TREATING COMPLEX
TRAUMATIC
STRESS DISORDERS IN
ADULTS
Scientific Foundations
and Therapeutic
Models
SECOND EDITION
edited by
JULIAN D. FORD
CHRISTINE A. COURTOIS
Foreword by Judith
Lewis Herman
Afterword by Bessel A.
van der Kolk
In memory of Anne and Jim (J. F.) and Normand and Irene (C. C.), who are our role models for resilience, integrity, and love. To clients who have suffered the complicated consequences of complex trauma and whose symptoms have oen been misunderstood and misdiagnosed, oen compounding their pain and ability to recover. It is our hope that the material in this book assists in unraveling the complicated aereffects and leads to better understanding and more effective treatment. To therapists everywhere who seek to understand the complexities presented by these clients and who guide them on the oen arduous path to healing and recovery. We hope this book fills in the gaps that so many of us have experienced in our training and professional experience, and offers helpful guidance on the treatment process and the variety of therapeutic approaches that make a real difference.
About the editors
Julian D. Ford, PhD, ABPP, a clinical psychologist, is Professor of Psychiatry at the University of Connecticut School of Medicine, where he is Director of the Center for Trauma Recovery and Juvenile Justice and the Center for the Treatment of Developmental Trauma Disorders. He is past president of the International Society for Traumatic Stress Studies, a Fellow of the American Psychological Association (APA), and Associate Editor of the Journal of Trauma and Dissociation and the European Journal of Psychotraumatology. Dr. Ford has published more than 250 articles and book chapters. His research focuses on developmental trauma disorder and the Trauma Affect Regulation: Guide for Education and erapy (TARGET) therapeutic intervention.
Christine A. Courtois, PhD, ABPP, a counseling psychologist, is retired from clinical practice and now serves as a consultant/trainer on trauma psychology and treatment. She is a Fellow of the APA and the International Society for the Study of Trauma and Dissociation. Dr. Courtois is a past president of APA Division 56 (Trauma Psychology) and served as Chair of the APA’s Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder in Adults. She has received the Award for Distinguished Contributions to Independent Practice from the APA, the Sarah Haley Award for Clinical Excellence from the International Society for Traumatic Stress Studies, the Award for Distinguished Service and Contributions to the Profession of Psychology from the American Board of Professional Psychology, and the Lifetime Achievement Award from APA Division 56.
Contributors
Pamela C. Alexander, PhD, private practice, Natick, Massachusetts
Lynne E. Angus, PhD, Department of Psychology, York University, Toronto, Ontario, Canada
John Briere, PhD, Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine,
University of Southern California, Los Angeles, California
Laura S. Brown, PhD, ABPP, private practice, Seattle, Washington
James Caringi, MSW, PhD, College of Health Professions and Biomedical Sciences, University of
Montana School of Social Work, Missoula, Montana
Kathleen M. Chard, PhD, Cincinnati VA Medical Center and Department of Psychiatry and
Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio
Marylene Cloitre, PhD, Institute for Trauma and Stress, NYU Child Study Center and Department of
Psychiatry, NYU School of Medicine, New York, New York, and National Center for PTSD,
Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, California
Christine A. Courtois, PhD, ABPP, private practice, Bethany Beach, Delaware
Anke Ehlers, PhD, Centre for Anxiety Disorders and Trauma, Department of Experimental
Psychology, University of Oxford, Oxford, United Kingdom
omas Elbert, PhD, Department of Psychology, University of Konstanz, Konstanz, Germany
Janina Fisher, PhD, private practice, Sensorimotor Psychotherapy Institute, Oakland, California
Edna B. Foa, PhD, Center for the Treatment and Study of Anxiety, Department of Psychiatry,
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Julian D. Ford, PhD, ABPP, Department of Psychiatry, University of Connecticut Health Center,
Farmington, Connecticut
