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Vicarious learning from toilet training through animated film: case study of behavioral play therapy.

Author: Laura dos Santos Gomes Coelho

e-mail: lauragcoelho@mac.com homepage: http://www.homepage.mac.com/lauragcoelho

Abstract A report of the treatment of Lara (4 years and 5 months old) who was experiencing secondary retentive encopresis, with an interval of over 72 hours between bowel movements. The evaluation was conducted through interviews with the parents and nannies, observation in school, individual play sessions and family play sessions; the interventions focused on the use of animated films, play activities and toys to develop behavioral habits and to toilet train. After the intervention using animated film, Lara had bowel movements in the office and had daily bowel movements during the 12 months of treatment; she had three serious accidents in this period. Most likely, after watching the characters toilet train and earn stickers in the animated film, Lara was vicariously reinforced and learned the relationship between the behavior of the characters (toilet training) and the consequent reward (sticker). The game with the dolls used in the film is considered a type of play mediation. Key words: behavioral play therapy; encopresis; habituation; vicarious learning.

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1. Introduction Being autonomous in the activities of daily life during childhood (getting dressed, taking a shower, choosing and showing preference for clothes, toys, etc.) involves carrying out tasks with varying degrees of difficulty, in various contexts (school, social and family gatherings); carrying out toilet training correctly (i.e. with approximately 17 steps, beginning when the child expresses the desire to go to the toilet, and finishing with washing hands) is part of the development of an individual’s autonomy. The ideal situation, According to Brazelton (1962), is to begin toilet training at the age of two, and it should be based on the child's readiness for training (at about 18 months), rather than coercion; at 24 months, step-by-step training should begin; at 36 months, through positive reinforcement (praising the child’s performance), encouragement (inducing the child to accomplish the task) and showing understanding towards the child, it is possible to achieve fecal continence; finally, at 48 months, toilet training is complete (Stadler, Gorski, and Brazelton, 1999). However, pediatricians are often asked about the child’s refusal to undergo training and “there is a lack of empirical data on this phenomenon in the literature. There is no mention of either stool withholding or stool toileting refusal in Brazelton's 1962 study” (Taubman, 1997, pag. 56). Some studies suggest that the child’s refusal to toilet train is associated with past experience, i.e., constipation, where the child found it difficult to defecate and defecation was painful. (Issenman, Filmer and Gorski 1999; Blum, Taubman and Nemeth, 2004). According to Fleisher (2004), “although constipation is an important element in the pathogenesis of stool toilet refusal, not every young child with painful defecation becomes averse to the toilet; and not every child who is averse to the toilet has experienced painful defecation. Other factors such as anxiety may interfere with toilet learning” (Fleisher, 2004, page 1809). Fleisher’s (2004) criticism to the idea that constipation is not enough to explain toileting refusal implies that changes need to be made in the retention cycle proposed by Issenman, Filmer and Gorski (1999), in which constipation initially causes fecal impaction; then,

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defecating becomes painful; and the child refuses to use the toilet, and the whole cycle starts over again. The retention cycle proposed by Issenman, Filmer and Gorski (1999) does not take into account significant changes in the family dynamics (separation of parents, birth of siblings), and in the activities of daily life (transition from breast milk to new types of food, transition from diapers to toilet during toilet training, or changing schools) which may cause aversion to the toilet. For instance, during toilet training, the parent’s task, through instruction and examples, is to gradually establish the use of the toilet, replacing the previous habit of using diapers - which are easier and simpler - to defecate or urinate at any time. During this period, an aversive event (e.g., sudden withdraw of diapers, painful defecation, or fear of falling into the toilet) or a positive one (birth of a sibling or travel) may cause an intense reaction in the child, particularly crying and avoiding toilet training. The more parents try to establish the transition from diaper to toilet, the more the child’s reaction of refusal intensifies, and a situation of aversion to toilet is established. From a psychological perspective, reactions such as increased crying or refusal to use the toilet are called sensitization, which is defined as a reaction, of long or short duration, to abrupt changes in the environment, the function of which is to regulate and organize the vast amount of information in this new environment, for instance by distinguishing between harmful and positive stimuli (Domjan, 1996). Described in more detail, the cycle of fecal retention begins with sensitization (Figure 1A), i.e., the child’s reaction to some significant change in the environment (for instance, a reaction of crying when defecation is painful; resistance to a new nanny; refusing a new school or home; irritation and obstinacy faced with separation of parents; crying and anxiety on the birth of a sibling…). Sensitization causes aversion and fear of defecating in the toilet; aversion to the toilet causes the child ignore the physiological signs and retain feces; fecal retention over several days leads to fecal impaction, pain, abdominal distention, and behavioral changes which precede pain (irritability, refusal to eat meals, increase in the number of toys when playing, decrease in the duration of play activities with increased

