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(here’s the prompt)
Research on Religion-Accommodative Counseling:
Review and Meta-Analysis
Michael E. McCullough
National Institute for Healthcare Research
The present meta-analysis examined data from 5 studies (N = 111) that compared the efficacy
of standard approaches to counseling for depression with religion-accommodative approaches.
There was no evidence that the religion-accommodative approaches were more or
less efficacious than the standard approaches. Findings suggest that the choice to use religious
approaches with religious clients is probably more a matter of client preference than a matter
of differential efficacy. However, additional research is needed to examine whether religionaccommodative
approaches yield differential treatment satisfaction or differential improvements
in spiritual well-being or facilitate relapse prevention. Given the importance of religion
to many potential consumers of psychological services, counseling psychologists should
devote greater attention to religion-accommodative counseling in future studies.
The United States is a highly religious country; 92% of its
population are affiliated with a religion (Kosmin & Lachman,
1993). According to a 1995 survey, 96% of Americans
believe in God or a universal spirit, 42% indicate that they
attend a religious worship service weekly or almost weekly,
67% indicate that they are members of a church or synagogue,
and 60% indicate that religion is “important” or
“very important” in their lives (Gallup, 1995).
In addition, many scholars acknowledge that certain
forms of religious involvement are associated with better
functioning on a variety of measures of mental health.
Reviews of this research (e.g., Bergin, 1991; Bergin, Masters,
& Richards, 1987; Larson et al., 1992; Pargament,
1997; Schumaker, 1992; Worthington, Kurusu, McCullough,
& Sandage, 1996) suggested that several forms of
religious involvement (including intrinsic religious motivation,
attendance at religious worship, receiving coping
support from one’s religious faith or religious congregation,
and positive religious attributions for life events) are positively
associated with a variety of measures of mental health.
For example, various measures of religious involvement
appear to be related to lower degrees of depressive symptoms
in adults (Bienenfeld, Koenig, Larson, & Sherrill,
1997; Ellison, 1995; Kendler, Gardner, & Prescott, 1997)
and children (Miller, Warner, Wickramaratne & Weissman,
1997) and less suicide (e.g., Comstock & Partridge, 1972;
Kark et al., 1996; Wandrei, 1985).
Koenig, George, and Peterson (1998) reported that depressed
people scoring high on measures of intrinsic religiousness
were significantly more likely to experience a
remission of depression during nearly a 1-year follow-up
than were depressed people with lower intrinsic religiousness,
even after controlling for 30 potential demographic,
psychosocial, and medical confounds. Other studies have
Correspondence concerning this article should be addressed to
Michael E. McCullough, National Institute for Healthcare Research,
6110 Executive Boulevard, Suite 908, Rockville, Maryland
20852. Electronic mail may be sent to [email protected]
shown that religious involvement, as gauged through singleitem
measures of frequency of religious worship and private
prayer as well as more complex measures of religious
coping, is related to positive psychological outcomes after
major life events (e.g., Pargament et al., 1990; Pargament et
al., 1994; Pargament, Smith, & Brant, 1995). This is the case
even though several patterns of religious belief and religious
coping (e.g., the belief that one’s misfortunes are a punishment
from God) are associated with greater psychological
distress (Pargament, 1997).
Religion in Counseling and Psychotherapy
Some scholars (e.g., Bergin, 1991; Payne, Bergin, &
Loftus, 1992; Richards & Bergin, 1997; Shafranske, 1996;
Worthington et al., 1996) posited that considering clients’
religiousness while designing treatment plans might have an
important effect on the efficacy of treatment. Surveys of
psychiatrists (Neeleman & King, 1993), psychologists (Bergin
& Jensen, 1988; Shafranske & Malony, 1990), and
mental health counselors (Kelly, 1995) also indicate that
many mental health professionals believe that religious and
spiritual values can and should be thoughtfully addressed in
the course of mental health treatment. Moreover, a variety of
analogue and clinical studies (e.g., Houts & Graham, 1986;
T. A. Kelly & Strupp, 1992; Lewis & Lewis, 1985;
McCullough & Worthington, 1995; McCullough, Worthington,
Maxey, & Rachal, 1997; Morrow, Worthington, &
McCullough, 1993) indicate that clients’ religious beliefs
can influence both (a) the conclusions of clinicians’ structured
psychological assessments and (b) the process of
psychotherapy (cf. Luborsky et al., 1980).
