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THE ALLENDALE ASSOCIATION RECEIVES PRESTIGIOUS AWARD FOR INNOVATIVE PRACTICES

The Allendale Association recently received an Innovative Practices Award for its REStArTsm treatment model.  REStArT (Relational Re-Enactment Systems Approach to Treatment) is a comprehensive systems-approach to treatment with youth who struggle with emotional, behavioral, and mental health challenges.

REStArT is based on thirteen principles that guide human service professionals, family members and youth in developing interventions to help break chronic "conflict cycles", repair relationships and learn new ways to be successful at home, in school, and in the community.

The award was presented by The Council on Accreditation (COA), a 34 year-old independent not-for-profit international accreditor of the full continuum of community-based behavioral health care and human service organizations.  Allendale was one of three groups to receive the 2011 Innovative Practices Award.

"We are so pleased to receive this special recognition because it validates the work we are doing at Allendale", said Mary Shahbazian, president of the Allendale Association.  "This award also acknowledges the REStArT program as an innovative and evidence-based team approach to helping kids and families in need to learn better ways to cope, deal with conflict and implement a positive life plan", concluded Shahbazian.

The COA Innovative Practices Award was created to acknowledge accredited and first time applicant organizations that implement new and forward thinking practices that enhance the quality of services provided to vulnerable children, youth, adults, and families and are consistent with theory, practice, wisdom, and expert consensus reflected in current professional literature.

COA's Innovative Practices Award is designed to provide organizations the opportunity to share and be rewarded for uniquely meeting the needs of a service population and/or implementing distinctive methods for improving organizational capacity.

In a formal statement, the COA said, "It is extremely proud to recognize the Allendale Association for their creative work and innovative use of resources, and is honored that they are part of the COA family".

CLINICAL CONSULTATION AS A FAMILY INTERVENTION IN RESIDENTIAL TREATMENT: EXPLORING WHAT IMPACTS OUTCOMES

Catherine McConnell PhD & Patricia Taglione PsyD

Click On Title to Download this 2015 Research Article (requires Adobe Acrobat)

 

COLLABORATING WITH CLIENTS AND IMPROVING OUTCOMES: THE RELATIONAL RE-ENACTMENT SYSTEMS APPROACH TO TREATMENT MODEL

Catherine McConnell PhD & Patricia Taglione PsyD

Click On Title to Download this 2012 Research Article (requires Adobe Acrobat)

 


THE RELATIONAL RE-ENACTMENT SYSTEMS APPROACH TO TREATMENT

Click On Title to Download Principles (requires Adobe Acrobat)

Allendale's model, the Relational Re-Enactment Systems Approach to Treatment (REStArT), is a comprehensive child and adolescent mental health treatment model. Treatment is based on youth's "conflict cycles" (i.e., relational trauma), which are defined by their re-enactments of their attachment experiences in the present. By engaging all systems involved with a youth and the experiences the members of those systems have with him/her, the treatment team can develop an understanding of how the youth sees themselves, others, and their relationships. Plans for treatment, then, are driven by this conceptualization, which is unique to each youth, but created within a model that uses attachment theory, object relations theory, an understanding of the impact of trauma and neurobiological underpinnings to organize the youth's patterns into diagnostic categories. These plans are developed to interrupt this cycle, which gives youth a chance to experience the feelings that have been inaccessible to them because they were being acted-out. The interruption of their re-enactment also gives them a chance to find new ways of relating and responding.

The REStArT model has thirteen principles that capture the philosophy, theory, and practice behind the approach. These principles guide treatment process and implementation with the goal of developing and executing a successful life plan.

I. Developing a Working Therapeutic Alliance: Client, family and service providers agree on the goals and tasks of treatment. These goals and tasks need to be youth and family driven.

The principle of therapeutic alliance is an essential component in all the treatment principles and needs to be established before treatment can take place. More than just the quality of the relationship between caregivers, service providers, and youth, a therapeutic alliance is a collaborative relationship in which all parties agree on the goals and tasks of treatment. Even before there can be agreement about the goals and tasks of treatment, treatment providers need to learn how youth and their family view the problem to be addressed. The process of developing the therapeutic alliance may stall if there has not been agreement about the very nature of the problem behind the goals and tasks.

