Reconnecting for Recovery Multifamily Therapy Group: Capitalizing on Connection and Community in the Treatment of Adults with Anorexia Nervosa
By Mary Tantillo, PhD, PMHCNS-BC, Faed, CGP
“There are no strangers here; only friends you haven’t yet met.”
—William Butler Yeats
“What we need is here.”
Long before we became consumers in a health care system, we were citizens caring for one another in small communities. These caring communities were based on the value of connections and the belief that each person in the community had gifts to share with others (McKnight & Block, 2012). Abundance instead of scarcity was fostered, and community wholeness was closely linked with individual wholeness (Berry, 1977).
Today, patients with Anorexia Nervosa (AN) and their families seek health care services from medical providers in our consumer-driven, individualistic, and fragmented culture. The ideal provider is a specialist trained in eating disorders who is the “expert” with regard to treatment and recovery. While specialty care is essential in the treatment of AN, the act of placing oneself and one’s family in the hands of specialists can unwittingly lead to the idea that professional caregivers hold all the answers to achieving health and recovery. Individual wholeness becomes dependent on people and forces outside one’s family and community. Scarcity of resources (within the health care system), instead of abundance (in the community), becomes the rule, and patient and family may forget the gifts and strengths they bring to bear on eliminating the eating disorder and helping the patient restore health and reclaim life. These experiences also play directly into the hand of the eating disorder, which is notorious for the burden of care it exacts on personal and professional carers and for its quest to promote disconnections whenever possible.
Multifamily Therapy Group Treatment: Creating a Therapeutic Community for Patients With AN and Their Families
One way to build a competent community that can promote healing, wholeness, and recovery is through the use of Multifamily Therapy Group (MFTG). MFTG is, in essence, a “therapeutic village of support” composed of five to seven patients and their respective family of origin or family of choice members who routinely meet together (e.g., weekly or monthly) to gain knowledge about a particular illness and the most effective ways to help patients manage that illness and move ahead in recovery from that illness. MFTG has been used successfully since the 1960s to treat a number of chronic behavioral health and medical problems, including schizophrenia (Dyck et al., 2000; Laqueur, LaBurt, & Morong, 1964; McFarlane, 2002); depression (Anderson et al., 1986; Lemmens, Eisler, Dierick, Lietaerd, & Demyttenaere, 2009); bipolar illness (Moltz & Newmark, 2002); substance abuse (Kaufman & Kaufmann, 1977; 1979); diabetes, asthma, and cancer (Gonzales & Steinglass, 2002); and brain injury (Couchman, McMahon, Kelly, & Ponsford, 2014). Research on MFTGs for patients with illnesses other than eating disorders have shown symptom improvement and positive patient and family outcomes, including enhanced communication within and between families, and decreased treatment costs (Dyck et al., 2000; Lemmens et al., 2009; McFarlane, 2002).
MFTG may also offer benefits in the treatment of adults with AN because this modality involves the creation of an abundant, sustainable therapeutic community (Asen & Scholz, 2010; Eisler, 2005; Eisler, Lock, & Le Grange, 2010; McFarlane, 2002; Tantillo, 2006; Tantillo, Sanftner, & Hauenstein, 2013; Tantillo, McGraw, Hauenstein, & Groth, 2015) that capitalizes on and maximizes the strengths, resources, and adaptive coping strategies of a number of patients and their family members. MFTG increases the support networks and learning opportunities for patients with AN and their family members who commonly experience conflict, tension, and shame owing to the distress and burden of care created by AN (Schmidt & Treasure, 2006; Whitney, Haigh, Weinman, & Treasure, 2007; Zabala, MacDonald, & Treasure, 2009). MFTG has the potential to decrease patient and family member distress through leveraging the group as a resource in sharing the burden of care and promoting a sense of universality and cohesiveness (Asen, 2002; Asen & Scholz, 2010; Dare & Eisler, 2000; Eisler, 2005; Eisler, Lock, & Le Grange, 2010; Scholz & Asen, 2001; Tantillo, 2006; Tantillo et al., 2013; Tantillo et al., 2015). MFTG members work together as “co-therapists” with the MFTG therapist to eliminate symptoms, manage illness, and promote ongoing recovery for both patients and families (Tantillo, 2006; Tantillo et al., 2015; Eisler, 2005; Eisler, Lock, & Le Grange, 2010; Gonzales & Steinglass, 2002; McFarlane, 2002).
