Search

BackgroundAdolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments. ObjectiveThis trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents. MethodsThe trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment. ResultsIPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P

Emerging evidence indicates that perceptions of self-harm behaviours and self-harm scars may thwart recovery from depression, yet limited research has explored adolescent accounts of their self-harm and scars during therapy. This study sought to explore how adolescents describe their self-harm behaviours and scars during Cognitive Behavioural Therapy (CBT) and explore the sociocultural discourses that may influence these descriptions. The participants were six female adolescents (aged 14-17 years old) with clinical depression, who were engaging in self-harm. All participants accessed CBT as part of clinical trial evaluating three psychological treatments for major depressive disorder in Child and Adolescent Mental Health Services. Audio-taped CBT sessions were analyzed using discourse analysis. Within CBT sessions, adolescents drew upon stigma discourses in talking about their self-harm. Adolescent also described their self-harm scars as shameful and stigmatizing, and as "proof" of the legitimacy of their depression. It is important for CBT practitioners to understand the context of sociocultural discourses around self-harm behaviours and self-harm scars, which are reflected in how adolescents with depression describe these within therapy and may serve to maintain distress. The study indicates that awareness of use of language and intersecting sociocultural discourses can inform CBT practice. Plain language summary: We know that when teenagers are in treatment for depression, perceptions of their self-harming behaviours and self-harm scars can impact recovery. We also know that wider sociocultural beliefs around self-harm tend to be negative and stigmatizing, which might impact how teenagers perceive their self-harm and scars. This study aimed to explore how depressed adolescents talk about their self-harm behaviours and their self-harm scars during therapy for depression. The participants in this study were six female teenagers (aged 14-17 years old) with depression, who were engaging in self-harm. These teenagers participated in a type of therapy called Cognitive-Behavioural Therapy as a part of a larger study evaluating treatments for teenage depression in Child and Adolescent Mental Health Services in the UK. The therapy sessions were recorded, transcribed, and analyzed with a focus on the language used by the teenagers to describe their self-harm and scars. Within the therapy sessions, the teenagers talked about their self-harm in stigmatizing ways, which reflected prominent societal-held beliefs about self-harm. The teenagers in the study also believed that while their self-harm scars were shameful and stigmatizing, the scars also provided a sense of validation that their depression was legitimate. The findings of this study suggest that it could be helpful for therapists to consider how wider sociocultural beliefs around self-harm may impact how teenagers talk about their self-harm and scars in treatment for depression. [ABSTRACT FROM AUTHOR]

Introduction: Short-term psychoanalytic psychotherapy (STPP) is an evidencebased treatment for adolescents with depression, but like all treatment approaches, not all patients benefit from it. Previous investigations of the process of STPP have mostly focused on successful cases, and only a few studies have included the perspectives of young people, their parents, and therapists in the understanding of treatment non-response. Methods: Semi-structured interviews were carried out with young people who were considered "non-responders" to STPP, as well as with their parents and therapists. These cases were analyzed using a descriptive-interpretative approach. Results: The data analysis revealed three themes: (1) Therapy as a safe space; (2) Can short-term psychotherapy ever be enough?; and (3) Therapists making links and connections that did not make sense to the young people. Discussion: This study's findings indicate that "poor outcome" psychotherapy does not necessarily equate to a "poor experience" of psychotherapy, with different stakeholders appreciating the treatment setting as a "safe space." However, they also suggest that some felt that a relatively short-term treatment could not lead to substantial change and that young people in STPP might have a more negative view of their outcomes compared to their parents and therapists. Finally, the findings indicate that some interventions made by clinicians in STPP feel wrong or do not make sense to young people, potentially affecting the therapy process. [ABSTRACT FROM AUTHOR]