Evidence From Comparative Efficacy Studies
Given the existing research on religion and mental health,
an important question for counseling psychologists is whether
supporting clients’ religious beliefs and values in a structured
treatment package yield clinical benefits that are equal
to or greater than standard methods of psychological prac-
RELIGIOUS COUNSELING META-ANALYSIS 93
tice. Several empirical studies have addressed this issue.
Although the findings of studies that have examined such
questions have been reviewed in narrative fashion elsewhere
(e.g., W. B. Johnson, 1993; Matthews et al., 1998; Worthington
et al., 1996), no researchers have used meta-analytic
methods to estimate quantitatively the differential efficacy of
such treatments. Meta-analytic reviews that compare religious
approaches to counseling with standard approaches to
counseling are one of three meta-analytic strategies that can
be used to examine whether a given therapeutic approach
has therapeutic efficacy (Wampold, 1997).
In the present article, I review the existing research on
such religious approaches to counseling using quantitative
methods of research synthesis (e.g., Cooper & Hedges,
1994; Hunter & Schmidt, 1990) to estimate the differential
efficacy of religious approaches in comparison to standard
forms of counseling for depressed religious clients.
The PsycLIT, PsycINFO, Medline, ERIC, and Dissertation
Abstracts electronic databases were searched through August 1998
for published and unpublished studies that examined the differential
efficacy of a religion-accommodative approach to counseling in
comparison to a standard approach to counseling. The reference
sections of relevant articles were searched for other studies that
would be relevant to this review. This search process continued
until no new studies were revealed. In addition, several experts in
the field of religion and mental health were contacted to identify
Studies had to meet four criteria to be included in the metaanalytic
sample: They had to (a) compare a religion-accommodative
approach to counseling to a standard approach to counseling;
(b) randomly assign patients to treatments; (c) involve patients who
were suffering from a specific set of psychological symptoms (e.g.,
anxiety or depression); and (d) offer equal amounts of treatment to
clients in the religion-accommodative and standard treatments.
Five published studies and one unpublished dissertation (W. B.
Johnson, 1991), which was later reported in W. B. Johnson,
DeVries, Ridley, Pettorini, and Peterson (1994), met these inclusion
criteria. Several studies that investigated religious approaches
to psychological treatment (e.g., Azhar & Varma, 1995a, 1995b;
Azhar, Varma, & Dharap, 1994; Carlson, Bacaseta, & Simanton,
1988; Richards, Owen, & Stein, 1993; Rye & Pargament, 1997;
Toh & Tan, 1997) were obtained, but these studies failed to meet all
four inclusion criteria. Thus, they were omitted from the metaanalytic
sample. A single rater determined which studies met
inclusion criteria. This rater’s decisions were made without reference
to the results or discussion sections of the articles.
The resulting meta-analytic sample included five studies representing
data from 111 counseling clients. Descriptions of study
populations, measures used, and effect size estimates (with 95%
confidence intervals) are given in Table 1.
Researchers interested in accommodative forms of religious
counseling have taken standard cognitive-behavioral protocols or
specific techniques, such as cognitive restructuring (Beck, Rush,
Shaw, & Emery, 1979), cognitive coping skills (Meichenbaum,
1985), and appeals to rational thinking (e.g., Ellis & Grieger, 1977),
and have developed religion-friendly rationales for and versions of
such protocols or techniques (W. B. Johnson & Ridley, 1992b).
These adapted protocols or techniques are thought to be theoretically
equivalent to standard cognitive-behavioral techniques (Propst,
1996), but more amenable to the religious world view and religious
language that religious clients use to understand their lives and
their problems. The five studies are described in greater detail next.
Propst (1980). Propst (1980) examined the differential efficacy
of a manualized, religion-accommodative approach to cognitive
restructuring and imagery modification. Volunteers who scored in
the mild or moderate range of depression on the Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961)
and in at least the moderate range on the King and Hunt (1972)
religion scales were randomly assigned to one of two treatments.