Preliminary findings regarding outcomes for adolescents with eating disorders in MFTG provided in day-treatment and inpatient settings show improvements in AN patient symptoms, including stabilization of eating, reduced number of binge-vomit episodes, weight gain, and return of menses from baseline to end of treatment (Dare & Eisler, 2000; Scholz & Asen, 2001). In addition, findings show fewer dropouts from treatment (Asen, 2002), decreased inpatient length of stay, and less relapse (Scholz & Asen, 2001). Family outcomes from MFTG include reductions in negativity expressed by family members of patients with AN, and improved family functioning (e.g., joint problem-solving) (Dare & Eisler, 2000; Eisler, 2005; Scholz & Asen, 2001).
Research findings have also shown that MFTG is as effective as a single family therapy (SFT) format, but also more cost-effective (Bruneaux & Cook-Darzen, 2008; Geist, Heinmaa, Stephens, Davis, & Katzman, 2000). Results from Salaminou, Campbell, Simic, Kuipers, and Eisler (2015) showed high patient and family satisfaction and significant improvements in AN cognition, mood, and self-esteem. These findings compared favorably with outcome data from larger, more rigorous evaluations of SFT for adolescent AN currently considered to be the treatment of choice. Preliminary results from Eisler and colleagues’ multicenter randomized, controlled trial suggest that MFT may improve outcomes compared with SFT (Eisler, 2013).
MFTG’s strong and sustainable therapeutic community may be especially helpful for adults with AN, because clinical practice and research findings support an association between social functioning and relationships with close others and recovery for adults with AN (Berkman, Lohr, & Bulik, 2007; Isager, Brinch, Kreiner, & Tolstrup, 1985; Lowe et al., 2001; Bell, 2011; Kaplan, 2008; Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003; Wright & Hacking, 2012; Strober, Freeman, & Morrell, 1997). For example, research has shown that time to recovery is increased significantly among patients with disturbances in family relationships (Strober et al., 1997). In addition, adult women with AN report that empathic relationships with family and significant others are “the driving force” (Tozzi et al., 2003, p. 151) in recovery (Bell, 2011; Kaplan, 2008; Tozzi et al., 2003; Wright & Hacking, 2012). The quality of relationships with significant others in the life of patients with AN is critical, because the outcome of AN is influenced by caregiver high expressed emotion (i.e., hostility, criticism, and emotional over-involvement) and the resulting interpersonal disconnections (Butzlaff & Hooley, 1998; Stice, 2002; Szmukler, Eisler, Russel, & Dare, 1985; van Furth et al., 1996).
Despite the potential promise of MFTG for adults with AN, there has been limited research examining its effectiveness in adults (Colahan & Robinson, 2002; Dimitropoulos, Farquhar, Freeman, Colton, & Olmsted, 2015; Tantillo et al., 2015). The Dimitropoulos et al. pilot study (2015) suggested that there were no differences between MFT and SFT on family outcome measures at end of treatment and three months posttreatment. The Tantillo et al. (2015) content analysis of alumni who attended outpatient MFTGs revealed that recovery is long and arduous, marked by intense emotions and intra- and interpersonal disconnections. Findings suggested that MFTG helped repair these disconnections by promoting communication and connections among family members and assisting with identification and expression of emotions.
