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Expat-Informed Psychotherapy: A Deeper Dive into Cross-Cultural Mental Health Care

1. Introduction

  • Explanation of the Concept of Expat-Informed Psychotherapy

Expat-informed psychotherapy is a fresh, nuanced perspective in the mental health landscape. It's like a prism, refracting the light of traditional therapeutic practices through the lens of an expatriate's unique experiences, journey, and cultural sensibilities. [For a broader perspective on "expat psychology" as a whole see my previous post here.]

Unlike generic therapeutic approaches, it doesn't merely focus on diagnosing and treating symptoms. Instead, it seeks to understand the profound impact that living outside one's home country has on the psyche, considering cultural influences, languages spoken, migration history, and its aftereffects.

It’s an approach that is conscious of the kaleidoscopic cultural influences that mold an expat's identity, acknowledges the complex emotional tapestry of migratory grief and transitional phases, and respects the strength inherent in adaptive coping mechanisms developed by individuals living abroad.

  • The Importance of This Approach in Providing Targeted and Effective Mental Health Care for Expats

In our increasingly globalized world, expat-informed psychotherapy is not a niche concept but an urgent necessity. As millions journey across borders seeking better opportunities, new adventures, or refuge, they often grapple with a unique set of mental health challenges unknown to those who remain in their home countries. To borrow an analogy from horticulture, transplanting a tree from its native soil to foreign land involves more than just digging a hole and hoping it takes root; it requires understanding the new environment's sunlight, soil, and climate.

Similarly, providing mental health care for expats necessitates understanding the psychological impact of such transplantation: the struggle with cultural adjustment, the sense of loss, the yearning for belonging, and the possible challenge of forging a new identity. Expat-informed psychotherapy meets this need, offering a finely-tuned approach that is attuned to expatriates' unique experiences, offering a beacon of understanding in an often disorienting landscape of change.

2. Understanding the Expat Experience

The expat experience is an intricate, vivid, and sensory-rich odyssey, that often feels like learning to navigate an uncharted landscape. Imagine uprooting from all that is familiar - the sights, smells, sounds, the language, and the shared cultural context - and then trying to bloom in foreign soil. The day-to-day living that most people take for granted suddenly becomes a jigsaw puzzle that doesn't quite fit. You're reading new social cues, learning new cultural norms, interpreting a new language, and all these while attempting to find a sense of belonging in a place where you're fundamentally a visitor. This is the expat experience - as exhilarating as it is exhausting, as rewarding as it is challenging.

Unpacking the unique experiences of an expat means acknowledging the brave adventure they've undertaken. It's about recognizing their struggle for finding a comfortable rhythm amidst cultural adjustments, as they reshape their identity and mold themselves to resonate with the new environment. The unfamiliar streets, alien languages, and the subtle nuances of social interaction – the once mundane now turned profound. These experiences are much like a dance, oscillating between the footfalls of assimilation and authenticity, constantly striving to retain a sense of self while harmonizing with the new culture.

Underneath these seemingly mundane experiences lies the silent undercurrent of migratory grief (Wells, 2021). This is not simply a homesickness or nostalgia, but a profound sense of loss that often goes unrecognized. It's the grief of leaving behind the known and the comfortable - friends, family, places, routines - and stepping into the unknown. It can come in waves or persist as a dull ache, profoundly impacting the expat's mental health and sense of well-being. In understanding the expat experience, it's essential to give voice to this hidden grief, acknowledge its impact, and develop strategies to heal and move forward.

3. The Expat's Migration History & Its Effects

Migration history is a roadmap etched into any migrant's psyche. Each twist and turn, each border crossed, each home left behind, leaves an indelible mark, shaping their worldview and mental health in subtle and not-so-subtle ways. One's migration journey could be a willingly chosen adventure, a forced displacement, or an economically necessitated transition - but whatever the motivation, each move brings with it a shakeup of the familiar and the predictable. In the larger context of their lives, the frequency, timing, and nature of these moves form a unique pattern, influencing their sense of self, resilience, adaptability, and emotional well-being.

The psychological impact of migration is not always apparent at first glance. Just as a pond's placid surface can hide the tumult underneath, the obvious excitement of a new destination or the relief of escaping a troubled past can cloak the hidden strains of adapting to a foreign environment, leaving behind cherished connections, and grappling with a shifting identity. For those who have moved frequently, these stresses can accumulate, creating a sort of "migratory fatigue," a depletion of emotional reserves that may lead to symptoms such as anxiety, depression, or feelings of detachment.