Berthold Gersons, MD, PhD, Department of Psychiatry, Amsterdam University Medical Center,
University of Amsterdam, Amsterdam, and ARQ National Psychotrauma Center, Diemen, e
Netherlands
Ellen T. Healy, PhD, Women’s Health Sciences Division, National Center for PTSD, VA Boston
Healthcare System, Boston, Massachusetts
Elizabeth A. Hembree, PhD, Mood and Anxiety Disorders Treatment and Research Program,
Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania
Judith Lewis Herman, MD, Department of Psychiatry, Harvard University, Cambridge,
Massachusetts
Denise Hien, PhD, ABPP, Center of Alcohol and Substance Use Studies, Graduate School of Applied
and Professional Psychology, Rutgers, e State University of New Jersey, Piscataway, New Jersey
Christie Jackson, PhD, private practice, New York, New York
Deborah L. Korn, PsyD, private practice, Cambridge, Massachusetts
Lisa Caren Litt, PhD, Department of Psychology, e New School for Social Research, New York,
New York
Teresa López-Castro, PhD, Department of Psychology, Colin Powell School for Civic and Global
Leadership, City College of New York, New York, New York
Andrea Lopez-Yianilos, PsyD, New York State Psychiatric Institute, Department of Psychiatry,
Columbia University College of Physicians and Surgeons, New York, New York
Ari Lowell, PhD, New York State Psychiatric Institute, Department of Psychiatry, Columbia
University College of Physicians and Surgeons, New York, New York
John C. Markowitz, MD, New York State Psychiatric Institute, Department of Psychiatry, Columbia
University College of Physicians and Surgeons, New York, New York
Colleen E. Martin, PhD, Trauma Recovery Center, Cincinnati VA Medical Center, Cincinnati, Ohio
DeAnna L. Mori, PhD, VA Boston Healthcare System and Department of Psychiatry, Boston
University School of Medicine, Boston, Massachusetts
Hannah Murray, PhD, Centre for Anxiety Disorders and Trauma, Department of Experimental
Psychology, University of Oxford, Oxford, United Kingdom
Frank Neuner, PhD, Department of Psychology, Bielefeld University, Bielefeld, Germany
Mirjam J. Nijdam, PhD, Department of Psychiatry, Amsterdam University Medical Center,
University of Amsterdam, Amsterdam, and ARQ National Psychotrauma Center, Diemen, e
Netherlands
Barbara L. Niles, PhD, Behavioral Science Division, National Center for PTSD, VA Boston
Healthcare System and Department of Psychiatry, Boston University School of Medicine, Boston,
Massachusetts
Kore Nissenson, PhD, private practice, New York, New York
Pat Ogden, PhD, Sensorimotor Psychotherapy Institute, Broomfield, Colorado
Sandra C. Paivio, PhD, private practice, Toronto, Ontario, Canada
Laurie Anne Pearlman, PhD, private practice, Holyoke, Massachusetts
Katy Robjant, DClinPsy, Department of Psychology, University of Konstanz, Konstanz, Germany
Lesia M. Ruglass, PhD, Center of Alcohol and Substance Use Studies, Graduate School of Applied
and Professional Psychology, Rutgers, e State University of New Jersey, Piscataway, New Jersey
Maggie Schauer, PD Dr, Department of Psychology, University of Konstanz, Konstanz, Germany
Ulrich Schnyder, MD, Department of Psychiatry and Psychotherapy, University of Zurich, Zurich,
Switzerland
Francine Shapiro, PhD(deceased), EMDR Institute, Watsonville, California
Geert E. Smid, MD, PhD, Arq National Psychotrauma Center, Diemen, and University of Humanistic
Studies, Utrecht, e Netherlands
Stefanie F. Smith, PhD, Hanna Boys Center, Sonoma, California
Joseph Spinazzola, PhD, Foundation Trust, Melrose, Massachusetts, and School of Counseling,
Richmont Graduate University, Atlanta Georgia
Kathy Steele, MN, CS, private practice, Atlanta, Georgia
Ashley R. Trautman, MSW, JD, College of Health Professions and Biomedical Sciences, University of
Montana School of Social Work, Missoula, Montana
Onno van der Hart, PhD, Department of Clinical and Health Psychology, Utrecht University,
Utrecht, e Netherlands
Bessel A. van der Kolk, MD, Department of Psychiatry, Boston University School of Medicine,
Boston, and Trauma Research Foundation, Brookline, Massachusetts
Sarah Krill Williston, PhD, Behavioral Science Division, National Center for PTSD, VA Boston
Healthcare System, Boston, Massachusetts
Foreword
JUDITH LEWIS HERMAN
Sometimes the whole is greater than the sum of its parts.
