- I'd like to welcome you to our talk on creative coping with chronic illness.  It is my pleasure to introduce Dr. Heidi Beckman, who is a clinical psychologist at UW Hospitals, for today's talk, so...  (applause) - Thank you, and thanks for inviting me here.   I want to talk a little bit first about what department I'm in and explain what it is.  So I'm in the Department of Health Psychology at the University Hospital.  And health psychologists are, it's a specialty area of clinical psychology where we work with people who have a wide variety of medical conditions.  So it's sometimes people who are newly diagnosed with a challenging medical condition.  Sometimes it's people who have been living with chronic illness for a long, long time, and maybe some new challenges come up that are making it difficult to adjust to life with a medical condition.  I see people with chronic illness and chronic pain and people who are having some challenges doing what their medical team asks them to do in order to take good care of themselves.  So it's really a wide variety. 

 I'm currently running a group at the hospital that's called Creative Coping with Chronic Illness.  I've been running the group for about eight years now, and over the years, I've actually learned quite a bit.  I've had the pleasure of meeting a lot of strong and courageous and insightful people who have shared their stories with me and have taught me quite a bit about what it means to live well with a medical condition.  And so those are the insights that I'd like to share today.   Just a quick look at my agenda.  I'd like to start by talking about some of the specific challenges of living with a chronic medical condition.  And then, from there, talk about the phases of the chronic illness journey.  Also, I want to talk about a concept from a psychologist named Dr. Pauline Boss.  It's called ambiguous loss, and it fits quite nicely in the context of this discussion of talking about living with chronic illness.  And then, finally, I'd like to introduce some ideas for coping. 

  So if we look first at the challenges of living with chronic illness, I think the first one on there is the most obvious one.  It's the one that we think of first.  It's the physical symptoms.  So pain and weakness and fatigue, sometimes sensory disturbances, sometimes changes to sleep or changes to appetite.   So very common in the context of chronic illness.  But you'll notice, even though that's the one we think of first, there are six others on there.  And some of the others can be even more significant or more problematic sometimes than the physical symptoms.  So the other six we'll look at one at a time.  Functional changes, emotional symptoms, cognitive symptoms, negative thoughts, relationship changes and changes in self-image.  When I say functional changes, I mean changes to someone's participation in activities. 

 So sometimes, that's a reduction in participation, and sometimes that's stopping participation all together in things such as work or hobbies or chores around the house, et cetera.  So if we pair the physical symptoms with the functional changes, then it seems pretty obvious that a byproduct of that can be emotional symptoms.   So probably, the first two on that list, the anxiety and the depression, are some of the most common symptom, emotional symptoms, that occur with chronic medical conditions.  Also, people report changes in mood, anger and frustration, irritability, sometimes feelings of helplessness, feelings of hopelessness, like things are not going to get better, or feelings of worthlessness, feeling down on oneself.  Another part of the picture of chronic medical conditions would be cognitive symptoms in some cases.  By cognitive symptoms, I mean changes to our thinking skills.  So that could be difficulty making decisions, difficulty concentrating, changes to memory.  In certain medical conditions, you might see changes to someone's personal insight, their awareness of what's going on with themselves.  And sometimes changes to judgment.   Negative thoughts are very common with chronic medical conditions. 

 When people become more stressed or depressed, then a natural result of that is starting to think more negative thoughts about the self, about the world around us and about the future.  So for example, negative thoughts about the self might be, "I'm worthless," or "I'm a loser." Negative thoughts about the world around us might be "Life isn't fair," or "No one understands what I'm going through." Negative thoughts about the future might be "Things are just going to keep getting worse from here," or "My whole body is falling apart, "and everything is going downhill." So those are really common, especially in the early stages of adjusting to a chronic medical condition.  A psychologist by the name of Dr. Aaron Beck called those three areas the Negative Cognitive Triad.  So he said if you think about a triangle, the three points on the triangle are self, world, and future.  That as we get more stressed and depressed, our thinking gets more negative in those three areas.   Relationship changes.  So we all live in an interpersonal context.  Very common when we're living with a chronic medical condition to have changes to that interpersonal context.  So in some cases, when we're not feeling a way, we start to isolate ourselves.  We pull away from other people. 

