debate in mental health.  At its simplist, it is an argument about whether biological or social factors are the predominant cause of mental health problems, including those difficulties at the most severe end of the spectrum, including schizophrenia, bi-polar, severe depression and personality disorders.  Debates that follow from this, orientate around the extent to which commentators and researchers endorse or dispute the ‘medicalisation’ of mental health.  Debates such as whether diagnostic categories are a useful way of understanding mental health problems, whether psychiatric medication is over prescribed, whether the social influences on human suffering are overlooked in favour of biological, medical explanations.  Recently the Division of Clinical Psychology (DCP) released a position statement, basically arguing for a ‘paradigm shift’, away from psychiatric diagnoses, in favour of a ‘formulation’, and context specific understanding of mental ill health.

 

I am an avid follower of this debate. I always, since the start of my career in psychology, have been. It has, as different stages, fascinated me (“I can’t believe there are such different ways of understanding the same thing”), filled me with professional confidence (“I am sure my way of understanding these issues is the most helpful for clients”), filled me with uncertainty (“I really thought my way was the ‘best’, and now I’m not so sure”), and most recently, left me feeling perpetually conflicted, and at times, markedly irritated.

 

That’s why, when I found out Lucy Johnstone, one of the most outspoken advocates of the hotly debated ‘paradigm shift’ in mental health, was speaking at the Manchester University’s Clinical Psychology Annual Review, I jumped at the chance to attend.

 

As a Twitter follower of Dr Johnstone’s, I had a good idea of what her position would be, but the chance to hear her elaborate on some of her ideas was genuinely exciting to me.

 

I find myself in an almost constant state of conflicted ambivalence about this debate, most likely attributable to the unpleasant and unhelpful polarisation that has taken place within the field in recent years (this being at its most distilled and distasteful on social media).  Would the talk by Lucy Johnstone in Manchester help me with my own search for a greater sense of certainty and understanding? Would it help me feel more aligned to my professional bodies’ recent position statement. Or, conversely, would I have greater confidence in challenging some of the assumptions on which it is based? The answer…..none of the above. What it did do is spur me on to write this blog, to express in writing some of the thoughts and ideas that I find myself pondering on a near daily basis.

The Caricatured Professional

One of the main concerns I have had with this debate is the polarisation that has taken place. The ‘us’ versus ‘them’ positioning I have seen emerge between many psychologists and psychiatrists involved.  This happens on both sides of course. At Johnstone’s talk there was an undeniable caricaturing of psychiatrists. I say it was undeniable, but Johnstone did indeed deny this when it was suggested by the chair of the event. To paraphrase, according to Johnstone, a typical psychiatrist is likely to list a client’s historical adversities and conclude by suggesting something along the lines of “and on top of all this you have gone on to develop ‘x’ mental illness”, as though the historic traumas have nothing to do with the client’s current psychological difficulties. This simply does not tally up with my experience of working with many psychiatrists. Maybe it’s because I’ve spent most of my career in CAMHS, maybe I have just been lucky, but I am not convinced that the majority of psychiatrists view historical adversity and trauma as unrelated to adulthood psychological problems.

 

The caricaturing goes both ways. I often hear complaints that Clinical Psychologists are motivated simply by power; they are resentful of the dominant position psychiatrists have in mental health services and want to overthrow the hegemony for their own professional gains. I have worked very closely with many psychologists staunchly critical of psychiatry, and I can honestly say their motivation and drive is centred around the welfare of clients, and by their belief that changing the system will honestly improve outcomes for those they work with.

 

Maybe it’s a lack of vision on my behalf, but I can’t envisage a mental health system that does not involve medication and forced hospitalisation for clients at their most confused and distressed.  On the other hand, I find it peculiar that medics are the default clinical leads for services in a field where psychological and social factors are so central. Similarly, why do medics hold ultimate clinical responsibility for mental health clients they work with?  Senior psychologists and social workers should be able to take these positions, and even better, some kind of multidisciplinary panel should share clinical responsibility for the most complex clients, rather than one professional with one professional (at present medical) perspective.

