Day 2 :
Professor, Department of Psychiatry, the Chinese University of Hong Kong, Hong Kong
Professor WK Tang was appointed to professor in the Department of Psychiatry, the Chinese University of Hong Kong in 2011. His main research areas are Addictions and Neuropsychiatry in Stroke. Professor Tang has published over 100 papers in renowned journals, and has also contributed to the peer review of 40 journals. He has secured over 20 major competitive research grants. He has served the editorial boards of five scientific journals. He was also a recipient of the Young Researcher Award in 2007, awarded by the Chinese University of Hong Kong.
Background and objectives: To identify the risk factors, frequency, symptoms, pathomechanism and treatment of IIP through a comprehensive literature review.
Design: Systematic literature review.
Setting: Not applicable.
Participants: Not applicable.
Main outcome measures: The first author screened the titles and abstracts of all 288 records. One hundred and two studies that do not meet the eligibility criteria. Full-text versions of the remaining 186 articles (151 original articles and 35 review articles) were then screened by the principal investigator. After this screening, 14 original articles and 3 review articles were excluded, leaving 169 articles (137 original articles and 32 review articles).
Results: Psychotic symptoms are common amongst Ice users, the frequency of any psychotic symptoms ranged from 16% to 81%, with a median of 78%. The prevalence of IIP ranged from 24% to 76%, the median of prevalence of IIP is 42%. The most frequently reported symptoms of IIP are delusions of persecution and auditory hallucinations.
Conclusions: Long-term studies that track the Ice users for a decade or more are necessary to collect sufficient evidence to understand the relationship between Ice use and the development of IIP.
Founder, Clinical Director and Counsellor in Private Practice at ALW Emotional Health Services
Statement of the Problem: How do different generational and family systems/dynamics play into/contribute to the cycle of abuse often ongoing and repetitive within generational and family relationships. Does the Power and Control interpersonal characteristic of Abuse including domestic, physical, sexual, financial and emotional abuse hold a long lasting and negative impact on one’s overall Emotional Health and Personal Well-Being? Further, are the resources available: including programming, the cross intersection of social systems and counselling frameworks currently help or hinder? Are resources available to provide both intervention and prevention awareness and education, programs for individuals, couples, families, children, and youth to further prevent the abuse cycle from repeating itself within families and relationships? The ultimate Goal being to break the cycle of abuse and create long lasting healthy, happy, positive energy relationships that deeply fulfill and enrich the personal and professional lives of all parties involved. Looking at all types of Abuse from an Intersectionality framework including: Domestic, Sexual, Physical, Emotional and Financial Abuse/ Assaults, the Impact of Abuse and the Long Lasting Effects of growing up in/ living with Abuse and in Abusive Relationships has on an Individual's Emotional Health and Personal and Professional State of Well-Being.
Methodology & Theoretical Orientation: Looking deep into and understanding/ beginning to understand The Impacts , Negative Effects and Trauma of the Abuse Cycle and the long lasting effects ultimately on an individual’s, couples and families Emotional Health and Well-being using a Feminist Analysis, and Intersectionality Approach/Framework. Primary focus is placed on family systems as a whole unit and family dynamics including and acknowledging through information gathering the family history, children’s upbringing, and parenting styles. Then acknowledging and being able to recognize and accept how these roles and systems effect and have an impact (positive or negative) on children’s, youth, and adolescents relationship choices, intimate partner relationship patterns and relationships with others outside of intimate partner relationships: i.e.: friendships, coworker relationships, etc.
Findings: All types of Abuse contribute to and have a significant impact on one’s individual Emotional Health and Personal state of Well Being. Family Systems, Family Dynamics, generational ‘baggage’ upbringing and deep rooted patterns of family knowledge, parenting styles, and learned vs inherited behaviour all play a huge role in both the intervention and prevention models of abuse and breaking the cycle of abuse within families and intimate partner relationships to further repeat the wheel of power and control behavioural traits when moving forward in new relationships and partnerships.