The beauty of the complex posttraumatic stress disorder (PTSD) concept is in its integrative nature. Rather than a simple list of symptoms, it is a coherent formulation of the consequences of prolonged and repeated trauma. e first time I proposed the concept (Herman, 1992a), it was an attempt to bring some kind of order to the bewildering array of clinical presentations in survivors who had endured long periods of abuse. e concept gained sufficient recognition that it was subjected to field trials in DSM-IV, the American Psychiatric Association’s official diagnostic manual (American Psychiatric Association, 1994). I was privileged to be part of the PTSD Working Group for DSM-IV, and so had a chance to participate in these studies. e data seemed promising: My co-investigators and I found that somatization, dissociation, and affect dysregulation, three cardinal symptoms of complex PTSD, were present particularly in survivors of childhood abuse, less commonly in those abused in adolescence or adulthood, and rarely in people who had endured a single acute trauma that was not of human design. Moreover, these three groups of symptoms were highly intercorrelated (van der Kolk et al., 1996). We thought this demonstration of the prevalence and internal consistency of the diagnosis would constitute a strong argument for its inclusion in the DSM, and the PTSD Working Group agreed. Unfortunately, we were overruled at higher levels. e argument against inclusion of a separate diagnosis, as I understood it, went something like this: “We can’t include complex PTSD as part of the trauma spectrum, because it does not fit neatly under the category of anxiety disorders. It might fit equally well under dissociative disorders, or somatization disorders, or even personality disorders.” Which was, of course, exactly the point.
ough relegated to the “associated features” of PTSD in DSM-IV, the concept of complex PTSD nevertheless took on a life of its own. I like to think that this was because it was congruent with a vast body of clinical observation and experience, and it helped clinicians make sense of what they were observing. It also helped patients make sense of themselves.
When it came time for the next edition of the DSM, the same arguments were repeated (Resick et al., 2012). Asked to consult to the PTSD committee for DSM-5, I proposed that the concept was both parsimonious and clinically useful. While complex PTSD shared features of many other diagnoses, I argued, failure to recognize it as a separate and coherent entity resulted in many practical clinical problems: multiple diagnoses, multiple treatment protocols, and polypharmacy (Herman, 2012). Instead of recognizing complex PTSD as a separate diagnostic entity, however, DSM-5, in its wisdom, simply expanded the basic definition of PTSD to include many of the features of complex PTSD (American Psychiatric Association, 2013). Fortunately, our international colleagues have approached the issue with greater clarity. Based on collaborative international research that clearly supported the validity of the concept (Hyland et al., 2017; Palic et al., 2016), the World Health Organization’s (2018) International Classification of Diseases, 11th edition (ICD-11), finally recognized complex PTSD as a distinct entity.
ese days, when I teach about complex PTSD, I always begin with the social ecology of prolonged and repeated interpersonal trauma. ere are two main points to grasp here. e first is that such trauma is always embedded in a social structure that permits the abuse and exploitation of a subordinate group. e predominance of women among patients who meet criteria for complex PTSD starts to make sense when one understands the insidious pervasiveness of violence against women and girls (Tjaden & oennes, 1998; Breiding et al., 2014; World Health Organization, 2013). e second point is that such trauma is always relational. It takes place when the victim is in a state of captivity, under the control and domination of the perpetrator.
Violence is but one among an array of methods that a perpetrator uses to establish dominion over a victim. Others include use of threats, control of bodily functions, capricious enforcement of petty rules, and random intermittent rewards; isolating the victim; and forcing the victim to engage in activities that are degrading or immoral. ese methods break down normal capacities for self-regulation, autonomy, and initiative; they humiliate the victim and undermine the victim’s closest relationships. ese methods are cross-cultural and international; they are used because they work (Amnesty International, 1973). e symptoms later observed in survivors oen make sense when one understands the methods of coercion to which they have been subjected.
