Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmh20

Stress and stress management in clinical

psychology: Findings from a systematic review

Ben Hannigan, Deborah Edwards & Philip Burnard

To cite this article: Ben Hannigan, Deborah Edwards & Philip Burnard (2004) Stress and stress
management in clinical psychology: Findings from a systematic review, Journal of Mental
Health, 13:3, 235-245, DOI: 10.1080/09638230410001700871

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Journal of Mental Health, June 2004; 13(3): 235 – 245

REVIEW

Stress and stress management in clinical psychology:

Findings from a systematic review

BEN HANNIGAN, DEBORAH EDWARDS, & PHILIP BURNARD

School of Nursing and Midwifery Studies, University of Wales College of Medicine, Cardiff, UK

Abstract
Background: Occupational stress is a major problem for individuals and organizations. Stress can cause
burnout, ill-health, high workforce turnover, absenteeism, lowered morale and reduced efficiency and
performance.
Aims: To identify factors that contribute to stress, burnout and job satisfaction for qualified UK clinical
psychologists; to identify the various coping strategies that are employed; to identify stress management
interventions that have been used by members of the clinical psychology profession in the UK.
Method: Systematic review, focusing on stressors, moderators and stress outcomes and on stress
management interventions.
Results: Seven studies were included in the review. Just one reported an evaluation of a stress
management intervention. Reported sources of stress for clinical psychologists included client
characteristics, excessive workloads, professional self-doubt and poor management. Coping strategies
included talking with colleagues, and other ‘‘active’’ approaches to personal stress management. Up to
40% of UK clinical psychologists participating in studies were found to be experiencing ‘‘caseness’’
levels of distress.
Conclusions: Mental health work is stress-provoking. However, organizational and professional factors
may militate against psychologists seeking and receiving support at work.
Declaration of interest: This study was undertaken with the support of the Wales Office of Research and
Development for Health and Social Care.

Keywords: Clinical psychology, stress, coping, burnout, stress management.

Introduction
Occupational stress is a major problem for individuals and organizations. Stress can cause
burnout, ill-health, high workforce turnover, absenteeism, lowered morale and reduced
efficiency and performance (Sutherland & Cooper, 1990). Reflecting the extent of this
problem, increasing attention has been paid in recent decades to the study of stress and its
consequences, and to the development of strategies aimed at the reduction of occupational
stress.

Correspondence: B. Hannigan, Senior Lecturer in Mental Health Nursing, School of Nursing and Midwifery Studies, University of
Wales College of Medicine, Eastgate House, 35-43 Newport Road, Cardiff CF24 0AB, UK. Tel: + 44 20917726.
Fax: + 44 29 20917803. E-mail: hanniganb@cardiff.ac.uk
ISSN 0963-8237 print/ISSN 1360-0567 online # Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230410001700871
236 B. Hannigan et al.

In an earlier summary of research investigating stress in clinical psychologists, Cushway

and Tyler (1996) found that clinical psychologists—and trainee clinical psychologists in
particular—were experiencing significant levels of distress. Levels of general psychological
distress experienced by men decreased with grade, whereas for women no such reduction
was observed. More experienced clinical psychologists reported less distress than junior or
trainee psychologists. Sources of stress included the difficulties faced by clients, and client
behaviours. Professional self-doubt also triggered stress for psychologists.
It is important that stress research is based on a theoretical model. Three levels of the
stress process are proposed in the model developed by Carson and Kuipers (1998). First
are external ‘‘stressors’’. These include occupation-specific stressors, everyday ‘‘hassles’’
and ‘‘uplifts’’ and the stress associated with significant life events. At the second level of
the stress process are ‘‘moderators’’. These include a wide range of personal protectors,
the possession of which help to reduce the impact of stress. These are: high levels of self-
esteem; good social support networks; hardiness; good coping skills; mastery and
personal control; emotional stability; and good physiological release mechanisms. The
final level of the stress process in Carson and Kuipers’ model is that of stress outcomes.
Positive outcomes include good mental and physical health and high levels of job
satisfaction, whilst negative outcomes include poor health, burnout and diminished job
satisfaction.
This review reports findings from a systematic review into stress and stress
management within the clinical psychology profession, using the Carson and Kuipers
(1998) stress model as a framework. This research was part of a larger study which
systematically reviewed the current evidence for the effectiveness of stress management
interventions for those working within the mental health field (clinical psychologists;
psychiatrists; psychiatric nurses; social workers; occupational therapists; mental health
professionals whose professional affiliation was not known). Findings relating to the other
mental health professions are being reported elsewhere in a series of companion papers
(Coyle, Edwards, Hannigan, Fothergill, & Burnard, in press; Edwards & Burnard, 2003;
Edwards & Burnard, in press; Edwards, Hannigan, Fothergill, & Burnard, 2002;
Fothergill, Edwards, & Burnard, in press). The clinical psychology section of the review
was conducted with the aim of bringing together information on stress in psychologists,
and updating Cushway and Tyler’s (1996) previous review of stress in UK clinical
psychologists.
Specific objectives for the study were to:

