Randomized Controlled Trial of Cognitive Behavioral Social Skills Training for Older Consumers With Schizophrenia: Defeatist Performance Attitudes and Functional Outcome
Open accessAbstract
Objectives To determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST.Design An 18-month, single-blind, randomized controlled trial.Setting Outpatient clinic at a university-affiliated Veterans Affairs hospital.Participants Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45-78.Interventions CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals.Measurements Blind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction.Results Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction.Conclusions CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning.Trial registry ClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796).
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In pharmacologically stabilized patients, CBSST produced no significant change in psychopathology but significant improvement in social activities, cognitive insight, mastery of problem-solving skills, and reduction in defeatist attitudes at the end of the intervention.
“While there was no significant change in psychopathology in pharmacologically stabilized patients, there was significant improvement in social activities, cognitive insight and mastery of problem‐solving skills, as well as a reduction in defeatist attitudes, at the end of the intervention.”
From Mental health care for older adults: recent advances and new directions in clinical practice and research (2022) · cites this paper as [277]
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Mobile-assisted cognitive-behavioral social skills training in older adults with schizophrenia
Granholm, E. L., Holden, J. L., Dwyer, K., & Link, P. C. (2020) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2020.03.006 · Cited by 25 · see citing works
Self-citationUsing Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms
Lincoln, T. M., Riehle, M., Pillny, M., Helbig‐Lang, S., Fladung, A.-K., Hartmann-Riemer, M. N., & Kaiser, S. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.02108 · Cited by 23 · see citing works
“However, following the logic of the FA model, these interventions are even more likely to be effective if patients are preselected for dysfunctional beliefs (as indicated in work by Granholm et al., 2013) and if they are combined with interventions at the other levels of the model.”
BackgroundDevelopment of the Demotivating Beliefs Inventory and Test of the Cognitive Triad of Amotivation
Pillny, M., Krkovic, K., & Lincoln, T. M. (2018) · Cognitive Therapy and Research · doi:10.1007/s10608-018-9940-7 · Cited by 23 · see citing works
Norman, R. M. G., Manchanda, R., Harricharan, R., & Northcott, S. (2015) · Schizophrenia Research · doi:10.1016/j.schres.2015.09.010 · Cited by 22 · see citing works
“, 2015), and there is evidence that clinical interventions often bring about coincident improvement in mood and reduction in negative symptoms (Granholm et al., 2013; Turkoz et al., 2008).”
Merging Evidence-Based Psychosocial Interventions in Schizophrenia
Lecomte, T., Corbière, M., Simard, S., & Leclerc, C. (2014) · Behavioral Sciences · doi:10.3390/bs4040437 · Cited by 21 · see citing works
“Granholm and colleagues [11,12] have merged two evidence-based psychosocial interventions to cater to the specific needs of aging individuals with psychosis who might be struggling not only with symptoms but also with social and cognitive deficits.”
BackgroundResultSmart, E. L., BROWN, L. J. E., Palmier‐Claus, J. E., Raphael, J., & Berry, K. (2020) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.5264 · Cited by 21 · see citing works
Ebrahimi, A., Poursharifi, H., Dolatshahi, B., Rezaee, O., Hassanabadi, H. R., & Naeem, F. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.707291 · Cited by 21 · see citing works
Luther, L., Fukui, S., Firmin, R. L., McGuire, A. B., White, D. A., Minor, K. S., & Salyers, M. P. (2015) · Psychiatry Research · doi:10.1016/j.psychres.2015.06.022 · Cited by 20 · see citing works
“Specifically, given that the interventions used in this study did not directly target negative beliefs about success, those with low levels of expectancies of success may benefit from techniques or interventions that focus on modifying beliefs to reduce negative symptoms (e.g. Grant et al., 2012; Granholm et al., 2013…”
Clay, K. B., Raugh, I. M., Bartolomeo, L. A., & Strauss, G. P. (2021) · Early Intervention in Psychiatry · doi:10.1111/eip.13024 · Cited by 19 · see citing works
“Despite these inconsistencies, psychosocial treatments targeting DPBs have been shown to improve negative symptoms and functioning (Granholm et al., 2013, 2017; Grant et al., 2012; Pos et al., 2019; Staring et al., 2013; Velligan et al., 2014), suggesting DPBs may be a critical mechanistic target.”