If the victim is a child, and the perpetrator, as is most commonly the case, is a parent, a close family member, or a primary role model, such as a teacher, coach, or religious leader, the absence of a protective parent or the presence of passive bystanders is felt as palpably as the presence of the perpetrator. Abuse is compounded by neglect, when others fail to notice or intervene. It seems increasingly clear that the pathological changes in relationship and identity seen in survivors reflect the disruptions in attachment that almost always attend childhood abuse. e “characterological” features of complex PTSD start to make sense if one imagines how a child might develop within a relational matrix in which the strong do as they please, the weak submit, caretakers seem willfully blind, and there is no one to turn to for protection.
What kind of “internal working models” (Bowlby, 1973) of self, other, and relationship would be likely to develop under such circumstances? is thought experiment turns out to be quite useful clinically. One begins to understand the survivor’s malignant self-loathing, the deep mistrust of others, and the template for relational reenactments that the survivor carries into adult life. Forming a therapeutic alliance becomes somewhat easier if the clinician understands at the outset why the patient might be unable to imagine a relationship that is genuinely caring, freely chosen, fair to both parties, mutually attuned, and mutually rewarding. It becomes the therapist’s task, then, to model, explain, and engage the patient in such a relationship, knowing that initially the patient will perceive this is as another likely setup for betrayal.
e past two decades have seen the flowering of clinical innovation in the psychotherapy field, with the development of many new evidenceinformed treatment models addressing some of the core manifestations of complex PTSD. e wealth and diversity of therapeutic approaches are well represented in this comprehensive volume. We are still in a period of experimentation; it is far too early to make any kind of judgment about which treatment approaches might be the most effective for which patients. Nevertheless, some constants have emerged.
First, many authors cite the importance of recognizing areas of strength and resilience, even in the most severely traumatized individuals, as this will constitute the basis for forming a therapeutic alliance (Harvey & TummalaNarra, 2007). One of the many advantages of group therapy for this population is that group members are called upon to give supportive feedback to one another, and in the process discover that they have something of genuine value to give (Mendelsohn, Zachary, & Harney, 2007). Couple and family systems therapies also provide opportunities for survivors to discover or build healthy relationships and new working models for trust and security within their most immediate relationships.
Second, there does seem to be a consensus about the central importance of developing a trusting and truly collaborative, rather than authoritarian, treatment relationship. Indeed, the strongest “evidence base” we have in the study of psychotherapy supports the central importance of the therapeutic alliance (Horvath, Del Re, Flükiger, & Symonds, 2011). Most authors also recognize that forming a stable, collaborative relationship is particularly challenging with a person who has been subjected to coercive control, because of the mistrustful survivor’s tendency to engage the therapist in relational reenactments. e difficulties of maintaining a wellbounded therapeutic frame and the risks of vicarious traumatization are now well understood, as are the prescriptions for therapists’ self-care and self-reflection.
Beyond the notion of collaboration or mutuality, many authors invoke some concept of an observing therapeutic alliance, that is, a relationship within which the patient develops an “observing ego,” or the capacity to “mentalize” (Fonagy, Gergely, Jurist, & Target, 2002; Bateman & Fonagy, 2006). In mentalizing trauma, the aim is “to help patients think, feel, and talk about the experience so as to be able to have the experience in mind without being overwhelmed by it” (Allen, 2013, p. 202).
Finally, most current treatment approaches make use of a tripartite model of recovery stages (Herman, 1992b). e task of the first stage is to establish safety. at of the second stage is to come to terms with the trauma story. Finally, the task of the third stage is to repair and enlarge the survivor’s social connections. is sequence has always seemed commonsensical to me, and apparently most of the authors in this volume have agreed.
Of course, these stages are not meant to be applied rigidly. In early recovery, for example, issues of safety and self-care always take priority, but this does not mean the subject of trauma should be avoided. On the contrary, patients in early recovery oen benefit greatly from trauma- informed treatment. Acknowledging the trauma and naming its consequences begin the process of meaning making. Survivors come to understand, oen for the first time, that their symptoms make sense in the context of a formative relationship of coercive control. is understanding is a powerful antidote to the feelings of malignant shame and stigma that afflict so many survivors. What one does not do in early recovery is any form of “exposure” therapy. Coming to terms with the grim details of the trauma story must await the development of a solid therapeutic alliance and some sort of secure base in the present from which the past can be safely approached. is is a task that requires more than a few scripted sessions.