. identify the various factors that contribute to stress, burnout and job satisfaction for
qualified UK clinical psychologists;
. identify the various coping strategies that are employed;
. identify stress management interventions that have been in use in the clinical
psychology profession.

Method
Guidelines on undertaking systematic reviews produced by the NHS Centre for Reviews
and Dissemination at the University of York were used in this study (University of York
NHS Centre for Reviews and Dissemination, 2001).
The review was conducted in two parts. The first part focused on stressors, moderators
and stress outcomes and included articles and other items of output on stress, burnout and
job satisfaction. The second part of the review retrieved papers that evaluated stress
 Stress in clinical psychology 237

management interventions. Studies included were research articles dating from 1966 to
2000 undertaken in the United Kingdom that specifically identified participants as qualified
clinical psychologists.

Search strategy
The electronic databases PUBMED and Embase (Excerpta Medica Online) were searched
to provide coverage of the literature for both English language and European language
journals. SCI Search (the Science Citation Index), SSCI Search (the Social Science Citation
Index) and Pascal (the Science, Technology and Medicine index) were also used to ensure
as comprehensive a search of the literature as possible. The following specialist databases
were also searched: CINAHL (Nursing and Allied Health Literature); ASSIA (Social
Sciences); PsychLit (Psychology, including Clinical Psychology); ClinPsych; Healthstar;
and Cochrane. In preparing this paper for publication, and in order to maximize the chances
of securing complete coverage of the literature relating to stress and stress management in
the profession of clinical psychology in the UK, the specialist database of papers published in
the professional journal Clinical Psychology (previously called Clinical Psychology Forum) was
also searched. This database is maintained by Dr Mike Jellema of the Department of
Clinical Psychology, Shotley Bridge Hospital, Durham.
The literature search strategy included searching Medical Subject Headings (MeSH), and
by key word and text searches. The text word search included the following terms:

. Clinical Psychologist*
. Mental Health Professional*
. Mental Health Staff

The MeSH Search Terms used were:

. Clinical Psychologists (ClinPsych, PsychLit)

. Psychologists (CINAHL)
. Psychology, clinical (PUBMED, Healthstar)
. Clinical Psychology (EMBASE)
. Mental Health Personnel (PsychLit, ClinPsych)
. Mental Heath Service (EMBASE, CINAHL)
. Community Mental Health (EMBASE)

Search terms were used in conjunction with the terms:

. Stress*
. Burnout*
. Job Satisfaction
. Coping

Different keywords were used with different databases as, in some instances, keywords
which returned papers in some databases produced no returns in others. Modifying and
adding to search terms for individual databases as detailed above was successful in
producing potentially relevant papers. In searching the Clinical Psychology journal database,
the following keywords were used: clin psychology stress; coping as a therapist; job
satisfaction; staff stress; stress management; support systems; work stress.
238 B. Hannigan et al.

In addition, the electronic database SIGLE (System for Information on Grey Literature)
was searched for unpublished articles, conference proceedings, university theses and
commissioned reports. In order to locate any current research, a search was also undertaken
on the UK National Research Register.
After completing the electronic searches, the search was drawn to a conclusion by several
stages of follow-up to identify any further relevant articles. This was undertaken by checking
reference lists of selected articles and reviews, by handsearching key journals and by writing
to key authors. Journals which were handsearched included: International Journal of Social
Psychiatry; Stress Medicine; and Social Psychiatry and Psychiatric Epidemiology. These journals
were purposively selected for handsearching as a large number of the papers returned
through the database searches had been published in them. In preparing this paper for
publication, the journal Clinical Psychology and Psychotherapy was also handsearched.

