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Foulkes (1975) referred to group therapy as “ hall of mirrors “ in which people can see themselves reflected in others. Group therapy is a powerful therapeutic tool to help the patients, correct maladaptive personal behaviors and to enhance a patient’s ability to function as a contributing member of the community. The experience of being in a group does not deny the uniqueness of each person. Rather, it allows people to directly experience their talents and possibilities through the eyes and personal experience of others. By using a variety of technical maneuvers and theoretical constructs, the leader directs group members’ interactions to bring about changes. The principles of group psychotherapy have also been applied with success in the fields of business and education in the form of training.
Group therapy is a method of therapeutic intervention based on the exploration and analysis of both internal (emotional) and external (environmental) conflicts and the group process. [LEGO, 1996] Group therapy is an identifiable system consisting of at least 3 people who share a common goal. [NUDELMAN, 1986]
Group therapy is a “hall of mirrors” in which people can see themselves reflected in others. [FOULKES, 1975] 1
Group psychotherapy, as a recognized form of psychological treatment, traces its origin to the early 1900’s. in 1907, Joseph Pratt, an internist in Boston, developed a psycho educational method for teaching patients with TB about their disease and improving their morale. He used a combination of lecture and informal group discussion. The success of his group treatment approach inspired Pratt and others to use a group format to treat other chronic diseases such as diabetes. Later, Pratt expanded its use to the treatment of neurotic disorders. The idea of sharing a “common bond in a common disease”, which Pratt advocated at the turn of the century, serves as the basis for many contemporary support and mutual help groups. The notion of combining psycho education with informal group discussion is used increasingly with patients and families because of the benefit of combining didactic information with individuals’ experiences. Samuel R Slavson, considered the father of group psychotherapy in America, worked with, inner- city children and adolescence. He found that a group format using a combination of games, tools and food to engage children in actively communicating with each other, encouraged co- operative behaviors among children who otherwise might not talk to each other. This work laid the ground work for group activity therapy, in which arts and crafts help children experience and direct their energies in productive way.
CHARACTERISTICS OF AN EFFECTIVE GROUP
• • • • • Goals are clearly identified and collaborately developed. Open, goal directed communication of feelings and ideas is encouraged. Power is equally shared and rotates among members, depending on ability and group needs. Decision making is flexible and adapted to the group needs. Controversy is viewed as healthy because it builds member involvement and creates stronger solutions. 2
• • •
A healthy balance exist between task and maintenance role functioning. Individual contributions are acknowledged and respected. Diversity is encouraged. Interpersonal effectiveness, innovation and problem solving adequacy are evident.
PURPOSES OF GROUP THERAPY
• Psycho educational purpose of some groups is to help patients and families
better understand the disease process, treatment and modifiable risk factors • To help patients to understand and modify maladaptive patterns of relating to others. • • Strengthen healthy patterns of behavior and to help patients learn new, better ways of relating. Self help and mutual aid groups frequently do not have a professional
leader. Their purpose is to provide patients and families having similar health concerns a place to share their experiences, derive comfort , share information and exchange practical advice.
ELEMENTS / CURATIVE FACTORS
Certain essential elements are common to all types of group therapy. Yalom (2005) has identified eleven essential elements of group therapy. This include 1. Instillation Of Hope: It is the first and often most important factor. People participating in the group experience initially feel demoralized and helpless. So providing them with hope is therefore a most worthwhile achievement. Client should be encouraged to believe that they can find help and support in the group and that it is realistic to expect that problem will eventually be resolved. 2. Universality: It can be defined as the sense of realizing that one is not completely alone in any situation. Group members can identify this factor as a 3
major reason for seeking group therapy. During the sessions, members are encouraged to express complex, often very negative feelings in the hope that they will experience understanding and support from others with similar thoughts and feelings. 3. Imparting Of Information: This includes both didactic instructions and direct advice, and refers to the imparting of specific educational information plus the sharing of advice and guidance among members. The transmission of this information also indicates to each member the other’s concern and trust. 4. Altruism: It is the personalized help that one group member extends to another. Clients have the experience of learning to help others, and in the process they begin to feel better about themselves. Both the group therapist and the members can offer invaluable support, insight and reassurance while allowing themselves to gain self knowledge and growth. 5. Corrective Recapitulation Of The Primary Family Group: This allows members in the group to correct some of the perceptions and feelings associated with unsatisfactory experiences they have had with their family. The participants receive feedback as they discuss and relieve early familial conflicts and experience corrective responses. Family roles are explored, and members are encouraged to resolve unresolved family business. 6. Development of Socializing Techniques: It is essential in the group as members are given the opportunity to learn and test new social skills. Members also receive information about maladaptive social behaviors. 7. Imitative Behaviour: It refers to the process in which members observe and model their behaviors after one another. Imitation is an acknowledged therapeutic force; a healthy group environment provides valuable opportunities for experimenting with desired changes and behaviors. 8. Inter Personal learning: This includes the gaining of insight, the development of an understanding of a transference relationship, the experience of correcting emotional thoughts and behaviors and the importance of learning about oneself in relation to oneself.