 

I digress though; what I am saying is that this caricaturing is bad, and often inaccurate. Like the one about critical psychologists holding their views in the absence of front-line work.  It goes something like this, “if those psychologists saw how disturbed these patients were when they come in to hospital, they wouldn’t be denouncing the use medication, or terms such as mental illness”. Codswallop. Some of the most critical psychologists I have known, work in acute, inpatient mental health settings and are well aware of the severity of inpatients’ difficulties.

 

Why is caricaturing bad? Well I have personally seen colleagues on both ‘sides’ become more entrenched and polarised in their positions.  They see and hear the over simplified arguments, and inaccurate representations of their profession and move away from the middle ground.

What is the Alternative?

I think I would find the whole ‘paradigm shift’ agenda far less difficult to consider if a clear alternative was set out.  An alternative to how services are structured and research organised (if not according to diagnostic groupings).

 

Sticking to research for the moment, Johnstone was explicit in her opinion that research based on diagnostic categories had offered us absolutely nothing in furthering our understanding of mental health.  Really?!? Do we not now know much more about which therapies are better for which problems.  For example, DBT for people diagnosed with Borderline Personality Disorder1, IPT for Depression2 (but certainly not panic3), and most recently, Mindfulness based interventions for depression (but at present not anxiety disorders)4.  Does research not tell us something about relapse rates and patterns for certain categories of distress5?  Has research not told us the significantly increased likelihood of developing a diagnosable mental health problem if exposed to early life trauma6?  In fact, aren’t most of the recommendations for psychiatric and psychological interventions for mental health problems set out by the National Institute for Clinical Excellence (NICE) based on research into diagnostic categories?

 

There will hopefully be improvements to research outcomes as refinements are made to how we group participants’ problems together. Like considering how people diagnosed with depression may have different information processing styles or different attachment styles7. But these changes would represent an improvement in the sensitivity of a categorical system, rather than the wholesale rejection of it.

 

Johnstone cited NIMH’s announcement that the research they funded would no longer be based on diagnostic categories, and instead they would look to other, trans-diagnostic processes and experiences on which to base research questions. Fair enough. I think a symptom/experience based focus could further our understanding of certain presentations, particularly when we remember that a proportion of people satisfying the criteria for a diagnostic category will not represent the archetype, and will sometimes have quite divergent experiences from one another. But, firstly, NIMH’s emphasis on trans-diagnostic processes seem, at the moment, to favour underlying biological processes; hardly a good example of how the mental health establishment is turning its back on a medical understanding of mental health.  Secondly, any symptom/experience based approach to research would have to include some system for organising participants into meaningful groups. Some people who hear voices will do so in the context of substance misuse, some following a bereavement, some is the context of a brief emotional crisis, and some in the context of a much longer-standing course of psychological dysfunction. Some will have overt experiences of childhood trauma, many will not.  Lumping all of these people together could be problematic for conducting reliable research, but separating them up is, essentially, just another way of categorising people.

 

Johnstone revealed that she was, along with some other high profile Clinical Psychologists, working on an alternative system for organising people with mental health problems, for the purposes of research and intervention.  She admitted that this was proving difficult, and at present any details are sketchy at best. She indicated that their focus was on the identification of underlying psychological processes, such as, for example, guilt cognitions.  She denied that this would operate anything like a categorical or clustering system, and that there would be no concept of co-morbidity in the system, as people could be identified as having any number of experiences without this being understood as representing multiple conditions.

 

Unclear? Me too. I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups. By the way, Psychologists are as partial to categorical systems as the next Mental Health professional (think attachment styles or personality types).

 

In saying all of this, DSM 5 was an omni-shambles and there is surely a more scientifically sound way of organising the presenting problems of service-users. I am all for developing new, more robust systems, but calling for a wholesale ‘paradigm shift’, when a workable alternative has not yet been developed, never mind validated, is a bit of a misstep in my opinion.

 

Regarding mental health services, this is an area of even greater personal conflict for me. I have worked on inpatient units, most recently with adolescents.  I was concerned about the sheer quantity of PRN medication being used, and the essentially uni-professional (medical) running of the ward.  The care of the young people I worked with could, and should be improved.  But would the abolishment of a diagnostic system facilitate this? I think not.  What the service did need was more funding, better training for staff of all levels, a team approach to understanding and working with very high levels of distress, and a truly multi-disciplinary approach to decision making and clinical responsibility.  Do these changes require a less medically dominated system? Yes. Do they necessitate a revolution in mental health, and the abolishment of the very concept of diagnosis and categorical systems? I, personally, think not.  What we do need is more money to train more staff, to spend more time with clients, to provide more evidence-based alternatives to PRN medication.

