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Article appeared in Illness, Crisis & Loss, Vol. 7, No. 4, October 1999 390-401
1999 Sage Publications
Impact of a grief-crisis intervention immediately after a sudden violent death
Griefwork Center, Inc.
A challenging concern of grief-crisis intervention is providing appropriate emotional and educational support immediately after a sudden violent death. Research suggests that coping after this type of loss is laborious for the entire family, including children, adolescents and adults. The survivor's grief response is intense with a prolonged trauma. The consensus of the research indicates that grief-crisis intervention helps the survivors want to go on living in the face of disaster and positively impacts on their ability to cope.
"When children are kidnapped from their bedrooms and murdered, when diners are massacred in a restaurant in mid-afternoon, when a federal building where people are attending to routine, daily business explodes, when a shopkeeper is murdered by robbers over little more than pocket change, the deaths seem senseless, meaningless, and deeply personal even to individuals not directly involved in the events" (Haney, Leimer & Lowery, 1997, p. 160).
The sudden death of these innocent men, women and children, impacts the survivor's ability to cope. Moos (1995) maintains that "While the grief centers on the emotional and physical responses, coping refers to active or passive attempts to go on living" (p. 358). Their death causes a grief-crisis, and immediate intervention after these and any sudden violent death is essential. This article reviews some of the current literature dealing with grief-crisis intervention immediately after a sudden violent death and explores how it positively impacts on the survivor's ability to cope.
In the literature examined in this article, researchers were in agreement that when a person is killed suddenly and violently, in the absence of support, survivors will not effectively deal with their grief. Murphy, Baugher, Lohan, Scheidman, Heerwagen, and Johnson, (1996), conducted a study of 156 bereaved parents from Seattle and Portland, whose children, ages twelve to twenty-eight, died by accident, homicide or suicide, found that "all aspects of problem-focused support were rated higher by parents whose children died in accidents than by parents whose children died of other causes" (p.465). The authors found that participants reported talking helps, but that listening helps even more. The two hour, twelve week program included program-focused support to offer information and skill building, which was then followed by emotion-focused support. The time since the child's death ranged from six weeks to just over seven months. Though intervention six weeks after the crisis is beneficial, immediate grief-crisis intervention is preferable. Eisenstadt (as cited in Dilworth & Hildreth, 1997) reports that "the bereavement reaction can be impetus for creative effort, a force for good, or it can have the effect of stunting personality growth and producing the concomitant antisocial acts, destruction of social relationships, and even the taking of one's own life" (p. 147). Therefore, immediate crisis intervention is especially important for the survivors who cannot cope with their grief and become suicidal.
The bereaved are faced with psychological crisis, which Aguilera (1998) defines as "an individual's inability to solve a problem" (p.1). The problem stems from the violent and sudden nature of the death which has caused many questions to unfold. What the bereaved need is someone to listen to their story and help them understand their unique responses to grief. These needs are met when crisis intervention is effectively in place.
According to Murphy, Johnson, Cain, Gupta, Dimond, Lohan and Baugher, (1998), parents have unique responses to the violent death of their child. In accidental death, parents believe they should have been better able to protect their children. In suicidal death, parents feel their child rejected and abandoned them. They also feel a social stigma. In homicidal death, they feel rage and revenge against the person who murdered their child and frustrated with the criminal justice system. Cook and Oltjenbruns (as cited in Moss, 1995) point out that "in our culture, suicide is the most difficult type of death to deal with; however; accidents and homicide are also tragic and unexpected and thus require more time for support for the bereaved individuals and families" (p. 343). Through immediate crisis intervention, support is offered and parents are better able to discuss their problems and recognize their special grief needs.
In the Murphy, et. al. (1998) study, examining preventive intervention following the sudden violent deaths of their children, the authors found that sudden, violent death interferes with emotional expression and cognitive performance. Without intervention, parents would experience increased mental distress, trauma symptoms, delayed loss accommodation, declining physical health, and marital problems. Their findings show "that parents bereaved by the violent deaths of their children exhibit varying levels of emotional trauma" (p.221). Though fathers did experience grief, mothers scored three times higher on mental distress.