9. Group Cohesiveness: It is the development of strong sense of group membership and alliance. The concept of cohesiveness refers to the degree to which a group functions as a supportive problem solving unit. Ideally, each member feels acceptance and approval from all others in the group. This factor is essential in ensuring optimal individual and group growth. 10. Catharsis: It is similar to group cohesiveness and involves members relating to one another through the verbal expression of positive and negative feelings. 11. Existential Factors: These factors are consistently operating in the group and help to make up the final component. These intangible issues encourage each group member to accept the motivating that he or she is ultimately responsible for his or her life choices and actions.
TYPES OF GROUP THERAPY:
SUPPORTIVE PARAMETERS GROUP THERAPY FERGUENCY ANALYTICALLY ORIENTED GROUP THERAPY PSYCHOANLYSIS OF GROUPS TRASACTIONAL GROUP THERAPY BEHAVIOURAL GROUP THERAPY
1-3 times a Once a week Upto 6
1-5 times a week 1-3+years Anxiety & personality disorders Always Primarily past life experiences& intra group relations
1-3 times a week 1-3 years Psychotic & anxiety disorders Usually
1-3 times a week Up to 6 months Phobias, passivity, sexual problems Usually Specific symptoms without focus on causality
week 1-3+years Anxiety & personality disorders Always Present & past
months Psychotic & anxiety disorders
INDIVIDUAL SCREENING INTERVIEW
life situations, Intra group & extra group relations
Primarily intra group relations
Positive transference Positive & negative Transference
encouraged to promote improved functioning
transference evoked and analyzed
neurosis evoked and analyzed Always
fostered, negative feelings analyzed
fostered, no examination of transference Not used
Not analyzed Intra group dependence encouraged,
Analyzed frequently Intra group dependence encouraged, dependence on leader variable
analyzed & encouraged Intra group dependence not encouraged, dependence on leader variable
Analyzed rarely Intra group dependence encouraged, dependence on leader not encouraged
Intra group dependence not encouraged, reliance on leader is high Create new defenses, active and directive
members relay on leader to great extend Strengthen
Challenge defenses, active, give advice or personal response
Challenge defenses, passive, give no advice or personal response Transference, ventilation, catharses, reality testing Discouraged Extensive reconstruction of personality dynamics
Challenge defenses, active, give personal response, rather than advice Abreaction, reality testing
existing defenses, active, give advice
MAJOR GROUP PROCESSESS
Cohesion, transference, reality testing Generally
SOCIALIZATION OUT OF GROUP
Alteration of behaviour through mechanism of conscious control
discouraged Moderate reconstruction of personality dynamics
Discouraged Relief of specific psychiatric symptoms
adaptation to environment
TYPES OF THERAPY GROUPS
The functions of a group vary depending on the reason the group was formed. Clark identifies three types of groups in which nurses most often participate: task, teaching & supporting or therapeutic groups, self help groups 1. TASK GROUPS The function of a task group is to accomplish a specific outcome or task. The focus is in solving problems and making decisions to achieve this outcome. Often a deadline is placed on completion of task, and such importance is placed on a satisfactory outcome, that conflict within the group maybe smoothed over or ignored to focus on the priority at hand. 2. TEACHING GROUPS Teaching, or educational groups exist to convey knowledge and information to a number of individuals. Nurse can be involved in teaching groups of many varieties such as medication education, child birth education, breast self education and effective parenting classes. These groups usually have a set time frame or set number of meetings. Members learn from each other as well as from the designated instructor. The objective of teaching group is verbalization or demonstration by the learner of the material presented by the end of the designated period. 3. SUPPORTIVE OR THERAPEUTIC GROUPS The primary concern of support group is to prevent future upsets by teaching participants effective ways dealing with emotional stress arising from situational or developmental crises 4. SELF HELP GROUPS An additional type group in which, nurses may or may not be involved is the self help group. It allows clients to talk about their fears and relieve feelings of isolation while receiving comfort and advice from others undergoing similar experiences. Eg. Alcoholic anonymous, narcotic anonymous, over eaters anonymous, women’s groups and men’s group.