 

Similarly, I agree with Johnstone’s calls for mental health services to have, at their heart, a psychosocial perspective, with intervention driven by a formulation-based approach.  Can this only exist in the absence of a diagnostic system? I don’t think so.  I really don’t see why the two approaches must be mutually exclusive.  One of the therapy models I practice is Interpersonal Psychotherapy (IPT).  It takes the approach that depression is an illness. It emphasises the utility of making a diagnosis of depression, and also welcomes the use of anti-depressant medication if therapy is not progressing as expected, and the client is inclined to use meds based on an understanding of the evidence base around medication usage.  At the same time, this illness is understood to have been brought about by problematic relationship experiences, life changes or loss.   It is completely formulation driven. It focuses immediately on the life changes required to increase the chances of a positive outcome from therapy.  It focuses thereafter on supporting the client to reflect on and adapt how they relate to others, and how they work through and come to terms with major life changes or bereavement. Calling depression an illness, and making a diagnosis simply has not, in my experience, undermined the therapy, and may well have optimised it.

 

Similarly, Dialectical Behaviour Therapy (DBT), another intervention I use regularly, emphasises the biological and social underpinnings of emotional dysregulation or, for adults, Borderline Personality Disorder (BPD).  Personally I despise the name BPD, but, at the same time, certainly see the value in having a group or category that captures the kind of difficulties often experienced by this group of clients.   Again, as psychologists I think we use categories all the time. We might prefer to describe BPD as an ‘emotional dysregulation difficulty’ or a ‘complex trauma reaction’. Were these concepts formalised, they would have their own value and drawbacks, but would constitute categories none the less.

 

A phrase I have written a few times throughout this blog is ‘at the same time’.  Whilst I share some of my colleagues’ concerns regarding the relative dominance of a medical model for understanding human suffering, I think both can exist together, at the same time.  The balance of influence should be re-dressed, but I fear that the recent calls for a wholesale abandonment of diagnosis, and a general denial of the value of psychiatric input is both unnecessary and unhelpful. I would call for evolution rather than revolution. A combination of perspectives is always favourable, surely?

 

References

1. Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling.
Kliem, Sören; Kröger, Christoph; Kosfelder, Joachim
Journal of Consulting and Clinical Psychology, Vol 78(6), Dec 2010, 936-951

2. Interpersonal Psychotherapy for Depression: A Meta-Analysis
Pim Cuijpers, Ph.D.; Anna S. Geraedts, M.A.; Patricia van Oppen, Ph.D.; Gerhard Andersson, Ph.D.; John C. Markowitz, M.D.; Annemieke van Straten, Ph.D.
Am J Psychiatry, 2011, 168:581-592.

3. A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia
Vosa, S.P.F, Huibers, M. J. H., Dielsa, L., Arntza, A
Psychological Medicine, Volume 42, Issue 12, 2012, pp 2661-2672

4. Mindfulness-Based Interventions for People Diagnosed with a Current Episode of an Anxiety or Depressive Disorder: A Meta-Analysis of Randomised Controlled Trials.Strauss C, Cavanagh K, Oliver A, Pettman D
PLoS ONE, 2014, 9(4)

5. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders 1
Jan Scott, Francesc Colom, Eduard Vieta
Int J Neuropsychopharmacol, 2007, 10(1):123-9

6. The link between childhood trauma and depression: Insights from HPA axis studies in humans Christine Heim, D. Jeffrey Newport, Tanja Mletzko, Andrew H. Miller, Charles B. Nemeroff
Psychoneuroendocrinology, 2008, 33 (6), 69 – 710

7. Attachment Theory, Psychopathology, and Psychotherapy:
The Dynamic-Maturational Approach
Crittenden, P. M.
Teoria dell’attaccamento, psicopatologia e psicoterapia: L’approccio
dinamico maturativo. Psicoterapia, 2005, 30, 171-182.