Yet the potentially traumatic aspect of migration often comes not from the predictable, planned transitions, but from the unexpected, abrupt ones. An unforeseen move can feel like a rug pulled out from under the feet, disrupting the tentative sense of stability an expat may have started to cultivate. The shock and disorientation resulting from such an unexpected change can exacerbate feelings of loss, create acute stress responses, and even trigger post-traumatic stress disorder (PTSD) in some cases. Recognizing the potential for trauma in these experiences is a vital step in expat-informed psychotherapy, as it allows for a holistic approach to healing that addresses not just the present, but also the echoes of the past, and a vision for the future.

4. Culture, Language, and Mental Health

Culture and language are far more than just backdrop settings in the expat story - they are potent forces shaping their mental and emotional landscapes. Picture culture as a river that's been flowing for millennia, etching deep impressions and shaping the very terrain it traverses. When expats immerse themselves in a new culture, they willingly step into this river's flow, letting it reshape their understandings, behaviors, and even self-perception. This cultural immersion influences their mental health in multifaceted ways, coloring their emotional expression, their interpretation of experiences, and their coping mechanisms.

Language, on the other hand, serves as the bridge between the individual and the world around them (see Liemacher-Riebold, 2023 on effective multingual communication). As expats traverse this bridge into their new environment, the linguistic challenges they face can vary from minor inconveniences to formidable barriers that can exacerbate feelings of isolation and alienation. Moreover, language intricacies can also shape thought patterns, with each language offering its unique way of perceiving and expressing the human experience. Therefore, mental health professionals working with expats must recognize the dual impact of culture and language, considering these elements as crucial aspects of the expat's mental health narrative.

When it comes to therapy, the intersection of culture and language can present unique challenges. Traditional psychotherapy is steeped in Western cultural norms, values, and language, which may not fully resonate with expats from diverse cultural backgrounds. Misunderstandings can arise from these cultural disparities, and these can complicate the therapeutic process. For example, an expression of distress that is normative in one culture might be misinterpreted as pathological in another. Likewise, a therapeutic intervention that's effective in one cultural context might fall flat in another due to differences in social norms or values. These potential pitfalls underscore the necessity for therapists to approach their expat clients with cultural humility and a readiness to learn, adapt, and even unlearn, as needed. An expat-informed approach to therapy is, at its heart, an exercise in cross-cultural translation, seeking to bridge the gaps and create a shared understanding that respects and values the expat's unique cultural and linguistic context, whilst also nurturing the psychic nature that binds us all.

5. Key Therapeutic Topics in Expat-Informed Psychotherapy

Expat-informed psychotherapy, as an approach, necessitates a deep dive into several pivotal areas that hold paramount importance in an expatriate's life. At the forefront of these topics lie notions of belonging, identity, and attachment style. Each of these plays an intricate role in how expats perceive themselves and interact with their new environment. Belonging is the emotional tether that connects us to the social world around us. For expats, the quest for belonging can be an arduous journey, marked by a continuous ebb and flow between assimilation and distinction, between blending in and standing out. Unpacking this dynamic and nurturing a healthy sense of belonging is an essential focus in expat-informed psychotherapy.

Similarly, identity forms the cornerstone of our understanding of who we are and where we fit in the larger social context. Expats often face a profound reshaping of their identity as they negotiate the cultural expectations of their host country and reconcile them with their roots. Therapy, in this context, aids expats in this identity navigation, providing the support and space to integrate the old and the new. Attachment styles also play a crucial role in the expat's experience. Migratory journeys, with their inherent unpredictability and change, can challenge and influence expats' attachment patterns, affecting their relationships and sense of security in their new homes. Beyond these themes, expat-informed psychotherapy also extends its focus to coping mechanisms, the evolving concept of 'home,' and the trials and tribulations of cultural integration. Coping mechanisms developed by expats are often a testament to their resilience and adaptability, acting as vital tools for managing the unique stresses they encounter. The notion of 'home' for an expat can be a fluid, transformative concept. It's no longer a fixed geographical location but a movable emotional space that can encompass multiple places, cultures, and communities. Helping expats define, redefine, and make peace with their sense of home is another significant aspect of this therapeutic approach. Finally, the journey of cultural integration presents its own challenges and rewards. It involves a delicate balance of adaptation and preservation of one's own cultural identity. By examining these issues in therapy, mental health professionals can provide tailored support, helping expats to navigate their complex cultural landscapes with confidence and authenticity.

