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A Review of Visual/Kinesthetic Disassociation in the treatment of Posttraumatic Disorders: Theory, Efficacy and Practice Recommendations

Visual Kinesthetic Disassociation (V/KD) (Bandler & Grinder, 1979; Field, 1990; Hossack & Bentall, 1996; Konefal, Duncan & Reese, 1992; Muss, 1992) is an exposure-based approach that helps individuals attain a degree of kinesthetic detachment from kinesthetic memories of trauma and thereby enables them to process the event(s) from a de-centered perspective. Individuals basically attain a "visual-kinesthetic reframe" of the experience. According to Koziey and McLeod (1987, p. 278), V/KD was initially used by Erich Fromm, who described the approach as a means of dissociating the "observing ego" from the "experiencing ego." Bandler extended Fromm's usage from a 2-point position of displacement (i.e., the observing ego watching the experiencing ego) to a 3-point displacement (i.e., a "higher order" observing ego watching the observing ego watching the experiencing ego) (Koziey & McLeod, 1987). Clients are asked to imagine observing themselves (e.g., from the vantage point of a projection booth in a movie theatre) watching themselves (sitting in a theatre seat) view their traumatic experience as though in a moving picture (up on the screen), while they consciously re-process the event from the safety of the therapeutic setting.

Visual/Kinesthetic Disassociation vs. Traumatic Dissociation

Disassociation from trauma through the V/KD technique differs from the traumatic dissociation that occurs as a response to an overwhelming experience. Traumatic dissociation occurs with gradations of severity, ranging from primary through secondary to tertiary dissociation (van der Kolk, van der Hart, & Marmar, 1996). Primary dissociationrefers to a fragmentation of sensory and emotional elements of a traumatic event, such that certain aspects of the experience remain isolated from conscious awareness and resurface in the form of intrusive recollections, nightmares, and flashbacks. Secondary (peri-traumatic) dissociation involves primary dissociation of cognition plus the experience of leaving one’s body and observing the trauma from a distance. On the surface, this definition would seem analogous to Fromm’s notion of a dissociation between observing ego and experiencing ego. Tertiary dissociation involves the dissociation of cognition, feelings, and emotions; the dissociative experience of leaving one's body; and the dissociation of distinct ego states (as in Dissociative Identity Disorder). The Visual/Kinesthetic Disassociation technique appears to elicit a state similar to that experienced with secondary dissociation; however, V/KD does not seem to involve the dissociation from awareness of cognition. Moreover, the disconnection from kinesthetic feelings occurs in a controlled manner through the help of the therapist, rather than as a biologically-mediated response to extreme stress.

V/KD Procedure

At the start of the V/KD procedure, the therapist is to establish and reinforce safety and comfort for the clients (Koziey & McLeod, 1987). Once the clients have attained a sense of safety and comfort, they are asked to form a picture of themselves (a "stillshot") as they were prior to the traumatic event in question (Bandler & Grinder, 1979; Koziey & McLeod, 1987). Once they have attained a clear image of themselves just prior to the traumatic experience, they are to take an observer perspective and watch themselves watch themselves re-live the traumatic experience.

One means of having clients attain this 3-point displacement is to ask them to imagine themselves "floating out of themselves" (e.g., up into the projection booth) while they watch themselves sitting there looking at the "younger" pre-trauma self (Koziey & McLeod, p. 278). This detachment process can be done as frequently as necessary to ensure client comfort (i.e., freedom from emotional distress). The clients are told that they can modulate the degree of feelings they need to connect with in order to get a clear, focused image of themselves at this earlier point in time, and they are instructed to have feelings of strength as they watch the image (Bandler & Grinder, 1979). Modulation of affect is assisted through the use of imagery such as "volume control" (the client can increase or decrease the volume), "colour options" (making the picture black and white to decrease affect intensity; making the picture colorful to increase affect intensity), and so forth (Konefal, Duncan, & Reese, 1992).

When the process has been completed (i.e., the clients have visualized the traumatic experience in full, as many times as necessary so that they no longer feel overwhelmed), the therapist has them "float" back into the present day self, where they are encouraged to make new meanings and to have the present day self provide the "younger" self with these new meanings, as well as with feelings of resourcefulness and other positive affect (Koziey & McLeod). Once accomplished, the therapist instructs the client to bring the younger self back inside the body of the present day self (Koziey & McLeod).

The therapist is to ensure that client resources that had been segregated from the traumatic context become available in that context through imagery, while the client is anchored to the here-and-now by the presence of the therapist. It should be noted that clients can come to positive reframes spontaneously.

Procedural Variants

There are many variants to this procedure. One variant involves instructing the client to watch the trauma while blaring music of the client's choice plays, then playing the music backwards such that everyone is moving backwards, and so forth. This may function to modify the client's kinesthetic memory of the trauma so that it no longer holds the same mnemonic associative power. Another variation is to completely change the color of the picture (e.g., to all green) to modify the visual memory of the trauma. These modifications can be done at each dissociation point in the three-point procedure. Thus, introducing variant stimulus properties may function to break the previously conditioned chains of response and to render the strength of the fear conditioning less powerful. Another variation is to have the clients go through the process backwards. After each point of reverse displacement (e.g., going from the booth to the seat, etc.), the therapist can have the clients step back into the "you" at the end of the movie and have them play the movie backwards so that they feel themselves going through the trauma backwards.

Postulated Mechanism of Change

It has been suggested that following V/KD the traumatically conditioned fear response is replaced, not only with a new set of feelings associated with the visual trauma stimuli but also with more choice/control by the client (Gallo, 1996). Bandler and Grinder (1979) postulate that new sequences (i.e., associations) are formed through the incorporation of new information (e.g., more adaptive cognitions) that was not available at the time of the actual trauma. According to Bandler and Grinder (1979), the aim is not for clients to re-experience the fear/trauma kinesthetically but to become distanced from the kinesthetic fear sensations as they associate the images of trauma with inner resources, such as feelings of power and competence. In so doing, new associations are fostered.

Bandler and Grinder (1979) refer to the V/KD process as "structured regression," in contrast to a complete regression in which the client re-lives the experience in all sensory modalities simultaneously. According to Bandler & Grinder, complete regression acts to reinforce the associations between fear and the traumatic situation, whereas structured regression is hypothesized to break the earlier stimulus-response pattern.