 In other cases, the people around us are somehow challenged by our chronic medical condition.  Maybe they're not sure how to be helpful to us or they're not sure how to relate to someone who has this new diagnosis.  And so they start pulling away.  So either way, the end result of all that could be more isolation, more feelings of loneliness.  And then the unfortunate result of that is often, at the very time when we need the most social support and the most help from our friends and family members that we're becoming more isolated.   And then, finally, changes in self-image.  So what I mean here is people often find, when they begin having serious medical symptoms, that they start feeling differently about themselves, that they feel broken somehow or like they're not a whole person or not a complete person anymore.  Sometimes there are changes to self-esteem or self-confidence.  And a very common reaction would be a longing to have your old self back and just wanting things to go back to the way they were before.   So given that chronic illness can impact so many aspects of our lives, I always think that it takes so much courage and energy to take on the task of managing a chronic illness better. 

 But many people do find that they do regain some control over their existence, and they move through the phases of the chronic illness journey, and they get to a place where they're managing their chronic illness better.  So you'll see the two circles on the screen.  I call those identity pies.  So if I gave you just a circle on a sheet of paper and I said this circle represents your identity or your sense of self, and then I ask you to take a pen and just divide the circle up into the different aspects of yourself, people will often say, okay, well one piece of my identity pie would be my family relationships.  Another piece would be my friendships.  Another piece would by my hobbies and interests.  Another piece might be my work, et cetera.   So it's kind of an interesting activity, you know, to divide up your identity pie and identify what is most important to your sense of self.   Now the circle that's on the left-hand side, if you look at the red part of it, I'm using the red color in this slide to represent the chronic medical condition.  So when people are newly diagnosed with a chronic medical condition, their identity pie often looks like the one on the left. 

 The medical condition is in the center of their sense of identity, and it's bleeding over into every aspect of their life.  So it's kind of at the forefront of their consciousness.  When they're reflecting on themselves, the chronic illness is dominant in their mind, at the center of their sense of self.  The goal is to make your identity pie look more like the one on the right-hand side of the screen.  And So in that case, you can see the red shaded piece.  That's the chronic medical condition.  So in this case, the person would say, okay, I've got my family relationships, I have my friendships, I have my work, I have my hobbies and interests, et cetera, and, oh, by the way, one slice of my identity is my chronic medical condition.  So it just happens to be one piece of who I am.  So you can see the difference there.  It's integrated into your sense of self, but it's not bleeding over into every aspect of who you are and every domain of your life. 

 So for many people that I meet within the Health Psychology Department, that's the goal, is to move from the identity pie on the left side of the screen to the identity pie on the right side of the screen.   There are many different theories about the stages or the phases that people go through as they cope with a chronic condition, So I'd like to introduce one that I really like.  It's been designed by a medical social worker by the name of Patricia Fennell.  And she summarizes it, she has a few different books where she summarizes it.  The one that I like best is called The Chronic Illness Workbook: Strategies and Solutions for Taking Back Your Life.  And she talks a little bit about this journey of integrating the chronic medical condition into your sense of self.   She divides the process into four phases.   The first phase she calls the crisis phase.  So just as the name of the phase suggests, it's a phase where there's a lot of crisis and chaos.  It's typically right after someone gets a new diagnosis and they're simply trying to wrap their mind around what this is. 

 What is this condition, and what is this going to mean for me?  In the crisis phase, people are learning to observe their body and how it reacts in different situations.  Very often, they're testing things out to find out how they can preserve their energy with this new medical condition.  The main task is to deal with the immediate hurts and traumas of your new illness to weather the crisis and regain some control over your existence by simplifying your life as much as possible.   After you've weathered the crisis, then you move into phase two, which she calls the stabilization phase.  I always think of phase two as the phase where people are trying to sort out what makes a good day and what makes a bad day.  Trying to learn what their patterns are.  You know, how much gardening can I handle before my body doesn't want to cooperate with me anymore? Or how many hours of sleep do I need in order to optimize my functioning with this medical condition? In phase two, people have often reached a plateau of their symptoms.  So their symptoms are starting to become more familiar to them.  Perhaps the medical team has started this person on a medication regimen that's helping to manage the symptoms somewhat.  And so that allows you some space to start to define the boundaries of your new life. 