6. The Role of Attachment and Belonging

In the realm of expat psychology, attachment and belonging play starring roles (Bushong, 2013; Ota, 2014). They are the invisible threads that connect us to our past, anchor us in our present, and influence our future. Migration, by its very nature, tugs and tests these threads in ways that can significantly impact an individual's mental health and emotional well-being.

A fascinating perspective that came up in a recent conversation with a colleague was the notion that the act of returning to a known environment could potentially strengthen our attachment style. Moving back to familiar people, places, and cultural contexts reinforces those emotional bonds and thus our attachment to them. However, this is a hypothesis that, while intriguing, needs further exploration and empirical testing in future research.

On the other hand, migration without return - a one-way journey into the unknown - can potentially disrupt these attachments. Geographic and emotional distance may weaken them over time, and this one-way journey may also disrupt one's sense of belonging, as the familiar is replaced with the unfamiliar, and the known with the unknown.

Esters, et al. (2022) also shed light on the role of early attachment styles in relation to migration and belonging. Our research indicates that individuals with an insecure attachment are more likely to migrate early in life and, generally, are at risk of a negative sense of belonging later in life. These findings underscore the importance of recognizing and addressing attachment issues within the therapeutic context, providing clients with strategies to nurture healthier attachments and foster a positive sense of belonging.

In the context of migration, the idea of a multigenerational sense of belonging can be a powerful anchor. The notion that our belonging is not solely defined by our current geographic location, but also by our ancestral roots and familial ties, can serve as a source of continuity amidst change. This can be particularly empowering for expats, as it creates a link between their past, present, and future, facilitating their adaptation to new environments without feeling completely detached from their roots.

Our study’s findings overall highlight the intricacy of the relationship between migration, attachment, and belonging. They underscore the need for an expat-informed approach to psychotherapy that gives due consideration to these dynamics, leading to more targeted and effective therapeutic interventions.

7. Family Dynamics and Relationships

The impact of frequent migration extends far beyond the individual, permeating family dynamics and relationships with a host of unique challenges and opportunities. The movement from one environment to another often initiates a series of adjustments, not just for the individual, but for the entire family system. Whether it's navigating the shifting roles of trailing spouses or understanding the complexities faced by Third Culture Kids (TCKs), frequent migration introduces a new dimension to familial relationships (Van Reken, Pollock, & Pollock, 2017). Trailing spouses and TCKs represent two groups within the expatriate family system that face distinct issues. Trailing spouses, who often relocate to support their partner's career, can grapple with a range of challenges from career disruptions to identity shifts and cultural adaptation. Meanwhile, TCKs - children who've spent a significant part of their developmental years outside their parents' culture - may experience difficulties related to identity formation, belonging, and adapting to continually changing environments. Providing the necessary support for these groups, understanding their unique experiences, and addressing their specific needs are vital aspects of expat-informed psychotherapy. Moreover, frequent migration may result in physical distance between family members and friends, which can, in turn, place emotional strain on these relationships. Maintaining connections across time zones and cultural differences requires extra effort and can sometimes lead to feelings of isolation or alienation. In therapy, aiding clients to nurture these long-distance relationships and develop new social networks can be a key aspect of supporting their overall mental health. Equally critical is the need to address the more sinister side of migration: the potential lack of external oversight in cases of neglect and abuse within expatriate families. Crossman, Vahey-Smith and Wells (2022) conducted a survey on the risk factors of globally mobile families and noticed a significantly higher amount of phsyical, emotional and sexual abuse and neglect occuring, than the norm of many countries. Their findings strengthen the need for prevention and educated precaution to mitigate risk and enhace more positive and healthy outcomes. The transient nature of expat life can sometimes create an environment where signs of neglect and abuse go unnoticed or unreported. As mental health professionals, it's crucial to remain vigilant to these potential issues, providing a safe space for disclosure and helping connect clients with necessary resources and support.Ultimately, understanding the unique challenges and dynamics within expat families is essential in offering effective, targeted therapeutic interventions.