State Dependent Memory

My proposed explanation for mechanisms of action in effective trauma treatment involves the notion of state dependent memory. Traumatic experiences may be processed by both current and latent mental schemes that "compete" with each other, particularly for individuals who had experienced traumas previous to the most recent traumatic event (van der Kolk, McFarlane, & van der Hart, 1996). These competing schemes may vary for different persons in terms of severity of dissociation. Severe (tertiary) dissociation between schemes may manifest as dissociative identities or ego states. Somewhat less severe (secondary) dissociation may manifest as polarized cognitive/affective states (e.g., Complex PTSD; Borderline Personality Disorder), and still less severe (primary) dissociation may manifest as avoidant symptoms in response to intrusions and hyperarousal, as in simple PTSD. It is possible that there is an even less severe form of dissociation that may manifest as situation-dependent avoidance or numbing (e.g., an initial, temporary flight or freeze response when confronted with trauma-related stimuli), and may correspond to partial PTSD. These gradations of dissociative experiences may also relate to the notion of dissolution, as proposed by John Hughlings Jackson (as cited in Porges, 1997), and will be elaborated upon below.

Clinical experience suggests that direct exposure techniques (such as flooding and live exposure) can result in unmodulated activation of more latent schematic content (e.g., state-dependent abreactions or elicitation of earlier modes of functioning) during re-exposure with individuals who are vulnerable, leading to re-traumatization (e.g., see Briere, 1997). Research findings appear inconclusive in this regard, with some reports showing improvements in symptoms of persons with PTSD (e.g., Keane & Kaloupek, 1982) and others reporting exacerbation of pre-existing morbidity (e.g., Kilpatrick & Best, 1984; Litz, Blake, Gerardi, & Keane, 1990; Pitman et al., 1991; Pitman et al., 1996; Scott & Stradling, 1997; Solomon et al., 1992; Vaughan & Tarrier, 1992; Watson et al., 1995). The reader is referred to Shalev et al. (1996) for a more complete review. It may be that direct exposure treatments exacerbate secondary and tertiary dissociation. Studies comparing direct exposure-based interventions for simple or subclinical PTSD symptoms with exposure-based interventions for Complex PTSD and Dissociative disorders would shed some light on this issue; however, such studies present ethical issues.

Stephen Porges (1997) has developed a polyvagal theory of emotion, based on evidence for a phylogenetically advanced ventral vagal system that is postulated to assist in the modulation of affect. In brief, the autonomic nervous system (ANS) has undergone a shift with evolution, such that we have progressed in stages. In the first, oldest stage of ANS development, the vagal system was primitive and unmyelinated and thus slow in its actions. This system would function to render the individual immobile in response to stress (i.e., promotes a "freeze" response). The second stage of nervous organization involves the spinal sympathetic system, which prepares the individual for fight or flight responses. The latest, myelinated ventral vagal system originates in the brainstem and has an inhibitory effect on sympathetic activities, promoting calm rather than fight or flight or immobilization.

Vagal tone has been shown to be related to affect regulation (Porges). It is possible that when the nervous system is overwhelmed by trauma, affective processing reverts from reliance on myelinated vagal processes to sympathetic (fight or flight) and/or more basic (immobilization) responses, or what Tinnin (personal communication) has referred to as an instinctual trauma response. It is also feasible that utilization of "latent mental schemes" correlates with utilization of older ANS processes. Porges postulates that when faced with a challenge, people initially rely on the more advanced ventral vagal system, and if it should fail, revert to earlier phases of response. When the system is overwhelmed by traumatic stimuli, it may be that the ability to utilize the ventral vagal system to calm and self-soothe is lost. Individuals may thus resort to fighting or running, and should this fail, to immobilization. This parasympathetic immobilization response may be involved in peritraumatic dissociation.

It is possible, though not established empirically, that the guided disassociation process in the V/KD technique may assist traumatized individuals in distancing themselves to some degree from the distressing affective components of the earlier trauma experience when faced with trauma-related stimuli (e.g., the "movie") and, consequently, enables cognitive re-processing and integration. Intense arousal is known to alter perceptions (van der Kolk, 2000). In short, the relative distancing from affective distress may help the individual maintain more objective contact with current cognitive schemes (e.g., by reducing the likelihood of perceptual distortions from high arousal), and thereby aid in the counter-conditioning of the traumatic response and reprocessing of the trauma by way of current schemata. As postulated by van der Kolk, Burbridge, and Suzuki (1997), intense emotional arousal may prevent the Central Nervous System (CNS) from integrating traumatic sensory fragments. Therefore, the lessened affective response that occurs with the V/KD procedure (Field, 1990) may assist the CNS in the integration of previously fragmented traumatic material.

The Anatomy and Neurophysiology of Traumatic Memory

In relation to the above theory, it should be noted that there is not consensus among neuroscientists regarding the role of trauma on memory, including dissociative amnesia or state-dependent recall. Although there is supporting evidence for the view that traumatic memory (a) may be stored in somatosensory form (see vanOyen Witvliet, 1997) and in a distributed manner as nodes throughout the cerebral cortex (Nadel & Jacobs, in press), (b) is not integrated via the hippocampus due to intense emotional arousal (e.g., Joseph, 1998; Nadel & Jacobs, in press), and (c) is reported by clients as vivid, veridical flashback experiences of their actual trauma (see vanOyen Witvliet, 1997; cf. Frankel, 1994), the view that traumatic memories are remembered vividly and accurately in the form of dissociated flashbacks is not generally accepted (van der Kolk, 1998). McNally (1997) states that implicit memory biases for trauma cues in PTSD patients are not found for memory tasks that involve perceptual input but may be found only with more conceptually complex tasks. The implicit memory biases that occur from elicitation by presentation of trauma-related stimuli in a lab setting may be substantively different from internally-generated intrusive flashbacks, particularly if those flashbacks have their basis in neurochemical events.