BackgroundGranholm, E. L., Holden, J. L., Sommerfeld, D. H., Rufener, C. A., Perivoliotis, D., Mueser, K. T., & Aarons, G. A. (2015) · Trials · doi:10.1186/s13063-015-0967-8 · Cited by 19 · see citing works
“In addition, one trial also found significantly greater improvement in amotivation/asociality negative symptoms in CBSST relative to GFSC [20].”
BackgroundResultSelf-citationCaruso, R., Grassi, L. G., Biancosino, B., Marmai, L., Bonatti, L., Moscara, M., Rigatelli, M., Carr, C. E., & Priebe, S. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-242 · Cited by 19 · see citing works
“; licensee BioMed Central Commons Attribution License (http://creativec reproduction in any medium, provided the or including cognitive-behavioural therapy [8], integrated psychological therapy [9], social skills training [10], cognitive remediation [11], and others [12-17].”
BackgroundLe, T. P., Holden, J. L., Link, P. C., & Granholm, E. L. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.10.011 · Cited by 19 · see citing works
Self-citationZechner, M., Pratt, C. W., Barrett, N. M., Dreker, M. R., & Santos, S. (2019) · Psychiatric Rehabilitation Journal · doi:10.1037/prj0000342 · Cited by 19 · see citing works
Luther, L., Coffin, G. M., Firmin, R. L., Bonfils, K. A., Minor, K. S., & Salyers, M. P. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.08.016 · Cited by 18 · see citing works
Overview of measurement-based positive psychiatry
Eglit, G. M. L., Palmer, B. W., & Jeste, D. V. (2018) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2018.1459834 · Cited by 18 · see citing works
Self-citationSaperia, S., Plahouras, J., Best, M. W., Kidd, S. A., Zakzanis, K. K., & Foussias, G. (2025) · Psychological Medicine · doi:10.1017/s0033291724003325 · Cited by 16 · see citing works
“…Fisher et al., 2023; Granholm et al., 2020; Granholm et al., 2022; Granholm, Holden, Dwyer, & Link, 2020; Granholm, Holden, Link, & McQuaid, 2014; Granholm, Holden, Link, McQuaid, & Jeste, 2013; Grant & Beck, 2009; Green et al., 2022; Green, Hellemann, Horan, Lee, & Wynn, 2012; Kiwanuka,…”
Devoe, D. J., Cadenhead, K. S., Cornblatt, B., Granholm, E., & Addington, J. (2021) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465821000461 · Cited by 16 · see citing works
“These results are consistent with studies using structural equation modelling in schizophrenia which have found a direct path from defeatist performance beliefs to negative symptoms and from negative symptoms to functional outcome (Granholm et al., 2013; Green et al., 2012; Quinlan et al., 2014).”
ResultSelf-citationRajji, T. K., Mamo, D. C., Holden, J. L., Granholm, E. L., & Mulsant, B. H. (2021) · Schizophrenia Research · doi:10.1016/j.schres.2021.11.051 · Cited by 18 · see citing works
Self-citationMahmood, Z., Patten, R. V., Keller, A. V., Lykins, H. C., Perivoliotis, D., Granholm, E. L., & Twamley, E. W. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.113620 · Cited by 16 · see citing works
“It is possible that suboptimal public transportation also contributed to our dropout rate, given evidence for better session attendance in prior CBSST trials when transportation was provided (Granholm et al., 2013), compared to when it was not (Granholm et al.”