Conclusion & Significance: From a Neural Network Therapy(how patterns in the brains are formed to create patterns of behaviour and relations with others- See Canadian Family Health Collective.com) Counselling Approach and Primarily Emotional Health based focus/standpoint, it is imperative to look at the family system as a whole and to acknowledge and recognize from a neuroscience field how patterns of behaviour are formed, created and ultimately and ‘stick’ within our brains unwanted or wanted create our relationships with others based on past life experiences and events (whether perceived by one as positive or negative experience). For an individual’s Emotional Health and Personal Well-being it is both imperative and crucial that an individual acknowledges, recognizes and becomes personally aware of the warning and danger signs of abuse. Including but not limited to abuse behaviours, characteristic traits of abusers, why people abuse/ put down/ control/ ‘need’ others and how patterns of abuse are formed within one's subconscious mind over the developmental human lifespan from infancy to child, to adolescent and teens years to adulthood through generational baggage, family history and upbringing. Abuse stems from deep rooted fears and insecurities within an abusers mindset and interpersonal traits often from learnt behaviour/ passed down behaviours of what is the ‘norm’/ accepted, expected within family systems and family relationship roles with others within the family system and family dynamics. All types of abuse are highly correlated/ intersected. However, each in their own way hold their own challenges, complexities, lasting effects within the mind and body and can create a Traumatic response ultimately negatively affecting ones individuals Emotional Health and Well Being. There are many Grey areas to abuse and each case should be treated with care, exceptions and on an individual basis with thorough knowledge, understanding, informative screening of the family history and background information leading up to the relationships and experiences of abuse and assault. ABCS of Behavioural Motivation: The Antecedent followed by the Behaviour followed by the Consequence- repeats itself depending if the consequence was positively or negatively reinforced or whether it was encouraged/ positively or negatively enabled by others.
Next Steps: Design, Create and Implement Programming Moving Forward with a focus on preventive model framework instead of interventive based programming with the focus on young children, youth and school aged relationships: promoting positive, healthy energy, give and take reciprocal relationships. Programming focusing needs to be on young boys and young girls roughly before aged 12 in a fun, interactive way to prevent the cycle of abuse and domestic, sexual, physical and emotional abuse in relationships.
Professor and Associate Dean, Faculty of Social Sciences, University of Macau, China
Keynote: Understanding the Links among Alcohol Use, Aggression and Violence among Chinese Adolescents
Time : 00:00
Spencer D. Li is Professor and Associate Dean in the Faculty of Social Sciences at University of Macau. His research interests include juvenile delinquency, substance abuse, child development, and sociology of religion. Dr. Li has served as principal investigator on a number of publicly and privately funded projects related to juvenile delinquency, substance abuse, and corrections, including grants from the U.S. National Institutes of Health, U.S. Administration for Children and Families, and Social Welfare Bureau of Macao Special Administrative Region Government. His publications have appeared in several major academic journals, including Criminology, Journal of Research in Crime and Delinquency, Justice Quarterly, Evaluation Review, and Journal of Early Adolescence.
Statement of the Problem: Past research has shown that alcohol use, aggression and violence are some of the most commonly observed delinquent activities among Chinese adolescents. Despite their high prevalence, the relationship among the three types of delinquent behavior in Chinese adolescent population has not been well understood. It is not known if alcohol use is similarly related to aggression and violence, or if the relation varies by type of behavior and level of use. This study aims to answer these questions. This study first identifies the risk profiles of Chinese adolescents who used alcohol and perpetrated aggressive or violent acts. It then assesses the interrelationship among alcohol use, aggression, and violence.
Methodology & Theoretical Orientation: Survey data are collected from a multi-stage, stratified probability sample of 3,407 students who attended secondary schools in one of the largest metropolitan areas in China. Regression analyses are conducted to test the relationships among alcohol use, aggression, and violence. It is posited that the impact of alcohol use on aggression and violence is resulted from an impaired capacity to attend to the instigative and inhibitory cues in situations conducive to aggression or violence.
Findings: Frequency of alcohol use is positively related to both aggressive and violent behavior although it is more strongly related to violence. Frequency of heavy drinking, which is the form of alcohol use known to reduce situational inhibition of violent impulses, predicts violence but not aggression.
Conclusion & Significance: Alcohol use appears to increase aggressive and violent behaviors among Chinese adolescents. Policy aimed at reducing adolescent involvement in aggression and violence should consider limiting underage drinking through promoting prevention programs and setting legal restrictions on adolescent alcohol use.