There is evidence from both animal and human neurological studies in support of morphological and, to a lesser degree, functional changes consistent with van der Kolk and Fisler's (1995) and Jacobs and Nadel's (in press) theory, including the role of the limbic system in fear conditioning (Bloom, 1995; Joseph, 1998; LaBar, et al, 1998; LeDoux, 1995; LeDoux & Muller, 1997; Weinberger, 1995); the role of the limbic system in processing of traumatic material (Bremner et al., 1995; Bremner et al., 1996; Cahill,,1997; Cahill & McGaugh, 1996; Cahill & McGaugh, 1998; Joseph, 1998; Rauch et al., 1996; van der Kolk, 1997; van der Kolk & Saporta, 1991); hemispheric lateralization in the recall of traumatic memories (Rauch et al, 1996; Schiffer, Teicher, and Papanicolaou, 1995); lateralization in hippocampal atrophy in traumatized samples, with abused children showing left hippocampal atrophy (Bremner, et al., 1997), adult combat vets with PTSD showing right hippocampal atrophy (Bremner et al., 1995), and another study on combat vets showing bilateral hippocampal atrophy (Gurvits & Pitman, 1996); lateralization of amygdala activation in response to self-generated trauma imagery in combat veterans (Shin, et al., 1997); the role of neurohormones and transmitters in emotional memory processing, including consolidation and storage (Jacobs & Nadel, in press; McGaugh, 1992; Cahill, Prins, Weber, & McGaugh, 1994; Margarinos, Verdugo, & McEwen, 1997; Schulkin, McEwen & Gold, 1994); the role of the hippocampus in memory storage and context for memory storage (Joseph, 1998; Nadel & Moscovitch, 1997; Parkin, 1996); the role of corticosteroids and enkephalins in hippocampal damage (see Joseph, 1998; cf. Yehuda, 1997), and the possibility of a kindling-like phenomenon with repeated exposure to stressors (Adamec, 1997; Yehuda, 1997). However, there is less evidence in support of the postulated neurobiological events believed to underlie the complete processing and integration of traumatic memories.

In terms of the functional processing of memory and its relation to trauma, the view that implicit memory influences behavior in a nonconscious manner appears to be well-established (Gazzaniga, 1995; Moscovitch, 1995; Schachter, 1995), as is the evidence for state-dependent memory (Rolls, 1995) and the effects of arousal on memory encoding, storage and retrieval (see Bremner et al., 1996; Christianson & Nilsson 1984; Joseph, 1998; Nadel & Jacobs, in press; cf. Christianson & Mjorndal, 1985; Shobe & Kihlstrom, 1997), which may be mediated by a catecholaminergic stress response system (vanOyen Witvliet, 1997). Moreover, there is evidence that sexually abused children and adults with PTSD have injury and atrophy of the hippocampus with related disturbances in memory (Bremner et al., 1995; Bremner et al., 1997; see also Joseph, 1998). In relation to the veridicality of flashbacks, Southwick et al (1993) showed that when yohimbine was administered to Vietnam veterans with PTSD, approximately 50% of the veterans stated that they experienced perceptions that were identical to their actual war experiences (as cited in van der Kolk, Burbridge, & Suzuki, 1997). van der Kolk and Fisler (1995) found that all of their sample of 46 traumatized women and men originally remembered their trauma as somatosensory or emotional flashbacks. van der Kolk, Burbridge and Suzuki (1997) found that of 62 participants with a history of childhood or recent trauma, all of the participants in the childhood trauma sample (N = 34) and 78% of those in the recent trauma sample (N = 28) reported that their initial memories of the trauma were in the form of somatosensory flashback experiences, rather than in narrative format.

In summary, this postulated view that the kinesthetic disassociation technique assists in modulating arousal upon exposure to trauma-related cues is premised on van der Kolk’s theory of traumatic memory processing. Although there has been criticism of this view of traumatic memory, it appears to find a substantial degree of support from biological studies, as noted above. This evidence is at this time, however, more suggestive than conclusive.

V/KD Literature Review

Koziey and McLeod (1987) utilized V/KD in the treatment of two adult female rape victims, who reported having had received no prior psychological intervention. Both participants were university undergraduates. Case 1 is a 19-year old female who had experienced acquaintance rape almost two years prior. Case 2 is an 18-year old woman who had experienced acquaintance rape about one-and-a-half years prior and had also been sexually assaulted at age 10 when she was on her way home from school. Both women reported fear and anxiety, distrust of men, and anger/irritability, all of which interfered with their interpersonal functioning.

The pre, post, and in-session assessment package consisted of the Symptom Checklist-90-Revised (SCL-90-R), the Veronen-Kilpatrick Modified Fear Survey, the Profile of Mood States, and the State-Trait Anxiety Inventory (STAI). Following initial assessment, each participant participated in one session of trance induction. In the second treatment session one week later, participants completed the assessment package again, the induction was re-administered, and then both participants received the V/KD intervention. The participants were interviewed three weeks later, at which time the assessment package was again completed and the participants provided a subjective evaluation of the procedure and their respective level of functioning.

Case 1 had pre-treatment elevations of at least one standard deviation (SD) above the mean on 15 of the 28 dependent measures (the scales were not specified). Following the hypnotic induction, she had elevated scores on eight of the dependent measures, with a significant reduction (i.e., at least one SD) in 11 of the measures (unspecified). After the V/KD procedure, six of the 28 measures remained elevated. The V/KD treatment for Case 2 was focused on the sexual assault at age 10. Case 2 had elevations on 16 of the 28 pre-treatment assessment measures, which had dropped to seven following the hypnotic induction (see Table 1). Following the V/KD procedure, all scores on all scales were in or below the normal range for Case 2. Both women reported notable changes in their affect state and in their interpersonal relationships following treatment.