8. Healthcare Navigation for Expats

Navigating healthcare as an expatriate can feel like piecing together a complex jigsaw puzzle. With providers spread across multiple countries, coordinating care can be a daunting task. From language barriers and unfamiliar healthcare systems to different medical practices, expats often find themselves facing a labyrinth of challenges while seeking care. In this context, expat-informed psychotherapy doesn't just mean providing mental health support, but also assisting clients in navigating these healthcare complexities.

When you're an expat, your healthcare journey doesn't end at the borders of your host country; it often transcends continents. It's not uncommon for expats to have healthcare providers in multiple countries. Imagine having your psychiatrist in Saudi, your dentist in Nigeria, gynecologist in Germany, and the elderly care for your parents in America. This presents the unique challenge of coordinating care and ensuring seamless communication between providers. Key to this is developing a robust and effective healthcare plan that considers the various geographic locations and healthcare systems involved. Therapists can play a vital role in facilitating discussions around healthcare planning and encouraging proactive engagement with health services.

However, accessing healthcare across borders isn't without its hurdles. Cultural differences and language barriers can significantly impact the understanding and delivery of care. Healthcare systems can vary dramatically from one country to the next, leading to potential confusion and miscommunication. Therapists can support clients by providing information, bridging gaps in understanding, and advocating for their healthcare needs when necessary.

Moreover, expats might face difficulties related to insurance coverage and the financial aspects of healthcare. Navigating international health insurance policies and understanding out-of-pocket costs can be a source of stress. Therapists can help clients tackle these issues by facilitating problem-solving discussions and providing referrals to financial advisors familiar with expatriate insurance concerns.

In essence, healthcare navigation for expats is about more than managing illness; it's about promoting wellness in a global context. As mental health professionals, we have an important role to play in assisting expats in this journey, advocating for their needs, and supporting them in accessing and coordinating care.

9. Privilege, Service, and Expat Life

The concept of privilege, like a chameleon, takes on different hues and forms in the context of expat life. Although the term "expat" is used widely, it often unconsciously points towards a more affluent, skilled migrant subset – those who have relocated for work or education and often live within an 'expat bubble.' Recognizing this privilege and understanding its implications forms a critical part of an expat-informed approach to psychotherapy.

Research by Danau Tanu (2016; 2020), sheds light on the inherent privilege embedded within the expat experience and the international school environment. It highlights how English-speaking International schools, while fostering global mobility, predominantly educate their students in Western norms. This education system might at times subtly craft a hierarchy of ethnicity, culture, and class, influencing not only the immediate school environment but also having deeper sociocultural implications.

In a world increasingly characterized by social and economic disparities, the narrative of the affluent migrant or "expat" often sparks tension and unrest. Graffiti stating "expats not welcome," like the one I observed in Rotterdam, epitomizes this tension, reflecting perceived inequities in housing and resources between expats and locals. Recognizing and addressing these social dynamics is integral to fostering a more inclusive, balanced, and empathetic understanding of the expat experience.

However, privilege isn't a uniform blanket that covers all expats. Its extent and influence vary greatly depending on a range of factors, from nationality and ethnicity to class and educational background. Even the definition of who is considered an 'expat' can be arbitrary, with preferred terms such as Globally Mobile, (Adult) TCK, and CCK reflecting the diverse spectrum of expat experiences. Regardless of the label, all these individuals share a common thread: they have moved, integrated various cultures and languages, and grapple with questions around belonging, attachment, and identity.

With privilege comes responsibility - an opportunity to pay it forward and serve others. As expats, we are uniquely positioned to bridge cultural gaps, foster understanding, and contribute positively to our host communities. This service can take myriad forms, from volunteering at local charities to mentoring local students or supporting locally-owned businesses. By leveraging our skills, resources, and experiences, we can help promote inclusivity and cohesion within our diverse communities. This concept of service, therefore, forms an essential aspect of a comprehensive, holistic approach to expat mental health.

In the end, acknowledging and addressing the nuances of privilege, and fostering a culture of service, is useful to a truly expat-informed approach to psychotherapy. It allows us to provide mental health services that respect the complexity of the expat experience, promote empathy, and drive positive social change.