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    • Samei Huda
    • July 23rd, 2014

    Hi Jamie some comments
    Re: motivation, CP leaders can have a mix of motivation not just 1, I’m sure patient care improvement is one of them but don’t dismiss the roles of increasing power and also narcissism. People often don’t acknowledge or recognise these motivations but they would be less than human if this weren’t a factor.
    Some psychologists (small minority) been rude on twitter to me and refuse to apologise. Dunno whether it’s cause I’m a psychiatrist but they clearly feel entitled to cross lines presumably because they get some sort of narcissistic charge out of being on a self perceived Crusade

    • Samei Huda
    • July 23rd, 2014

    Another comment, if a CP works on an inpatient unit and sees how distressed and disabled people can be , I’m wondering how they can deny medication can help some of those people and thus have a role? How can they deny that “illness” ( viewed as at an extreme of the range as in so many physical illnesses like high blood pressure , in this case very distressed or experiencing marked psychotic symptoms) can be a useful model for some people to use in helping people in these states even if they personally don’t want to use that model?
    Practically all the EIT patients I’ve sent to the ward where your buddy works have needed meds in order to get well enough to leave (I’m not sure whether he is against meds or not) as well as other interventions
    I would contend that if you work in wards and u r against the use of meds in mood & psychotic disorders and don’t want others to use terms like “mental illness” then u have a prior belief that is skewing how u interpret your experience

    • Hi Samei. My friends and colleagues on the wards don’t dismiss the utility of meds. Rather they question their over-use. I do too. Having worked on one for a year until recently, PRN was given out so readily, there often wasn’t much scope to try alternative ways of coping. I also think sometimes there is a rush to prescribe, before a proper assessment, formulation, and, dare I say it, diagnosis, has been developed.

      Regarding the ‘illness’ question, I am less concerned about that. By the time a service user is admitted, their functioning has been so impacted, and their emotional suffering so intense, that ‘ill’ is a reasonable way of explaining where they are at. In saying this, if a client had strong feelings about this terminology, I would happily use other terms of reference with them.

    • elvis jones
    • July 23rd, 2014

    I wonder if:
    1) people calling for a paradigm shift are making a power bid (with fame and reputation staked on it.). Puerile.

    2). Pointing out limitations of present language, which knowledge and experience have outgrown.

    3). Are engaged in guerilla warfare against medical power.

    Formulation looks like discursive formations in Archaeology of Knowledge and other works by Michael Foucault. Problem is they are barely intelligible.

      • Samei Huda
      • July 23rd, 2014

      Hi Elvis, any relation to Halo Jones (comic geek reference)
      I suppose formulations are technical speak used by professionals to summarise info thought to be clinically relevant summarising a case
      They can communicate this to other professionals
      Would this count as a discursive formation?

        • elvis jones
        • July 24th, 2014

        I don’t know whether it counts or not. The works of Foucault are all about the relationship between power and knowledge and are difficult to understand. Saying that service users needs should be reflected in a system of classification is to oppose the power of professionals to define, objectify, make the same, discipline and make docile, compliant and untroublesome (didn’t work for me!). But it could also be ridiculous and dangerous too, to be balanced about it.
        I’m not qualified to talk about this, but as member of the public and service user it strikes me that there are some cage rattlers about who are tactically upsetting professionals, mainly psychiatrists, who appear not to like being challenged. The fact they get upset suggests their systems are not as perfected as they hope. Given that someones future can be decided by a doctor, it is a little disturbing that treatment may depend on caprice, because getting upset betrays weakness (sometimes.) No one gets upset when 2+2=8. I think getting upset about professional attacks on psychiatric medicine’s evidence and practices looks like being angry with yourself and with the evidence of your senses contradicting the thesis you are advancing, demonstrating it to be weak.
        However, this is not the same as being upset when denyiny people medication when they will not recover. To play games like this is very very risky. If it is tactical hit and run, what happens if this anarchy wins by a miscalculation and becomes the prevailing view? That is very unlikely though.
        I think the slavery comment by Johnstone is quite interesting. The relationship between master and slave was explored by Hegel. Masters cannot get the freely given respect of the slave because they have subjugated them. Why should BAD psychiatrists expect freely given respect when exercising power through the instrument of diagnosis to flatten a patient? It doesn’t come with the job i’m afraid…