Table 1. Number of Scale elevations of at least one standard deviation above the mean on indices of general psychopathology and fear/anxiety.
________________________________________________
Pre-Treatment Post-Hypnosis Post V/KD
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Case 1 15 8 6
Case 2 16 7 0
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Muss (1991) conducted an uncontrolled study with a sample of 19 British police officers referred for stress management by a medical insurance company. Of 70 officers seen, 19 met DSM-III criteria for PTSD. The nature of their trauma ranged from near-death experiences to witnessing scenes of horror and death. All the participants suffered from intrusive images. Muss treated the 19 participants with V/KD. Although "a number of modifications to the technique were...necessary" (p. 92), Muss did not specify the nature of the modifications. The mean number of treatment sessions administered to participants was three. Treatment effectiveness was evaluated by the participant's verbal self-reports immediately following the procedure, at a one-week follow-up interview, and at long-term follow-up interviews occurring in an interval anywhere from three months to two years after V/KD treatment. Muss reported that most of the participants (exact number was not specified) stated that they "felt as if a great weight had suddenly been lifted; others (number unspecified) did not remark on any immediate change" (Muss, 1991, p. 92). All 19 officers reported "feeling well" at the one-week follow-up. Fifteen of the 19 officers were reviewed for longer term follow-up, at which time 10 were contacted by phone and five were reviewed at the clinic. The other four could not be contacted. Muss (1991, p. 92) reported "all [fifteen] confirmed freedom from recurring intrusive images and a return to normal behavior."

Hossack and Bentall (1996) conducted a study with five males who met DSM-III-R criteria for PTSD. One participant had survived a helicopter crash, and the other four were survivors of the Hillsborough football stadium disaster in the UK. The participants had been receiving psychiatric care, which was discontinued at the start of the V/KD procedure. Four of the participants had been unable to maintain employment at the beginning of the study. All five men reported vivid intrusive imagery of death and dying at the initiation of treatment.

Measures of PTSD symptomatology were obtained at the beginning of treatment, after treatment was complete, and at three months post-treatment. Assessment measures included the 30-item General Health Questionnaire (GHQ-30), the SCL-90-R, and the Impact of Events Scale (IES). Participants also completed the Hospital Anxiety and Depression Scale (HAD) within the first 17 weeks of the study and completed daily diaries of the duration, clarity and distress of intrusive imagery on a nine-point scale.

A multiple baseline design was used, such that the participants in the baseline condition functioned as controls for the participants actively receiving the intervention. Case 1 and 2 had a baseline period of three weeks, Case 3 had a baseline period for six weeks, and Cases 4 and 5 had a baseline of nine weeks. During the baseline period, assessment measures and daily ratings were recorded. Following the baseline, participants were taught Jacobson's progressive relaxation method coupled with relaxing guided imagery using all sensory modalities for two sessions. In the next two sessions, the V/KD procedure was implemented in a standardized manner for all participants.

Case 1 evidenced little change in intrusive symptomatology, other than modest declines in frequency of the images. Duration and clarity were not diminished. Case 2 evidenced little intrusive imagery at the beginning of treatment, and the frequency, duration, and clarity of the images decreased to near zero following the relaxation procedure. They worsened slightly around week eight (the week following the second V/KD procedure). As noted by the authors, this was the week of the anniversary of the Hillsborough disaster, which could account for the increase in intrusive symptoms. The ratings for Case 3 were not affected by the anniversary of the disaster. This person experienced approximately 90 intrusive images in the week prior to the relaxation training. Relaxation training had a small effect on the duration, clarity, frequency and distress of the images for this participant, whereas the V/KD procedure resulted in a substantial reduction in these ratings. Participant 4 was reported to have experienced problems in following the V/KD procedure, and no improvement was evident in his ratings. For participant 5, there were dramatic reductions in the frequency, duration, and clarity of his intrusive images following the relaxation procedure and more improvement following the V/KD procedure. These improvements were maintained throughout the follow-up period.

All participants showed reductions in IES scores except for the fourth participant. Two of the five men evidenced an increase in avoidance symptoms following the interventions. Cases 2, 3, and 5 showed reductions in HAD scores, and all subjects but Case 4 showed substantial changes in the GHQ-30 and SCL-90R scores. All participants except subject 4 showed improvements in social and occupational functioning following treatment.

Limitations of Studies Reviewed.

Limitations of the V/KD studies are as follows: All of the V/KD studies looked at single-event traumas, with no chronically traumatized populations sampled. Hossack and Bentall (1996) included a relaxation procedure prior to the V/KD intervention for all subjects; however, the order of administration of the relaxation and V/KD interventions were not randomized to control for the confounding of treatment variables. Similarly, Koziey and McLeod (1987) included a hypnosis session prior to the V/KD intervention, which was not randomized. Muss (1991) measured PTSD as per DSM-III criteria and client verbal self-report, and did not obtain inter-rater reliabilities or use standardized outcome assessment instruments. Muss included no description or discussion of the modified procedure, so the degree to which the intervention protocol was adhered to is not clear. In summary, two of these studies were confounded and the third used a modified V/KD procedure.

Summary of Literature Review

In summary, a database search resulted in only three published reports on the V/KD technique: two case studies and one uncontrolled study. Sample sizes were small, ranging from two to 19. The populations from which the samples were derived include survivors of sexual assault, near death experiences, aircraft crashes or near-crashes, and a football stadium disaster as well as witnesses to horror and death.

Although V/KD is categorized as an Experimental Treatment according to APA Division 12 Task Force criteria (1995), the results of these studies suggests that V/KD appears somewhat effective for treatment of posttraumatic intrusive imagery, fear, and diminished social/occupational functioning for most participants studied. Though the experimental design of these studies was generally poor, the treatment efficacy appears promising. These results need to be qualified by the confounding of V/KD proper with hypnotic induction/relaxation techniques. Nonetheless, utilizing V/KD with hypnosis appears to be fairly effective in the treatment of some posttraumatic sequelae, and controlled, randomized studies are called for. The study by Hossack and Bentall meets many of the controls for internal validity in case studies as set forth by Kazdin (1998).