e concept of stages can be applied to both group and individual psychotherapy. At the Victims of Violence Program (in the Department of Psychiatry at Cambridge Health Alliance), we have developed a wide array of time-limited groups. ese range from an “entry-level” Stage 1 group, the Trauma Information Group, which has minimal screening requirements or demands for commitment (Herman et al., 2018), to a trauma-focused, Stage 2 group, the Trauma Recovery Group, which has careful screening requirements and demands a high level of commitment from group members (Herman & Schatzow, 1984; Mendelsohn et al., 2011). e former is a psychoeducational group with weekly topics and homework assignments similar to those described in this volume. e latter is a goalfocused group in which trauma narratives are shared, empathic feedback is cultivated, and survivors experience active mastery in affiliation with others.
We do not have a Stage 3 trauma group model, because we find that at this stage, the survivor no longer feels that his or her identity is defined by her trauma history. Furthermore, with an expanded capacity for relationship, the survivor will have gained confidence that mutual understanding and compassion are possible even with people who have not endured the same kinds of traumas. ere is no need, therefore, to restrict group membership only to trauma survivors. If group therapy is indicated, a basic interpersonal psychotherapy group will be quite suitable.
In the Foreword to the first edition of this volume, 10 years ago, I expressed the hope that the future would bring more cooperative ventures integrating different treatment models. In this regard, I imagined that the congruence between features of complex PTSD and borderline personality disorder (BPD), first documented now almost 30 years ago (Herman, Perry, & van der Kolk, 1989; Ford & Courtois, 2014), might have increasing importance from a practical standpoint because of clinical advances in the treatment of BPD.
For example, in a remarkable 8-year follow up study of a randomized controlled trial, Bateman and Fonagy (2008) demonstrated that a psychodynamic, “mentalization”-based treatment program was much more successful than treatment as usual for patients with BPD. eir model called for 18 months of intensive day treatment, followed by 18 months of biweekly group psychotherapy. Certainly, this time frame seemed much more realistic to me than that of existing evidence-based treatment models for PTSD; therefore, I expressed the hope that we would soon develop similarly intensive, multimodal treatment models that might become the standard of care for complex PTSD.
Alas, this has not happened—yet. Rather, we have seen the proliferation of many brands of short-term therapy for classic PTSD, along with attempts to apply these models to complex PTSD. e limitations of this approach are well demonstrated in a meta-analysis by Dorrepaal et al. (2014), who further suggest that the next phase of research should focus on direct comparison of active treatment modalities. In practice, many of the models described in this book are designed for greater flexibility than their short-term research protocols might suggest, or they are techniques designed for integration into a relational, open-ended psychotherapy rather than a stand-alone model. Since it is not realistic to expect that practitioners will become expert in numerous different, specialized techniques, some researchers now suggest that we might be ready to shi our focus from studies of competing models to studies that elucidate the common features of effective therapies (Laska, Gurman, & Wampold, 2014).
But that is for the future. In the meantime, it makes sense to pause and reflect on how far the field has come in a quarter century, and to represent the state of current knowledge in the field of complex traumatic disorders. is is the task that these editors and authors have set for themselves. is volume captures the intellectual excitement of a field in rapid development —or perhaps I should say, of multiple fields, intersecting in surprising and unforeseen ways. It also captures the spirit and passionate commitment of the many contributing authors, researchers, and clinicians who have devoted their professional lives to the project of survivors’ recovery.
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Acknowledgements
We are most grateful to many colleagues—too many, unfortunately, to mention all by name. We are deeply appreciative of the insights and expertise contributed to this book by each of the chapter authors and by our Foreword and Aerword authors and mentors Judith Lewis Herman and Bessel A, van der Kolk. All were enthusiastic in joining this project and contributing their work, as well as admirably tolerant of our timelines, deadlines, and editing.
We want to especially thank our colleagues who have championed the issue of complex trauma and metamodel of complex traumatic stress disorders over the past 30 years and whose dedication and hard work in the past decade has so greatly informed this book. Many have generously served as the contributors for this book, while others have provided leadership and both intellectual and moral support to the professionals and the survivors who strive to prevent complex trauma and to heal and promote the recovery of all who have experienced its multifaceted consequences.