The results of the Murphy, et al. (1998), study "provide empirical support for the efficacy of a theory-based preventive intervention for highly distressed, but not lesser distressed mothers, and no apparent benefits for fathers bereaved as a result of the violent deaths of their children" (p.228). Many parents blame each other and stop communicating after the death. Thus, a high divorce rate for bereaved parents. The authors also found that "intervention-group fathers appear to have more Post Traumatic Stress Disorder symptoms six months after the program ended" (p.229). Though the findings show that mothers benefited from the group more than fathers, future research can explore men's grief from sudden violent death.
Williams & Frangesch (1995, citing Rando 1984; Weiss, & Parkes, 1974, and Worden, 1982) explain that "Violent sudden deaths such as suicide and homicide cause added struggles for the survivors" (p .475). One of the most important findings in the literature is how society reacts to the survivors. Society has a difficult time in supporting those whose loved ones have experienced a violent sudden death. At a time when survivors need support, they are left with those who do not know how to deal with the intense grief response.
Sprang & McNeil (1998, discussing a 1985 study by Lehman et al.) found that
|The lack of social support for grieving individuals is based on societal misconceptions. Their study revealed that feelings of threat or vulnerability experienced by the person offering the support are directly related to the mode of death. The more sudden, unexplained, and unnatural the death, the greater the difficult expressing support. Second, society lacks the knowledge and skill to respond to the bereaved individual, especially after a traumatic death. The fear of committing an error in word or action may prevent the individual from offering support. In general, society has misconceptions about the intensity and duration of reactions to trauma and may impose unrealistic expectations upon the grieving individual. In the absence of some supporting social structures, it is observed that some individuals do not effectively deal with the tasks of grieving. They may experience prolonged and destructive reactions (p.46).|
|The Williams and Frangesch (1995) study was designed to meet the needs of the grieving survivor at the time of death notification and two months later. They used a sample of those seen in the Emergency Room of a 600-bed acute care hospital. The RN's offer a holistic nursing intervention with trained crisis team members whose goal is to normalize grief symptoms and offer community referrals. They provide a private area and a telephone, a hospital chaplain is present, and when the death is pronounced, all questions are answered. Before the bereaved leaves the emergency department, the nurse takes part in the wrap-up phase that includes giving them the name and telephone number of a hospital contact person, information about funeral homes, body location, autopsy, organ donation, the grief process, and the community resources for grief support. This initial intervention gives the survivors some sense of normalcy when the world around them is falling apart. The care giver is listening to them and they are not left alone to deal with the crisis.
Although most crisis intervention is an organized effort on part of school, church or other caregiver group, there are those who take it upon themselves to create rituals to deal with the immediate crisis. Although spontaneous memorialization is outside the scope of this paper, I wish to show briefly how community as a whole is effected by tragedy, and how they can take it upon themselves to do something when faced with crisis. According to Haney, Leimer and Lowery (1997) "spontaneous memorialization is a public response to the unanticipated violent deaths of people who do not fit into the categories of those we expect to die, who may be engaging in routine activities in which there is reasonable expectation of safety, and with whom the participants in the ritual share some common identification" (p.161). This ritual offers the community an opportunity to display outward signs of mourning. The crisis team works with the immediate survivors, however, when there is a sudden violent death, the entire community is touched by the senseless and meaningless death.
Those touched by tragedy need to respond to the loss in some way. What happens in those first few hours after hearing the news is critical. When an immediate crisis occurs, the family is notified. They depend upon those in authority to provide them with the facts in a compassionate way. Frazer and Atkins note (as cited in Williams & Frangesch, 1995, 476) note that sudden death survivors reported several helpful nursing behaviors, including acknowledging the need to express grief and showing caring concern. Throughout this process, the survivor is coming to terms with their grief based on their own cultural values and beliefs. Mourning and recovery is more difficult due to the violent and sudden nature of their loss. Therefore, professional assistance during these first few hours is essential, as the survivors try to cope with the news of the death within the framework of their cultural and religious beliefs.