The standard treatment was an integration of Beck’s (1976)
cognitive therapy for depression and Meichenbaum’s (1973) cognitive-
behavior modification. During eight 1-hr sessions conducted
over 4 weeks, clients were trained to observe their cognitions and
imagery during depressed moods. After clients were convinced of
the links between their moods, thoughts, and images, they practiced
cognitive restructuring skills for modifying their thoughts and
images using imagery and positive self-statements (e.g., “I can see
myself in the future coping with that particular situation”). Ten of
eleven clients assigned to this condition completed it.
In the religion-accommodative treatment, clients completed the
same therapeutic protocol as that used in the standard treatment.
The only difference is that participants were trained to replace their
negative cognitions and imagery with religious images (e.g., “I can
visualize Christ going with me into that difficult situation in the
future as I try to cope”). Seven of 9 clients assigned to this
condition completed the treatment.
Pecheur and Edwards (1984). Pecheur and Edwards (1984)
assessed the differential efficacy of Beck et al.’s (1979) cognitive
therapy for depression and a religion-accommodative version of
the same therapy. Clients were students from a Christian college
who met research diagnostic criteria for major depressive disorder.
Sample Sizes, Effect Sizes, and 95% Confidence Intervals (Cl)for the Studies Included
in the Meta-Analysis
Pecheur & Edwards (1984)
Propst etal. (1992)
W. B. Johnson & Ridley (1992a)
W. B. Johnson et al. (1994)
They also scored in the depressed range on the BDI, the Hamilton
Rating Scale for Depression (HRSD; Hamilton 1960), and a
single-item visual analogue scale. In the standard treatment, clients
completed eight 50-min sessions of cognitive behavior modification.
All 7 clients who were assigned to this treatment completed it.
In the religion-accommodative treatment, clients completed the
standard cognitive therapy tasks specified in Beck et al. (1979);
however, challenges to negative cognitions were placed in a
religious context. For example, rather than replacing negative
views of self with statements such as “Our self-acceptance and
self-worth are not lost or lessened when we fail,” the religionaccommodative
approach trained clients to use self-statements
such as, “God loves, accepts, and values us just as we are.” This
treatment was also administered according to a manual, which
appears in Pecheur (1980).
Propst, Ostrom, Watkins, Dean, and Mashburn (1992). Propst
et al. (1992) compared the efficacy of Beck et al.’s (1979) cognitive
therapy for depression with a manualized, religion-accommodative
version of the same therapy (see Propst, 1988). Clients were
recruited from the community and scored at least 14 on the 28-item
version of the HRSD. They also scored at least in the moderate
range on standard measures of religious commitment (e.g., Allport
& Ross, 1967; King & Hunt, 1972). Clients in the standard
treatment completed 18 sessions of individual cognitive therapy for
depression. All 19 clients enrolled in this condition completed it.
In the religion-accommodative treatment, clients completed 18
sessions of cognitive therapy that challenged negative cognitions
and images by replacing them with positive thoughts and imagery
of a religious nature, as in Propst (1980). All 19 clients enrolled in
this condition completed it.
W. B. Johnson & Ridley (1992a). Johnson and Ridley (1992)
compared the efficacy of rational-emotive therapy (RET), using
Walen, DiGiuseppe, and Wessler’s (1980) treatment manual, with a
manualized, religion-accommodative version of the same therapy.
Clients were theology students and local church members who
scored in at least the mildly depressed range on the BDI. They also
scored in the “intrinsic” range on a standard measure of religious
motivation (Allport & Ross, 1967), suggesting that their religious
faith was highly internalized. In the standard RET condition, clients
completed six 50-min sessions in 3 weeks, including homework
sessions and in-session rehearsal of rational-emotive techniques.
All 5 clients assigned to this condition completed it.
In the religion-accommodative treatment, three explicitly Christian
treatment components were added. First, clients were directed
to dispute irrational beliefs using explicitly Christian beliefs, as in
Propst (1980). Second, clients were encouraged to use Christian
prayer, thoughts, and imagery in their homework assignments.
Third, counselors used brief prayers at the end of each session. All
5 clients assigned to this condition completed it.
W. B. Johnson et al. (1994). W. B. Johnson et al. (1994)
compared the efficacy of standard RET and a religion-accommodative
form of RET, as in W. B. Johnson and Ridley (1992a).
Selection criteria were almost identical to those reported in W. B.