Reconnecting for Recovery: The Promise of a Relational/Motivational Multifamily Therapy Group for Adults with AN
With the aim of contributing to the efforts at identifying new and innovative approaches to treating adults with AN, the author worked in partnership with patients and families over the past decade to design a Relational/Motivational Multifamily Therapy Group for adults with AN, “Reconnecting for Recovery.” This 16-session outpatient MFTG (over 26 weeks) is informed heavily by Relational-Cultural Theory, as well as by Stages of Change Theory and Motivational Interviewing (Banks & Hirschman, 2016; Jordan, 2010; Miller & Rollnick, 2013; Miller & Stiver, 1997; Prochaska, Norcross, & DiClemente, 1994; Tantillo, 2006; Tantillo & Sanftner, 2010a; Tantillo et al., 2013). Stages of Change Theory (Prochaska et al., 1994) assists with the evaluation of an individual’s stage of and readiness for change, and Motivational Interviewing is a patient-centered, collaborative approach for helping patients to resolve ambivalence and move through these stages (Miller & Rollnick, 2013; Tantillo & Sanftner, 2010a). Relational-Cultural Theory emphasizes how disconnection from the self and others can contribute to and perpetuate psychological and physical health problems. It also asserts that psychological change, motivation for change, and recovery occur through the experience of Perceived Mutuality (PM) in connections with others (Banks & Hirschman, 2016; Genero, Miller, Surrey, & Baldwin, 1992; Jordan, 2010; Miller & Stiver, 1997; Tantillo & Sanftner, 2010b). PM is the feeling of mutual trust, understanding, and empathy experienced when individuals are able to be emotionally vulnerable with one another. They understand how they influence others and allow others to influence them. In relationships marked by PM, each person in the relationship is able to develop clearer understandings about themselves, the other, and the relationship; feel empowered to advocate on behalf of themselves and the relationship; feel increased self-worth; and experience a desire for more connection (Miller & Stiver, 1997; Jordan, 2010).
Reconnecting for Recovery is also informed by clinical observation and earlier evaluation data (Tantillo, unpublished raw data, 2010c). The latter indicated that patients and families attending the original outpatient eight-week Relational-Motivational MFTG (Tantillo, 2006) experienced fewer eating disorder symptoms at the end of treatment, greater patient and parent PM from baseline to end of treatment, and high patient and family satisfaction at end of treatment. PM and eating disorder symptoms were also negatively correlated, indicating that a decrease in eating disorder symptoms was associated with an increase of PM. In 2015, Tantillo et al. conducted a content analysis of feedback from alumni who attended the eight-week MFTGs. Study findings revealed patient and family experiences of recovery and the MFTG, and they included recommended refinements of the MFTG to specifically target adults with AN (e.g., lengthening the group to 16 sessions and moving it from weekly to every other week to monthly sessions). The author is currently conducting a pilot study, funded by the Hilda & Preston Davis Foundation, evaluating the feasibility and effectiveness of the new 16-session MFTG format. *
Reconnecting for Recovery MFTG is similar to the relationally focused MFTGs for adolescents with AN (Asen & Scholz, 2010; Depestele, Claes, & Lemmens, 2014; Eisler, 2005; Eisler, Lock, & Le Grange, 2010) because these MFTG models externalize the AN, understand it within a relational context, promote self-awareness through interpersonal learning, and foster new and different perspectives through mutual support and feedback. However, Reconnecting for Recovery is also different from these other MFTGs for AN because it does not include family meals, minimizes the emphasis on refeeding and weight, and includes family of origin as well as “family of choice” members (e.g., partners, best friends, and mentors) who have an emotional investment in the patient’s recovery. Most important, it includes an up-front reframing of AN as a disease of disconnection. It proposes that AN disconnects the patient from his or her own genuine thoughts, feelings, needs, and bodily states, and from significant others.
Figures 1 and 2 show the circles we draw on the board at the start of each MFTG to remind participants about the disconnections associated with AN. These disconnections can be characterized by those that involve separation and isolation (i.e., presence of an “I” and a “You” but no “We”) (Figure 1), or those characterized by “over-involvement and over-closeness” (i.e., little or no distinction between the “I” and the “You” and lack of a healthy differentiated “We”) (Figure 2). In the first kind of disconnection (Figure 1), there is no communication. In the latter kind of disconnection (Figure 2), the patient and/or family may interact in a “pseudo-mutual” way but may actually be “walking on eggshells.” They may be unable to voice different feelings, thoughts, or needs for fear that the last shred of connection with one another will be lost.
Figure 3 is the Venn diagram we draw on the board to remind members about the goal of MFTG: developing PM (i.e., mutual relationships) where there is an “I,” a “You,” and a healthy differentiated “We.” In these relationships, there is respect for the unique feelings and needs of each person, as well as an honoring of the relationship. The experience of PM (i.e., the back-and-forth flow of mutual trust, empathy, and empowerment) fostered by MFTG helps patients and family members to connect with their own genuine feelings, thoughts, and needs, and with each other, thus allowing them to practice being “different in connection” (i.e., being able to share different thoughts, feelings, and needs). Relational-Cultural Theory asserts that this process fosters repair of disconnections, healing, psychological growth, and recovery (Jordan, 2010; Miller & Stiver, 1997; Tantillo & Sanftner, 2010a; Tantillo et al., 2013).