- Drug addiction
Schulte Research, Hong Kong
Paul Schulte has a BA and MA from The Catholic University of America (Washington DC) in Philosophy. He has a MA from Tufts University in international economics. He has a degree in Alcohol and Drug Counseling from Loyola Marymount University in LA and he did his internship at the UCLA School of Medicine. He has been active in LGBT drug addiction for 15 years and has established counseling groups for, among others, victims of sexual abuse and crystal meth users. He is Founder and Editor of Schulte Research. He is retired from banking.
Statement of Problem: Many in the LGBT community seek drug-taking activity, particularly meth, in part because they have PTSD due to bullying, sexual abuse, rape, assault or homelessness. As with veterans, the problem is too big for a stretched mental health community. The LGBT community could use models that veterans employ to take care of their own who have PTSD. The absence of treatment of underlying issues like widespread PTSD makes continuous sobriety problematic.
Methodology & Theoretical Orientation: In my book “Paths to Recovery for Gay and Bisexual Drug Addicts”, I examined methods used by the military veterans to help their brothers and sisters returning from battle to cope with PTSD.
Findings: Military programs for soldiers with PTSD can be easily modified for the LGBT community. These include celebrations of life (with symbols & plays) as well as programs which offer mentors, leaders, values, and moral compasses for the LGBT community.
Conclusion & Significance: The mental health crisis in the LGBT community in Asian cities is deepening and needs urgent attention.
- Rehabilitation Therapies
Anouk Prop is a psychologist and registered Yoga Alliance (500RYT) yoga teacher and trauma therapist, originally from the Netherlands. With additional postgraduate education in trauma healing, she’s an expert in addressing the roots of addiction, which are often nurtured by psychological stress, unresolved trauma and deep lack of self-love. She combines psychology, trauma healing and yoga through their very compatible aspects and stresses on the non-medical methods in healing and offers a holistic approach as such. Anouk has a broad range of experience in the field, in clinical and rehabilitation settings in several countries, varying from working with children and adults with a history of abuse, addiction, anxiety disorders, depression, but also car-accidents and other traumatic events like war or natural disasters. She encounters people with deeply rooted tension, trauma or blockages on a level which goes beyond cognition and shows that addictive behavior can be replaced by more healthy habits to overcome obstacles in life. Her mindful approach is focused on empowerment and guiding people towards their own unique essence by gently inviting them to look in the beautiful, though sometimes confronting mirror life provides, taken by her hand of compassion, positivity and enthusiasm.
Nowadays there are many programs available to treat addiction and substance abuse. An increasing number is focusing on a more holistic approach, encompassing a variety of methods and tools to help achieve, maintain, and enhance recovery. Yoga as a complementary health practice is increasingly being used in substance abuse treatment programs and throughout recovery to help prevent relapse, reduce withdrawal symptoms and cravings, and provide a healthy outlet to cope with potential triggers and daily life stressors. Yoga has been used for thousands of years as a means of promoting physical, mental and spiritual health and is seen as a very beneficial coping tool in recovery. The physical benefits support increasing strength, flexibility and dealing with withdrawal pains. Breathing exercises, gentle motions and a mindfulness-based approach reduces stress, cravings and treats any psychological distress or trauma. The improved circulation lowers blood pressure and increases oxygen flow to the brain that has a mood altering effect on the accompanying depression in recovery. Self-awareness and self-discipline is enhanced through the practice of yoga and its full on exposure therapy nature. Moreover, the origins of yoga are believed to have existed before many other belief systems were born, which provides a solid foundation for a connection with a higher power that has proven to be the crucial step in 12 step recovery programs. In addition, mindfulness based yoga focuses on the principles of acceptance and compassion that are key principles in recovery. In this session, best practices methods of mindfulness-based yoga as a tool in recovery are demonstrated in combination with an overview of its benefits and implications for practice.
- Group Therapies
Assistant Professor of Psychology, Qatar University, Qatar
Dr. Eid Abo Hamza has a PhD in counseling from University of Arkansas 2011; he is a counselor (ACA member) and works as an Assistant professor at Qatar University. He received several grants and scholarships from CSSA (Open Society Foundation), Ford Foundation, and Fulbright Scholar at University of South Florida. He is interested in Addiction, Autism, Family therapy, Wellness, and Psychological Disorders. More specifically, his work examines the intervention of group counseling in different settings such as drug abuse, Anxiety, depression, and family relations.