When service providers are viewed as experts not just of their profession but also of the clients themselves, the development of a true collaborative relationship can be undermined and the result may be compliance from the family and youth without real ownership for the treatment and treatment outcomes. Instead, an alliance allows providers to do treatment "with" the client rather than "to" the client. Each of the other twelve principles - from understanding the unique experiences of the client to the need for systems to work as a unified whole - is designed to build and maintain an alliance with the client that puts their goals and choices at the center of treatment.

II. Relational Re-Enactment: Identify youth's attachment style through the ways in which the youth re-enacts it in his/her behavior with others (i.e., identify the conflict cycle).

Using attachment and object relations theories and informed by research on trauma, the treatment within the REStArT model begins by identifying youths' internalized representations of their interactions with others (Siegel, 1999; Bowlby, 1980; Masterson, 1976). The conflict cycle consists of a youth's most potent relational stressors and the feelings and behaviors that accompany these stressors. The process becomes cyclical in that the youth's behavior pulls for particular responses from adults - responses that perpetuate the youth's responses either by managing the stressor for him or her or by intensifying the impact of the stressor. Neurobiological research (Schore, 1994) suggests that the responses generated in others are a form of "right-brain" communication through which the youth elicits emotional reactions in others as a way of communicating their own internal experiences. Because these internal experiences are not part of the youth's explicit memory, the experiences of adults living and working with the youth - while sometimes difficult to acknowledge - are valuable data in understanding the youth and the meaning behind their behaviors.

III. Managing Counter-Response(1): Identify the adult counter-response (feelings and subsequent behavior) within that youth's particular conflict cycle; identify the adult's unpleasant reality (related to the youth's conflict cycle) that is being avoided by the adult; face the adult's unpleasant reality and the adult's feelings so that they are not driving the adult's behavior (counter-response).

The feelings and behaviors generated in adults when they are living with or interacting with a particular youth in treatment are valuable for conceptualizing the youth, as referenced above. However, these responses - the feelings and behaviors that the adults use to "counter" the behaviors of the youth - are also identified so that the responses of the adults (family, significant others, professionals working in the program) are no longer driven by the youth's re-enactments, but are rather grounded in what is in the best interest of the youth. Responses to the youth can be characterized as "counter-aggressive", meaning adults counter a youth's behavior with anger and frustration, wanting only for the youth to change and losing sight of an understanding of the youth's behavior; or "counter-indulgent" which are unbalanced in the direction of understanding, that is, the adults understand and align with the youth and lose sight of expectations for the youth to be accountable for their own behavior.

Often these counter-responses are maintained when adults working with youth in treatment are unaware of one or more "unpleasant realities" associated with living or working with the youth. While youth themselves often have to confront unpleasant aspects of their worlds - abusive experiences, personal limitations, losses - the adults working with them face unpleasant realities, as well. For example, youth may not have the same goals for themselves as the adults have for them, or they may make choices contrary to the choices the adults wanted them to make. In order to interrupt the youth's cycle, adults need to be open with themselves regarding the unpleasant realities they face interacting and working with the youth. When these unpleasant realities are named and accepted, adults can work toward managing their counter-responses to the youth; this can be very powerful in helping the youth focus on him/herself to gain insight into self-defeating patterns of behavior and try new, more adaptive, behaviors to manage stress.

(1) Allendale Association Counter-Responsesm Training, Copyright 2003.

IV. Systems-Oriented: Identify all the adults involved with the youth and have them come together to develop a shared understanding of and way of approaching the youth and to identify a common interest or goal.

The systems orientation of the REStArT model takes into account that each of the youth's interactions with the adults in his or her life takes place not in isolation but within a larger system. All of the adults in the youth's life are a part of that system, and, as a result, the interaction of each adult with that youth affects all the other adults in that system. If one member of the youth's treatment team is counter-indulgent with the youth, for example, this will affect others who are trying to hold the youth accountable for his or her behavior. The systems approach, then, is not simply an invitation to be as inclusive as possible when considering the youth's treatment team - although this, too, is important. It also calls on all members (family, significant others, professional staff, advocates) of the treatment team to consider the "ripple effect" that will occur in the system based on their interactions with the youth.

V. Finding the Imbalance in the System: Identify polarities in youth's behavior and subsequent polarities in adults' counter-response (i.e., splits/divisions within the system).