Katz and Bartone (1998) point out that
|Freud (1917), and more recently Horowitz (1987), Bowlby (1969), Pollock (1977), Parkes (1972), and Raphael (1983) have described the psychological processes of mourning and recovery in a variety of cultures and situations. They agree that the mourning process functions to facilitate the psychological integration of the loss. According to Parkes (1972), when sudden, accidental or violent deaths occur . . . , the greater shock and trauma increases the burden of morning and recovery. Horowitz (1978) maintains that recovery from traumatic loss depends upon the working-through and resolution of grief. This 'working-through' process involves both avoidance or turning away from the traumatic event, as well as its painful intrusion in to the subject's awareness" (p.194).|
|The painful truth is being told the devastating news that your loved one has been killed in a car crash. If the death is caused by the negligence of a person who got behind the wheel drunk, the survivor's rage is intensified. They experience grief and post traumatic stress. Figley (as cited in Leenars & Wenchstern, 1998), defines "post traumatic stress disorder as a set of conscious and unconscious behaviors and emotions associated with dealing with the memories of the stressors of the catastrophe and immediately afterwards" (p.361) Sprang and McNeil (1998) studied 171 primary family members of drunk driving victims. They were randomly selected from Texas support groups and social service agencies. They found that surviving family members experienced grief and PTSD. Subjects who had high levels of social support had lower levels of mourning, grieving and PTSD. They found that religious beliefs aid in adaptation and resolution of trauma. Informational groups, such as Mothers Against Drunk Drivers, also offer valuable support to the bereaved. Their natural support system includes their families, friends, houses of worship, and support service within their local community. Sprang and McNeil found that "there is some suggestion in the literature that resolution of the process of grief may take many years to complete for individuals who have lost a family member due to an intoxicated driver" (p.48). The driver's negligence caused a violent sudden death. When this death is a younger person, it is not expected and difficult to understand. Neugarten (as cited in Gamino et al., 1998) "has argued that it is not death itself that is tragic as much as a death that occurs "off time" in the life cycle, specifically, death judged to be premature according to socially determined expectancies abut the life span" (p.349). If the death is premature, then there is more chance of that death becoming a crisis in the lives of the survivors.
Survivors need to rely on their supportive network and utilize it. Parkes and Weiss (as cited in Sprang & McNeil, 1998) report that "the presence of supporting relationships, while valuable at the time of bereavement, had no significant association with later recovery. What seemed important was not whether support was initially available, but whether it was available and utilized"( p. 46). Our society is offering support services to the bereaved. The bereaved must reach out and accept this assistance, or else the crisis intervention will not work.
Sprang & McNeil (1998, citing Rando 1984; Sprang & McNeil, 1995) write that "the violence of the death may prelude usual mourning rituals such as identifying or viewing the body because of extensive damage that may have occurred during the crash. Acceptance of the death may be impeded or prolonged in such cases due to ruminations about the physical status of the body at the time of death, or the level of awareness of the deceased" (p. 43).
Whether the death occurred through a car or plane crash, the crash itself caused severe damage to the body, which may be unrecognizable or cannot be found. This is especially true in the case of airline disasters. Katz and Bartone (1998) studied the effects of mourning and ritual after a chartered army jetliner crashed in Gander, Newfoundland, killing all 248 soldiers from one battalion. The President of the United States attended the three-hour memorial ceremony honoring the dead. This was a sudden and tragic loss that affected the entire community. "Immediately upon conformation of the crash, flags around post were lowered to half-mast. The brigade commander made a short speech to families assembled to welcome their returning loved ones. The MPs were alerted to initiate special security measures around post" (p.197). An immediate crisis intervention was in place. A memorial service, a flag at half-mast, and a moment of silence are all powerful tools to help the survivors of this type of tragedy. In Fort Campbell, "mourning rituals were numerous and elaborate. And they apparently facilitated the mourning process at both the individual level and the group level" (p.197).
Grief-crisis intervention is a valuable tool for survivors of suicide. Facilitating the mourning process when someone dies by suicide is critical. Campbell (1997) found that "adequate and early postvention services may normalize the grief process after suicide, identify more at-risk survivors, and reduce contagion" (p.336). The author found that "By increasing access to survivors through postvention teams, the impact of postvention services can facilitate the grief process while providing information about resources in the community. The long-term consequences of suicide may be averted if the problems of access for survivors to services and awareness of resources is overcome" (p.336). For adults, the resources can come in the form of a local suicide survivor support group. There are suicide survivors who provide grief-support, free of charge, in the home of the newly bereaved. There are non-profit organizations dedicated to suicide prevention that will help create a memorial fund in their loved one's name. Adults find that resources and emotional support are valuable tools in healing after the loss of a loved one.