CONCEPTS IN GROUP DYNAMICS:
Patient Selection: Member selection is based on a patient’s treatment need capacity to contribute to group goals. Group members do not know each other before entering the group, and it is best not to include people in the same group who socialize with each other. It is not possible to have full control over patient selection, particularly in inpatient or partial hospitalization settings, but the therapist should carefully consider the rationale for including patients who are actively psychotic, uncontrolled manic, paranoid or hostile even in inpatient setting. These individuals cannot benefit from the group when their symptoms are intense and they will disrupt the group even with the most skilled leadership. Functional Similarity: Group members should have enough in common with each other to feel interpersonally comfortable in the group and it is referred as the functional capacity. This means that group members should have sufficient levels of functional ability and social recognizability to allow them in meaningful conversation. Significant differences in educational level, life experiences or developmental levels can be barriers to full participation. When group members feel uncomfortable, they are not as likely to talk with each other. The leader should avoid including members who are the only ones with permanent characteristics such as different race, gender, education or age than the other members. MacKenzie referred to this as the “ Noah’s Arch” phenomenon. That is, a therapy group ideally should have at least two members with similar characteristics. Pairing members in this way precludes the creation of a group social isolate. For eg: it would not be appropriate to place a single adolescent girl in a group of adolescent boys.
Capacity to contribute: 8
Group members must be able to both contribute to group goals and derive benefit from this treatment modality. Usually, patients with more than mild cognitive disorders, anti social behaviors, strong hostility or paranoid symptoms do not profit from group intervention. First, their symptoms disrupt the group functioning. Second, their pathologies interfere with their own ability to derive benefit because their symptoms preclude the necessary co – operation with other members. They should be included only after their symptoms are under sufficient control that they gain some benefit from group membership. All group members need to be able to contribute in a meaningful way to the functioning of the group as a whole. Matching individual need with membership: Another factor to consider with group composition is the issue of homogenous compared with heterogeneous group membership. Homogenous group include patients with same diagnosis, similar age group and same gender. They are particularly useful in treating disorders in which denial plays a role, for example, addiction or eating disorders. Heterogeneous groups draw their membership from a variety of diagnoses. These groups are composed of men and women, rather than being single gender and prospective members can run the age gamut of adulthood. The advantage of a heterogeneous group is that the rich complexity of its membership can provide several different ways of approaching interpersonal relationships. The format works well with patients experiencing relationship difficulties. Choosing open or closed groups: Another decision is whether to have open or closed membership. Open groups are those in which group membership changes frequently. This type of group is found in inpatient settings that depend on member residency and in many mutual help and support groups. Closed groups are those in which group membership does not change for the life of the group or only for a clearly understood reason. Members often must meet certain criteria for acceptance, such as a diagnosis or a particular therapeutic issue. Foe example, alcoholic anonymous is open only to
people with a drug problem .psychotherapy group can share characteristics of both open and closed membership. They are open in that as one member leaves the group, another fills the empty slot, but they have a closed membership in that members cannot arbitrarily enter the group simply because they have similar interests or problems. Group size: Psycho educational groups can consist of 10-15 members. In psycho educational groups, the members discuss a particular topic such as medication, prevention or symptom management of a mental disorder, but the process does not allow individual to address personal psychological issues unrelated to the discussion topic. Most insight oriented therapy groups limit membership to six to eight. This size not only allows for a variety of interpretations but also permits sufficient interpersonal space for intimate sharing. Therapy group needs to have at least five members. With fewer than five members, the group is likely to produce an emotional intensity or to form sub groups, both of which are difficult to regulate. Time boundaries: Time boundaries in group therapy are extremely important. Most group therapy sessions last 75 – 90 minutes. Therapy sessions should begin and end on time. Attention to time boundaries respects the need of individuals to have lives outside the group and firmly integrates the group as a set pattern in the patient’s life. Inpatient versus outpatient groups: Inpatient groups differ from outpatient groups in several ways. Group membership in the inpatient groups depends on the particular patient population. Because of short stays, the focus of group may be on spotting mal adaptive behaviors that can be worked on in outpatient therapy and stabilizing symptoms enough to permit discharge. The content and process of inpatient therapy is more superficial than in outpatient settings. With inpatient therapy, the therapist takes a much more active role, clarifies more often and directs the process of establishing appropriate norms.