A system tends to seek balance. In the physical world, for every action there is an equal and opposite reaction. This seems to be true for the emotional world, as well. When there is an extreme (unbalanced) emotional reaction, it is usually responded to by an equally extreme (unbalanced) opposite emotional reaction, resulting in polarities. For example, one's counter-indulgence is often responded to by another's counter-aggression and vice versa (i.e., one member of the team does not hold the youth consistently accountable to important rules of conduct while another applies overly negative and rigid consequences for every small infraction).

Although ultimately the REStArT approach seeks to create balance in the systems surrounding the youth, the identification of discrepancies in the way the youth is understood is an important step in developing a plan to work with each youth. Divisions in the system working with a youth often represent the splits within the youth's own internal experiences. Understanding the divisions can help family members and treatment providers understand the internal conflict of the youth. Because these internal conflicts are generally not in the explicit awareness of the youth, they are externalized through the youth's interactions with others. Because the internal conflict is, by definition, divided, its re-enactment is done in such a way as to allow some people to see one aspect of the conflict and others to see only other aspects of the conflict. In treatment, then, adults using the REStArT model identify their primary responses to the youth (counter-indulgent or counter-aggressive) and the behaviors from the youth to which they are responding in order to better understand the youth as a whole.

One common consequence of imbalance when left unchecked is the "treatment trap". In this imbalance, the system emphasizes understanding the youth to the exclusion of expecting change. After some time of indulging the youth in this way, members of the system become frustrated at the lack of progress the youth has made, and become counter-aggressive. The counter-aggression escalates until it eventually takes the form of believing that the youth is misplaced and should be moved either to a different milieu/team or to an entirely different level of care.

VI. Seeing the Whole Youth: Identify ways in which our view of the youth has been compartmentalized (i.e., sees the youth in a particular way). Work together and dialogue so that all parties see both sides of the youth - the adaptive side and the maladaptive side.

Attachment theory and object relations theory both offer an understanding of the importance of wholeness as it applies to an individual's development (Bowlby, 1980; Fairbairn, 1958; Kernberg, 1975; Masterson, 1976). Internalized experiences with others that result in internal models in which "good and bad" aspects of self and other are not integrated lead to ways of interacting with the world that are split, as well. Because youth are often acting-out their conflicts in ways that are destructive, it follows that treatment aims to help them integrate their feelings about their conflicts, allowing them the opportunity to be in control of rather than controlled by their experiences.

In order for youth to integrate their experiences of the world, both good and bad, the adults and systems around them will need to integrate their various experiences of the youth. Wholeness from this perspective is equivalent with health, and the focus on wholeness then promotes the health of the individual as well as the health of the system. This part of the REStArT model requires ongoing dialogue with the involvement of as many parties as possible: parents, school professionals, milieu staff, therapists, advocates, etc. Because each view of the youth is valid, no party is considered an "expert" on the youth. The goal of these dialogues is to create a whole picture of the youth that involves an empathic understanding of their behavior as well as an expectation that the youth can change.

It is not necessary for each member of the team to experience or personally witness the youth in all ways in order for an aspect of the youth to be considered in treatment. Additionally, a "wholeness" approach reminds treatment team members that even youth who are not acting out currently still have the characteristics and potential for behavior that resulted in their need for treatment. Similarly, youth who are engaged in acting-out behaviors still have their adaptive side, as well.

VII. Restoring the Balance: Use dialogue and consensus to restore balance in developing a plan to interrupt the youth's conflict cycle (integrate both extremes of the adults' counter-response reactions in order to arrive at a more balanced response).

Armed with this unified understanding of the youth, individual adults and their respective systems can use this balanced view to create a balanced response to the youth. This part of treatment does not involve "brainstorming" techniques, but rather requires adults to listen to one another's issues and concerns and to bring forth one's own concerns without trying to convince, argue or debate. Keeping in mind that splitting has been one way the youth involved has coped with their conflict, adults trust that each person has a view of the youth that is valid and may have been invisible to them. The goal of this step is to reach a consensus about the plan, not a compromise. Compromise often implies that someone has "given in", and this is likely to maintain rather than resolve the splits and imbalances in the system. Remaining grounded in concrete evidence adults have about the youth is crucial at this step, as it allows for a more disciplined approach which is more likely to result in consensus than a debate that is based on personal reactions to the youth.