 What is life going to look like for me now, now that I'm living with this condition?  In this phase, people develop new norms for themselves, and they clarify their values and their priorities now that they understand that life is probably not going to return to normal.  They're probably never going to be exactly the same person they were before the onset of the medical condition.   People are also dealing with problems that arise in their relationships.  So it's really common in phase one that friends and family members rally around you.  You know, they see you're in chaos and crisis, and they want to be there for you.  And so there tends to be good social support in phase one, but by phase two that might fade a bit.   People are starting to realize that you're probably not going to return to the person you were before.  That you're probably not going to return to normal, whatever normal was.  And so sometimes, people begin to back away or your relationships shuffle themselves a bit.  So in phase two, that could mean, you know, finding who are the people who are there for the long haul. 

 Who are the people who can be my social support structure going forward, versus who are the people who have backed away and what do I want to do about those relationships?  So the main goal in phase two is to stabilize and restructure your life patterns, your relationships and your perceptions.   Phase three she calls the resolution phase.  I always like to call this one the meaning-making phase because this is the phase where people start to ask the larger questions, like why did this happen? Or why did this happen to me? Or now that this happened, is there any way that I can use this in a positive way, or is there any way I can make meaning out of this so that I can live with the illness with more grace or with more ease? So in the resolution phase, people have learned how their illness behaves and how the world responds to it.  They've learned that they can't be the person that they used to be before they became ill.  And so their task now is to try to maintain insight, develop meaning into what's going on and construct a new sense of self.   In this phase, people are often coping with grief and loss.  So it's the realization that some of your functioning may not return, and if you can't return to some of you valued activities, there's a sense of loss that comes with that.   Another task here is to just develop a new authentic self and begin to locate a personally meaningful philosophy to live by.  You know, what's the philosophy, the life philosophy that I can use that will help me live well with this chronic medical condition?  And then, finally, phase four she calls the integration phase.  So the way I think about that is when you're walking through this chronic illness journey, sometimes there are parts of yourself that get suppressed for a while, or they get set aside for a while because you're so busy with the task of coping with these medical symptoms. 

 By the time someone gets to phase four, they're often able to reintegrate those parts of themselves back into their life again.  Maybe in a different way than before, but nevertheless it becomes a part of their identity again.  So the task here is to integrate illness into a whole and meaningful life.  Integrating parts of your old self from before the illness with the person that you are now.  The task is also to continue to find ways to express your new personal best.  To integrate your illness into your life and arrive in a new whole complete life of which illness is only one part.  In phase four and the social domain, people are typically working on expanding their social horizons as much as their medical condition will permit them to do so.   In relationships with others, when you're in phase four, you're including the reality of your chronic disability in your friendships and family relationships.   And also in phase four, you're developing a strong network of new supporters, people who acknowledge and accept the life that you live now.  They understand your limitations, and they want to be supportive for the long haul. 

  So those are the four phases.  Important to keep in mind that not everyone goes through the phases in that exact order.  It's possible to skip stages.  It's possible to go forwards or backwards through them.  Sometimes people even revisit a stage that they thought they were finished with because perhaps there's a new flare up of their condition or a new twist on their condition, and they might find that they're redoing some of the work of some of the earlier phases.  So that's normal and common as a medical condition evolves and as your physical status changes over time.  I guess what I hope you would take from these stages is that you don't have to be psychologically stuck in one place over the course of your illness experience, and that there is hope to move forward and work on some tasks of better integration.   Okay, so Pauline Boss.  Dr. Pauline Boss is a psychologist who has worked quite extensively with people who have chronic medical conditions.  And she has coined a term ambiguous loss that I think makes a lot of sense here. 

 There's a recurrent theme in chronic illness, and that's the theme of a mismatch.  So sometimes there's a mismatch between what you feel on the inside and what people can see on the outside.  So people will sometimes say, well, I don't feel well but my friends are coming up to me and saying, well, you look fine, (chuckles) or you look better, you must be feeling better.  So there's sometimes that mismatch.  Sometimes the mismatch shows up in a different way.  People in your life may come up to you and say, gosh, you know, you're the same but you're different.  Or I can't put my finger on it, but since you've had you medical condition, you're the same but you're different.  So you're the same person, but something about you has changed.  So that mismatch phenomenon can be unsettling.   Both versions of it can be unsettling. 