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Figura 1 – (A) Cycle of retention is initiated with the sensitization that begins aversion, fear and fecal retention (B) behavioral habituation to the toilet reduces fear, the abdominal behavior of fecal retention and pains eliminating the cycle of fecal retention.

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running, and apathy towards play). In the last stage of the retention cycle, following the administration of laxatives, medication and a fiber-rich diet, the child may expel dry feces, owing to the retention pattern, reporting pain, which leads to a restarting of the long-term sensitization cycle. From this perspective, the retention cycle can be altered through the habituation process (Figure 1B). From a psychological point of view, habituation is defined as a reaction, of long or short duration, characterized by a progressive reduction in the intensity of the behavior (e.g., crying, fecal retention and refusal to use the toilet) as the individual is exposed to the stimulus that sparks off the behavior (e.g. the toilet, foods which facilitate defecation). The habituation process is the opposite process to sensitization, and is characterized as a reaction to a specific stimulus. Like sensitization, it has a selfregulatory function, enabling the child to organize the information from the environment (Domjan, 1996). According to Taubman (1997), toileting refusal can cause severe constipation, and if not resolved, can lead to primary encopresis. The most commonly recommended procedure for treating encopresis is cognitive and behavioral approaches, associated with medication. More recently, play therapy has been used as an alternative way of treating children with encopresis, as it allows behavioral and/or cognitive strategies to be integrated in play activities, seeking to evaluate and interfere in situations which cause suffering to children and parents (Knell, 1995). This case study refers to the medical care given to a child (named Lara) with retentive secondary encopresis. The objective of this study is to investigate the factors related to the start and maintenance of the defecation pattern, to analyze and clarify the process of habituation and sensitization during toilet training, and to carry out behavioral intervention through an animated film.

2. Method 2.1. Participant

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Lara, aged 4 years and five months, was attended between September and October 2005. She lived with her parents, one brother, and two nannies. Lara began school at the age of 1 year and 8 months. In the second half of 2004, her family moved to another house and, in this given period, Lara moved to a different school. She has adapted well in both of the schools she has attended. Lara is introverted, shy, jealous and loving with her parents, and shows difficulty in adapting to new environments.

2.2. Assessment The assessment lasted 11 days (from 19th Sept 05 to 30th Sept 05), and consisted of the following stages: an interview with parents, a questionnaire on Lara’s daily activities, two play sessions with Lara, two family play sessions in the presence of the parents and brother, contact with the two nannies, a visit to Lara’s schools, a session with the parents to hand over the results. The use of laxatives was suspended during the assessment, and mineral oil was used for 10 days. Given the parent’s concern and request as to what attitude they should take, the therapist recommended that they do not force their daughter to use the toilet, that they reduce the time on the toilet to 3 or 5 minutes, and that they mark on a calendar the days when she defecated.