    • Lucy Johnstoe
    • July 23rd, 2014

    Thanks for this post. In the interests of constructive debate I would like to clarify some points:
    1. I made no reference to a ‘typical psychiatrist’ as reported. Instead, I was careful to describe certain types of logic as an example of typical psychiatric thinking. I also took the opportunity to point out to the chair that I had used the word ‘psychiatry’ not ‘psychiatrists’ in the quote he was commenting on, and that it is certain ways of thinking that I dispute. These can be found within and across all professions, including some but not all psychiatrists – ditto psychologists, nurses, and others. I share your desire to avoid caricatures, and caricaturing what I said does not help.
    2. I agree that we know quite a bit about psychological interventions for distressing experiences such as very low mood, feeling extremely anxious, being overwhelmed by chaotic emotions, and so on. However, these experiences and hence the helpful aspects of these interventions are not diagnosis-specific (and neither is medication). Non-valid diagnostic terms are a handicap, not a help, as a starting point for research (as NIMH is now admitting), and useful findings emerge despite not because of them. In fact the most productive area of research and intervention of the last 20 years has come from the Hearing Voices Network, based on a simple descriptive term.
    3. I am well aware that NIMH is still committed to a primarily biological model of mental distress. This does not diminish the significance of its rejection of diagnosis. I also agree that we will need some alternative ways of grouping experiences. My point – as others have also argued – is that this does not have to be, indeed should not be, the particular type of categorisation that we have at present – ie one that was developed within the natural sciences to describe bodily dysfunction. ‘We need a way of grouping people’s experiences’ is too often conflated with ‘We need diagnosis.’ The second absolutely does not follow from the first. You say that ‘I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups.’ Since no one is disputing the need for ways of grouping experiences, I assume what you mean is that you can’t conceive of how to do this in a non-medical way. Yes, it is hard, given the deep hold that medicalization has on our current ways of thinking. But not impossible. It will, however, be a lot more complicated than ‘psychological processes based on guilt cognitions’ – not a phrase I have ever used, so I am not sure where that came from.
    4. In the meantime, I dispute the contention we can’t abandon the current system because we don’t yet have a fully- developed alternative. The most obvious alternative, as I think I said, is simply to ask people what their problems are (anxiety, mood swings, fears, hearing voices, worries about food etc etc) and work with that. At a more sophisticated level, we can offer a formulation of how and why these experiences have come to be problematic. No diagnosis is needed. Many psychologists have always operated in this way.
    I will not be commenting further on your post, but as always I welcome the opportunity to debate.

    Lucy Johnstone

    • Hi Lucy. Thanks for your comments and clarifications.

      I’m sorry if you feel I have misrepresented your talk in any way. Regarding your first point, you did clarify that you were referring to ‘psychiatry’ and not ‘psychiatrists’, but this, I feel, is a subtle distinction which does very little to temper the virtual demonising of an entire profession which was apparent throughout your talk. You did clarify that you can work just fine with psychiatrists in your daily practice, but at one point you compared the practice of psychiatry, or at least the current mental health system as it is currently run, to the slave trade. This is provocative to say the least, and exactly the type of rhetoric that I think is unhelpful. I’m afraid to say that there was a take home message, even if you didn’t intend it to be, of psychiatrists bad, psychologists good.

      Yes, I agree, and discuss in my blog that research could be furthered by a different organising system, and I am big advocate of the HVN, with whom I have previously worked quite closely. But, again, I was responding to how extremely you presented your view that research based on dx categories told us absolutely nothing; this just doesn’t stand up to scrutiny. Again, I find this rhetoric unhelpful.

      Regarding the work you are doing on alternative systems of grouping clients, I am sorry if I have misremembered, and would happily edit that bit of my blog. I recall you saying that you were originally looking at pathways that lead to particular experiences, but moved to an approach favouring the identification of underlying psychological processes, and I was sure you said one example of this would be a pre-occupation with guilt?? Please do let me know if this is inaccurate and I will change it.