 And so Dr. Pauline Boss has said this is called ambiguous loss, where it's not clearly defined what the loss is that you've had, but you've clearly had a loss.  So she says due to the ambiguity surrounding the loss, individuals, couples and families remain confused.  Without comprehension, people can't find meaning.  Without meaning, they can't find hope to move forward with their lives.  Both coping and grief processes are immobilized.  She goes on to describe some of the problems that result from ambiguous loss.   So one would be immobilizing people and their relationships.  So if you don't know how to make sense of the change that's happened to you, then that can become paralyzing and difficult to know what you should do next in order to cope.  It often confuses the decision-making process.  It's hard to make informed and balanced decisions about your medical care when you're not even quite sure what this loss was. 

 It can freeze the grief process and block the coping process.  It can prevent closure.  People often report feeling stuck somehow.  Psychologically stuck somehow.  It can lead to feelings of helplessness and hopelessness and also exhaustion.   So psychologist Pauline Boss says it's not hopeless, that there are ways to work through this, and she summarizes her goals for intervention.  One is to find meaning.  So just as I mentioned before when I was talking about the phases of chronic illness, meaning making can be really important.  Naming the problem and acknowledging that the ambiguity is the culprit not the patient.   Tempering your need for mastery. 

 So what she means there is we live in a culture where being in charge and being in control are considered very important.  But when you have chronic illness and you're uncertain how your illness will react from day to day, or how it's going to unfold over time, then you can't control everything.   So tempering your need for mastery means lowering your expectations, going with the flow and letting things unfold in their own time.  Easier said than done, right?  Reconstructing identity.  That's asking who am I now, what roles do I play now, and how do I redefine my role in my family and in my friendships?  Normalizing ambivalence.  By this she means it's normal to feel like you're being pulled in two different directions.  On the one hand, you might feel like you want to resign yourself to your illness and retreat.  But on the other hand, there's a part of you that really wants to be able to move forward with your life.  So being pulled in those two opposite directions is common and expected.   Revising attachment. 

 This goes back to something I said earlier.  It's that relationships often reshuffle themselves when you're living with a chronic medical condition.  And so there may be a task here of having to build new human connections or make sure you can surround yourself with people who are supportive.   And discovering hope.  Here I mean imagining future possibilities, imagining options, recreating fun rituals and celebrations.  One of the things that Dr. Pauline Boss observed was that when people are dealing with a newly diagnosed condition, they often stop celebrating the things that had always been meaningful to them.  Or they often stop following through with their old traditions.  And so she finds it really important for people to recreate those fun rituals and celebrations.  She also encourages people to use spirituality and resiliency to temper their need for mastery when things don't go their way.   Okay? So and now I'll move into some of the ideas for coping And I call them the seven As. 

 I had to force them all to start with an A somehow.  (laughter) But it worked out pretty well, I think.  The first one is accept, and so that is working on acceptance.  Acceptance is not surrendering to a sense of defeat.  It's not passively resigning yourself to your illness or taking a defeatist stance.  It just means allowing yourself to willingly engage your illness.  It means making an active choice to accept the aspects of your condition that cannot be changed.  It's a positive embracing of your experience undertaking, so that you can more fully live your life.  The more you fight the aspects of your illness that cannot be changed, the more of your life it takes away.  Some ideas for how to increase a sense of acceptance. 

 One is learning as much as you can about your condition.  So understanding your illness or disability has to precede acceptance.   Another one is being open-minded.  Persisting in learning as much as you can about how you've changed and being open to creating a new identity pie.   Taking a self-growth perspective.  So remembering that this is a process, or this is a work in progress.  You're not going to wake up one morning and say, okay, I've arrived at 100% acceptance.  This is something that takes some time.   A very specific activity that often helps to foster acceptance is making a list of what you've lost forever, what you've gained, and what you can still work on.  So people often find it helpful, especially when it feels overwhelming and it feels like everything outside of your control, this list helps you to remember that sometimes you actually gain some things in coping with a chronic medical condition. 

 Maybe you realize some strength that you didn't realize that you had before.  Or people sometimes discover a new purpose in their medical condition.  They find ways to get involved in support groups and support other people who have the same medical condition.  And then the list of what you can work on, you know, that is to remind you that there are always some aspects of your health that remain under your control.  And so it's not all in the out-of-control category.  You know, some of it would be things that you can continue to work on.   Another specific activity, spend some time imagining what it would look like when you've achieved an increase in self-acceptance.  So what would be different inside yourself? How would you think differently about things? How would you feel differently about things?  And then finally, see yourself as courageous and adaptable.  Believe if you nurture those qualities that they will help to see you through the difficult times.   The second A is allow. 