Johnson and Ridley (1992a). The standard RET condition was an
eight-session protocol delivered over 8 weeks, and was based on
two popular RET treatment manuals (Ellis & Dryden, 1987; Walen
et al., 1980). All 16 clients assigned to this condition completed it.
The religion-accommodative treatment was based on two treatment
manuals discussing Christian versions of RET (Backus, 1985;
Thurman, 1989). Although the basic structure of RET was kept
intact, clients were encouraged to dispute irrational beliefs based
on scriptural beliefs and biblical examples. Homework assignments
also used biblical examples and beliefs. All 16 clients
assigned to this condition completed it.
Effect Size Estimates
Effect sizes and homogeneity statistics were calculated from
means and standard deviations using the DSTAT statistical software,
Version 1.10 (B. T. Johnson, 1989), using the formulas
prescribed by Hedges and Olkin (1985). Effect sizes were based on
the difference between the mean of clients in the standard
counseling condition and the mean of clients in the religionaccommodative
conditions. This difference was divided by the
pooled standard deviation of clients in both conditions. All effect
size estimates, expressed as d+ values, are corrected for the bias
that is present in uncorrected g values, as recommended by Hedges
and Olkin (1985). Effect sizes can be interpreted as the increased
amount of symptom reduction afforded to participants in the
religion-accommodative condition, expressed in standard deviation
units. In calculating aggregate effect size estimates, individual
effect sizes were weighted by the inverse of their sampling error
variance, so that studies with larger samples were given greater
weight in the calculation of d+ (Hedges & Olkin, 1985).
The Q statistic was also used to estimate the degree of variability
among the effect sizes. The Q statistic is basically a goodness-of-fit
statistic with a roughly x2 distribution that enables a test of the
hypothesis that all observed effect sizes were drawn from the same
population. Significant Q values imply a heterogeneous set of effect
sizes (Hunter & Schmidt, 1990).
Handling Multiple Dependent Measures
All five studies used the BDI as a dependent measure of
depression. Although two of the studies also used the HRSD or a
single-item visual analogue measure of depression, or both (Pecheur
& Edwards, 1984; Propst et al., 1992), effect size estimates
were based exclusively on the BDI for three reasons. First, the BDI
has been shown to produce conservative effect size estimates in
comparison to rating scales that are completed by clinicians, such
as the HRSD (Lambert, Hatch, Kingston, & Edwards, 1986).
Second, single-item visual analogue measures of depression (e.g.,
Aitken, 1969) appear to contain remarkably little true score
variance (Faravelli, Albanesi, & Poli, 1986). Third, the aggregation
of data across multiple dependent measures requires knowing their
intercorrelations, which were not available for all five studies.
Thus, the individual and mean effect size estimates reported here
can be considered to be somewhat conservative.
Handling Data From Multiple Follow-Up Periods
All five studies collected follow-up data within 1 week of the
termination of the trial. Although three of the studies (W. B.
Johnson et al., 1994; Pecheur & Edwards, 1984; Propst et al., 1992)
also reported follow-up data collected between 1 and 3 months
after the termination of the trial, and one study (Propst et al., 1992)
reported an effect size for a 24-month follow-up, we based our
effect size estimates only on the data from the 1-week follow-up.
Other Problems With Coding Effect Sizes
Some studies reported data on additional experimental conditions,
including self-monitoring and therapist contact conditions
(Propst, 1980), waiting list control conditions (Pecheur & Edwards,
1984; Propst et al., 1992), and pastoral counseling conditions
(Propst et al., 1992). Because none of these conditions were
relevant to the central goal of this study, these data were neither
coded nor included in the present meta-analytic study.