Background and Amis: The study's purpose is to examine the effectiveness of Motivational Enhancement Therapy (MET) on motivation to change as measured by the University of Rhode Island Change Assessment (URICA) in a controlled environment.
Methods: The treatment program contains 10 sessions; 2 sessions every week in a group format. Participants were drawn from a convenience sample of 22 adolescent males (treatment group n=11; control group n=11) who were in a mandated residential adolescent substance abuse program and who held a formal diagnosis of substance abuse or dependence.
One-way repeated measures ANOVA utilized to examine the difference in the means of URICA among participants whose scores were recorded at three different times: before treatment, after treatment, and after a 5-weeks follow up.
Results: The overall results show that there is a statistical significance for the time effect. Additionally, there is a significant difference for the group time interaction effect, which indicates that the MET intervention is significant across time. Further, the simple main effects show no significant difference for the control group across times, but did find significant differences for the experimental group. Finally, tests on the group simple main effect indicated significant differences between control and experimental groups at the pre-assessment, but no significance difference were found between the control group and experimental group in either the post-assessment or follow-up assessments.
Conclusion: Implications of the study and suggestions for future research are explored further, the research recommend using EMT.
- Addiction Treatment and Rehabilitation
Head of Department of Psychiatry Cipto Mangunkusumo Hospital – Universitas Indonesia
Dr. Kristiana Siste graduated from University of Indonesia, subspecialized in addiction psychiatrist. As lecturer, she developed addiction module for undergraduate and trainee programs, and one-stop services for alcohol and behavioral addiction patients in Cipto Mangunkusomo Hospital, Jakarta. She researched on cannabis, HIV/AIDS and Internet addiction. She has been granted scholarship for addiction training in Japan, Adelaide, and Netherlands. In 2014, she received travel award for International Society Addiction Medicine (ISAM).
Statement of the Problem: In Indonesia, about 4 million people aged between 10 to 59 years old used illegal drugs in 2014 and around 15% of those were injecting drug users (IDUs) associated with the HIV/AIDS cases. Methadone maintenance treatment (MMT) was conducted in Indonesia as a harm reduction program focusing on IDUs. Despite its effectiveness and advantages, several drop outs were recorded. Predictor factors, such as program, patient and social characteristics, were needed to assess the treatment retention. This study aimed to evaluate the rate and to identify the predictors of MMT retention among patients with opioid dependence in Indonesia.
Methodology & Theoretical Orientation: This study was a quantitative research conducted on 264 subjects with opioid dependence who met the inclusion and exclusion criteria through consecutive sampling established in four community health centers in Jakarta. They were measured for independent variables using geographic data, SCL-90, ASI, and URICA, before started the MMT. On the third and sixth month, they were evaluated and measured for retention. The data were analysed using univariate Chi-square/ Mann-Whitney test and multivariate logistic regression test.
Findings: Among 264 subjects who enrolled in this study, 227 were male (86.0%) and 37 were female (14.0%), aged 29-37 years old and received 50.0-133.8 mg of methadone dose. There was no subject who lost to follow-up. The retention rate was 91.3% (n=241) after 6 months. Predictors of retention found in the study including (1) financial support (p=0.029); (2) history of psychiatric problem (p=0.031); (3) action motivation (p=0.004); and (4) contemplation motivation (p=0.016).
Conclusion & Significance: From the study, we can conclude that financial support and history of psychiatric problem were positive predictors for MMT retention. Furthermore, motivation did contribute to the retention. While contemplation motivation was a positive predictor for retention, action motivation proven otherwise. Therefore, intervention program is needed for the patients who are prone to drop out.
Family Intervention & Recovery Services, USA
Karen is a certified intervention professional, public speaker and the co-author of the acclaimed book Addicted Like Me, A Mother-Daughter Story of Substance Abuse and Recovery as featured on ABC World News Tonight with Diane Sawyer. In Addicted Like Me, Karen and her daughter share their personal story of the tragic effects of multi-generational addiction to provide inspiration and insight into the hope and healing that is possible when the cycle of addiction is broken through intervention and family recovery. Karen excels in working with Codependency & Family Systems affected by Addiction. Her own personal experience combined with her professional training and credentialing in the field, gives her a unique perspective in educating and guiding families through one of the most difficult challenges a family can experience. Karen is a "road warrior" often traveling nationwide and internationally to where the need is to help families break the cycle of addiction.