 By allow, I mean allow yourself to feel all of your emotions.  As human beings, we like to push away the negative emotions and just try to focus on the positive ones, but it's not a good long-term strategy.  So in order to remain emotionally healthy, we have to allow ourselves to feel anger, sadness, frustration, et cetera.  We also have to allow ourselves to experience challenging emotions without letting those emotions take over our life or our identity.  That's also easier said than done.  If you feel bogged down by negative emotions, then often, it helps to consult with a primary care physician or with a mental health professional, psychiatrist, psychologist, social worker, et cetera and get evaluated for depression or other stress conditions.  Depression and stress are easily treatable, sometimes with medication, sometimes with talk therapies, and sometimes with both.  And so there are good treatments out there, and it's not worth it to just try to live with depressive symptoms and accept that as the norm.   The third A is assemble.  By assemble I mean assemble a strong support group. 

 Get support from your family, friends, your medical team.  If there is a support group that is specific to the medical condition that you have, those are often very helpful to talk with other people who have the same medical condition.  Know that some people in your life will believe in your illness and they're going to try their best to help and support you, but other people may not make the effort to understand your illness at all.  Most people are somewhere in between the two extremes.  So realize that some of your old relationships may not survive.  But you can seek out new people who will support you, and you can integrate them into your life.  I think another piece of this too is to remember that you can be ill and you can still be a friend to others.   So you can still talk and listen and care even if your physical functioning has changed dramatically.  To maintain a friendship, you have to give equal time to your friend's concerns.  So be careful not to overload any one friend with too much about your illness. 

  The fourth A is actively cope.   So active coping means assuming responsibility for your self-management.  Passive coping means withdrawal from activities and becoming dependent upon other people for physical relief.  So there's a lot of good research on active coping, and it shows that active coping is related to lower levels of pain, depression and functional disability.  Passive coping, on the other hand, is predictive of increased pain and depression.   So active coping means actively engaging in your self-care, and it's kind of just the good, basic self-care strategies that we've been hearing about our whole lives.  Get good sleep, eat healthy foods, get some form of physical activity.  Another good active coping strategy is learning and practicing some type of relaxation or stress reduction practice.  Very popular nowadays, the mindfulness classes.  You probably read about mindfulness all over the news and see it on TV. 

 There's a wide range of mindfulness programs available both at the UW Hospital and throughout UW Health and throughout the community as well.  Really a great self-care strategy that allows people to remain active in their coping, even when their functioning has changed dramatically.   Another one would be managing negative emotions.  And then, finally, being an active partner in your healthcare.  So that means finding a healthcare team that you really feel like you can work with.  So physicians and nurses and other providers who really feel like they're a partner to you or people who really feel like they're listening to your concerns when you go to medical visits.   The fifth A is adhere to your treatment plan.   Individuals who are depressed or stressed tend to have less energy, focus and motivation.  If we have less energy, focus and motivation, it's harder to do all of the things that our medical team asks us to do to take care of ourselves.  So when we're stressed and depressed, we often begin to have problems with treatment adherence. 

 In chronic illness, treatment adherence is a long-term undertaking.  Very often, what you do at home and in your day to day life to manage your illness has a much great impact on your health than what happens in your doctor's office.  So a lot of managing chronic illness depends upon what you do, and I think that's good news because that means that a lot of your management of your medical experiences is under your control.   The sixth A is attitude check.   So your attitude and the content of your thoughts can exert a strong influence on your emotions and your behavior.  So you might ask yourself these questions: what goes through my mind when I think of myself having a chronic illness? What do I find myself thinking when my health is worse than expected? What thoughts have led me to feel like giving up my self-care efforts in the past? Do I have any concerns, worries or fears that come to mind when I think about managing my illness? Once you answer these questions, challenge yourself to replace the negative thoughts with more balanced alternative thoughts.  So I'll give you an example of that.  If I go through my attitude check and I find that the thought that's coming up for me is my whole body is falling apart, well, I might replace that with a balanced thought such as some days, it feels like my whole body is falling apart, but I know I have good days and bad days and the best thing I can do on a bad day is to figure out how to take good care of myself until I feel better.  So you might notice, and this is actually quite typical, you might notice that the negative thoughts that pop into our head tend to pretty simple and overgeneralized and sometimes pretty extremely on the negative side.  The balanced thoughts tend to be longer and more complex, and there are two components to the balanced thought. 