The reframing of AN as a disease of disconnection is based on Relational-Cultural Theory, as well as an emerging research literature that is addressing the important role of interpersonal (e.g., affective and behavioral) and intrapersonal (e.g., biological and psychological) processes (Tantillo et al., 2013) that contribute to the patient’s experience of being disconnected from his or her authentic self, body, and close others (Connan, Campbell, Katzman, Lightman, & Treasure, 2003; Lask & Frampton, 2011; Nunn, Frampton, Fuglset, Torzsok-Sonnevend, & Lask, 2011; Schmidt & Treasure, 2006; Schmidt, Wade, & Trestler, 2014; Southgate, Tchanturia, & Treasure, 2005).
Research findings suggest that the interplay of intrapersonal and interpersonal processes characterizing AN can amplify interpersonal disconnections experienced in relationships with family members. For example, an intrapersonal process such as poor interoceptive awareness (involving inaccurate perception of internal bodily states and confusion or fear/nonacceptance of one’s emotions [Garner, 2004; Merwin, Zucker, Lacey, & Elliott, 2010]) can interact with two interpersonal processes, i.e., avoidance in the face of intense emotion in relationships (Haynos & Fruzzetti, 2011; Schmidt & Treasure, 2006; Tantillo et al., 2013), and silencing one’s feelings and needs in relationships (Geller, Cockell, Hewitt, Goldner, & Flett, 2000), to create misunderstanding and conflict in relationships with family members (interpersonal disconnections). The clinical vignette below provides an example of the above processes for a young adult patient (Melissa, age 28) and how the interplay of these processes associated with AN created disconnection in her relationship with her brother (Sean, age 40). The vignette also shows how MFTG helped them identify and repair disconnections, allowing them to practice emotional and relational processing skills facilitating reconnections with self and others. Reconnections and new connections help the patient meet needs and regulate emotions without the use of AN.
Group Facilitator: So, last week we made a list of all the disconnections and points of tension created by AN. Some of these were directly related to the eating disorder, some to recovery, and some to relationships. The group wanted to start with examining a point of tension/disconnection that can happen when the person in recovery does not hear something the way it is intended. Does anyone want to give an example of how this happens in their relationships with one another?
Sean: I am the one who wrote that down, and I did that because it seems like no matter what I say, it is the wrong thing for Melissa. She takes things the wrong way.
Melissa: (Responds by shaking her head in disagreement with her eyes cast downward.)
Group Facilitator: Melissa, it seems like you are disagreeing with Sean?
Melissa: That’s not true that I always hear something different. I think he is talking about what happened the other night, and he doesn’t get what that was like for me.
Group Facilitator: Melissa, maybe you and your brother can each share what happened the other night so we can get a sense of how you each experienced it. It could be very different for each of you, and that is OK.
Melissa: (Quiet and looking anxiously at her brother.)
Sean: This is kind of what happens at home when I try to get her to tell me what is going on inside. She shuts down and then goes to her room or leaves the house. The other night, we were supposed to go to our sister’s home for our parents’ anniversary party, and Melissa was going to go with me and my wife. When it came time to go, she said she was changing her mind, and I got frustrated because we tried to do everything we could to make it easier on her. We ensured that safer foods would be served, and we planned to sit next to her at the table to give her support. My parents really wanted her there.
Melissa: You don’t get what it is like to eat in front of so many people. It was only supposed to be us and Mom and Dad and Grandma. I had no idea everything had changed and suddenly all our aunts and uncles and all our cousins were coming, too. It was too much.
Sean: But I told you that the answer was simple. It was an easy fix. We would just rethink where you could sit at the table, what you wanted to say before you went, and we could figure it out. Susan [Sean’s wife] and I would be there with you.
Melissa: (Became visibly tearful and annoyed, and remained quiet.)
Group Facilitator: Melissa, can you tell us how you are feeling inside as Sean is sharing his experience of the other night? Your experience could be different from his.
Melissa: He said it again, just like the other night. It is so easy and simple. It is NOT easy and simple.
Group Facilitator: Those are important thoughts. Can you tell us how you feel in your heart?