Inclusion criteria
This search strategy produced a total of 74 studies which were considered potentially
relevant to the clinical psychology section of the review. All 74 were obtained in hard copy.
Each study was then read in full and assessed for relevance to the review, with reference to
the following inclusion criteria: English language publication; relates to qualified clinical
psychologists in the UK; primary research paper; and measures stressors/moderators/stress
outcomes. Papers were read and assessed independently by two reviewers, with differences
being resolved by re-reading and re-assessing the relevant studies. Table I summarizes
findings from this part of the review. As this table shows, the majority of studies located
through the database searches and handsearching of journals were excluded from the final
review. Thirty-nine of the reports retrieved either did not include qualified UK clinical
psychologists as study participants, or presented data relating to UK clinical psychologists in
such a way as to prevent the disaggregation of this information from data relating to other
mental health professional groups. A further 14 retrieved studies were not research papers,
whilst seven did not report on stressors, moderators or stress outcomes.

Results
Seven studies were finally included in the clinical psychology section of the review. All seven
reported data on psychologists working in the UK. Just one of the studies (Cormack,
Nichols, & Walsh, 1991) reported an evaluation of an intervention designed to manage
stress and its consequences. The small number of studies located, and the use of different

Table I. Studies excluded from the review.

Exclusion criteria Number

Foreign language publications 5

Studies not including UK qualified clinical psychologists as subjects, or studies including UK clinical
psychologists as subjects but data relating to psychologists not clearly disaggregated from data relating
to other groups 39
Not primary research articles 14
Articles containing insufficient statistical data 1
Papers not reporting stressors, moderators or stress outcomes 7
Duplicate publications 1
Total 67
 Stress in clinical psychology 239

research tools, ruled out the possibility of undertaking a meta-analysis. Table II summarizes
the characteristics of the included studies.

Stressors
Three-quarters of the clinical psychologists in Cushway and Tyler’s study reported being
either ‘‘moderately’’ or ‘‘very’’ stressed (Cushway & Tyler, 1994). ‘‘Too much work’’ was
the most frequently-reported source of stress in this study, with over half of the participants
confirming this as a particular stressor. Other frequently-mentioned stressors included
‘‘poor quality of management’’, having ‘‘too many different things to do’’, and experiencing
a ‘‘lack of resources’’. ‘‘Professional self doubt’’ was a significant source of stress for

Table II. Characteristics of studies included in the review.

Outcome Research
Author/s Sample and location of study Response measures instruments used

Boakes (1998) 208 108 (52%) B MBI

South Thames RHA JS OSI, TCI; TIS &
PIS
PDQ
Cormack et al. (1991) 24 21 (87.5%) SM PDQ
1 CP Department in South
West England
Crowley and Avdi (1999) All adult mental health 6 (100%) S PDQ
psychologists in 1 CP
Department in Birmingham
Cushway and Tyler (1994) 151 101 (67%) S Stress Question-
naire
West Midlands RHA C CS
PD GHQ-28
Cushway et al. (1996) 220 154 (70%) S Development of
MHPSS, SCL-18
(210 MHNs) (111 (53%)) M PDQ
West Midlands RHA C CS
JS NSI
PD GHQ-28
Darongkamas et al. (1994) 496 321 (65%) S PDQ,
UK M PDQ
PD GHQ-28
Walsh and Cormack (1994) 165 95 (58%) (Stage 1) M Stage 1: PDQ,
South West of England 25 (75%) (Stage 2)* Stage 2: Group
33 feedback session
One CP department and discussion