Children are also survivors of suicide and postvention helps them cope with the crisis. Schneidman (as cited in Leenaars & Wenckstern, 1998) defines postvention as "those things done after the dire event has occurred that serve to mollify the after effects of the event in a person who has attempted suicide, or to deal with the adverse effects as the survivor-victims of a person who has committed suicide" (p.357). PTSD is a good description as to the reactions of suicide survivors and trauma in the school and community. Leenaars and Wenckstern believe that when working with survivors of suicide there should be an immediate response. There should be an attachment formed between the crisis intervention team and the survivors. The survivors must find hope that they can get through the crisis. This intervention should begin with the first 24 hours if possible.
Hoff (as cited in Leenaars & Wenckstern, 1998) writes that "attachment is, in fact, a key to working with people in crisis. The postventionist must be willing to express attachment and to work quickly to establish a trusting relationship with everyone involved, without postvention is extremely problematic" (p.367). Leenaars & Wenckstern (1998) write "The postventionist needs to work diligently, always striving to give persons realistic transfusions of hope until the intensity of the pain (or distress) subsides sufficiently to reduce the pain to a tolerable level" (p.367). Once the pain is reduced to a tolerable level, questions can be explored.
Children who see a classmate die by suicide have many questions. Their feelings must be acknowledged. The school is their social environment and it is the place they spends most of his day. Therefore, it is imperative that a crisis-team be in place to handle the problems that arise in this type of situation. The child's's recovery is based on how he is told, who listens to him, the rituals shared, the counseling sessions, and the memorialization offered. In a Leenaars study (as cited in Leenaars & Wenckstern, 1998) it was found that "School suicide postvention programs represent a systematic model-guided response" (p.358). Teachers, students and staff members can be deeply affected by a suicide in their school. Immediate intervention following a suicide helps students and staff deal with the immediate grief response and may lessen long-term effects.
Leenaars and Wenckstern (1998) point out that "a positive response needs to begin with school administrators, followed by school, staff and other involved individuals" (p.371). The authors write that "emergency or crisis response is provided by means of basic problem-solving strategies. We believe that students and staff of the local school(s) are likely to need support in responses to a suicide trauma" (p.378). In a Robinson and Mitchell study (as cited in Leenaars and Wenckstern, 1998), it was "reported that people found a response after a trauma as not only helpful but stress reducing, a view held by Lindemann (1944) more than 50 years ago" (p.383).
"The origin of modern crisis intervention dates back to the work of Eric Lindemann and his colleagues after the Coconut Grove fire in Boston on November 28, 1942. In what was at that time the worst single-building fire in the country's history, 493 people perished when flames swept through the crowded nightclub" (Aguilera, p.2). Lindemann wanted to maintain the good mental health of the community and prevent emotional disorganization. He and Caplan created a community-wide mental health program. Fifty years later, many programs are in place to help the bereaved cope with their tragedy.
The full tragedy of war has not affected America in a few years; however, a crisis mentioned in the literature is that of combat death. When a soldier is killed in action, the family must deal with any unfinished business and a lack of preparation. They may experience anger and be preoccupied with the death. "Given that death in combat is always of a violent nature, the bereaved may become preoccupied with the details in an attempt to answer questions about the circumstances, which are often sketchy in the chaos of war. She or he may focus on the terror, helplessness, pain, or loneliness that the deceased might have felt" (Cook & Dworkin, p.24). This is a time when families are deeply affected.
Hogancamp and Figley (as cited in Cook and Dworkin) write that "although family relationships can be adversely affected, little attention has been given to addressing the family system issues that arise" (p.26). Families can attend support groups together. When survivors seek out support groups immediately after the death, they meet others who have experienced a similar loss. They will be given resources and a place to openly share their grief.
No matter what type of loss, it is more difficult to cope with the loss of a younger person. Gamino et al. (1998) found that "in their sample the result was higher levels of grief affect in the survivor when the decedent was a younger person" (p.349). Murphy, et al. (1998) summarize research showing that "Mutual support groups that meet monthly are the predominant source of help for parents following the violent deaths of their children" (p.213). According to Murphy, et al. (1998) "intense problem-focused and emotion focused support are needed early in the bereavement transition to reduce mental distress, delayed loss accommodation, poor health, and role strain" (p. 213). Lehman, et al. (as cited in Murphy, et al., 1998) point out that "the problems associated with coping with the violent death of one's child appear to occur very early in bereavement and persist for many years" (p.210). Therefore, immediately attending a support group with others who have experienced a similar loss, can help one cope with their grief.