PHASES OF GROUP DEVELOPMENT: The phases of group development are sequential and overlapping, beginning with planning, which takes place before the group starts and ending with termination and referrals if needed. Tuckman 1965 describe the phases of group development as forming, storming, norming, performing and adjourning. Pre Interactive Phase : The leader’s first task is to establish suitable foundation for the group selecting an appropriate time and place for the group sessions and clearing these arrangements with other staff members. Psychotherapy groups must take place in a quite, well ventilated room where the group is not disturbed and the chairs should be arranged so that all group members face each other. The initial assessment interview takes place as an individual session before the first group session. Assessment interviews provide the therapist with an important opportunity to evaluate motivation and personal commitment. Another important goal of the pre group assessment interview is to make entry into the group easier. People may have preconceptions about the therapy that the therapist can dispel. During this initial discussion, the patient begins to experience the “person” of the leader. Experiencing the group leader as a human being and a consistent member of the group beforehand often reduces the patient’s anxiety about joining the group. During the pre group assessment interview, the therapist can provide necessary information about the group purpose, format and expectations and the patient can ask questions that may make the difference between whether he or she rejects or accepts group membership. Forming Phase: The forming phase of group therapy is the orientation phase in which group members begin to know each other. The therapist can begin the group with a self introduction and ask the members to say their names and tell the group something about 11
themselves. The manner in which the individuals express themselves and the type of information they choose to share provide important data that can be used later, in the working phase. However, the therapist needs to make sure that members do not prematurely disclose lengthy intimate details about themselves because premature sharing can lead to intense discomfort when the shares reflects on it, resulting in unanticipated termination. Acceptance, inclusion and trust are primary values held by members in beginning group meetings. Initially, group communication tends to be tentative, polite and guarded, as members explore their values and ideas with each other. They need to know that other group members, including the leader, will respect their contribution and will not make them look foolish to their peers. Finding that other members have had similar experiences and related feelings help strengthen initial emotional bonding among group members. The group leader encourages the development of universality by linking member contributions together, pointing out similarities, and stressing the importance of group members as therapists for each other. When the group begins to meet, the leader plays an important role in establishing the group structure. A standard first meeting format is to (1) identify the group‘s purpose and goals; (2) name fundamental structural norms such as expected attendance, confidentiality, and what to do incase of absence; and (3) explain how the group will function. A general statement about the nature of work (i.e., that the group provides a place where members can discuss serious personal issues and receive personal feedback from each other) establishes the task of the group as serious. If members have never been in group therapy before, the therapist briefly educates them as to their roles as members. Storming Phase: The storming phase of group development signals movement beyond the initial hesitancy and fear about being in the group. It can appear as a subtle questioning of appropriateness of time or group objectives. This opens the door to exploration of stronger feelings, hidden agendas and open conflicts as members struggle with issues of power and control. Although uncomfortable, this phase of group development is
absolutely essential because it sets the foundation for the development of the group specific norm that will guide the group in the working phase. This phase usually does not last long. Establishing trust remains a central task for this phase of group development. During this phase, the therapist acts as a gatekeeper by helping individual group members identify but move beyond their personal agendas and engage in their group dialogues. During this phase group members begin to engage with each other at deeper level and to reveal more of their issues while asking for a similar commitment from others. Norming Phase: During this phase, the group develops norms- behavioral standards and basic operating procedures- that provide structural boundaries and guidelines for behaviors that will or will not be tolerated. Some behaviors as classified as universal norms because they are standards found in all psychotherapy groups. These are predetermined norms, voiced during the opening session, that include regular attendance, confidentiality and the expectation of verbal contributions. Other standards are group specific norms, which emerge from the need of group members to facilitate goal achievement. For eg, group specific norms for a chronic schizophrenic therapy group might include specific basic group behaviors such as talking one at a time, not leaving the room during the session, refraining from violent behaviors towards other group members and refraining from obscene language. Specific norm in a drug abuse group would be to remain drug free during the group session. The group pressure on members who do not confirm to expected norms helps reinforce bonding. Because norm violation by one member affects the entire group, the leader must always address norm violations as being significant. Performing/Working Phase: Once the ground rules for operating the group are in place, members actively engage in working on group determined agendas. The performing phase is characterized by cohesion and productivity and the most in depth work of the group takes place during 13