Abbreviations: B = Burnout; CP = Clinical Psychology; JS = Job Satisfaction; M = Moderators; MHNs = Mental

health nurses; PD = Psychological distress; Response = Number of total clinical psychology respondents/participants
or total number of respondents who returned ‘‘useable’’ questionnaires; RHA = Regional Health Authority;
S = Stressors; SM = Stress management; * = Sample included clinical psychology trainees.
Psychometric tests: CS = Coping Schedule (Moos, 1984); GHQ-28 = General Health Questionnaire version 28
(Goldberg, 1978); MBI = Maslach Burnout Inventory (Maslach & Jackson, 1986); MHPSS = Mental Health
Professionals Stress Scale; NSI = Nurse Stress Index (Harris, Hingley, & Cooper, 1988); OSI = Occupational Stress
Indicator (Cooper, Sloane, & Williams, 1988); PDQ = Purpose designed questionnaire; SCL-18 = Symptom Check
List 18 (Derogatis, 1983); Stress Questionnaire (Sampson, 1991); TCI = Team Climate Inventory (Anderson &
West, 1994); TIS & PIS = Team Identification Scale and Professional Identification Scale (Onyett et al., 1997).
240 B. Hannigan et al.

participants in the study by Cushway, Tyler, and Nolan (1996), with those psychologists
who were involved in supervision reporting higher levels of ‘‘workload’’ stress. In the study
completed by Darongkamas, Burton, and Cushway (1994), psychodynamically-oriented
clinical psychologists were found to be more likely to report stress than were cognitive –
behavioural or eclectic psychologists. Clinical psychologists in this study who had experience
of personal therapy were also more likely to report being stressed in their work, as were those
who were single or divorced. In the study undertaken by Crowley and Avdi (1999), six
psychologists completed questionnaires relating to 97 of their clients. Psychologists reported
feeling ‘‘stuck’’ in their work with over half of these clients. Forty-eight of the clients
precipitated feelings of tiredness or exhaustion, whilst 45 clients caused psychologists to feel
‘‘overwhelmed’’. Feelings of ‘‘incompetence’’, ‘‘worry’’, or ‘‘irritation’’ were also expressed
by practitioners in relation to significant numbers of their clients.

Moderators
Coping strategies most frequently reported were behavioural and cognitive methods,
including talking to other clinical psychologists, exercising and talking to a partner
(Cushway & Tyler, 1994). Psychologists were found to use active behavioural coping
strategies more than a comparison group of mental health nurses (Cushway et al., 1996).
The opportunity to participate in a professional support network was valued by many of the
psychologists in the study completed by Cormack et al. (1991), with specific benefits
reported including enhanced self-awareness and workload management. Walsh and
Cormack’s (1994) two-stage study invited clinical psychologists to complete a questionnaire
focusing on attitudes and practices towards self-care. Over half of those responding
indicated that they participated in a support group, the beneficial functions of which
included the provision of ad hoc supervision, informal support and the sharing of skills.

Stress outcomes: burnout

Higher levels of personal accomplishment and lower levels of depersonalization were
reported by the clinical psychologists participating in Boakes’ (1998) study than were
previously found in normative samples of other mental health workers. However, a large
number also appeared to be experiencing an increased level of emotional exhaustion, which
in turn appeared to be associated with low levels of role clarity.

Stress outcomes: job satisfaction

High levels of job satisfaction were reported by Boakes’ sample of UK clinical psychologists
(Boakes, 1998), whilst in Cushway et al.’s (1996) study psychologists were found to be more
satisfied with their jobs than were a comparative sample of mental health nurses.

Stress outcomes: psychological disturbance

Three of the included studies measured psychological disturbance using the General Health
Questionnaire (GHQ). Three out of ten psychologists reached ‘‘caseness’’ level in Cushway
and Tyler’s (1994) study, compared to four out of ten in the later study reported by
Cushway et al. (1996). Twenty-four per cent of Darongkamas and colleagues’ sample
reached or exceeded the GHQ ‘‘caseness’’ threshold (Darongkamas et al., 1994). In all three
studies women were found to be more psychologically distressed than men.
 Stress in clinical psychology 241

Stress management interventions

In a short paper, Cormack et al. (1991) reported a questionnaire evaluation of a support
network set up for members of a clinical psychology department located in England.
Twenty-one participants completed questionnaires 6 months after the inauguration of the
network, and their responses pointed to specific perceived benefits. These included changes
to work and personal life, such as increased self-awareness, improved job satisfaction and
improved personal care.