Limitations and Contraindications of Visual/Kinesthetic Dissasociation

Some limitations and contraindications of the V/KD procedure are as follows:

(a)Some clients may have difficulties in obtaining a detached or observer perspective, which will prevent the effective implementation of the procedure and may increase the risk that clients will be retraumatized through the re-experiencing of intense affect. As such, it might prove advantageous to assess the client's ability to obtain a detached or observer perspective prior to implementation of the technique. If clients are unable to obtain such a perspective then an alternative treatment strategy may be advisable. Some clients may experience increased avoidance symptomology following the V/KD procedure, and thus continual assessment of client functioning is required throughout the procedure;

(b) Part of the technique involves the "current self" providing the "younger self" with information necessary to ensure understanding and healing. However, not all clients will be equipped with such information, and, in these cases, some sessions for strengthening self- and coping-capacities may be required before implementation of the V/KD procedure;

(c) According to Bandler and Grinder, one-trial positive anchoring (conditioning) is held to be sufficient to override the fear response in phobic individuals and to provide the client with behavioral choice. However, with traumatized clients the fear response may be so intense that a one-trial conditioning session will be insufficient to override fear and terror and additional sessions would be required for successful treatment;

(d) The technique may be less effective with clients both chronically and interpersonally traumatized, where there is no one specific traumatic incident for the clients to visualize. In such cases, it is the transference material that usually requires desensitization rather than specific traumatic incident material (Briere, 1997). As such, V/KD may not be suitable for these clients;

(e) It unclear whether this treatment, or some modification of it, would be effective for symptoms other than intrusive visual imagery, such as ruminations and other sensory imagery (e.g., auditory, olfactory, gustatory), avoidance symptoms, and so forth;

(f) Some degree of sensory re-experiencing of the trauma (other than visual) may be necessary for complete integration of the incident, given that traumatic memories are stored as sensory fragments in various sensory modalities (van der Kolk & Fisler, 1995; van der Kolk, Burbridge, & Suzuki, 1997). However, it is possible that re-experiencing and processing of all sensory components of the trauma through imagery occurs with the V/KD procedure, but simply has not been measured;

(g) Because the V/KD technique enhances dissociation, pre-screening for dissociative disorders is advisable. Particular care needs to be taken when utilizing this procedure with persons who suffer from secondary and tertiary dissociation. The V/KD technique should be used by professionals highly trained in trauma and dissociation treatment.

Recommendations

It is recommended that all clients be screened for dissociation and risk factors for decompensation and that clinicians be familiar with grounding techniques when using V/KD and any other exposure-based treatment for trauma. In terms of using grounding techniques, it is advisable that a thorough assessment for dissociative phenomena and self-resources be conducted prior to any intervention. For clients who are dissociative and lacking in self-resources, grounding is advisable to prevent excessive dissociation during exposure-based interventions.

Caveat: Is Grounding Always Necessary? Care needs to be used with grounding techniques as well, especially for clients who have good ego strength and who are not highly dissociative. For such clients the utilization of grounding techniques by the therapist when the client is in the midst of effective trauma processing may be experienced by the client as an unnecessary or unwanted intrusion and may actually interrupt or impede healthy processing. Therapists should gain a clear sense of client strengths prior to trauma-based interventions and need to use care to appropriately discern when grounding is necessary for the client and when it may be being used to alleviate the distress of the therapist.

Screening. Use caution with exposure-based treatments with clients who exhibit the following, as there is some evidence to suggest they are at increased risk of retraumatization, increased anxiety and panic, alcohol abuse, increased shame and guilt, and obsessional thinking following exposure (Litz, et al, 1990):

· current substance abuse
· history of impulsivity
· ongoing life crises, such as suicidality
· prior failed treatment with exposure-based therapy
· a history of noncompliance
· a recent claim for compensation
· difficulty using imagery
· absence of re-experiencing symptoms
· inability to tolerate intense arousal
· history or presence of a co-existing psychiatric disorder

Clients can be pre-screened for dissociation by therapists trained in assessment using the Dissociative Experiences Scale (DES; Carlson & Putnam, 1993). A cutoff score of 31 is suggestive of PTSD, and a cutoff score of 57 is suggestive of DID (Wagner, 1999). Note that these are suggestive, not diagnostic. If a dissociative disorder is suspected through a preliminary screen using the DES, a more thorough assessment by way of structured interview can be conducted. The Dissociative Disorder Interview Schedule (DDIS; Ross et al., 1989) or the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R; Steinberg, 1994) is recommended. Note that these require training for their use. If the client meets criteria for DID or has highly elevated scores on measures of dissociative symptoms, be aware of potential complications when using trauma interventions. It is important to also maintain awareness of possible symptom underreporting. Clients who are exhibiting avoidance symptoms (including dissociation) may deny or mask trauma-related symptoms (Elliott & Briere, 1994; Epstein, 1993). Complete and thorough pre-assessments are an important component of treatment planning.

Stabilization Techniques. During the exposure-based technique per se, pay particular attention to evidence of extreme anger, anxiety, dependency, or fragmentation. Avoid moving too quickly in treatment with clients who have a known history of trauma yet appear asymptomatic (Briere, 1997).

Signs of dissociation in session include fixed or glazed eyes, sudden flattening of affect, long periods of silence, monotonous voice, stereotyped movements, "unreal" responses, and excessive intellectualization (Briere, 1997).
It is important to take steps to insure that the pacing and timing of exposure-based interventions are carefully monitored. Slow down the speed of interventions and/or adjust the intensity of the interventions when clients attempt to adjust or titrate the emotional intensity (Briere, 1997).

In milder forms, signs of titration include periods of silence, dissociation, misunderstanding concepts that are usually understandable, and sudden changes in the direction of the discussion. At more extreme levels, titration may involve acting out behaviors, verbal attacks, distraction with sexualized material, an increase in adversariality, or termination of therapy (Briere, 1997).

In general, stabilization within sessions may be facilitated through reducing stimulation, reassurance, and grounding. Have clients attend to their dissociative behavior and ask them to reduce the dissociative behavior to its minimal level, if possible. If the dissociation continues, decrease the client’s immediate distress or increase the client’s level of self-support (Briere, 1997).

Help focus the client on the facts of what is happening in the here-and-now. The therapist can help set limits on overwhelming stimuli, divert to less threatening topics, use toys or objects in the room on which the client can focus, have the client switch seats or change body posture, stand facing the client with client facing him/her, and rock back and forth sideways from foot to foot; go cognitive (e.g., talk about what to do next; talk about the theory behind what is happening), draw pictures, teach clients to notice how present they are in their bodies by having them provide a percentage and experiment with how clients can increase the percentage to about sixty percent (Fisher, 1999; Linehan, 1993).

Summary and Conclusions

Although V/KD was originally used by Bandler and Grinder (1979) in the treatment of phobias, the literature reviewed for this paper suggest that V/KD is useful in the treatment of posttraumatic sequelae. V/KD appears to be a specialized variant of re-conditioning and exposure therapy, and may function to assist clients in reprocessing and desensitizing trauma-related material from a de-centered point of view.