Objective: To identify and describe in-session interaction patterns between psychoanalytic therapists and adolescents diagnosed with major depressive disorder, comparing good and poor outcome cases. Method: Audio recordings for 100 psychotherapy sessions from 10 Short-Term Psychoanalytic Psychotherapies were analysed using the Adolescent Psychotherapy Q-Set (APQ). The cases and sessions were evenly divided into two groups (poor outcome and good outcome, 5 patients and 50 sessions per group). Interaction patterns were analysed with an Exploratory Factor Analysis (EFA), while group differences were assessed through t-tests. Results: The EFA revealed three factors: (1) "Open, engaged young person working collaboratively with a therapist to make sense of their experiences", (2) "Directive therapist with a young person fluctuating in emotional state and unwilling to explore", (3) "Young person expressing anger and irritation and challenging the therapist". Factor 1 was significantly more prominent in the good outcome cases, while factor 3, on the contrary, was more significantly related to the poor outcome cases. Factor 2 was equally present in both groups. Conclusion: Besides reinforcing to researchers and clinicians the association between a collaborative psychotherapy process with good outcomes, our findings also provide empirical data regarding the role of anger in adolescent depression and the psychotherapy process. [ABSTRACT FROM AUTHOR]

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (Mage = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child's treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability. [ABSTRACT FROM AUTHOR]

The development of evidence-based practice guidelines for psychotherapy is based primarily on the findings from randomised controlled trials, but there is also a need to understand and learn from the experience of those who attend therapy. Some studies have begun to examine the experience of children and adolescents who have been in psychoanalytic psychotherapy. However, no investigations to date have synthesised this body of work and drawn clinical implications from this research. Therefore, this study aimed to provide the first qualitative meta-synthesis of empirical studies examining children and young people's experiences of psychoanalytic psychotherapy. Articles meeting the inclusion criteria (n = 11) addressed treatments taking place in the UK, Scandinavia and Western Europe, and most of them focused on those who were in therapy as adolescents. The overall methodological quality of the studies was high. Based on the qualitative meta-synthesis, four over-arching themes were identified: (1) Children and adolescents learn to navigate their role during therapy; (2) The importance of the therapeutic relationship; (3) Psychoanalytic psychotherapy as a 'painful' process; and (4) Perceived impact of psychotherapy varies and is difficult to gauge. Some of the findings were consistent with the literature on adults' experiences of psychoanalytic therapy, as well as young people's experiences of other types of therapy. However, the findings also point to certain unique features of psychoanalytic psychotherapy for children and adolescents. The clinical implications of the findings are discussed. [ABSTRACT FROM AUTHOR]

This study examines how transference work (TW) impacts alliance ruptures in short-term psychoanalytic treatment (STPP) for adolescents with depression. Using a mixed-methods approach, this study analyzed 16 STPP sessions with 4 adolescents. Observer-based measures were employed to assess both alliance ruptures-resolutions and TW, while qualitative analysis provided insight into TW's role in repairing ruptures. The findings demonstrate that TW was commonly employed in STPP sessions and also in response to ruptures. The most frequently utilized forms of TW centered on interpretations addressing immediate issues within the therapeutic relationship, rather than drawing connections to relationships outside of therapy (genetic interpretation). Overall, this type of TW contributed positively, albeit modestly, to repairing alliance ruptures. Key factors enhancing TW efficacy included the therapist's ability to maintain a focus on transference dynamics in the present moment and their capacity to be validating and flexible in applying TW techniques. Conversely, rigidity in the use of TW and promoting dependency between the adolescent and therapist/therapy hindered the resolution of ruptures. [ABSTRACT FROM AUTHOR]

Objective: To explore young people's perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression. Method: As a part of a randomized controlled trial, 18 adolescents aged 15–19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis. Results: The findings are reported around four main themes: "a meaningful and significant relationship with someone who cared", "a helping relationship with someone who guided and motivated me through therapy"; "a relationship made safer and more open by the fact that we didn't have to meet" and "a nonsignificant relationship with someone I didn't really know and who didn't know me". Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge. Trial registration: ISRCTN.org identifier: ISRCTN16206254.. [ABSTRACT FROM AUTHOR]