10. Understanding Traumatic Migratory Grief

The process of migration, while often filled with anticipation and new beginnings, can also be a breeding ground for profound grief . This sense of loss is magnified when the move is unexpected or coupled with chronic stress, giving rise to what we refer to as traumatic migratory grief (Wells, 2021). To truly practice expat-informed psychotherapy, we must dig deep into the crux of this trauma and understand how it weaves itself into the mental health fabric of the expat community. Moreover, there is still we have to further research as to how this presents itself.

Imagine this: you're uprooted abruptly from a place you've begun to call home, yanked away from familiar sights, sounds, and faces, thrust into a milieu of new experiences sometimes without a moment's notice. This sudden, disorienting transition often triggers what we call traumatic migratory grief. It's a sense of loss so deep and profound, it transcends the bounds of traditional grief and ventures into the realm of trauma. Unlike conventional grief, which tends to follow a somewhat predictable trajectory, traumatic migratory grief often catches you off guard, leaving you in a state of perpetual emotional turmoil.

Chronic stress, which is often intertwined with the expat experience, can act as a catalyst, amplifying the effects of this grief. When you're under continuous stress, your ability to cope with change and loss diminishes, leaving you vulnerable to traumatic migratory grief. Unexpected moves can further exacerbate this stress, triggering a cycle of anxiety and grief that can be hard to break free from.

Understanding traumatic migratory grief means acknowledging the double-edged sword of migration. On the one hand, migration can provide new opportunities, exciting experiences, and the chance to explore different cultures. On the other hand, it can result in profound grief, especially when the move is sudden or accompanied by chronic stress. Recognizing this dual nature is key to expat-informed psychotherapy, guiding therapists to support clients in navigating the complexities of grief while also leveraging the unique opportunities that an expat life presents.

Navigating traumatic migratory grief is like traversing a tumultuous sea – it's unpredictable, tumultuous, and at times, overwhelming. But with the right support, understanding, and therapeutic tools, we can guide individuals to calmer waters, helping them navigate their grief and find new ways to forge meaningful connections in their new environments.

11. Future Directions for Research and Practice

Just as the expatriate experience is a continually unfolding journey, so too is our understanding of expat-informed psychotherapy. While we've begun to shine a light on the unique complexities and challenges faced by this population, our knowledge is still in its early stages. Unraveling the intricacies of the expat psyche requires us to probe further, dig deeper, and continually reassess our understanding. In this pursuit, there are several avenues for future research and practice that promise exciting discoveries and insights. One fascinating area of exploration is the dynamic relationship between migration and attachment style. While our study (Esters, et al., 2022) has begun to uncover this complex interplay, the suggestion by a colleague that the act of returning could potentially strengthen attachment style provides an intriguing new perspective that warrants further examination. Similarly, we have only just begun to scratch the surface of how cultural and linguistic factors affect mental health within the expat community. Future research should aim to delve deeper into this domain, examining the intricate dance between culture, language, and psychological well-being in a multinational, multicultural context. Looking at clinical practice, there's a pressing need to refine and develop our therapeutic approaches. This means not just incorporating an understanding of expat experiences into our work, but also translating that understanding into tailored interventions and strategies that can effectively address the unique mental health needs of this population. One promising avenue for practice is the cultivation of cultural competency, helping therapists to navigate and bridge cultural divides, and foster an environment of understanding, empathy, and acceptance. As we forge ahead, collaboration and the sharing of knowledge are critical. Expat-informed psychotherapy is not just the perspective of a single researcher or practitioner, but a collective endeavor. We must be open to learning from one another, pooling our resources and knowledge, and continually challenging our preconceptions and assumptions. In conclusion, expat-informed psychotherapy is a rich, dynamic field brimming with potential. As we continue to explore, learn, and grow, we look forward to seeing how this field evolves, and the positive impact it can have on the lives of expatriates worldwide. Together, we can work to ensure that every expat, no matter where they are or where they've come from, feels seen, heard, and supported in their mental health journey.