this phase. Self disclosure is more spontaneous and honest in the performing phase. Members know what to expect from each other. In the process of working through differences, a genuine respect for other members has developed, members trust the comments of others and the sense of belonging is at its highest peak. Here, group members experience the altruism of helping others, interpersonal learning, self understanding, and recapitulation of the family. Throughout the performing phase, the therapist’s primary function is to facilitate movement towards the group goals by providing an accepting interpersonal environment in which group members feel supported in exploring difficult issues. Group members take responsibility for leadership activities and, in essence, become therapist for each other. Adjourning (termination) phase: Good endings are as important as good beginnings in group life. The adjourning phase of group relationships occur in a variety of ways: members leave, the group disbands, or a member is asked not to return for violating the group contract. Most often, individual group members leave a psychotherapy group because their work is finished or because they are discharged from the hospital or treatment program. Preparation for voluntary endings in an outpatient group can begin with a non established in the first meeting or during the initial interview when the therapist asks each group member to tell the group of impending departure one weak and to return the next to say goodbye. Terminations are important both for the group as a whole and for the patient. Sufficient time for effective goodbye should be provided during each patient’s last session. Ask the patient to tell the group what has been helpful and to say something to each group member. If the group as a whole is ending the therapist can help the group summarize the goal achievement and gain closure on any unresolved issues. Providing feedback about positive goal achievement individually and collectively is important to individual members and the group as a whole.
INDIVIDUAL FUNCTIONS WITH IN A GROUP: Roles involving task functions: Initiator: proposes new ideas, directions, tasks, methods. Elaborator: expand son existing suggestions and develops the group’s plans further. Evaluator: critically evaluates ideas, proposals, and plans, examining the practicality of proposals and the effectiveness of procedures. Co–ordinator: helps to pull together ideas and themes to clarify suggestions that have been made and to help various subgroups work more effectively together towards their common goals. Roles involving group maintenance functions: Encourager: Offers praise to and agrees with other members; communicates acceptance of others and their ideas and an openness to differences within the group . Harmonizer: mediates conflicts and disagreements that crop up, trying to relieve or reduce tension within the group. Compromiser: seeks a position between contending sides; seeks a compromise that all parties can accept. Roles involving primarily personal, individualistic functions:
Aggressor: Acts negatively, with hostility toward other members; criticizes others’ contributions; attacks the group and its members. Recognition-seeker: towards self. calls attention to own activities; boasts; redirects things
Help-seeker or confessor: uses the group as a vehicle either to gain sympathy or to achieve personal insight and self-satisfaction without consideration for others or the group as a whole. Dominator: asserts authority and seeks to manipulate others so as to be in control of everything that happens.
HOW GROUP THERAPY WORKS? Display of inter personal pathology Feed back and self observation Sharing reactions Examining the results of sharing reactions Understanding ones’ opinion of self Developing a sense of responsibility Realizing ones’ power to effect change High affect potentiate change
COMMON PROBLEMS AFFECTING GROUP THERAPY AND PROCESS AND ASSOCIATED NURSING INTERVENTIONS: SL. NO 1. Fear of authority resulting in timid,agreesive, hostile or withdrawn behavior • • Use non verbal and verbal communication techniques, listen to and encourage client to share and explore feelings Respond in an understanding manner when the client expresses feelings (even when they are hostile). • Reassure client that nurse-therapist will not respond punitively to the expression of feelings. 2. Initial anxiety in a group, displayed by silence, fidgeting, nervous movement and selective hearing. • • • Give “strokes” for positive interactions Help client establish a role in the group, one related to the client’s skills Share with client that discomfort in the initial state of group development is common. • Meet client’s dependency needs. GROUP PROBLEM NURSING INTERVENTION
Hidden Agenda • Identify the source of individual and group anxiety causing the hidden
agenda. • Explore the hidden agenda with the group and its meaning and effect on the group’s functioning. 4. Sub grouping • Establish clarifying goals and purpose of the group (thereby lessoning the group’s anxiety an aiding in elimination of subgroups. • Direct subgroup interest towards the goals of the group, thereby lessoning subgroup pre occupation with outside themes
Deviant behavior- behavior that needs personal need and undermines the group
Identify deviant behavior and discuss it with the client.