Introduction: Depression constitutes one of our largest global health concerns and current treatment strategies lack convincing evidence of effectiveness in youth. We suggest that this is partly due to inherent limitations of the present diagnostic paradigm that may group fundamentally different conditions together without sufficient consideration of etiology, developmental aspects, or context. Alternatives that complement the diagnostic system are available yet understudied. The Power Threat and Meaning Framework (PTMF) is one option, developed for explanatory and practical purposes. While based on scientific evidence, empirical research on the framework itself is still lacking. This qualitative study was performed to explore the experiences of adolescents and young adults with depression from the perspective of the PTMF. Methods: We conducted semi-structured interviews with 11 Swedish individuals aged 15– 22 years, mainly female, currently enrolled in a clinical trial for major depressive disorder. Interviews were transcribed verbatim and analyzed with framework analysis informed by the PTMF. Results: A complex multitude of adversities preceding the onset of depression was described, with a rich variety of effects, interpretations, and reactions. In total, 17 themes were identified in the four dimensions of the PTMF, highlighting the explanatory power of the framework in this context. Not all participants were able to formulate coherent narratives. Discussion: The PTMF provides a framework for understanding the complexities, common themes, and lived experiences of young individuals with depression. This may be essential for the development of new interventions with increased precision and effectiveness in the young. [ABSTRACT FROM AUTHOR]

Internet-delivered, therapist-guided, self-help programs are novel ways to deliver psychotherapeutic interventions adapted from established therapy models. Such programs can be easily accessed online and may offer an important treatment option for patients who struggle with barriers to seeking out and engaging in face-to-face psychotherapy, including depressed adolescents. While there are evidence-based Internet-delivered self-help programs based on cognitive-behavioral therapies (i.e. ICBT) for adolescent depression, a program based on psychodynamic principles (i.e. IPDT) has so far been lacking. In this article we describe the IPDT program developed within the ERiCA project, which has so far been evaluated in two randomized controlled trials (RCTs). We further provide a case example from one of the trials to illustrate the treatment process and therapeutic interaction in detail. Given the novelty of the approach, we will particularly highlight and discuss how a psychodynamic understanding of adolescent development and depressive dynamics as well as affect-focused treatment principles inform the treatment, including the therapist's role, tasks, and choice of interventions. The potential implications and utility of IPDT for regular clinical practice are elaborated as well as potential research directions for the future. [ABSTRACT FROM AUTHOR]

Introduction: High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement. Method: Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators. Results: The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress. Discussion: The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment. [ABSTRACT FROM AUTHOR]

The importance of child and adolescent mental health services (CAMHS) collaborating with other agencies is of paramount concern for children with complex difficulties, including children in care. However, there is a lack of research exploring the role of child and adolescent psychoanalytic psychotherapists in multi-disciplinary and multi-agency work surrounding these children. Aims: to develop a theory of how child and adolescent psychoanalytic psychotherapists function within a social care setting, including how they position themselves in a multi-disciplinary and multi-agency environment. Methods: an ethnographic case study design, consisting of participant observation supplemented by interviews. Findings: grounded theory analysis identified that the child psychotherapists balanced three elements of their professional identity: discipline-specific identity; CAMHS team member identity; child's care network member professional identity. To be effective in their role, the child psychotherapists needed to integrate the elements of their professional identity. The findings have implications for understanding the contribution of child psychotherapists in this field, particularly how to integrate into multi-disciplinary and multi-agency settings, whilst retaining their distinctive professional identity. [ABSTRACT FROM AUTHOR]

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive−behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com ; ISRCTN83033550. [ABSTRACT FROM AUTHOR]

Background: Outcome measures mostly focusing on symptom reduction to measure change cannot indicate whether any personally meaningful change has occurred. There is a need to broaden the current understanding of outcomes for adolescent depression and identify whether holistic, interlinked patterns of change may be more clinically meaningful. Objective: To create a typology of therapy outcomes based on the experiences of adolescents with depression. Method: Interview data from 83 participants from a clinical trial of the psychological treatment of adolescent depression was analysed using ideal type analysis. Results: Six ideal types were constructed, reflecting different evaluations of the holistic impact of therapy: “I’ve worked on my relationships”, “With the insight from therapy, and feeling validated, I can cope with life challenges better”, “My mood still goes up and down”, “If I want things to change, I need to help myself”, “Therapy might help, but it hasn’t been enough”, and “I don’t feel therapy has helped me”. Conclusion: Assessing change using outcome measures may not reflect the interconnected experience for adolescents or the contextual meaning of symptom change. The typology developed offers a way of considering the impact of therapy, taking into account how symptom change is experienced within a broader perspective. [ABSTRACT FROM AUTHOR]