Methodological issues
There are a number of methodological issues that need to be addressed when conducting a
review of this nature. Stress and its consequences can be identified in many different ways:
through questionnaires, interviews, indirect observation (staff turnover, sickness records),
examination of biochemical markers, etc. There needs to be some attempt to utilize common
measurement approaches, which enable researchers and others to compare data across
studies and to conduct meta-analyses. There are numerous established measures available
which have been shown to be valid and reliable for measuring stressors, moderators and stress
outcomes. Investigators frequently find the need, however, to develop new instruments. Six
out of the seven papers and reports included in this review used questionnaires that had been
specifically designed for the study. These must be evaluated in terms of the extent to which
reliability and validity have been established. Of these studies only one was classified as a pilot
study (Crowley & Avdi, 1999), and only the work by Cushway and colleagues provided
details of validity and reliability (Cushway et al., 1996). One paper, however, referred the
reader to a previously published paper for further information on one of the tools used (Walsh
& Cormack, 1994). One area where there was consistency was in the use of the General
Health Questionnaire to measure psychological distress. The three studies that measured this
used the 28 item version enabling direct comparisons to be made.
The number of respondents taking part in the studies ranged from 6 to 321, an extremely
large variation. Larger samples are more likely to be representative of the wider population of
clinical psychologists; small sample sizes will produce less generalizable results. The studies
that included larger numbers also drew their samples from regional or UK-wide databases,
as opposed to drawing their samples from individual NHS Trusts or clinical psychology
departments.

Discussion
Evidence from the studies reviewed here suggests that many UK clinical psychologists find
their work demanding and stress-provoking. Reported sources of stress include the
characteristics of clients, excessive workloads, professional self-doubt and poor management.
High levels of psychological disturbance are reported in the literature, with up to four out of
ten UK clinical psychologists participating in studies recording ‘‘caseness’’ levels of distress.
Care needs to be taken in comparing stress, coping and stress outcomes in UK clinical
psychologists with stress reported in non-UK samples of psychologists. Different approaches
to the organization of health care, and variations in the preparation of practitioners, make
direct comparisons problematic. Nonetheless, it is interesting to consider the findings from
this UK study with findings from broadly similar international studies. Just as UK clinical
psychologists have done, licensed psychologists in the US have reported stressors associated
with engagement in clinical work (Hellman, Morrison, & Abramowitz, 1986). Stress in this
242 B. Hannigan et al.

group has also been associated with having larger caseloads (Hellman, Morrison, &
Abramowitz, 1987). Social support as a means of managing stress was reported in the UK
literature reviewed in this study; similar stress moderators have been reported in a sample of
Canadian psychologists (Kahill, 1986). Various active approaches to coping with stress have
also been reported by samples of US psychologists, including participation in non-work
related activities, taking periodic holidays and seeking periodic consultation (Sherman &
Thelen, 1998). There is also an international literature on burnout in psychologists. For
example, Kahill (1986) reported low to moderate levels of burnout in a sample of Canadian
psychologists, as did Farber (1985), who described US clinical psychologists as less ‘‘burnt
out’’ than samples of other occupational groups. Interestingly, Ackerley, Burnell, Holder,
and Kurdek (1988) found that the US psychologists in their study were more ‘‘burnt out’’
than other groups of mental health workers.
Significantly, whilst this review succeeded in locating a number of studies which have
specifically investigated stress and its consequences in samples of UK clinical psychologists,
we found only one study which had focused on the development and evaluation of stress
management interventions for the profession. This relative absence of literature evaluating
specific stress management interventions for clinical psychologists reflects a generalized gap
in the literature. In our wider review of stress and stress management in all mental health
occupational groups, in both the UK and elsewhere, we found many papers describing
investigations into stress and its consequences, but far fewer papers reporting evaluated
efforts to ameliorate this (Coyle et al., in press; Edwards & Burnard, 2003; Edwards &
Burnard, in press; Edwards et al., 2002; Fothergill et al., in press). From the limited
literature on stress management for other mental health workers, specific recommended
interventions have included: relaxation training (Peacock, 1991; Watson, 1986); organiza-
tional problem solving (Peacock, 1991); staff support groups (Peacock, 1991); confidential
counselling (Peacock, 1991); staff sensitivity sessions (Peacock, 1991); in service training in
behavioural therapy (Milne, Burdett, & Beckett, 1986); creative accommodation (Gordon &
Goble, 1986); stress management workshops (Kunkler & Whittick, 1991; Watson, 1986);
staff development workshops (Hunnicutt & MacMillan, 1983); staff consultations
(Hunnicutt & MacMillan, 1983); ward reorganization (Milne et al., 1986); stress reduction
programmes (Mehr, Senteney, & Creadie, 1995); change in care delivery (Melchior et al.,
1996); interdisciplinary education (Bhatara, Fuller, O’Connor-Davis, & Misra, 1996); and
training in ‘‘Type A’’ therapeutic skills (Lemma, 2000).
A number of factors may help explain the relative dearth of literature addressing stress
management in the profession of clinical psychology, and indeed in other mental health
occupational groups. Commenting on the experiences of US psychologists, Millon, Millon,
and Antoni (1986) have observed how the choice of psychology as a career is fraught with
intrinsic stressors from the off. In their view, initial educational preparation presents student
practitioners with multiple academic and clinical demands, which often lead to early self-
doubt. Similar arguments have been made with respect to clinical psychology training in the
UK. For example, Nichols, Cormack, and Walsh (1992) have argued that programmes of
preparation have tended to ignore the support needs of trainees. Participation in clinical
practice post-qualification can also be stress-provoking. Working in publicly-funded
institutions, as most clinical psychologists in the UK do as employees of the National
Health Service, brings specific stressors. Millon et al. (1986) have drawn attention to
problems of excessive workloads, organisational politics and the difficulties faced by
clinicians in working with ‘‘recalcitrant or otherwise unsatisfying patients’’ (p.125). As the
studies obtained for this review have shown, organisational and client-related factors of this
sort do appear to act as specific sources of stress for psychologists.
 Stress in clinical psychology 243