Bandler and Grinder (1979) postulate that anchoring different (i.e., positive and negative) feeling states also anchors the respective physiological state that corresponds to each feeling state. According to Bandler and Grinder, when both anchors are stimulated simultaneously, the distinct physiological states become integrated, and the positive feeling state takes precedence whenever the individual is triggered. This presumes that different feeling states have their own unique patterns of peripheral physiological arousal, as opposed to the view that there is one more or less general pattern of physiological arousal that corresponds to all feeling states and that feelings are differentiated by way of cognition. It also presumes that positive emotional states will take precedence over negative emotional states. For persons who suffer from PTSD, this presumption seems unrealistic. Recent evidence suggests that there is a general arousal state, as well as different states that correspond to specific emotions (Panksepp, 1999). Anchoring both positive and negative feeling states may prove harmful, in that integration of positive and negative affective states may result in further disturbance (e.g., integration of fear with sexual arousal).

Bandler and Grinder suggested that V/KD interrupts previously conditioned patterns of association or sequencing between feared stimuli and response. Through the disruption or disconnection of various sensory modalities, the previous associations between fear and the traumatic memory or stimulus are broken, leading to the opportunity to make new, more functional associations. It is possible that the guided dissociation process in the V/KD technique assists in the integration of current and latent mental schemes of the trauma, such that the material can be processed with reduced levels of affective intensity (perhaps concomitantly with increased ventral vagal processing) and less chance of treatment regression and cognitive distortions. Moreover, it simultaneously allows processing of the material through current cognitive resources.

The studies reviewed for this paper suggest that V/KD, although currently at an experimental level of efficacy and in need of further well-designed empirical study, may be a promising treatment for at least some forms of Posttraumatic Disorder. Intrusive symptoms, avoidance behaviors, and interpersonal and occupational functioning improved for many of the participants in the studies reviewed. A small number of participants evidenced more modest improvement, and two showed exacerbation of pre-existing avoidant symptoms following the V/KD procedure proper.

Therapeutic interventions, including V/KD, should be used with caution with some traumatized client populations. If clients present with pronounced affect dysregulation, notable dissociation, or other symptoms of destabilization, trauma treatment should be postponed until clients have been stabilized (Herman, 1992). Care should be used to monitor clients closely following the implementation of the V/KD technique proper, since some clients experience increased avoidance symptomology following the intervention.

Knowledge of "grounding" techniques or other means of assisting clients in modulating affective distress or dissociation is an important adjunct to the use of any trauma intervention, as well as knowledge of when grounding techniques are needed. Further empirical study is required to shed light on the effectiveness of V/KD in the treatment of trauma, to tease out the exact mechanisms of action in the V/KD technique, and to determine more precisely which posttraumatic sequelae are most suited to the V/KD intervention.

References

Adamec, R. (1997). Transmitter systems involved in neural plasticity underlying increased anxiety and defense--implications for understanding anxiety following traumatic stress. Neurosci Biobehav Rev, 21(6), 755-765.

American Psychological Association, Division 12 Task Force. (1995). Training in and dissemination of empirically validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3-23.

Bandler, R. & Grinder, J. (1979).In J.O. Stevens (Ed.) Frogs into Princes.NeuroLinguistic Programming. Utah:Real People Press.

Bloom, F.E. (1995). Cellular mechanisms active in emotion. . In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1063-1070. Cambridge MA: MIT Press.

Bremner, J.D., Krystal, J.H. Charney, D.S., Southwick, S.M. (1996). Neural mechanisms in dissociative amnesia for childhood abuse: relevance to the current controversy surrounding the “false memory syndrome.” Am J Psychiatry, 153 (7 Suppl), 71-82.

Bremner, JD, Randall, P., Scott, T.M., Bronen, R.A. Seibyl, J.P., Southwick, S.M., Delaney, R.C., McCarthy, G., Charney, D.S. & Innis, R.B. (1995). MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. American Journal of Psychiatry, 152, 973-981.

Bremner, J.D., Randall, P., Vermetten, E., Staib, L., Bronen, R.A., Mazure, C., Capelli, S., McCarthy, G., Innis, R.B. & Charney, D.S. (1997). Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse -- a preliminary report. Biological Psychiaty, 41(1), 23-32.

Briere, J. (1997). Therapy for adults molested as children.Beyond survival. NY: Springer Publishing Company.

Cahill, L. (1997). The neurobiology of emotionally influenced memory. Implications for understanding traumatic memory. Ann N Y Acad Scie, 821, 238-246.

Cahill, L. & McGaugh, J.L. (1996). Modulation of memory storage. Curr Opin Neurobiol, 6(2), 237-242.

Cahill, L. & McGaugh, J.L. (1998). Mechanisms of emotional arousal and lasting declarative memory. Trends Neurosci, 21(7), 294-299.

Cahill, L., Prins, B., Weber, M. & McGaugh, J.L. (1994). B-adrenergic activation and memory for emotional events. Nature, 371, 702-704.

Carlson, E. B., Putnam, F. W.(1993).An update on the Dissociative Experiences Scale. Dissociation, 6, 16-27

Charney, D.S., Deutch, A.Y., Krystal, J.H., Southwick, S.M., & Davis, M. (1993). Psychobiologic mechanisms of Posttraumatic Stress Disorder. Archives of General Psychiatry, 50, 294-305.

Christianson, S.A. & Mjorndal, T. (1985). Adrenalin, emotional arousal and memory. Scandinavian Journal of Psychology, 26, 237-248.

Christianson, S.A. & Nilsson, L.G. (1984). Functional amnesia as induced by a psychological trauma. Memory and Cognition, 12, 142-155.

Dilts, R., Grinder, J., Bandler, R., Bandler, L.C. & DeLozier, J. (1980). Neuro-linguistic programming: The study of the structure of subjective experience. CA: Meta Publications.

Einspruch, E.L. & Forman, B.D. (1985). Observations concerning research literature on Neuro-Linguistic Programming. Journal of Counseling Psychology, 32, 589-596.