This process of dialogue and consensus may not result in restoring balance initially. There are a number of potential barriers that may need to be addressed. The adults working with the youth may have an easier time identifying the counter-response in others and therefore, may not be open to looking at or managing their own responses. When the plan is agreed on without true consensus, balance is also not likely to be restored. Because youth have been engaging in splitting to manage their own painful feelings, they will continue to do so even if the lack of agreement between the adults in their world is subtle. This split also allows the youth to avoid resolving their own internal conflicts. If adults resonate with one side of the youth's conflict, this, too, will stall the process of restoring balance. The process of using one's own responses to a youth to understand the youth and his/her conflicts is a challenging one, and sometimes the focus of individual members of the treatment team can become externalized as a way to manage this. While external factors are not irrelevant, they are generally out of the control of individual team members, and focusing on them can keep the process stuck.

VIII. Interrupting the Conflict Cycle: Implement a plan that interrupts the way the youth typically responds to stressors which provides an opportunity for the youth to respond in a new more adaptive way.

Each youth's conflict cycle is unique to his or her own way of responding to stressors and is based on the data that family members, staff, and significant others have accumulated from their specific interactions with the youth. However, the conflict cycle also offers a sense of continuity within a framework that allows for great individual variability. The conflict cycle itself is based on the work of Nick Long (Wood & Long, 1991). The four classifications of conflict cycles are related to the "core sensitivities" from the work of Cooper, et al (2005). The classification of a youth's conflict cycle into one of four categories provides a starting point for treatment planning and intervention. The four classifications are: control sensitive, closeness sensitive, independence sensitive, and self-esteem sensitive. Each conflict cycle type refers to the particular stressor or predominant precipitant for the youth's conflict cycle as well as the nature of the responses the youth generates in others. Because different behaviors can appear to different people to be classified in any one of these categories, conflict cycle determination is made by careful attendance not only to antecedent events, but also to the youth's subsequent behavior and the adults' responses, using specific and detailed tracking of these cycles.

Treatment with REStArT is flexible in that no two treatment plans are identical. Plans for interrupting the youth's conflict cycle are unique to each youth and relevant to the understanding of that youth's particular sensitivity. However, the approach is also one of continuity in that treatment is based on a framework grounded in theory and evidence. Like the REStArT model more broadly, these plans remain cognizant of the need to maintain balance by being aware of typical adult responses that may err on the side of only expecting change in the absence of understanding or focusing too heavily on understanding the youth's sensitivities with little expectation of change.

IX. Working with Ambivalence: Be aware of and identify examples of ambivalence toward the current circumstance in the family and the youth so that this can be verbalized instead of expressed through behavior.

Ambivalence can be defined as having both positive and negative feelings toward something. It is expected that youth and their families experience polarized feelings about their individual goals, their discharge goals, and their relationships. In an effort to see the youth as a whole, participants in the REStArT model need to become aware of the ways in which the youth and his/her family cope with ambivalence. For example, if expressed intentions are different than actual behaviors, this may represent conflicting feelings regarding the stated goal. Rather than trying to get the family and/or youth to commit to a decision, service providers within this treatment approach encourage them to talk about both parts of their feelings, so they can eventually develop a more balanced response to the situation. As with other internal conflicts, however, the youth and their family will be unable to talk about their ambivalence as long as they are acting it out. If participants in the youth's system take on the task of trying to resolve this ambivalence - either by encouraging a particular outcome or feeling hopeless about any outcome - the youth, family, and rest of the team will remain stuck. The REStArT model guides the assessment of the ambivalence so that treatment providers can remove themselves from the conflict and, instead, assist the youth and family in acknowledging, discussing, and resolving it.

X. Expecting Health: Trust the youth's ability to determine their own goals, tolerate disappointments, and repair relational disruptions.