Statement of the Problem: Studies have confirmed the central role of family in addiction treatment positively impacts outcomes. Addiction recovery may appear to be a personal journey; however, it often actually ends up being a group effort. Family members have a role to play in every phase of addressing addiction – from the earliest stages of encouraging them to seek treatment on through the maintenance of ongoing recovery.
Methodology & Theoretical Orientation: Intervention helps to change perspectives for many families giving them the first exposure to addiction as a disorder affecting the brain of the person struggling. The family is educated on how their own denial and how enabling of the problem plays into the cycle that is addiction. When the family stops contributing to the problem, there is the beginning of change to break the cycle. Without education, the family continues in the cycle of dysfunction, chaos and distress.
Findings: A study at a treatment facility in India examined whether family members involvement in intervention and relapse prevention would improve the individual’s success in remaining sober. The study was conducted by Prasanthi Nattala, Kit Sang Leung, Nagarajaiah and Pratima Muthy. The intervention group participants consistently showed better results than those in the non-intervention group on all of the outcomes, such as reduction in quantity of alcohol, drinking days, and number of days with dysfunction in family, occupational and financial dimensions. The study’s findings show the important of family “buy-in” when an individual enters treatment for alcohol use disorder. The involvement of a family member helps ensure that an individual will be successful in avoiding relapse.
Conclusion & Significance: On-going involvement in case management, family recovery coaching and after care planning by an intervention professional, helps the family to begin their own journey of recovery which in turn helps them to become stronger and more supportive in healthy behaviors.
- Addiction Therapy
The Cabin Chiang Mai, Thailand
Stuart Fenton (Stu) is a clinical psychotherapist with over 12 years of experience working in the addiction treatment field. Stuart has worked in residential long term and short-term rehabilitation settings, public and private sector rehabilitation, community health centers in both Addiction and Family violence, outreach and GLBTI services whilst for the last ten years simultaneously building a private psychotherapy practice in both Sydney and Melbourne mostly working in the areas of chemical and process addictions, GLBTI issues, codependence issues, family interventions & sex & love addiction. From 2011 to 2013 Stuart facilitated two ongoing process groups in Sydney for gay men which were very popular. Stuart is currently training to become an IITAP certified sex addiction therapist and regularly presents for AUSMED organization in Australia on the topics of Resources & Referral Pathways”, Treatment Approaches to Crystal Meth Addiction “and “My own Personal Journey.”
Recent studies have shown that LGBTI clients who were in treatment with a specialized program tailored had much higher rates of abstinence once they completed the program than those who were not in treatment for LGBTI individuals. In different research it was found that 57% of the gay and bisexual participants in their particular study said that they thought their sexual orientation had negatively affected their treatment experience. Gay and bisexual men were less likely to complete their treatment programs than heterosexual men and were more likely to have left treatment because their needs were not being met.
Statement of the Problem: Recovery from substance abuse is a supportive process; the support of family and friends often plays a large role in recovery from substance abuse. As a family member, spouse or friends, the supporting role can be crucial and confusable to help the loved ones focus on his or her health and recovery. The Person addicted to any substance cannot be considered as cured as soon as they step out of a De-addiction or a Rehabilitation center as recovery from substance abuse is just not quitting the substance, it’s about the life style change of the affected person on a day to day basis which is impossible for him to do it alone. The role of family members in recovery from addiction has been discussed in several researches. This study tries to find out the effect of behavioral modification adopted by the family members to support the patient recovery after the treatment from De-addition and rehabilitation centers. For this research, suffering families were identified across Tamilnadu state in India. Where, in few families were taught about BMT (Behavioral modification techniques) and reaming families were allowed to follow their own method of handling patient who had come out from the treatment centers. As a result, it has been observed from the study that families followed BMT (Behavioral modification techniques) were able to support their loved ones recovery positively than with the families who didn’t follow the BMT.
Methodology & Theoretical Orientation: Research design used for the proposed data is Descriptive. Both primary (Interview schedule through questionnaire) and secondary data (books magazines and journal) were used and analysed. Questionnaire was evaluated sensibly to the reliability analysis.
Test used: t- test, (paired t-test)
Findings: As a result, it has been observed from the study that families followed BMT (Behavioral modification techniques) were able to support their loved ones recovery positively than with the families who didn’t follow the BMT.