This text is in the form of a discussion, based on a transcript of a talk that was given at the International Congress on Mentalization-Based Treatments with Children and Young People, in Barcelona, on 29th June 2023. As the topic of the conference was the dialogue between clinical practice and research, we took the decision to present our project in the form of a conversation. In doing so, we hoped to show the value of bringing different perspectives together, in the spirit of the mentalizing stance. As the clinical lead for the Reflective Fostering Programme, Sheila Redfern reflected on her perspective together with Nick Midgley, as the Principal Investigator on the Reflective Fostering Study. The two speakers have a mentalizing conversation about the main themes arising from integrating clinical practice with research. The talk began with an introduction from the chair, Nicole Muller. [ABSTRACT FROM AUTHOR]

Introduction: Innovative moments (IMs) pinpoint new and more adaptative meanings that emerge in clients' discourse during psychotherapy. Studies with adult clients have found a greater proportion of IMs in recovered compared to unchanged cases, but similar studies have yet to be conducted with adolescents. Aims: The paper aims (1) to study retrospectively the emergence of IMs in therapy, using a post‐therapy interview, in adolescents that underwent psychotherapy for depression, and (2) to characterize the themes present in IMs identified retrospectively in the interviews. Method: Semi‐structured post‐treatment interviews conducted with 24 adolescents on the experience of taking part in a clinical trial of youth depression, were coded using the Innovative Moments Coding System. After identifying IMs, a thematic analysis identified the prominent themes within them. Results: Higher presence of IMs were found in recovered compared to unchanged cases. Two main themes emerged in the IMs, changes that occurred with therapy and attributions of changes. Recovered cases presented more IMs centred on the self, whereas unchanged cases identified more non‐specific changes. Conclusion: This study suggests that it is possible to code IMs, identified retrospectively, based on post‐therapy interviews with adolescents. Meaningful differences were found between recovered compared to unchanged cases. Therapeutic recovery was associated with a higher focus on the self and more specificity in clients' representations of the change process. [ABSTRACT FROM AUTHOR]

Psychotherapy dropout is a common phenomenon in youth mental health, often due to dissatisfaction with treatment. However, little is known about the therapeutic processes that precede dropout due to dissatisfaction. This mixed-methods empirical case study aimed to explore the therapeutic process of a 12-session, prematurely ended therapy with a young person with depression in short-term psychoanalytic psychotherapy (STPP). The Adolescent Psychotherapy Q-set (APQ), an empirically validated process measure, was used as a framework for qualitative analysis exploring the therapy process over time. Analysis of APQ ratings of the 12 sessions found a productive patient-therapy dyad working collaboratively to understand the young person's experiences and emotions. Following an initial phase of the young person presenting as emotional and vulnerable, she became increasingly ambivalent about continuing in psychotherapy. A lively and argumentative period exploring the young person's ambivalence and increased sense of well-being culminated in eventual dropout. This study suggests that even in a strong, collaborative working relationship with an engaged young person, ambivalence around dependency and vulnerability can threaten treatment completion. Therapists' enhanced sensitivity to relevant processes that precede therapy dropout have the potential to improve engagement of young people in psychotherapy, which may optimise outcomes. [ABSTRACT FROM AUTHOR]

The need to account for adolescents' views during the design and development of therapeutic interventions is well documented, yet there remains a paucity of research doing so, particularly among internet-based therapies. This study aimed to address this by exploring adolescents' expectations and experience of an internet-based psychodynamic therapy (I-PDT) for adolescent depression. Fourteen semi-structured interviews were conducted and thematically analysed. From this, five overarching and interrelated themes were identified: 'negative expectation', 'strong therapeutic relationship', 'significant commitment', 'facilitated change', and 'gained appreciation'. The prominent effect of personal characteristics was also evident, whereby those young people who were highly motivated, or less confident, spoke most positively of their experience. The findings support government policies to increase availability of digitally enabled models of therapy, by highlighting adolescents' positive experiences. However, the impact of individual characteristics and working styles on adolescents' experiences signals that internet-based therapies may not be suitable for all. Young people may benefit from a range of different treatment options, able to meet their various needs and preferences. [ABSTRACT FROM AUTHOR]