ResultSelf-citationBrowne, J., Harvey, P. D., Buchanan, R., Kelly, D. L., Strauss, G. P., Gold, J. M., Holden, J. L., & Granholm, E. L. (2022) · Behavioral Sciences · doi:10.3390/bs12030060 · Cited by 15 · see citing works
Self-citationLuther, L., Raugh, I. M., Grant, P. M., Beck, A. T., & Strauss, G. P. (2024) · Schizophrenia Bulletin · doi:10.1093/schbul/sbae128 · Cited by 15 · see citing works
Kukla, M., Strasburger, A. M., Salyers, M. P., Rattray, N. A., & Lysaker, P. H. (2016) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000601 · Cited by 15 · see citing works
The role of defeatist performance beliefs on cognitive effort-cost decision-making in schizophrenia
Luther, L., Westbrook, A., Ayawvi, G., Ruiz, I., Raugh, I. M., Chu, A. O. K., Chang, W. C., & Strauss, G. P. (2023) · Schizophrenia Research · doi:10.1016/j.schres.2023.09.035 · Cited by 13 · see citing works
Cognitive‐behavioural social skills training for first‐episode psychosis: a feasibility study
Herman, Y., Shireen, H., Bromley, S., Yiu, N., & Granholm, E. L. (2016) · Early Intervention in Psychiatry · doi:10.1111/eip.12379 · Cited by 13 · see citing works
Self-citationCampellone, T. R., Sanchez, A. H., Fulford, D., & Kring, A. M. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.12.045 · Cited by 12 · see citing works
Addressing defeatist beliefs in work rehabilitation
Mervis, J., Lysaker, P. H., Fiszdon, J. M., Bell, M. D., Chue, A. E., Pauls, C., Bisoglio, J., & Choi, J. (2016) · Journal of Mental Health · doi:10.3109/09638237.2016.1139069 · Cited by 12 · see citing works
“…defeatist beliefs are a prominent expectation-based barrier that can be parsed into global attitudes or traits that expect failure at every turn and the inflated need for acceptance (Rector, 2004) or more taskspecific beliefs about performance and competency (Granholm et al., 2009, 2013).”
BackgroundSommerfeld, D. H., Aarons, G. A., Naqvi, J. B., Holden, J. L., Perivoliotis, D., Mueser, K. T., & Granholm, E. L. (2018) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-018-0904-8 · Cited by 11 · see citing works
Self-citationTessier, J. M., Erickson, Z. D., Meyer, H. B., Baker, M. R., Gelberg, H. A., Arnold, I. Y., Kwan, C., Chamberlin, V., Rosen, J. A., Shah, C., et al. (2017) · Military Medicine · doi:10.7205/milmed-d-16-00405 · Cited by 11 · see citing works
Schormann, A. L. A., Pillny, M., Haß, K., & Lincoln, T. M. (2023) · Pilot and Feasibility Studies · doi:10.1186/s40814-023-01284-4 · Cited by 10 · see citing works
Meesters, P. D., van der Ham, A. J., Dominicus, M., Stek, M. L., & Abma, T. (2019) · Community Mental Health Journal · doi:10.1007/s10597-019-00389-6 · Cited by 10 · see citing works
Wright, A. C., Browne, J., Cather, C., Pratt, S. I., Bartels, S. J., & Mueser, K. T. (2020) · Cognitive Therapy and Research · doi:10.1007/s10608-020-10171-8 · Cited by 9 · see citing works
“In addition, scores on the ILSS were lower in this sample than two samples of older adults with schizophrenia (Emmerson et al. 2009; Granholm et al. 2013).”
ResultLuther, L., Ahmed, A. O., Grant, P. M., Granholm, E. L., Gold, J. M., Williams, T. F., Pratt, D. N., Holden, J. L., Walker, E. F., Arnold, L., et al. (2024) · Schizophrenia Bulletin · doi:10.1093/schbul/sbae220 · Cited by 8 · see citing works
Self-citationNegative Symptoms and Their Assessment in Schizophrenia and Related Disorders
Blanchard, J. J., Shan, L., Andrea, A. M., Savage, C. L. G., Kring, A. M., & Weittenhiller, L. P. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-815012-2.00007-9 · Cited by 8 · see citing works
Cognitive-Behavioral Social Skills Training Adapted for Youth at Clinical High Risk for Psychosis
Kelsven, S., Brummit, K., Devoe, D., Santesteban-Echarri, O., Auther, A., Cornblatt, B., Cadenhead, K., Granholm, E., Holden, J., Kelly, M., et al. (2022) · Journal of Cognitive Psychotherapy · doi:10.1891/jcp-2021-0029 · Cited by 8 · see citing works
Self-citationInchausti, F., García‐Poveda, N. V., Ballesteros-Prados, A., Fonseca‐Pedrero, E., Sierra, J. O., Sánchez-Reales, S., Prado-Abril, J., Aldaz-Armendáriz, J. A., & Mole, J. A. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1378-z · Cited by 7 · see citing works
Have the potential benefits of CBT for severe mental disorders been undersold?