Gamino, Sewell and Easterling (1998) studied predictors of intensified mourning and found that participants believed supportive people around them is what helped them the most. The authors also studied trauma, denial, guilt, and violence and found that "widows showed more denial, whereas bereaved parents showed more guilt and were more likely to have experienced a loss via trauma and/or violence" (p.347). The participants reported that friend and family support, church, mate, support group, Christian faith (no other religions were mentioned), staying busy, professional counseling and work helped them to cope with their tragedy.
Bradach and Jordan (1995) write that "Current stressors a client or family is coping with should be assessed with past losses in mind, particular for families that have a history of traumatic losses which may have made them exceptionally vulnerable to dysfunction under current stress" (p.332). During the assessment the crisis worker explores the bereaved's coping style and his personality. Factual data is collected including his support system, his religion and cultural background. The survivor's ability to cope is based on his past history of coping. After the data is collected, the counselor offers support.
Leenaars and Wenckstern (1998) write that the "response with a preplanned protocol needs to be immediate; indeed, waiting even 24 hours can be suidiogenic in some cases. Equally important is the compilation and sharing of accurate reliable information about the event as it becomes known. This is to combat often mourning hysteria as misinformation, often of a sensational nature, quickly proliferates" (p.366). Leenaars and Wenckstern (1998, 365) modified the principles of postvention for application to any trauma within a school setting to include the following:
WHY GRIEF-CRISIS INTERVENTION IS NECESSARY
Extensive research clearly indicates the need for immediate crisis intervention. In a violent sudden loss, there is much to deal with. Everything the person believes about his assumptive word is shattered. They may never fully recover from the event. Their grief process will become a part of their very being, forever changing as they form a new bond with the deceased. This process is a lifelong one. However, immediate intervention will help survivors cope with a "sense of lingering presence, a sense of personal longing, and perhaps, a deeply felt lesson learned about life and death that continues to occupy our consciousness throughout our lives" (Marrone, 1998, 331).
The survivor's loved one is violently and suddenly killed. The intervention offered must be immediate to help them deal with their grief. It must also be by those who not only truly want to help, but those who truly want to build a trusting relationship. Prigerson, Shear, Biehals, Pilkonis, Wolfson, Hall, Zonarich & Reynolds (1997, p. 21) found that the nature of an individual's attachment relationships critically influences the propensity to develop traumatic grief. Leenaars and Wenckstern write "Attachment is, in fact, a key to working with people in crisis. The postventionist must be willing to express attachment and to work quickly to establish a trusting relationship with everyone involved, without which postvention is extremely problematic" (p.367).
Research has found that for parents especially, this bond with the crisis member must be in place, as they experience the severity of their painful loss. For parents, immediate crisis intervention is also a valuable tool to heal. Janoff-Bulman and Frieze, (as cited in Murphy, et al., 1998), suggest that the predominant early postloss emotional experiences are fear and anxiety, which was supported by the study findings" (p.229). They also found that the grief response was intense and there was a prolonged trauma for the participants.
As we look at crisis intervention immediately after a sudden violent loss, we must understand that it is the entire family that is effected. The way the family copes during this tragedy is based on how they coped in past traumas. The children learn many of their coping skills from their parents. Moos (1995) report the following:
One characteristic of coping strategies for dealing with death is that they are typically adapted from coping skills previously used in other crisis. Families come to a death with an abundance of coping skills that have been developed over time and with experience. The family relies on what is familiar and may attempt to use strategies that have worked in the past, such a humor, or problem solving, or simply denial. This does not ensure that the family will choose coping strategies that will promote healthy relationships and solidify family bonds. Many may choose strategies that get them through the current crisis, but fail to provide them with the support they may need later (p.359).