Melissa: I am frustrated and feel invalidated again. He doesn’t understand how overwhelmed and panicked I felt about going to the party. He always minimizes it.
Sean: But I did not intend to minimize what was going on. This is exactly the problem. I was trying to fix things so you would not feel so upset. I just think I should be able to say whatever I need to say without always watching what I say and how it will be interpreted. She should know by now that what I say comes from the heart and I mean well.
Group Facilitator: Sean, you are her big brother and it makes sense that you want to fix things for her. It sounds like you intended to be supportive of Melissa. How are you feeling in response to what she is sharing?
Sean: Well, I feel frustrated, too, because I am tired of this cycle of trying to help and then being misunderstood. It’s like nothing is going to change.
Group Facilitator: So it’s important to notice that the eating disorder is trying to make you both think in very all-or-nothing ways and that you both feel similar feelings for different reasons. And, of course, this is what the eating disorder wants. It wants you both to feel frustrated so it can have its way and keep you disconnected. I am sure that Melissa and Sean are not the only ones who have experienced something like this. Would anyone else like to share a similar experience?
Ben (another patient): Sean, you have to understand that when you say something to us, it goes like this—(he makes several twisting motions in the air with his finger and then points it to his head). You intend it to be heard one way, but the illness makes us hear it in another. That has happened with my mom and dad, too. We are so anxious about being with others and eating with others that whatever you say at times like that, it is probably not going to be heard the way you hope. You also can’t totally fix what is happening for Melissa, but you can listen and help her figure out what she is feeling inside. When I get like that, I am usually pretty scared. It is hard to process anything when I am like that. I just want to isolate in my room and not eat. And, of course, I feel like a failure because I can’t do something my parents or partner wants me to try.
Sally (Ben’s mother): It is true, what Ben is saying. It has taken me awhile to figure out what to say and how and when to say it to help him when he is on overload. It gets easier in time. Sean, you have to remember that Melissa probably doesn’t always know what she feels or needs, and that is why she can’t immediately tell you. Eight weeks ago, Ben was not able to talk the way he just did. He had lots of trouble figuring out what was going on inside. He is better at it now, and I am better at just being with him and feeling less worried about what to do all the time. I initially felt very helpless and hopeless and frustrated—I think the ways you are feeling. The eating disorder likes to take advantage of situations like this in order to keep us apart from each other. I have learned to slow down and help Ben figure out what is going on inside, and sometimes he needs space and time to do that, and sometimes he can do that more quickly now.
Sean: Well, I am feeling helpless and more hopeless this week. And it makes the frustration worse. I don’t know what to do.
Group Facilitator: Melissa, I am wondering about what you think about what Ben and his mom have shared.
Melissa: Well, I did feel guilty and like a failure when I felt like I could not go to the party. I didn’t want to let my parents or my brother down, but I also felt frustrated because I did not think Sean really understood what was going on for me. I probably didn’t know exactly what I felt or needed, either, because all I knew at the time was I wanted to run. I felt panicked. And I guess I also felt embarrassed about this. I am 28 years old and can’t go to my parents’ anniversary party. I am so sick of this illness, but also so scared to let it go. Everything just went south. I didn’t want to eat and I wanted to isolate.
Group Facilitator: So this is very important for Sean to understand. Thinking back, what would be the very first clue that you were “going south”? Like, is there a certain way you start thinking, or something you start doing, or a way you start feeling inside that is the first clue? It would be important for you and Sean to know this early on, so you can let him know and he can help in some way.
Melissa: I guess it is when I start feeling a tightness in my chest and I start feeling like I can’t breathe. I start telling myself that “this feels too much.” I think that is when the anxiety starts.
Group Facilitator: And what could be helpful at times like this?
Melissa: I am not positive. I probably need to think more on that.
Group Facilitator: OK. Well how about you keep doing that, and we can also ask the group for help with that. Can other patients and family members share what they think might help or what you have done in similar situations that has helped in the past? (The group provides several suggestions and Melissa eventually shares with Sean what would have been helpful the other night. Sean also lets Melissa know she is not a failure and that he will practice giving her time and space to figure out what is going on inside at times like this and not throw up his hands and walk away.)