Identify sources of discomfort in the environment that affects the client.
Explore with the client whether he or she identifies the behavior as deviant.
Help members of the group identify deviant behavior.
Help the client explore how this behavior affects his or her relationship
in the group. • Use group pressure to help the deviant member change or conform to group norms. 6. Resistance to therapy(eg. Grunting, moaning, staring into space, over responding to situations, changing the subject, absence from group). • Confront the client with his or her behavior, using an understanding approach. • Help the client identify what he or she has accomplished while a member of the group. • Help the client work through feeling of loss during termination. (ie feelings of anger, euphoria, depression, rejection). • Help the client express both positive and negative feelings about the group and evaluate the group experience realistically. Plan a termination activity that allows expression of group members’ feelings. • Lesson intensity of group interaction as group nears termination. • Explore resistant behavior with the client.
NURSES’ RESPONSIBILITY IN GROUP THERAPY The primary role of the nurse – therapist in group therapy is to guide individuals through a problem solving process by anticipating and responding to the needs and concerns of the group members. The nurse therapist has both task and maintenance role functions. Group task functions are concerned with the practical issues of leading a group, where as group maintenance functions focus on less tangible group process. ADVANTAGES: 1. More clients can be treated in a group, making the method cost effective. 2. Members benefit by hearing others discuss similar problems; feelings of isolation, alienation, and uniqueness. 3. It provides the client opportunity to explore their specific styles of communication in a safe atmosphere where they can receive feedback and undergo changes. 4. Members learn multiple ways of solving a problem from others and group exploration may help them to discover new ways of solving problems. 5. Members learn about the functional roles of individuals in the group. Sometimes a member shares the responsibility as a co-therapist. 6. The group provides for its members’ understanding, confrontation and identification with more than one person. The member gains a reference group. DISADVANTAGES: 1. A member’s privacy may be violated, such as when a conversation is shared outside the group. This behaviour obstructs confidentiality and hampers complete and honest participation. 2. Clients may experience difficulty exposing themselves to a group or believe that they lack the skill to communicate effectively. Some clients may use these factors
as resistance; others may be reluctant to expose themselves because they do not want to change. 3. Group therapy is not helpful if the therapist conducts the group as if it is an individual therapy. Such a therapist may see dynamics and group process as incidental or antagonistic to the therapeutic process. The effective group leader must be skilled in techniques and interventions that foster group interaction and shape group behaviour and growth. CONCLUSION Purpose of group therapy is to intervene in mentally disorder behaviour, thinking and feeling. Group therapy offers multiple stimuli to reveal examine and resolve distortion in interpersonal relationship. The purpose of the group is related to goals and expected outcomes. The group therapist focuses on the process of interpersonal learning and change.
1) Benner, Carson, Verna. Mental health nursing: The nurse patient journey. 2nd ed. Philadelphia: W B Saunders Company; 2000. Page no. 354 – 362. 2) 3) Taylor M, Cecelia. Essentials of psychiatric nursing. 14 th ed. Philadelphia: Mosby publishers; 2001.Page no. 468 – 476. Rebraca L, Shives. Basic concepts of psychiatric mental health nursing.7 th ed. Philadelphia: Lippincott publishers; 2000. Page no.206 – 211. 4) Benjamine J S , Virginea A S . Synopsis of psychiatry. 10 th ed. Philadelphia: Lippincott publishers; 2001. Page no. 934 – 940. 5) Townsend M C. Psychiatric mental health nursing. 5th ed. New Delhi: J P Publishers; 2004. Page no. 151 – 157. 6) Mohr K W. Psychiatric Mental Health Nursing. 6 th ed. Philadelphia: Lippincott Publishers; 2006. Page no: 198 – 205. 7) Johnson D P, Penn D L, Bauer D J, Meyer P, Evans E. Predictor of the therapeutic alliance in group therapy for individuals with treatment resistant auditory hallucinations. British journal of clinical psychology. 2008; 47: 171 – 183.
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