2.3. Case Conceptualization Based on the data collected during the play sessions, an interview with the parents, an interview with the nannies, analysis of questionnaires concerning her daily activities, observation at school, and an interview with the school psychologist, the hypothesis was proposed that Lara was probably consuming food which was hard to digest, which was making intervals between defecations longer than 24 hours, the feces were becoming dry, and when she defecated, she probably was probably straining too much, with bleeding and pain. Successive events of painful defecation, along with the other effects

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of sensitization (crying, irritation, refusal to eat) probably led to the toileting refusal. From this perspective, the refusal pattern was a way of avoiding pain. However, prolonged retention caused the feces to become drier, requiring the use of medication (laxatives and suppositories), and making defecation even more painful. Lara presented fecal retention with the following effects: mood changes (during fecal retention, Lara was nervous or quiet, hiding behind the furniture), anatomic and physiological changes (her abdomen was distended, and only reduced in size after defecation), social behavior changes (after each critical accident, she was ashamed to show her dirty underwear to the nanny), changes in eating behavior (Lara avoided eating fruits and other foods which contributed to fecal elimination), and cognitive changes (Lara asked the nanny whether she felt pain when defecating, said she found it painful, and that she did not want to pass a stool). This cognitive change suggests that Lara was still seeking information in order to form a judgment or belief about her change in defecation pattern and her ability to carry out toilet training on her own.

2.4 Course of Treatment To achieve the goal of facilitating defecation and establishing toilet training, the parents were advised to implement the following measures: 1) to change the family diet (introducing, for instance, Japanese food: soy sauce, Japanese risotto prepared with “Gohan”, salads, and olive oil); 2) to observe the behavioral indications of bowel functioning, and record the times of defecations; 3) to give Lara personalized stickers with different designs (hello kitty, Ariel and Sponge Bob, ballet shoes, hearts and flowers) after toilet training, according to the following rule: if Lara tried to defecate, she would be given a little sticker; if she managed to do it, she would be given a big one. The aim was to maximize the number of stickers she earned, to encourage her toilet train. During the first week, toilet training should begin with 3 or 4 minutes on the toilet, teaching her the right sitting posture; 4) if she did not manage to defecate in the toilet, she should be told by the family members that it was ok, that it was only an

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attempt, and that she was learning to use the toilet; 5) in the second week, they should take her to the toilet at the most favorable time to defecate, and keep marking the frog-shaped calendar on the days she defecated in the toilet. A play intervention session was proposed, to the parents, to take place at the clinic, using and animated film produced especially for Lara. The hypothesis was that the use of the animated film would establish: 1) vicarious learning of information on toilet training, and encouragement to carry out toilet training on a daily basis; 2) behavioral habituation to daily toilet training, as watching animated films was a regular habit for Lara, and generally not associated with contexts of emotional tension. The use of films in psychotherapy contexts is based on Bandura’s study of observational or vicarious learning through role models (Thellen, Fry, Fehrenbach and Frautschi, 1979). Within this perspective, vicarious learning is a result of three processes: 1) observation of a role model, whether live or through some other media (film, TV, comics, hypermedia resources on the Internet…), 2) vicarious reinforcement or punishment; and 3) cognitive mediation (mental representation). After vicarious learning, the learner may, immediately or after some time, perform the action that he or she observed. Thus, after Lara has watched the characters in the animated film carry out toilet training and receive stickers, it is expected that Lara would be vicariously reinforced, and a link established between the behavior of the characters in the film (toilet training) and the reinforcement obtained (stickers). After an attempt at toilet training encouraged by the parents, a play session took place, during which the animated film “A doll’s day” was shown (Figure 2). The intervention session took place on October 5th 2005, and lasted 1 hour and 20 minutes. The animated film was used to present, within a context of play, both daily activities belonging to the children's world (playing house, using dolls, and daily activities) and toilet training, which Lara’s parents tried to implement with her (focusing on the attempt to defecate, use of stickers, and the suggest diet for Lara). With live narration from the therapist, the film presented the daily routine of two dolls (Kelly® and Amanda) performing the

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Figura 2 – Frames of the animation Film "doll`s day"

following activities: one character wakes up, walks towards Amanda’s bed, and wakes her up; then they both have breakfast, and use the toilet, where Kelly® teaches Amanda which toilet to use, and how to mark the sticker on the calendar. next, the two dolls play hide and seek, and finally, they watch TV. The session was filmed with a Sony DCR TRV-140 digital camera. After explaining to Lara that she would watch a film with dolls that she knew, the 4’02’’ minute film was played, on a 12-inch screen of an Apple notebook (http://www.homepage.mac.com/lauragcoelho/filme). The computer was placed on a table adjusted to Lara’s height, with the dolls and furniture and setting used in the film placed next to it.