In order to implement a plan to interrupt the youth's conflict cycle, the treatment team needs to trust the youth's ability to determine what the standard of "health" is for them and to support the youth's goal in achieving this. This may mean relinquishing goals and expectations that the adults have for the youth even when adults believe that their vision for the youth is "healthier" than the youth's vision for themselves. By allowing the youth to pursue their own goals, within reason, the adults also trust the youth to be capable, with appropriate support, of tolerating setbacks. This requires the adults in the youth's system to create a balance between remaining emotionally available for the youth while allowing the youth to face situations that may be disappointing or frustrating. In particular, by allowing the youth to experience natural disruptions in their relationships with family/friends/caretakers/service providers, the system gives the youth the opportunity to better tolerate these relational events. This aspect of the REStArT model calls on adults to be willing themselves to tolerate disruptions in relationships, as counter-indulgence often serves to protect both the youth and the adult from this experience. As with other aspects of the model, dialogue and self-awareness promote the ability of adults in the system to work through these disruptions in healthy ways and expect that most disruptions can be repaired.

The expectation of health is not limited to the relationship between adults and the youth. In general, adults within the system need to expect health from one another, meaning that service providers need also to apply this principle to their work with youths' families and significant others. Additionally, this principle calls on staff at each level of the system to expect health from other staff/professionals, trusting in their ability to do their job and to work for better solutions when there are disruptions and setbacks.

XI. Ownership at Every Part of the System: Create investment in the model across the entire system and support each part's contribution to the plan, which promotes responsibility and accountability.

The components of treatment using REStArT - for example, utilizing imbalances in the system (splitting) to better understand and treat each youth - necessitate that every part of the system have an investment in and contribution to the youth's treatment. Rather than treatment planning and implementation stemming from a "top-down" model, REStArT uses frequent consultation, dialogue, and a system of checks and balances to ensure that all members of the youth's treatment team are equal partners. While this does not negate each individual's responsibility or unique role, it does provide greater support for each person's role because each individual knows that he or she is part of and has input into a larger plan. System-wide input increases the likelihood that the members of the system will feel that the plan belongs to them. Within the theoretical structure of REStArT, this system-wide investment also serves the function of creating the wholeness needed to interrupt the youth's conflict cycle.

This approach to wholeness is developed through "horizontal" dialogue in which leaders across multiple settings (clinical, school, residential milieu) are involved in dialogue, rather than communication being primarily "vertical" (supervisors communicate to their supervisees). Additionally, a collaborative relationship with family and collateral team members, who are viewed as an equal and integral part of the treatment team, is necessary. When families are not involved or say they are supportive of a plan but do not follow through, rather than viewing the family as resistant, the program is called upon to reflect on their work with the family. Clinical consultation is the family service that provides the bridge between all members of the system.

XII. Evidence-Based: Use concrete data about the youth to determine conflict cycle and plan development and to evaluate effectiveness and outcomes.

Evidence-based, within the REStArT model, refers in part to the need for concrete material to support the conceptualization of the youth, the plan to interrupt the conflict cycle, and the conclusion that the plan is working (or not working). Research on residential treatment in particular has identified the following factors as characteristic of an evidence-based practice: family involvement prior to discharge, stability in the post-discharge resource, and availability of after-care support (Frensch & Cameron, 2002; Hair, 2005). An evidence-based program is also one whose foundation is a coherent treatment model (Wampold & Malterer, 2007). And finally, evidence, in the context of a broader research program, benefits from multiple informants and objective data over the course of time to support conclusions (e.g., Behrens & Satterfield, 2006; Curry, 2004). The REStArT model serves as a coherent approach that directs the family-focus and discharge-focus of treatment. The members of the system, including the youth, make up the multiple informants. Objective data over the course of time is gathered by tracking the youth's interactions using specific examples across different settings and episodes. Because similar behaviors can have different meanings for different youth, closely tracking behavior and finding the themes that emerge protects against imputing the meaning from observing the behavior outside of its context.

XIII. Dynamic and Reflexive Process: Establish a continuous process of looking at our own responses/reactions and evaluating whether the plan is effective.

Because relational re-enactment is at the heart of this model, the responses and reaction of adults using the model are instruments in assessing and treating the youth in care. These interactions are inherently co-created, so adults in this process need to examine their own reactions both to understand the youth but also to manage how they respond to triggers of their own relational templates. Psychodynamic theories and also research on practices such as Multisystemic Therapy (MST) suggest that the treatment of others requires caregivers to engage in a process of self-examination (Henggeler, et al, 1997; Shedler, 2006).