RELIGIOUS COUNSELING META-ANALYSIS 95
Two other problems arose in coding effect sizes. First, although
Propst (1980) reported posttreatment means on the BDI for both
conditions, standard deviations were not reported. On the basis of
the assumption that the other four studies in the present metaanalysis
would yield similar pooled standard deviations for the
BDI, a mean standard deviation for posttest scores on the BDI from
these studies (5.81) was used as an imputed standard deviation for
Propst (1980). This imputed standard deviation produced a nonsignificant
test statistic for the comparison of the religious and
standard counseling conditions, as Propst (1980) reported, giving
us confidence that our imputed standard deviation was not wholly
Second, Propst et al.’s (1992) results reported treatment effects
separately for religious and nonreligious therapists, which was an
independent factor in their experimental design. To collapse
treatment effects across levels of the therapist religiousness factor,
means and standard deviations obtained for religious and nonreligious
therapists within each of the two religious counseling
conditions were pooled before calculating an effect size for the
Corrections of Findings for Unreliability
in Dependent Measures
Scholars in meta-analysis advise that effect size estimates be
corrected for biases (Hunter & Schmidt, 1990, 1994). One of the
easiest biases to correct is attenuation resulting from unreliability
in the dependent variable. This bias can be corrected by dividing
observed effect sizes and standard errors by the square root of the
internal consistency of the dependent variable. Because metaanalytic
estimates of the BDI’s internal consistency were readily
available (Beck, Steer, & Garbin, 1988, estimated its internal
consistency at a = .86), the observed mean effect size and its
confidence interval (CI) were divided by the square root of .86, or
.927. Corrections for attenuation resulting from unreliability of the
dependent variable produce increased effect size estimates but also
a proportionate increase in confidence intervals; thus, a nonsignificant
effect size will not become significant as a result of this
correction (Hunter & Schmidt, 1994).
Estimating Clinical Significance
We were also interested in whether religion-accommodative and
standard approaches to counseling yielded clinically significant
differences in efficacy (Jacobson & Revenstorf, 1988; Jacobson &
Truax, 1991). Thus, we calculated meta-analytic summaries of
clinical significance for two studies that reported clinical significance
data (using BDI > 9 as a cutoff for “mild clinical depression”;
Kendall, Hollon, Beck, Hammen, & Ingram, 1987).
Observed Mean Effect Size and Attenuation-Corrected
The mean effect size for the difference between religious
and standard counseling during the 1-week follow-up period
(number of effect sizes = 5, N = 111) was d+ = +0.18
(95% CI: -.20/+0.56), indicating that clients in religionaccommodative
counseling had slightly lower BDI scores at
1-week follow-up than did clients in standard counseling
conditions. This effect size was not reliably different from
zero (p = .34). The five effect sizes that contributed to this
mean effect size were homogeneous, Q(4) = 5.38, p > .10.
The mean effect size after correcting the effects for attenuation
resulting from unreliability was d+ = +0.20 (95% CI:
Differences in Clinical Significance
Two studies (W. B. Johnson & C. R. Ridley, 1992a;
Propst, 1980) reported the percentage of participants in the
religious and standard psychotherapy conditions who manifested
evidence of at least mild clinical depression (BDI
scores >9) during the 1-week follow-up period. Aggregation
of these data indicated that, among the 20 religionaccommodative
counseling clients in the two studies, 4
(20%) were still at least mildly depressed at the end of
treatment. Among the 26 standard counseling clients in the
two studies, 9 (34.6%) were at least mildly depressed when
treatment ended. This difference clinical significance was
not statistically significant, x2(l, N = 46) = 1.19,p > .10.
The goal of the present study was to review the existing
empirical evidence regarding the comparative efficacy of
religion-accommodative approaches to counseling depressed
religious clients. These data suggest that, in the
immediate period after completion of counseling, religious
approaches to counseling do not have any significant
superiority to standard approaches to counseling. Given that
the differences in efficacy of most bonafide treatments are
surprisingly small (e.g., Lambert & Bergin, 1994; Wampold,
1997), the existing literature on psychotherapy outcomes
would have portended the present meta-analytic results.
These findings corroborate some narrative reviews that
claim equal efficacy for religion-accommodative and standard
approaches to counseling (e.g., Worthington et al.,
1996), and help to resolve the inconsistencies that others
have observed among these studies (e.g., W. B. Johnson,
1993; Matthews et al., 1998).
Although it is true that the religious approaches to
counseling were no more effective than the standard approaches
to counseling, it is equally true that they were no
less effective than the standard approaches to counseling.