Elliott, D.M. & Briere, J. (1994). Forensic sexual abuse evaluations of older children: Disclosures and
symptomatology. Behavioral Sciences and the Law, 12, 261-277.

Epstein, R.S. (1993). Avoidant symptoms cloaking the diagnosis of PTSD in patients with severe
accidental injury. Journal of Traumatic Stress, 6, 451-458.

Field, E.S. (1990).Neurolinguistic Programming as an Adjunct to Other Psychotherapeutic/ Hypnotherapeutic Interventions. American Journal ofClinical Hypnosis, 32, (3), 174-182.

Fisher, J (1999, November). Assessment and Treatment of Complex PTSD. International Society for Traumatic Stress Studies Annual Meeting, Miami Florida.

Frankel, F.H. (1994). The concept of flashbacks in historical perspective. The International Journal of Clinical and Experimental Hypnosis, 42, 321-336.

Gallo, F.P. (1996).Reflections on active ingredients in efficient treatments of PTSD. Part 1.Traumatology-E Journal, [On-line], 2(1)Available: http://rdz.stjohns.edu/trauma/art2v2i1.html

Gazzaniga, M.S. (1995). Consciousness and the Cerebral hemispheres. In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1391-1400. Cambridge MA: MIT Press.

Gurvits, T., Shenton, M., HOkama, H., Ohta, H., Lasko, N., Gilbertson, M., Orr, R., Kikinis, R., Jolesz, R.,
McCarley, R. & Pitman, R. (1996). MRI-based measured hippocampal volume in patients with PTSD. American Journal of Psychiatry, 152, 973-981.

Herman, J. (1992). Trauma and recovery. NY: Basic Books

Hossack, A. & Bentall, R.P. (1996). Elimination of posttraumatic symptomatology by relaxation and Visual-Kinesthetic Dissociation. Journal of Traumatic Stress, 9, (1), 99-111.

Jacobs, W. J. & Nadel, L. (in press). Neurobiology of reconstructed memory. Psychology, Public Policy, and Law

Joseph, R. (1998). Traumatic amnesia, repression, and hippocampus injury due to emotional stress, corticosteroids and enkephalins. Child Psychiatry and Human Development, 29(2), 169-185.

Kazdin, A.E. (1998). Drawing valid inferences from case data. In A.E. Kazdin (Ed.) Methodological issues and strategies in clinical research. Second edition (pp. 403-418). Washington DC: American Psychological Association.

Keane, T.M., & Kaloupek, D.G. (1982).Imaginal flooding in the Treatment of a Posttraumatic Stress Disorder. Journal of Consulting and Clinical Psychology, 50(1), 138-140.

Kilpatrick, D.G., & Best, C.L. (1984). Some cautionary remarks in treating sexual abuse victims with implosion. Behavior Therapy, 15, 421-423.

Konefal, J., Duncan, R.C., & Reese, M (1992). NeuroLinguistic Programming, Trait Anxiety, and Locus of Control. Psychological Reports, 70, 819-832.

Koziey, P. W. & McLeod, G. L. (1987).Visual-Kinesthetic Dissociation in treatment of victims of rape. Professional Psychology: Research and Practice, 18 (3), 276-282.

LaBar, K.S. Gatenby, J.C., Gore, J.C., LeDoux, J.E. & Phelps, E.A. (1998). Human amygdala activation during conditioned fear acquisition and extinction: A mixed-trial fMRI study. Neuron, 20(5), 937-945.

LeDoux, J. (1995). In search of an emotional system in the brain: Leaping fromfear to emotion and consciousness. In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1049-1061. Cambridge MA: MIT Press.

LeDoux, J.E., & Muller, J. (1997). Emotional memory and psychopathology. Philosophical Trans R Soc Lond B Biol Sci, 352(1362), 1719-1726.

Linehan, M.M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. NY: Guilford Press.

Litz, B.T., Blake, D.D., Gerardi, R.D., & Keane, T.M. (1990). Decision-making guidelines for the use of direct therapeutic exposure in the treatment of post-traumatic stress disorder. The Behavior Therapist, 13, 91-93.

Margarinos, A.M., Verdugo, J.M. & McEwen, B.S. (1997). Chronic stress alters synaptic terminal structure in hippocampus. Proc Natl Acad Sci, 94, 14002-14008.

McEwen, B.S. (1995). Stressful experience, brain, and emotions: Developmental, genetic, and hormonal influences.In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1117-1135. Cambridge MA: MIT Press.

McGaugh, J.L. (1992). Affect, neuromodulatory systems, and memory storage. In S.A. Christianson (Ed.), Handbook of emotion and memory. Pp. 245-268. NJ: Lawrence Erlbaum.

McNally, R.J. (1997). Implicit and explicit memory for trauma-related information in PTSD. Ann N Y Acad Sci, 821, 219-224.

Muss, D.C. (1991).A new technique for treating Post-Traumatic Stress Disorder.British Journal of Clinical Psychology, 30, 91-92.

Nadel, L. & Jacobs, W.J. (in press). Traumatic memory is special. Contemporary Directions in Psychological Science

Nadel, L. & Moscovitch, M. (1997). Memory consolidation, retrograde amnesis and the hippocampal complex. Curr Opin Neurobiol, 7(2), 217-227.

Panksepp, J. (1999). The neural basis of the basic emotions in the mammalian brain. Encyclopedia of Human Emotions, Vol. 2 (ed. D. Levinson, J.J. Pnzetti, Jr., & P.F. Jorgensen), pp. 475-478. NY: Macmillan Reference.

Parkin, A.J. (1996). Human memory: the hippocampus is the key. Curr Biol, 6(12), 1583-1585.

Pitman, R.K., Altman, B., Greenwald, E., Longpre, R.E., Macklin, M.L., Poire, R.E., & Steketee, G.S. (1991).Psychiatric complications during flooding therapy for Posttraumatic Stress Disorder.Journal of Clinical Psychiatry, 52(1), 17-20.

Pitman, R.K., Orr, S.P., Altman, B., Longpre, R.E., Poire, R.E., Macklin, M.L., Michaels, M.J., & Steketee, G. (1996). Emotional processing and outcome of imaginal flooding therapy in Vietnam veterans with chronic Posttraumatic Stress Disorder. Comprehensive Psychiatry, 37 (6), 409-418.