In the clinical vignette above, the MFTG facilitator helps Melissa and Sean name the intra- and interpersonal processes Melissa experienced leading to their interpersonal disconnection—her difficulty naming internal states in the immediacy of an interaction, avoidance of intense emotion, and misinterpreting her brother’s help as an invalidation and shutting down in the face of high anxiety. Sean was also able to name his feeling states and challenges. This work included a bidirectional sharing of the meanings and emotions related to their interactions with each other, as well as feedback from other patients and families who have shared similar experiences. This work increased the experience of PM for Sean and Melissa, allowing them to identify and repair the disconnection they experienced. This repair helped them generate different problem solutions in the face of Melissa’s anxiety about eating at a social gathering and, thus, avoid unwittingly reinforcing her use of AN to manage her anxiety. The therapeutic work accomplished in this group also strengthened a sense of PM and universality for the group as a whole, fostering a sense of empowerment and confidence in their abilities to move ahead in recovery.
The overall goal of Reconnecting for Recovery MFTG is to develop an abundant, competent, and caring community that allows adults with AN and their families to learn, heal, and grow together in recovery. It reminds patients and families that what is needed to recover and reclaim life “is here inside of us and here in our community.” It helps patients with AN and their families see their gifts, strengths, and resources, and how to maximize them in the work of recovery. It helps patients and families feel more like “producers of [their] own future [instead of] purchasers of what others have in mind for [them]” (McKnight & Block, 2012, p. 26).
Patients and family members often comment that love alone is not enough and education alone is not enough to attain full recovery. What is needed is an educated AND caring community in which one can heal and grow. Reconnecting for Recovery has promise with regard to accomplishing this. I conclude with a quote from McKnight and Block (2012):
“A competent community is the place where I can be myself by sharing my unique gifts and revealing my unique sorrows. It is where one fully emerges as “one of a kind” [within our connections with others]…and if the community does not surround us like that, we will never fully become who we are. Our abundance will remain invisible…Making our gifts and sorrows explicit makes them available for sharing. The range and variety of the sorrows we hear gives us the fuel for community and connectedness” (p. 69).
If you or someone you know is between the ages of 18 and 40 and struggling with Anorexia Nervosa or an associated eating disorder marked by food restriction and weight loss, and you are interested in being screened for the Reconnecting for Recovery Pilot Study, please contact Judy Brasch at (585) 275-6629 or Judith_brasch@urmc.rochester.edu. The study website is: http://research.son.rochester.edu/MFTG
About the author:
Dr. Mary Tantillo is a Professor of Clinical Nursing at the University of Rochester School of Nursing and a Clinical Professor in the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry. Dr. Tantillo has devoted over 30 years to working with adolescents and adults with eating disorders and their families in a variety of clinical and community settings. Dr. Tantillo is a fellow of the Academy for Eating Disorders, having served as a previous AED board member and chairperson for the AED Credentialing Task Force for 9 years. The task force provided clinical recommendations for eating disorders inpatient and residential treatment adopted by CARF and The Joint Commission. She has also served as the co-chairperson for the AED Patient/Carer Committee and was awarded the Meehan-Hartley Award for Public Service and Advocacy by the AED in 2010.
Since 2005 Dr. Tantillo has been the Director of the Western New York Comprehensive Care Center for Eating Disorders (WNYCCCED), one of three NY State Department of Health-funded CCCED’s legislatively mandated to ensure prevention, early identification and intervention services, care management, education of laypersons and professionals, and continuous and comprehensive care for individuals with eating disorders and their family members in the 30 counties of Western NY.
In 2010 Dr. Tantillo founded The Healing Connection as a free-standing, NY State Office of Mental Health-licensed Eating Disorders Partial Hospitalization Program for adults and adolescents in Fairport, NY. She owned, operated, and clinically directed The Healing Connection from 2010-2013, and then transitioned the program into a 501 (c ) 3 nonprofit corporation of which she remains the CEO.
Dr. Tantillo has special clinical and research interests in the areas of prevention, women’s mental health, group treatment, and family-based treatment for eating disorders. Over the past 10 years she partnered with patients and families to develop a new and innovative relationally and motivationally-informed multifamlly therapy group approach to treating Anorexia Nervosa in young adults called “Reconnecting for Recovery.” Dr. Tantillo is currently engaged in a research study funded by a grant from the Hilda and Preston Davis Foundation to pilot this intervention and refine its present treatment manual.
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