 Usually, there's an acknowledgment of the reality of the situation, and then there's a more positive piece.  So listen to my balanced thought again, and see if you can identify those two things.  There's the acknowledgment of the reality of the situation, and then there's the positive piece.  Some days it feels like my whole body is falling apart, but I know I have good days and bad days and the best thing I can do on a bad day is to figure out how to take good care of myself until I feel better.  So there's actually more active coping built into the balanced thought.  The original thought, remember, was my whole body is falling apart.  If you're saying that to yourself repeatedly, that doesn't lead you to take a problem-solving stance.  It doesn't lead to some kind of action.  And so that's why the balanced thoughts are often more helpful because it leads you to some concrete steps that you can take to manage the difficult situation.   And then the seventh A, access joy, laughter and happiness. 

 So there's a famous happiness researcher named Sonja Lyubomirsky.  She's a psychologist, and she has done extensive studies of happiness and has reviewed the research done by many other research teams, and she's compiled it all into one pretty interesting statement, which is that 50% of your happiness is determined by your genetics, 10% is determined by your life circumstances.  So for example, what state you happen to live in, whether you have a chronic illness or not, what your hobbies and interests are, what your job is, et cetera.  So only 10% is determined by life circumstances.  I actually think that's good news for those of us who live in Wisconsin.  (laughter) That living in Wisconsin, even on the worst weather types of days, is not going to significantly impact our happiness level.  The good news is that 40% of our happiness is under our control.  So that's a large piece of the happiness pie that is under our control.   She goes on to summarize all of the different factors that contribute to happiness, and she said that they can be things like optimism, pursuing life goals, nurturing meaningful relationships, trying to maintain a positive outlook, practicing gratitude on a regular basis, practicing forgiveness when it's needed.  And she talks quite a bit about both self-forgiveness and forgiveness of other people. 

  Savoring the present moment, which actually goes along with the mindfulness stuff that I mentioned before, that much of mindfulness has to do with being present in the here and now and being able to appreciate the present moment.  And then, finally, sitting quietly and thinking about kindness and compassion.  So you don't even have to be out there practicing kindness and compassion.  You can be sitting quietly and thinking about it, and that has a significant impact on our overall level of happiness.   So I just thought those were some fun ideas that allow us to improve our coping with chronic medical conditions.   I want to talk just a little bit more about resources at the University Hospital.  So I mentioned earlier that I do run groups that are called Creative Coping With Chronic Illness.  They are 12-week groups, run through the Department of Health Psychology, designed to help people improve their self-care and their confidence in managing the distress that often comes along with chronic illness.  People sometimes ask, ooh, if I see a health psychologist at the hospital, do you have to assign a psychiatric diagnosis? And the answer to that is no, that as a health psychologist, I'm actually able to submit my billing using medical codes.  So whatever your medical diagnosis is, as determined by your physician, is what I use when I submit my billing, and that way I do not have to make a psychiatric diagnosis. 

 The billing codes, just for your information, the billing codes that allow us to do that are called the Health and Behavior Assessment and Intervention codes.  People sometimes ask me because they want to be sure that those are covered by their insurance.  I can tell you for sure that they are covered by Medicare and Unity.   And many of the people that we see at University Hospital fall in those categories.  If you have a different insurance provider and you're curious whether they would cover health psychology visits, you would just need to know that they're called Health and Behavior Assessment and Intervention codes when you call and ask your insurance provider.   So in addition to groups, we also do individual sessions.   My department has more inpatient providers than outpatient providers.  So it is a bit of a wait for individual sessions.  It's easier to get in the groups, but we are working on that and working on kind of reducing wait times, so if people want one-on-one sessions, they don't have to wait as long.  Our department phone number is listed there. 

 It's 608-263-8060.  And, you know, if you're interested in health psychology services, then anyone who answers that number should be able to answer questions about the groups and about the individual sessions.   So thank you for allowing me to spend time with you today, and I hope you enjoy the rest of the afternoon.  (applause)