And for their dedicated work in advancing the science and treatment of complex traumatic stress disorders, we sincerely thank the leadership and members of the International Society for the Study of Trauma and Dissociation, the International Society for Traumatic Stress Studies and the growing number of other Traumatic Stress Societies around the world, Division 56 (Psychological Trauma) of the American Psychological Association, the National Child Traumatic Stress Network, the Academy on Violence and Abuse, and the American Professional Society on the Abuse of Children.
We also gratefully acknowledge the ongoing support from our family members and friends, and especially from our spouses (Judy and Tom). ey have provided each of us with countless gis of wisdom, patience, and encouragement that have added immeasurable meaning to our lives and have helped to make this book possible.
Contents
Also by Julian D. Ford and Christine A. Courtois
Title Page
Copyright Page
Dedication
About the Editors
Contributors
Foreword
Acknowledgments
PART I.
OVERVIEW
Chapter 1 Defining and Understanding Complex Trauma and Complex Traumatic Stress Disorders Julian D. Ford and Christine A. Courtois
Chapter 2 Developmental Neurobiology Julian D. Ford
Chapter 3 Best Practices in Psychotherapy for Adults Christine A. Courtois, Julian D. Ford, Marylene Cloitre, and Ulrich Schnyder
Chapter 4 Therapeutic Alliance and Risk Management Christine A. Courtois
Chapter 5 Evidence-Based Psychological Assessment of the Sequelae of Complex Trauma Joseph Spinazzola and John Briere
Chapter 6 Assessing and Treating Complex Dissociative Disorders Kathy Steele and Onno van der Hart
Chapter 7 Cultural Humility and Spiritual Awareness Laura S. Brown
Chapter 8 New Perspectives on Vicarious Traumatization and Complex Trauma Laurie Anne Pearlman, James Caringi, and Ashley R. Trautman
PART II. EVIDENCE-SUPPORTED INDIVIDUAL TREATMENT MODALITIES AND MODELS
Chapter 9 Prolonged Exposure Therapy Elizabeth A. Hembree and Edna B. Foa
Chapter 10 Cognitive Therapy Anke Ehlers and Hannah Murray
Chapter 11 Cognitive Processing Therapy Kathleen M. Chard, Ellen T. Healy, and Colleen E. Martin
Chapter 12 Brief Eclectic Psychotherapy Berthold Gersons, Mirjam J. Nijdam, Geert E. Smid, and Ulrich Schnyder
Chapter 13 Eye Movement Desensitization and Reprocessing Therapy Deborah L. Korn and Francine Shapiro
Chapter 14 Narrative Exposure Therapy Maggie Schauer, Katy Robjant, Thomas Elbert, and Frank Neuner
Chapter 15 Emotion-Focused Therapy Sandra C. Paivio and Lynne E. Angus
Chapter 16 Interpersonal Psychotherapy Ari Lowell, Andrea Lopez-Yianilos, and John C. Markowitz
Chapter 17 Cognitive-Behavioral Therapy Christie Jackson, Kore Nissenson, and Marylene Cloitre
Chapter 18 Trauma Affect Regulation: Guide for Education and Therapy Julian D. Ford
PART III. GROUP/CONJOINT THERAPY MODELS
Chapter 19 Group Therapy Julian D. Ford
Chapter 20 Dual-Trauma Attachment-Based Couple Therapy Pamela C. Alexander
Chapter 21 Family Systems Therapy Julian D. Ford
Chapter 22 Complex Trauma and Addiction Treatment Denise Hien, Lisa Caren Litt, Teresa López-Castro, and Lesia M. Ruglass
PART IV. EMERGING PSYCHOTHERAPY MODELS
Chapter 23 Sensorimotor Psychotherapy Pat Ogden
Chapter 24 Experiential Approaches Janina Fisher
Chapter 25 Mindfulness Approaches Barbara L. Niles, Sarah Krill Williston, and DeAnna L. Mori
Chapter 26 Complementary Healing Therapies Stefanie F. Smith and Julian D. Ford Epilogue: Overview and Future Directions in Treatment for Complex Traumatic Stress Disorders Julian D. Ford and Christine A. Courtois Afterword Bessel A. van der Kolk Index About Guilford Press Discover Related Guilford Books
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