Mentalization theory suggest bidirectional links between a caregiver's capacity to mentalize their child and emotional regulation in their children. However, there has been little empirical investigation to verify this theory. The bidirectional relationship between caregiver mentalizing and child emotional regulation may be especially important to understand in caregiving contexts where there is greater risk of relationship breakdown or child emotional dysregulation, such as in fostering relationships. This study used a novel time-sequence analysis approach to explore the putative bidirectional relationship between caregiver mentalizing and child emotional regulation in the context of long-term foster care. Existing theories about caregiver mentalizing and child emotional regulation were evaluated and developed by looking at moment-by-moment interactions between a foster carer and a child in her care. The findings of this study gave mixed support for bidirectional relationships between foster carer mentalizing, and child emotional regulation predicted by existing theoretical models. These findings have implications for refining and applying mentalization theory broadly and more specifically in the context of foster care. Furthermore, this study provides a useful example of how time-sequence analysis may be useful for exploring the links between phenomena, such as caregiver mentalizing and child emotional dysregulation, occurring over time in observational data. [ABSTRACT FROM AUTHOR]

Originally rooted in philosophy and sociology, the concept of epistemic trust has recently transitioned to developmental psychopathology, illuminating social-cognitive processes in psychopathology. This narrative review synthesizes empirical evidence on epistemic trust to inform future research. A literature search highlighted 3 areas: i) the development of selective trust in children; ii) epistemic trust in non-clinical adults; iii) its link to mental health. Young children demonstrate selective learning from reliable sources using epistemic cues. Empirical studies beyond childhood were greatly facilitated in the last 2 years with the introduction of the Epistemic Trust, Mistrust and Credulity Questionnaire, a self-report scale measuring epistemic stance. Cross-sectional studies pinpointed dysfunctional epistemic strategies as factors in mental health vulnerability, and some qualitative work offered initial evidence linking restored epistemic trust to effective psychotherapy. For future research, we propose focusing on 3 primary areas. First, empirical investigations in adolescent samples are needed, as adolescence seems to be a pivotal phase in the development of epistemic trust. Second, more experimental research is required to assess dysfunctional and functional epistemic stances and how they relate to vulnerability to mental health disorders. Finally, intervention studies should explore the dynamics of epistemic stances within and between therapy sessions and their impact on therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background: The majority of children referred to Child and Adolescent Mental Health Services (CAMHS) in the UK will present with mixed emotional and behavioural difficulties, but most mental health treatments are developed for single disorders. There is a need for research on treatments that are helpful for these mixed difficulties, especially for school-age children. Emotion Regulation (ER) difficulties present across a wide range of mental health disorders and mentalizing may help with regulation. The ability to mentalize one's own experiences and those of others plays a key role in coping with stress, regulation of emotions, and the formation of stable relationships. Mentalization Based Therapy (MBT) is a well-evidenced therapy that aims to promote mentalization, which in turn increases ER capacities, leading to decreased emotional and behavioural difficulties. The aim of this study is to test the clinical- and cost-effectiveness of MBT compared to treatment as usual for school age children with emotional and behavioural difficulties. If effective, we hope this approach can become available to the growing number of children presenting to mental health services with a mix of emotional and behavioural difficulties. Materials and methods: Children referred to CAMHS aged 6–12 with mixed mental health problems (emotional and behavioural) as primary problem can take part with their parent/carers. Children will be randomly allocated to receive either MBT or treatment as usual (TAU) within the CAMHS clinic they have been referred to. MBT will be 6–8 sessions offered fortnightly and can flexibly include different family members. TAU is likely to include CBT, parenting groups, and/or children's social skills groups. Parent/carers and children will be asked to complete outcome assessments (questionnaires and tasks) online at the start of treatment, mid treatment (8 weeks), end of treatment (16 weeks) and at follow up (40 weeks). Trial registration: Clinical trial registration:ISRCTN 11620914. [ABSTRACT FROM AUTHOR]