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Before playing the film, the therapist established verbal interaction, telling Lara that a film would be played, praising her performance in the drawing task that she was doing, and investigating characteristics of the drawing (“is this blue here the sky?”). During the verbal interaction, Lara told the therapist about what she was doing (“I wrote my name here”) and asked about the material used in that task (“where’s the paintbrush?”). Lara agreed to watch the film. The therapist played the film and gave the following live narration: _ (Kelly®): oh, I’m waking up… the clock… I’m so lazy… but I have to get up. Oh, I’d like to stay in bed longer, I have to have breakfast, I have lots things to do… I think… I think Amanda is still asleep. Look, her feet are sticking up, it’s very dark in there, I can hardly see a thing. Ah I’ll turn around, ah now I’m awake! (I’ll have a look at Amanda). AMANDA! AMANDA! ...hello, I’ll turn you around! Let me see here from my window... Ha! You are already up ? Ah let’s have breakfast! Do you need any help? _ (Amanda): it’s not necessary… _(Kelly®): look at our table, let’s eat breakfast. I’d like… there’s cake, pie, look… there’s risotto (Lara looks at the paintbrush and the paper and looks at the screen again; dips the paintbrush into the paint), - now I’ll go there, I’ll wash my hands, no, I’ll go to the toilet now, you can’t use the big one, you must use this little one here. (large toilet, small toilet). _(Amanda): But I need to go! _(Kelly®): Now I’m going... _ (Amanda): I want to clean myself too! _(Kelly®): Look, I’ll put a little star here because you tried and me too. Let’s wash our hands, you too; look! Great! What shall we do now? Lara interrupted the narration when the two dolls began playing hide and seek. She said they used calendars, and when they passed a stool they were given stickers. The therapist asked (Do you

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have three stickers?), and interpreted Lara’s action (“Good idea! I’ll give this idea to Kelly® too!”), and tried to persuade her (“so, when you poo, do a big one! You’ll see, now you’ll do it every day! It’s easy now!”) as in the following extract of the conversation: - (Lara): I have (stickers)… when I do it, I have three stickers _ (therapist): really?! Do you have three?! _ (Lara): Yeap! _ (therapist): so, you’ve got lots of stickers too! _ (Lara): yeah, when I do a poo, they give me a big one. _ (therapist): That’s great, Lara! she too! good Idea! I’ll give this Idea to Kelly® too… so, when you do a poo, do a big one! You’ll see, now you’ll do it every day! It’ll be easy! Lara, do you want to put your voice in this story? (Lara nods), So, I’ll play the story from the beginning, here’s the microphone, you can start when you like! Lara asked to watch the film twice. The film was played again without narration, and Lara watched it while she was drawing. After watching the film, Lara decided, spontaneously, that the following activity would be to play toilet training with the dolls and the setting used in the film. Three toilet training play activities were carried out totaling 13 minutes. The first toilet training game lasted 5 minutes. The play began when Lara said that it was time for one of the dolls to pee or poo, and finished when the doll used the toilet and placed the sticker on the calendar. During the game, Lara said that she had various stickers, and that her mother placed a big sticker on the calendar each time she used the toilet. Lara recognized that the doll’s calendar, with the picture of a frog on it, was similar to hers. The therapist and Lara played with the dolls, offering them feeding-bottles and putting them on the toilet. The therapist encouraged the doll, emphasizing that she should try. Lara encouraged the doll to make an effort, as in the following extract of the conversation: _ (Lara): it’s time for the little doll to pee.