12. Conclusion

Navigating the journey of expatriation is akin to exploring uncharted territories - a thrilling mix of discovery and challenges, opportunities and uncertainties. This experience, while enriching, holds unique mental health complexities. Through this expansive exploration, we've delved into these complexities and unraveled the importance of an approach tailored to the expat experience: expat-informed psychotherapy. We began by understanding the concept of expat-informed psychotherapy, a unique form of therapeutic practice that takes into account the distinctive experiences and mental health challenges faced by expats. From there, we delved into various facets of the expat experience - from migration history and its psychological impacts to the profound role of culture and language on mental health. We've seen how critical topics such as belonging, identity, and attachment style become even more significant in the context of expatriation. The impact of migration on attachment and belonging, and the dynamic dance between these two pivotal aspects of human psychology, was particularly enlightening. We've seen how migration can impact family dynamics, from Third Culture Kids and trailing spouses to the effects of distance and lack of oversight in cases of neglect and abuse. The challenges expats face in navigating healthcare systems spread across different countries underlined the unique difficulties this population often contends with. We've also grappled with the role of privilege in the expat experience and the opportunity for service and positive impact in host communities. Traumatic migratory grief, an under-explored facet of the expat experience, emerged as a significant area of focus, particularly in cases of unexpected moves and chronic stress. And finally, we cast our eyes to the future, discussing potential areas of research and the need for continued collaboration and knowledge-sharing within the field. Expat-informed psychotherapy, in essence, is about truly seeing the individual - their experiences, their struggles, and their strengths. It's about going beyond the surface to understand the impact of migration on mental health, and using this knowledge to provide targeted, effective care. As we continue to explore and evolve in this field, our goal remains unwavering - to ensure that every expat, regardless of their journey, feels supported, understood, and empowered on their mental health path. In the ever-globalizing world, this endeavor is not just necessary, it is indispensable. 13. Bonus: Personal Narratives and Case Studies

Experiences are deeply personal, and their value is profound in understanding the unique challenges and triumphs of the expat journey. As an additional resource to the wealth of information presented thus far, we offer a collection of personal narratives and case studies from the heart of the expat world (Jones, 2018).

First, the personal narratives: the human voices behind the expat experience. Their stories illuminate the depths of the expat journey, shedding light on the unique challenges and opportunities they have encountered. The shared strategies and coping mechanisms that have aided their mental health resilience can serve as a beacon for others navigating similar paths.

Alongside these voices, we delve into the realm of case studies. As practical examples from practitioners working in expat-informed psychotherapy, these vignettes demonstrate how the principles and insights discussed throughout the post are actualized in therapeutic practice. They offer a lens into the depth and breadth of therapeutic interventions, techniques, and approaches informed by the expat perspective.

More than this, case studies can also reveal how particular challenges faced by expats can be addressed through specific interventions. They can highlight the therapeutic journey, underscoring how therapists adjust and adapt their techniques to the unique needs of their expat clients, bringing theory into practice.

In weaving together the personal narratives and case studies, we paint a more vibrant and multifaceted picture of expat mental health. This integration serves to add depth to our understanding and offer inspiration for more empathetic, effective, and personalized therapeutic approaches within the realm of expat-informed psychotherapy. There's still so much to learn and figure out. Case studies and personal narratives serve to ground the abstract in the concrete, offering living, breathing examples of the principles we've explored, further emphasizing the possible value of this approach. References

Bushong, L. (2013). Belonging Everywhere & Nowhere: Insights into Counseling the Globally Mobile. Indianapolis: Mango Tree Intercultural Services. Crossman, T. (2016). Misunderstood: The impact of growing up overseas in the 21st Century. Summertime Publishing. Crossman, T., Vahey Smith, E., & Wells, L. (2022, December 8). TCKs at Risk: Risk Factors and Risk Mitigation for Globally Mobile Families. Retrieved from Esters, P., Godor, B. P., & Van der Hallen, R. (2022). Investigating the role of residential migration history on the relationship between attachment and sense of belonging: A SEM approach. Journal of Community Psychology, 51(1), 468-485.

Jones, R. P. (2018). Finding home: Third culture kids in the world. Liemacher-Riebold, U. (2023, June 24). Home Page. Ute’s International Lounge & Academy.

Tanu, D. (2016). Going to school in ‘Disneyland’: Imagining an international school community in Indonesia. Asian and Pacific Migration Journal, 25(4), 429-450. Tanu, D. (2018). Growing up in transit: The politics of belonging at an international school. Berghahn Books. Van Reken, R., Pollock, D., & Pollock, M. (2017). Third Culture Kids (3rd ed.). Boston: Nicholas Brealey Publishing.


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