Mueser, K. T., & Glynn, S. M. (2014) · World Psychiatry · doi:10.1002/wps.20160 · Cited by 6 · see citing works
“For example, Sensky et al (6) evaluated the impact of CBT for psychosis on stable outpatients with persistent positive psychotic symptoms, Garety et al (7) focused on relapse prevention and psychotic symptoms in individuals who had recently experienced a relapse of psychosis, and Granholm et al (8) targeted defeatist…”
BackgroundJeste, D. V., Peschin, S., Buckwalter, K. C., Blazer, D. G., McGuire, M. H., Moutier, C. Y., Doederlein, A., Niederehe, G., Altman, B. A., Borenstein, J. E., et al. (2018) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2018.03.011 · Cited by 7 · see citing works
Self-citationFitriani, N., Keliat, B. A., & Wardani, I. Y. (2021) · Open Access Macedonian Journal of Medical Sciences · doi:10.3889/oamjms.2021.7846 · Cited by 6 · see citing works
“Practices against negative thoughts and behaviors caused anger; utilizing support systems from the family and community were critical to overcoming patients with schizophrenia’ mind disorders [21].”
BackgroundResultSocial skills training for persons with schizophrenia
Browne, J., Mueser, K. T., & Pratt, S. I. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-817752-5.00017-2 · Cited by 6 · see citing works
Schizophrenia and Severe Mental Illness
Combs, D. R., & Mueser, K. T. (2017) · Wiley eBooks · doi:10.1002/9781118877142.ch13 · Cited by 5 · see citing works
Inchausti, F., García‐Poveda, N. V., Prado-Abril, J., Sierra, J. O., & Gaínza-Tejedor, I. (2017) · Papeles del Psicólogo - Psychologist Papers · doi:10.23923/pap.psicol2017.2840 · Cited by 4 · see citing works
“Por ejemplo, Granholm et al. (2014; 2013; 2007) han obtenido resultados prometedores combinando el EHS con la terapia cognitivo-conductual (TCC) en adultos con esquizofrenia.”
BackgroundTherapeutic Considerations in Individuals at Clinical Risk for Developing Psychosis
Singh, F., DeJoseph, M. L., & Cadenhead, K. S. (2014) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-014-0009-2 · Cited by 4 · see citing works
Andresen, J., Jeppesen, A. C. E., Due, A. S., Mariegaard, L. S., Parvaiz, R., Hjorthøj, C. R., Pinkham, A. E., Nordentoft, M., Letnar, G., Jepsen, J. R. M., et al. (2025) · JMIR Research Protocols · doi:10.2196/72854 · Cited by 3 · see citing works
Varese, F., Sudell, M., Morrison, A. P., Longden, E., & Smith, C. T. (2024) · Health Technology Assessment · doi:10.3310/ncfr5074 · Cited by 3 · see citing works
Joseph, H. L., de Andino, A. M., & Wood, K. A. (2021) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2021.06.007 · Cited by 4 · see citing works
“The results of four randomized control trials suggest that the CBSST program is effective at improving functioning and reducing negative symptoms (Granholm et al., 2014; Granholm et al., 2013; Granholm et al., 2008; Granholm et al., 2005).”
BackgroundMental Health and Treatment Considerations for Older Adults
Edelstein, B. A., Spalding, R., & Katz, E. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-818697-8.00137-0 · Cited by 3 · see citing works
The Future of Psychosocial Interventions for Older Adults With Severe Mental Illness
Twamley, E. W. (2013) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2012.11.021 · Cited by 3 · see citing works
Chau, A. K. C., Fung, V. S. C., Chan, J. C. Y., Wong, S. C. Y., Wong, C. S. M., Myin‐Germeys, I., Strauss, G. P., & Chang, W. C. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf230 · Cited by 2 · see citing works
Lui, S. S. Y., Chan, J. W. S., Chan, J. L. F., Lam, K. H. Y., Choi, L.-Y., Wong, R. W. K., Leung, P. B. M., Zhan, N., Wong, J. W. Y., Chiu, M. W. Y., et al. (2026) · Psychiatry and Clinical Neurosciences · doi:10.1111/pcn.70094 · Cited by 2 · see citing works
Positive Psychiatry and successful aging in people with schizophrenia
Patten, R. V., Lee, E., & Jeste, D. V. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-800136-3.00013-2 · Cited by 3 · see citing works
Self-citationPillny, M., Mueser, K. T., Holden, J. L., Aarons, G. A., Sommerfeld, D. H., Perivoliotis, D., & Granholm, E. L. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf103 · Cited by 2 · see citing works
“23 ,24 ,28 Although this suggests that CBSST is effective in improving psychosocial functioning as well as in alleviating negative symptoms and defeatist beliefs, it is limited by the fact that in prior research CBSST has been delivered by highly trained professionals in specialized research…”
InfluentialSelf-citationPsychosocial Rehabilitation and Psychotherapy Approaches
Kern, R. S., Horan, W. P., Glynn, S. M., Reddy, L. F., Holden, J. L., Granholm, E. L., Turner, L. R., Sullivan, M. E., & Spaulding, W. D. (2014) · Springer eBooks · doi:10.1007/978-1-4939-0656-7_14 · Cited by 2 · see citing works
Self-citationIs Pupillary Response a Biomarker for Effort and Defeatist Attitudes in Patients With Schizophrenia?