The feedback process itself can sometimes be a source of imbalance in a system. Feedback may overly emphasize positive results at the expense of continued learning. Alternately, it may be equated with criticism, overlooking ways that the members of the system have worked well together. However, results of outcome research indicate that therapists have better results when provided with immediate feedback about their sessions, regardless of the nature of the feedback (Lambert, Hansen, & Finch, 2001). Feedback, then, is provided not as a consequence or reward, but rather as a means to improving treatment delivery and client functioning. Supervision and consultation offer ongoing opportunities for treatment providers to not only reflect on their own experiences but also receive feedback from others, as it is often difficult to "see" our own responses.

This process of self-reflection - with "self" referring not only to the individual but also to the treatment team as a whole (i.e., the system) - creates an environment of continuous quality improvement. The process is a repeating loop in that the results of one plan, in the form of the youth's responses, are the feedback used as further evidence to both understand and provide/modify treatment for the youth. The youth's responses to treatment are examined and compared to expectations of what change would mean for each particular youth. When a plan does not result in change, the process of examining how the youth's cycle is continuing in ways that may not be readily apparent begins anew. This process again includes the response of the treatment providers as it relates to this cycle.

As the name of this principle implies, the task of working with these youth is dynamic and, therefore, always changing. We may manage our feelings adequately in one interaction with a youth only to find the same interaction very challenging the next time we are confronted with it. Similarly, a youth may alter his or her behavior in one situation but then start acting out in new ways. While it can be uncomfortable to maintain this activity of assessing the youth's behavior and our responses, to do so is to take advantage of the many inherent opportunities for intervention in this process.

References

Behrens, E., & Satterfield, K. (2006, August). Report of Findings from a Multi-Center Study of Youth Outcomes in Private Residential Treatment. Presented at the 114th Annual Convention of the American Psychological Association at New Orleans, Louisiana.

Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books.

Cooper, G., Hoffman, K., Powell, B., & Marvin, R. (2005). The Circle of Security Intervention: Differential Diagnosis and Differential Treatment. In L.J. Berlin, Y. Ziv, L. Amaya-Jackson, & M. T. Greenberg (Eds.), Enhancing early attachments: theory, research, intervention, and policy (pp. 127-149). New York, NY: Guilford Press.

Curry, J. (2004). Future Directions in Residential Treatment Outcome Research. Child Adolescent Psychiatric Clinics of North America, 13, 429-440.

Fairbairn, W. R. D. (1958). On the Nature and Aims of Psychoanalytic Treatment. International Journal of Psychoanalysis, 39, 374-385.

Frensch, K. M., & Cameron, G. (2002). Treatment of Choice or a Last Resort? A review of residential mental health placement for children and youth. Child and Youth Care Forum, 31, 307-339.

Hair, H. J. (2005) Outcomes for Children and Adolescents After Residential Treatment: A Review of Research from 1993 to 2003. Journal of Child and Family Studies, 14, 551-575.

Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G., & Hanley, J. H. (1997). Multisystemic Therapy with Violent and Chronic Juvenile Offenders and their Families: The Role of Treatment Fidelity in Successful Dissemination. Journal of Consulting and Clinical Psychology, 65, 821-833.

Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism. New York: Jason Aronson.

Lambert, M., Hansen, N., & Finch, A. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. Journal of Consulting and Clinical Psychology, 69, 159-172.

Masterson, J. (1976). Psychotherapy of the Borderline Adult: A Developmental Approach. New York: Brunner/Mazel.

Schore, A. N. (1994). Affect Regulation and the Origin of the Self. Hillsdale, New Jersey: Lawrence Erlbaum Associates.

Shedler, J. (2006). That was Then, This is Now: Psychoanalytic Psychotherapy for the Rest of Us. Retrieved from www.psychsystems.net/shedler.html.

Siegel, D. J., (1999). The Developing Mind. New York: The Guilford Press.

Wampold, B. E., & Malterer, M. B. (2007). A Critical Evaluation of the Evidence-Base for the Effectiveness of Residential Treatment Centers: How Does Allendale Compare? Unpublished manuscript, University of Wisconsin at Madison.

Wood, M. M., & Long, N. J. (1991). Life Space Intervention. Austin, Texas: pro-ed.

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