      I also thought you disagreed with the chair when he referred to this work as ‘clustering’, and with someone else (possibly me when we spoke during the break), that it sounded like a categorical system. That’s why I say in the blog that I can’t comprehend an organising system that doesn’t use groups or categories.

      I agree that starting with an ‘experience’ based approach is useful and can be developed through formulation. You did say this in your talk. In fact this is how I work most of the time. But I feel there is enough utility in the diagnostic system, for workers, and service users, that a call for its complete abolishment (because it is not the framework clinical psychologists find most helpful) to be problematic.

      I think Lucy, if we were to compare the way we worked clinically, it would look strikingly similar. It’s the use of provocative and extreme language that I struggle with. I know that we sometimes have to shout loudly to facilitate change, but my fear is that rather than change, it’s bringing about division.

    • elvis jones
    • July 24th, 2014

    I guess the comment about Halo Jones by Samei Huda, psychiatrist, demonstrates that patients should be seen and not heard. Even when they are being discussed. Who else, but a fool, would think that the interests of patients are the sole item on the agenda?

    • john hoggett
    • July 25th, 2014

    I think professionals have very different experiences from service users. The service users I know say the psychiatrists I know have no interest in their life stories. That they use the diagnosis to force unwanted, dangerous medication on them. That they find the services anything ranging from appalling to mediocre. Conversely service providers describe the service as anything from brilliant to mediocre. So it could be that Lucy is representing the sort of service users I know more than you?

    Having seen people severely damaged by psychiatry, indeed some people are dead because they were forcibly drugged and their problems not addressed I think some extreme language might be justified.

    Perhaps it is because you have worked in CAMHS and have not experienced much adult mental health work that you find Lucy’s statements so appalling? Though round here if you not want to give your child ritalin you are often refused help.

    • elvis jones
    • July 27th, 2014

    I was diagnosed with BPD once for many years. It was not very pleasant because it led to being dismissed outright, as if people thought ‘its not worth trying with him.’ Interest in you as a human being dropped markedly, which precipitated some depression.
    Issues of diagnosis/categorisation from my experience as patient/SU:

    1). Scientific knowledge, when disseminated, can be practically used in a different way, such as to exclude.

    2). By abstracting the world you engage in ‘the vice of abstraction’, (berkley, philosopher) meaning you can hold it at arms length whilst discussing it rather than immediately experiencing it. I think teaching the bio-social theory of emotional dysregulation in the DBT skills group is as well as clinical psychology as a whole is very viceful!!!

    3). BPD as a diagnosis (dsm classifiation system) looks like the power relation between virtue and unvirtuous. A character assasination attempt, anathemising, pariah grouping. If a group of people are held in low esteem, what effects might that have over time?

    • elvis jones
    • July 30th, 2014

    At the moment, as a service user and untrained in science, I find keith laws more convincing than lucy johnstone. See twitter.

    I find it difficult to account for lucy johnstone’s views on treatments. If someone persistantly argues something then…….???!

    Ultimately I think it is quite a claim to suggest that psychiatrists are involved in a conspiracy to harm patients by using treatments they know dont work.

    • elvis jones
    • July 30th, 2014

    The herd instinct manifests itself in the obsession with diagnosis, treatment, data, blah, blah. DBT is the milk, or even….the CREAM! You even get a DVD (two disk edition with behind the scenes interviews). You too can be an expert!!!! You can hold expert conversations discussing ‘a borderline’. Gosh, wouldn’t that place me on an upward trajectory! It would be such an elevation to discuss someone in an intense psychologically orientated discussion.
    What I am saying is don’t forget basic common sense for the excitement of technical flair, cleverness, ‘being dialectical’. If you want philosophy, read The History of Western Philosophy by Bertrand Russell not DBT.

    • elvis jones
    • August 1st, 2014

    Apparent competence: Not about therapists 😉 the look of clients to appear more able to cope with strong emotions than they actually are. For people who are used to hiding their feelings, to the extent where they have forgotten to recognise them at all. Are DBT therapists so stupid that they actually need to jargonise this stuff to learn it? Isn’t it obvious?

    • elvis jones
    • August 4th, 2014

    I guess some people would say I am engaging in idealization/devaluation a la DSM.!!!!
    Thanks for the blog and soliciting views and comments.

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