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_ (therapist): Is it time? So, can I take her? I didn’t remember it was time. I’ll get the feeding-bottle, I guess she really wants to go! _ (Lara): Why? _ (therapist): Because her panties are already down, she was already taking them off. _ (Lara): I don’t want… if she tries she doesn’t want… _ (therapist): she can try, I think she wants to, and she really feels like trying. _ (Lara): I have one of these… _ (therapist): Do you? Do you want to feed her, or shall I? You tell me. _ (Lara): You. _ (therapist): shall I!? ok then, our Kelly®! ....I’m thirsty. (the therapist prepares the toilet and the feeding-bottle, and places the doll on the toilet) – it’s time to go to the toilet. -(therapist, imitating Kelly®'s voice): - Ok. _ (therapist): I guess she really needs to pee. _ (therapist, imitating Kelly®'s voice): I do... _ (Lara): every day she is holding it in, every day she… _ (therapist): every day she tries, she can’t hold it, we should let the pee come out, and the poo as well. _ (therapist, imitating Kelly®'s voice): ok, I’ll add a really big sticker to my calendar. _ (therapist): That’s right! A really big sticker. Ah, Kelly®, I already know, it’s going to be Sponge Bob. _ (Lara): No, in my house my mother… the day when she “does”, its… my mother puts it on for me… (smiling) _ (therapist, putting Kelly® on the toilet): Ah! That’s great! _ (Lara): Try hard… _ (therapist): Thank you very much, Lara! See, Kelly®? Just a little effort.

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The second toilet training game lasted 3 minutes. The therapist and Lara played at choosing stickers, and placed one of the dolls on the toilet. Lara smiled, encouraging the doll to make an effort (“she’s going to do a poo so that I can put another sticker”). She explored the doll’s setting, wrote down their names, and said that the doll would try again, humming a song. The game ended when the therapist said that if the doll tried again, they would give her other kinds of stickers. The third toilet training game lasted 5 minutes, and began when Lara said: _ (Lara): She wants to try! _ (therapist) : She wants to try again! _ (Lara): I guess it’s time! _ (therapist): It’s time to try… so, let’s put her there again. Lara suggested that the dolls defecate while watching TV. While Lara was doing the toilet training activities, she told the therapist about her activities at school and began drawing. Lara gave a very detailed description of the activities, as in the following extract of the conversation: _ (Lara): Open your legs (she opens the doll’s legs on the toilet). _ (therapist): Open your legs… I guess that’s enough, I’ll take her panties off, ok? _ (Lara): You do a poo there, and I’ll… _ (therapist, humming): I’ll make my tree … Kelly®, all right? _ (therapist, imitating Kelly®): All right… _ (therapist): great, very good… _ (Lara): Try hard, Kelly® ... _ (therapist): Listen to what Lara tells you, she’s trying to help you, just a little effort… _ (Lara): Just a little… After this third toilet game, Lara went to the toilet and defecated without the therapist’s assistance. Her mother came into the room, at Lara’s request, praised her daughter and watched the film.

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2.5 Follow-up After defecating during the play session while watching the film (October 5th), Lara defecated on a daily basis from October 2005 and September 2006, without any toileting refusal, using the school toilet, and eating various types of foods, as suggested in the assessment, as well as plums in the morning and evening. The use of mineral oil was suspended the day after the film session. In October 2005, Lara had three critical accidents with a pattern of diarrhea (she twice defecated in her underwear, on October 13th, after using the school toilet, and once at home, on October 16th). These critical accidents probably occurred because Lara was returning to the daily defecation pattern, as a consequence of the diet change (eating plums, for instance), and the behavioral habituation. There were no more critical accidents after reducing the consumption of plums. The use of calendars and stickers was suspended in December 2005. From December/2006 to April/2007, despite having normal bowel functioning and despite her parent’s encouragement to use the toilet and eat appropriately, Lara sometimes presented 48-hour intervals between defecations.

2.6 Discussion Lara’s pattern of fecal retention is described by the following retention cycle: beginning with sensitization, i.e., painful defecation, in June and July 2005, generating aversion and fear of using the toilet (Lara reported pain on defecation; her aversion to the toilet caused her to ignore the physiological signs and retain the feces); she had fecal retention for several days, causing fecal impaction, pain, abdominal distension and behavioral changes which precede pain (irritability, refusal to eat, and apathy towards play). In the last phase of the retention cycle, after the use of laxatives, without a diet rich in fibers, Lara expelled dry feces and reported pain. Lara had already learnt how to use the toilet, but only know a defecation situation without pain.