- Child & Adolescent Substance Abuse
Rajarata University, Sri Lanka
B.A.N.Madubashini is the under graduate student of Rajarata university of Sri Lanka. Madubashini studies BSc. Health promotion (Special) four year degree. She works with the community for health promotional works for more than three years. She has studied about Human resource management, Informational Technology and psychology. She was late President of University Health Promotion Society. Madubashini specially interests to work on control substance use and control Non communicable diseases of the rural community.
Statement of the Problem: Alcohol is the single most important cause of preventable illness and premature deaths worldwide. Behavior change and pharmacotherapy are the two key interventions to reduce alcohol consumption. Alcohol industry use diverse strategies to attract teenagers who are vulnerable and adventurous. Hence counter strategies such as improving knowledge on industry agenda and real harm of alcohol are needed to reduce alcohol use among teenage groups. This study reveals effectiveness of an intervention designed to generate collective actions through improving knowledge among schooling adolescents on real harm of alcohol and industry strategies. The study was conducted in a rural area where educational facilities are low and 140 schooling adolescents from the same area were recruited.
Methodology & Theoretical Orientation: A self-administrated questionnaire which focused on knowledge and attitudes on real harm and alcohol industry strategies were used to assess participants’ knowledge and also as a part of intervention. Focus group discussions were also conducted for the same purpose. An interactive workshop was conducted by expert to discuss industry strategies used to attract them, myths spread though advertisements and promotions and privileges given to drunkards in the society. Changes of knowledge and attitude of participants were assessed using qualitative methods and structured observations during focus group discussions following the intervention.
Findings: Students showed improvements in knowledge on physical, economic and social harms of alcohol. They also have improved view on strategies used by alcohol industry. Number of participants took actions to reduce alcohol consumption of their fathers and started showing disagreement with alcohol use in public by criticizing behavior of alcohol users. Students can be inspired to initiate and take part in collective actions and make supportive environment to quit alcohol and substance use.
Conclusion & Significance: Similar health promotion intervention targeting alcohol can be used in similar setting targeting teenage groups or student groups as change makers.
Ethiopian Public Health Institute, Ethiopia
Background: Alcohol is a psychoactive substance with dependence-producing properties. Consumption of alcohol and the related problems vary widely around the world. The burden of disease and death associated to alcohol remains significant in most countries. Less is known and noted on alcohol misuse in Ethiopia. The main purpose of this study was to determine the magnitude and predictors of alcohol use in Ethiopia. Method: The WHO stepwise approach to the surveillance of NCDs risk factors was used and, a community-based cross sectional study was carried out. Mix of stratified, three-stage cluster and simple random sampling were used to the study setting or clusters and households. Kish sampling method was used to identify the study participant from the selected households. The sampling frame was based on the population and housing census conducted for Ethiopia in 2007. Data were collected using WHO NCD STEPs questionnaire; alcohol misuse was taken as a dependent variable. Five hundred thirteen EAs as PSUs (404 rural and 109 urban) were selected with probability proportionate to size, followed by selection of households as a secondary sampling units (SSUs). A total of 10,260 households were selected from the 513 EAs (20 households per EA). Eligible individuals were selected from household using Kish method. Descriptive statistics including frequency table, mean, median, interquartile range and standard deviations were computed. Binary logistic regression was used to analyze the independent predictors of Alcohol misuse. An Estimator of 95% confidence interval was used both in computing frequencies and the predictors. Result: A total of 9,800 participants were interviewed in the study. The majority, 5,823 (59.4%), of the study subjects were female and 3,959 (40.4%) were 15 - 29 years of age. The overall lifetime prevalence was 49.3% and among them 89.6% drink alcohol in the 12-months preceding the survey. Among the lifetime drinkers, 92% are current alcohol user. Twenty nine percent (28.6) of life time alcohol user stopped drinking due to health reasons. In multivariate logistic regression, factors independently associated with alcohol misuse/binge alcohol use after adjusting for other characteristics were sex, residence type, marital status, and current smoking status.
Conclusion: Half of the Ethiopian population reported drinking alcohol at some point in their lives. The findings would be helpful to initiate effective alcohol prevention and control programs focusing on rural and would also serve as a stimulator to conduct further longitudinal studies on this topic in Ethiopia.