Porges, S.W. (1997). Emotion: An evolutionary by-product of the neural regulation of the Autonomic Nervous System. In C.S. Carter, I.I. Lederhendler, & B. Kirkpatrick (eds.) The Integrative Neurobiology of Affiliation. Annals of the New York Academy of Sciences, 807, 62-77.

Rauch, S., van der Kolk, B.A., Fisler, R., Alpert, N., Orr, S., Savage, C., Jenike, M., & Pitman, R. (1996). A symptom provocation study using Positron Emission Tomography and Script Driven Imagery. Arch Gen Psychiatry, 53, 380-387.

Rolls, E.T. (1995). A theory of emotion and consciousness, and its application to understanding the neural basis of emotion. . In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1091-1106. Cambridge MA: MIT Press.

Ross, C. A., Heber, S., Norton, G. R., Anderson, D., Anderson, G., & Barchet, P.(1989).The
Dissociative Disorders Interview Schedule:A structured interview. Dissociation, 2, 169-189.

Schacter, D.L. (1995). Implicit memory: A new frontier for cognitive neuroscience. In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 815-824. Cambridge MA: MIT Press.

Schiffer, F., Teicher, M.H., & Papanicolaou, A.C. (1995). Evoked potential evidence for right brain activity during the recall of traumatic memories. J Neuropsychiatry Clin Neurosci, 7(2), 169-175.

Schulkin, J. McEwen, B.S. & Gold, P.W. (1994). Allostasis, amygdala, and anticipatory angst. Neurosci Biobehav Rev, 18(3), 385-396.

Scott, M.J. & Stradling, S. G. (1997). Client compliance with exposure treatments for posttraumatic stress disorder. Journal of Traumatic Stress, 10, 523-526.

Shalev, A.Y., Bonne, O., & Eth, S. (1996).Treatment of Posttraumatic Stress Disorder: A review. Psychosomatic Medicine, 58, 165-182.

Shin, L.M., Kosslyn, S.M., McNally, R.J., Alpert, N.M., Thompson, W.L., Rauch, S.L., Macklin, M.L. & Pitman, R.K. (1997). Visual imagery and perception in posttraumatic stress disorder. A positron emission tomographic investigation. Arch Gen Psychiatry, 54(3), 233-241.

Shobe, K.K. & Kihlstrom, J.F. (1997). Is traumatic memory special? Current Directions in Psychological Science, 6(3), 70-74.

Solomon, Z., Bleich, A., Shoham, S., Nardi, C., & Kotler, M. (1992). The Koach project for the treatment of combat related PTSD: Rationale, aims and methodology. Journal of Traumatic Stress, 5, 175-194.

Southwick, S.M., Krystal, J.H., Morgan, A., Johnson, D., Nagy, L., Nicolaou, A., Henninger, G.R. & Charney, D.S. (1993). Abnormal norandrenergic function in posttraumatic stress disorder. Arch. Gen. Psychiatry, 50, 266-274.

Steinberg, M. (1994). Interviewer's guide to the Structured Clinical Interview for DSM-IV
Dissociative Disorders-Revised (SCID-D).Washington, DC: American Psychiatric Press.

van der Kolk, B.A. (1997, January). Presentation at the Trauma Conference. Vancouver, British Columbia, Canada.

van der Kolk, B.A. (1998, April). Presentation at the Trauma and Dissociation Conference. Chelan, Washington.

van der Kolk, B.A. (2000, March). Presentation at conference on Psychological Trauma: Maturational Processes and Therapeutic Interventions, Boston, MA.

van der Kolk, B. A. & Fisler, R. (1995).Dissociation and the fragmentary nature of traumatic memories:Overview and exploratory study. Journal of Traumatic Stress, 8, (4), 505-525.

van der Kolk, B. A., Burbridge, J. A., & Suzuki, J.(1997).The psychobiology of traumatic memory: Clinical implications of neuroimaging studies. In R. Yehuda & A. C. McFarlane (Eds.), Annals of the New York Academy of Sciences, (Vol. 821): Psychobiology of Posttraumatic Stress Disorder (pp. 99-113). New York
Academy of Sciences.

van der Kolk, B. A., McFarlane, A.C., & van der hart, O.(1996).A general approach to treatment of Posttraumatic Stress Disorder.In. B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.) Traumatic stress.The effects of overwhelming experience on mind, body, and society (pp. 417-440).NY: Guilford Press.

van der Kolk, B. A., van der hart, O, & Marmar, C.(1996). Dissociation and information processing in posttraumatic stress disorder.In. B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.) Traumatic stress.The effects of overwhelming experience on mind, body, and society (pp. 303-330).NY: Guilford Press.

van der Kolk, BA & Saporta, J. (1991). The biological response to psychic trauma: Mechanisms and treatment of intrusions and numbing. Anxiety research, 4, 199-212.

vanOyen Witvliet, C. (1997). Traumatic intrusive imagery as an emotional memory phenomenon: A review of research and explanatory information processing theories. Clinical Psychology Review, 17(5), 509-536.

Vaughan, K. & Tarrier, N. (1992). The use of image habituation training with posttraumatic stress disorders. British Journal of Psychiatry, 161, 658-664,

Wagner, A. (1999, November). Introduction to the diagnosis and treatment of Complex Dissociative Disorders. Workshop at the International Society for the Study of Dissociation annual meeting. Miami, Florida.

Watson, C.G., Tuorila, J., Detra, E., Gearhart, L.P., & Wielkiewicz, R.M. (1995).Effects of a Vietnam War Memorial Pilgrimage on veterans with Posttraumatic Stress Disorder.The Journal of Nervous and Mental Disease, 183 (5), 315-319.

Weinberger, N.M. (1995). Retuning the brain by fear conditioning. . In M.S. Gazzaniga (Ed.-in-Chief) The Cognitive Neurosciences. Pp. 1071-1089. Cambridge MA: MIT Press.

Yehuda, R. (1997). Sensitization of the hypothalamic-pituitary-adrenal axis in Posttraumatic Stress Disorder. In R. Yehuda and A.C. McFarlane (Eds.) Psychobiology of Posttraumatic Stress Disorder. Annals of the New York Academy of Sciences, 821, 57-75.

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