Factors associated with the organization of psychology work can also precipitate stress.
Practising clinical psychology can be an isolating activity, offering relatively few routine
opportunities for professional and social support (Millon et al., 1986; Walsh & Cormack,
1994). Practical barriers of this type may be only part of the problem, however. In the group
discussion phase of their two-stage study, Walsh and Cormack (1994) reported that clinical
psychologists found the idea of receiving support as being ‘‘psychologically threatening’’.
This threat comprised three elements: organizational/professional threat; fear of being a
client; and the requirement to ‘‘gatekeep’’ in order to manage threat. The first of these three
related to the organizational values of both the health service and, more specifically, to the
values of the clinical psychology profession. Walsh and Cormack argued that, as members of
a relatively small occupational group, clinical psychologists are prone to marginalisation and
professional insecurity. Seeking support in a climate of insecurity and rising workloads was
perceived by psychologists in Walsh and Cormack’s investigation as both self-indulgent and
stigmatizing. ‘‘Fear of being a client’’, the second of Walsh and Cormack’s barriers to
seeking support, was related to the risk of being unable to control the expression of emotion
during the process of help-seeking, and to the risk of being unfavourably compared to
psychologist colleagues who were apparently ‘‘perfect copers’’. Finally, Walsh and Cormack
argued that psychologists were likely to engage in various ‘‘gatekeeping’’ strategies in order
to minimise the threats described above. These included assessing the personal qualities of
potential support-givers, and assessing their perceived skill level.

Conclusion
Mental health professionals are required to attend to the needs of people experiencing a
range of mental health difficulties. The evidence from this review is that many clinical
psychologists practising in the UK are, themselves, experiencing significant levels of
psychological distress. Moreover, powerful organizational and professional factors may act
in ways that inhibit the capacity of psychologists to seek and obtain support for stress at
work. It is likely, in our view, that many of these factors will apply equally to other mental
health occupational groups. Nurses, psychiatrists, mental health social workers and others
are all equally vulnerable to the idea that seeking help may be threatening. The fear of
‘‘becoming a client’’, or of failing to manage work stressors where others appear to manage
adequately, may be powerful disincentives to practitioners seeking out support.
Perhaps our most striking finding has been the general absence of studies evaluating
interventions designed to manage stress. There is, in particular, a dearth of studies which
have investigated stress management using longitudinal research designs. This should be a
priority area for future stress researchers.

Acknowledgements
This study was undertaken with the support of the Wales Office of Research and
Development for Health and Social Care. The authors would like to express their thanks to
the anonymous referees, for their helpful comments on an earlier draft of this paper.

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