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She was beginning to learn something new: that defecation can sometimes be associated with pain and discomfort. The interview with her nanny showed that, in Lara’s view, defecation took on a new meaning. It had become associated with pain. It also showed that she had not yet formed a clearly defined judgment or belief about this new learning, and she was still gathering information about it in order to form a judgment (for example, the belief that she is not capable and/or that in her particular case, defecation is difficult and painful). The self-efficacy belief or judgment would be a by-product or a subsequent phase of this search for information from four main sources: relevant role models for Lara (the nanny, friends at school), emotional and somatic conditions (such as pain and discomfort), success or failure in the toilet training tasks, and information from the attempts at verbal persuasion by parents and relatives. The use of animated films and live play with the dolls from the film might have generated a context in which the four sources of information were present: role models (Lara’s favorite dolls), hints on the somatic conditions of the role model (painless defecation), verbal persuasion in the interaction between the dolls, and successful toilet training. The hypothesis that explains the changes observed in Lara’s defecation pattern is that the animated film produced habituation effects, i.e., progressively decreasing her toileting refusal as she was exposed, with each repetition of the film, to the specific context of using the toilet. As the process of habituation is the opposite to sensitization, the film may have enabled exposure to the context of using the toilet, without intensifying the sensitization effects. The habituation effect proposed by the film comes from the use of music, movement, the narrative, dolls, furniture, and the activities presented in the film (hide and seek game, use of stickers and calendars), which were all familiar to Lara. These components are incompatible with the emotional triggering of anxiety and apprehensiveness during real toilet training, when there is the possibility of pain or failure to defecate. The habituation brought by the film should reduce toileting refusal, fecal retention and subsequent behavioral reactions (irritability, apathy and refusal to eat) which are part of the retention cycle.

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Besides bringing habituation effects, watching the film appears to have results in the learning of certain relations. For example, the relation between using the toilet and filling in the calendar with stickers, and between using the toilet and the hide and seek game, which may have been learnt through watching the dolls in the animated film. This learning can be inferred by the three games played by Lara soon afterwards, with the dolls, in which she simulated using the toilet, followed by marking the calendar with stickers or by a leisure activity (e.g., watching TV, as shown in the film). While Lara’s parents had done the toilet training at home, using big and small stickers after she tried to defecate, the film presents two characters who are successful in the task and receive stickers for good performance. Learning, through observation, about use of the toilet / filling in the calendar and using the toilet / playing hide and seek, offered by the film, appears to have occurred the very first time she watched the film, because in the two repetitions of the film, she paid attention to details which bore little relation to using the toilet (e.g., Lara looked at the screen, in particular, when there was background music). Vicarious learning was possible because: 1) the dolls in the film became role models for Lara (the dolls were chosen as role models after observing Lara’s play activities and after an interview with the nanny), 2) Lara received vicarious reinforcement by watching the role models being given stickers after defecating and 3) the three play activities carried out after the film worked as mediators for the defecation in the office toilet (play mediation) enabling manifest practice of the toilet training sequences. In vicarious learning theory, role models are symbols (people or characters) whose actions the observer considers important. According to Bandura (1971), when the observer is affected by the positive or negative consequences of the actions of the role model, we say they have received vicarious reinforcement. For example, the consequences of playing hide and seek and using stickers obtained by the role models in the film, could have made Lara expect that both the she and the models would achieve the same result in a game, and the next time the film was played, respectively. Besides encouraging her to use the toilet, the vicarious reinforcement obtained by Lara when watching the role model’s behavior

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in the film may have given her information about the task (e.g., the notions that using the toilet is one of the role model’s behaviors which should be followed by the observer, and that the model talks about using the toilet with other people) and specified the behavior she should have in order to achieve success (e.g., the observer must try and expel feces).

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