Adolescents in particular are in need of crisis intervention after a sudden violent loss due to their high suicide rate. Bradach & Jordan (1995) write that
|experiencing a traumatic loss during one's own lifetime was significantly associated with various indicators of dysfunction. These adolescents reported more depression, more global psychological symptoms, higher levels of fusion with parents, lower levels of overall individuation, lover levels of intimacy with peers, and poorer college adjustment. These findings support the hypothesis that experiencing a traumatic death in one's own lifetime can have important effects on the individuation process in late adolescents" (p.329).|
|According to Bowlby (as cited in Dilworth & Hidreth, 1997) "children typically fear that the surviving parent will die or that the child himself/herself will die" (p.153). Through crisis intervention children are helped to understand various tasks of mourning and their understanding of death based on their developmental level. The death may not even be talked about at home, and therefore, the school becomes a place for the child to ask his questions and explore his fears and any anxiety they are feeling.
Murphy, et al. (1998) found that "without intervention, parents' perceptions could lead to disruptions of thought processes, sleep, and sense of well-being, which would threaten self-esteem and self-efficacy and lead to breakdowns in partner communication and poor coping responses. We posited that this negative trajectory could result in increased mental distress, trauma symptoms, delayed loss accommodation, declining physical health, and marital-role strain" (p.212).
Future research should attempt to identify the family issues that arise because of the death. Rather than exploring research that sets the groups apart, studies could explore how families stay together in crisis and what can be done immediately to help the entire family cope. The school, religious institutions, and various mental health facilities offer immediate crisis intervention. The survivors are getting most of their needs met. However, focus needs to be paid to family issues in immediate grief-crisis intervention. Studies could identify procedures that benefit the entire family unit and provide a structure for coping as a family unit during crisis.
The research reviewed in this article clearly support the need for grief-crisis intervention. With crisis intervention in place, survivors have lower levels of mourning. grieving and PTSD. According to Haney, Leimer and Lowery (1997) "violent deaths not only threaten our personal sense of security, they alter the existing social order and negate cultural values which bring us together" (p.162). As a culture, we must come together in times of crisis. However, the studies suggest that society lacks the skills to help. Therefore, immediate crisis intervention on the part of religious groups, school and community mental health organizations, should be expanded to meet these needs.
Leenaars & Wenckstern (1998, citing Green, Wilson, and Lindy, noted that "The social environment may contribute to a person's recovery" (p.371). This recovery is possible due to the social support that guides and comforts those who mourn a violent sudden death. Williams & Frangesch (1995, citing Fraser & Atins, 1990; Jones 1978) found that the literature demonstrates that individuals who perceive their social support to be of a high quality seem to feel less overwhelmed by the loss, less lonely, and better able to cope. Therefore, a review of the literature clearly shows that within out culture, immediate crisis intervention after a sudden violent death is a necessity.
When people are murdered, when innocent people are killed and their bodies disfigured from a violent death, survivors depend upon their culture to create rituals and cope with the tragedy. Survivors attempt to cope with the death but they need assistance. Sprang and McNeil (1998, citing Stephens) suggest that society shies away from the discussion of death. He blames this withdrawal on the urbanization of society that has caused the elimination of many traditional communities and rituals concerning death" (p.46). It is during this crisis, when ritual is most important.
Haney, Leimer & Lowery (1997) believe that violence also calls into question cultural values such as our ability to control death and our belief that we are a culture that values human life. When what we value is destroyed, we need tools to heal and measures to take in order to find meaning in the loss . According to Rando (as cited in Haney, Leimer & Lowery, 1997) "mass deaths, and deaths resulting in disfigured or unrecoverable bodies, complicate the mourning process, extending it and often requiring additional measures to aid survivors in obtaining closure" (p. 165). These additional measures are found in crisis intervention.
With support and guidance the bereaved cope with their immediate fear and anxiety and cope with their tragedy. There are programs in place throughout the United States to help people cope with violent, sudden loss. When a tragedy occurs, the community leaders, parents and educators know what they have to do. The programs in the schools are especially noteworthy. By helping the children, we are creating a healthier future for our society. Williams & Frangesch (1995) write that "the research notes that importance of effective grief intervention with sudden death survivors. As health care providers we must be aware that our work is not finished when death has been pronounced. Our work, like the survivor's grief work, has just begun" (p. 477).
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© 1999 Griefworkcenter, Inc. All rights reserved
Barbara Rubel, MA, CBS, CPBC
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