Diminich, E. D., & GOFF, D. C. (2016) · Biological Psychiatry · doi:10.1016/j.biopsych.2016.08.020 · Cited by 2 · see citing works
McCleery, A., Wynn, J. K., Novacek, D. M., Reavis, E. A., Şentürk, D., Sugar, C. A., Tsai, J., & Green, M. F. (2023) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-023-02518-9 · Cited by 2 · see citing works
“Similarly, through identification and remediation of maladaptive cognitions and cognitive biases, cognitive-behavioral therapy (CBT) can modify appraisal of stress and defeatist performance beliefs [19–21].”
Doğu, S. E., & Örsel, S. (2021) · Journal of Cognitive-Behavioral Psychotherapy and Research · doi:10.5455/jcbpr.49061 · Cited by 1 · see citing works
Mitchell-Miland, C., McCarthy, S., & Chinman, M. (2022) · Trials · doi:10.1186/s13063-022-06376-9 · Cited by 1 · see citing works
Antipsychotics for older adults with schizophrenia
Tampi, R. R. (2025) · The Lancet Psychiatry · doi:10.1016/s2215-0366(25)00278-0 · Cited by 1 · see citing works
Keller, A. V., Dwyer, K., Holden, J. L., Pickell, D., Twamley, E. W., & Granholm, E. L. (2025) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2025.10.002 · Cited by 1 · see citing works
Self-citationGranholm, E. L., Mueser, K. T., Holden, J. L., Worley, M. J., Sommerfeld, D. H., Perivoliotis, D., Ehret, B. C., Pillny, M., & Aarons, G. A. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf084 · Cited by 1 · see citing works
Self-citation
- Authors
- Granholm, E., Holden, J., Link, P. C., McQuaid, J. R., & Jeste, D. V.
- Affiliations
- University of California San Diego (US)
- Corresponding author
- Granholm, Eric
- Venue
- The American Journal of Geriatric Psychiatry
- Publisher
- Elsevier BV
- Published
- 2013-03
- Volume
- 21
- Issue
- 3
- Pages
- 251-262
- ISSN
- 1064-7481 (ISSN-L)
- PMC
- PMC3467335
- OpenAlex
- W2001567631
- Cited by
- 135
- References
- 35
- Citations by year
- 2026: 5 · 2025: 13 · 2024: 4 · 2023: 13 · 2022: 9 · 2021: 9 · 2020: 9 · 2019: 9 · 2018: 10 · 2017: 15 · 2016: 10 · 2015: 11 · 2014: 10 · 2013: 7 · 2012: 1
- FWCI
- 8.98
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Geriatric Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute of Mental Health (R01MH071410, P30MH66248, P30MH066248)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Counseling, Therapy, and Family Dynamics
- Keywords
- schizophrenia, older adults, functional outcome, independent living skills, schizoaffective disorder, veterans, supportive group therapy, amotivation, self-esteem, life satisfaction, problem-solving training, social skills training
- MeSH terms
- Aged, Aging, Attitude, Female, Humans, Male, Middle Aged, Patient Compliance, Problem Solving, Psychotherapy, Group, Schizophrenia, Schizophrenic Psychology, Social Adjustment, Cognitive Behavioral Therapy, Single-Blind Method, Treatment Outcome
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