Thus, the decision to use religion-accommodative approaches
might be most wisely based not on the results of
comparative clinical trials, which tend to find no differences
among well-manualized treatments, but rather on the basis
of patient choice (see Wampold, 1997). Not every religious
client would prefer or respond favorably to a religionaccommodative
approach to counseling. Indeed, the available
evidence suggests that all but the most highly religious
clients would prefer an approach to counseling that deals
with religious issues only peripherally rather than focally
(Wyatt & Johnson, 1990; see Worthington et al., 1996, for
On the other hand, many religious clients—especially
very conservative Christian clients—would indeed be attracted
to a counseling approach (or counselor) precisely
because the counseling approach (or the counselot) main96
tained that the clients’ system of religious values were at the
core of effective psychological change (Worthington, et al.,
1996). The research reviewed herein indicates that no
empirical basis exists for withholding such religionaccommodative
treatment from depressed religious clients
who desire such a treatment approach.
The Last Word?
There is inherent danger in publishing meta-analytic
results. Because of their ability to provide precise-looking
point estimates and short CIs (especially when the observed
effect size estimates are relatively heterogeneous), metaanalytic
summaries can be perceived to be the last word in
evaluating research questions. It would be unfortunate if the
present results were interpreted as the last word in evaluating
the efficacy of religious approaches to counseling, however,
because interesting and important questions remain.
For example, although religion-accommodative approaches
to counseling do not appear to be differentially
efficacious in reducing symptoms (at least depressive symptoms),
they might produce differential treatment satisfaction
among some religious clients. Also, comparative studies of
religion-accommodative therapy are needed with longer
follow-up periods. It is possible that religion-accommodative
approaches might prove to be superior to standard
treatments in longer term follow-up periods, particularly in
helping clients from relapsing, for example, back into
depressive episodes. The differential effects of religionaccommodative
and standard approaches to treatment also
need to be investigated for a wider variety of disorders,
including anxiety, anger, alcohol and drug problems, and
marital and family problems. As well, although religionaccommodative
and standard approaches to counseling do
not appear to influence clients’ religiousness or religious
values differentially (Worthington et al., 1996), it is possible
that religion-accommodative counseling yields differential
improvements in religious clients’ spiritual well-being.
Finally, on a technical note, it should be noted that the
studies in this body of literature currently have been
seriously underpowered (i.e., in all cases fewer than 20
clients per treatment). This literature would benefit enormously
from as few as three or four very high-quality,
large-sample (i.e., 30 or more clients per condition) studies
that investigated these questions in greater detail. W. B.
Johnson (1993) provided other helpful methodological recommendations
to which research on religion-accommodative
counseling should adhere.
The stability of meta-analytic findings comes from the
number of studies included in the meta-analysis as well as
the number of participants in the constituent studies. Thus,
the findings from meta-analyses with small numbers of
studies, such as the present study, are more easily overturned
than meta-analyses that include larger numbers of studies.
Although meta-analytic methods can be used to synthesize
the results of as few as two studies (for examples of small-it
meta-analyses, see Allison & Faith, 1996; Benschop et al.,
1998; Kirsch, Montgomery, & Sapirstein, 1995; Uchino,
Cacioppo, & Kiecolt-Glaser, 1996), our findings would
obviously be considered more trustworthy if more studies
had been available.
A second limitation of the present findings relates to the
nature of the meta-analytic sample. The five studies reviewed
herein all investigated religion-accommodative counseling
with depressed Christian clients. We can only speculate
whether the present pattern of results would generalize
to different religious populations or to people with different
sets of presenting problems. Obviously, research is needed
to fill in such gaps.
A variety of empirical data now suggest that certain forms
of religious involvement can help prevent the onset of
psychological difficulties and enhance effective coping with
stressors. In addition, the majority of mental health professionals
and the general public believe that patients’ religious
beliefs should be adequately assessed and taken into consideration
in mental health treatment. Moreover, data indicate
that patients’ religious commitments can play a substantial
role in counseling processes (Worthington et al., 1996). Data
from the present study also indicate that religious approaches
to counseling can be as effective as standard
approaches to counseling depressed persons. Thus, for some
clients, particularly very religious Christian clients, religionaccommodative
approaches to counseling could be, quite
literally, the treatment of choice. It is hoped that the present
study will encourage counseling psychologists to examine
whether religion-accommodative approaches yield similar
or even superior benefits on other important metrics of
therapeutic change and with other common difficulties in
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Received April 27,1998
Revision received September 4,1998
Accepted September 8, 1998
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